TEST BANK for Medical Surgical Nursing 10th Edition

Medical-Surgical Nursing - 10th Edition by Donna D Ignatavicius & M Linda Workman & Cherie Rebar & Nicole M Heimgartner (TEST BANK)

Medical Surgical Nursing 10th Edition Ignatavicius Workman Test Bank Chapter 01: Overview of Professional Nursing Concepts for Medical-Surgical Nursing Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A new nurse is working with a preceptor on a medical-surgical unit. The preceptor advises the

new nurse that which is the priority when working as a professional nurse? a. Attending to holistic client needs b. Ensuring client safety c. Not making medication errors d. Providing client-focused care ANS: B

All actions are appropriate for the professional nurse. However, ensuring client safety is the priority. Health care errors have been widely reported for 25 years, many of which result in client injury, death, and increased health care costs. There are several national and international organizations that have either recommended or mandated safety initiatives.

Every nurse has the responsibility to guard the client’s safety. The other actions are important for quality nursing, but they are not as vital as providing safety. Not making medication errors does provide safety, but is too narrow in scope to be the best answer.

DIF: Understanding TOP: Integrated Process: Nursing Process: Intervention KEY: Client safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 2. A nurse is orienting a new client and family to the medical-surgical unit. What information

does the nurse provide to best help the client promote his or her own safety? a. Encourage the client and family to be active partners. b. Have the client monitor hand hygiene in caregivers. c. Offer the family the opportunity to stay with the client. d. Tell the client to always wear his or her armband.

ANS: A

Each action could be important for the client or family to perform. However, encouraging the client to be active in his or her health care as a safety partner is the most critical. The other actions are very limited in scope and do not provide the broad protection that being active and involved does.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Client safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 3. A nurse is caring for a postoperative client on the surgical unit. The client’s blood pressure

was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action would the nurse take first? a. Call the Rapid Response Team. b. Document and continue to monitor. c. Notify the primary health care provider. d. Repeat the blood pressure in 15 minutes.

ANS: A

The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating before they suffer either respiratory or cardiac arrest. Since the client has manifested a significant change, the nurse would call the RRT. Changes in blood pressure, mental status, heart rate, temperature, oxygen saturation, and last 2 hours’ urine output are particularly significant and are part of the Modified Early Warning System guide. Documentation is vital, but the nurse must do more than document. The primary health care provider would be notified, but this is not more important than calling the RRT. The client’s blood pressure would be reassessed frequently, but the priority is getting the rapid care to the client.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Rapid Response Team (RRT), Clinical judgment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. A nurse wishes to provide client-centered care in all interactions. Which action by the nurse

best demonstrates this concept? a. Assesses for cultural influences affecting health care. b. Ensures that all the client’s basic needs are met. c. Tells the client and family about all upcoming tests. d. Thoroughly orients the client and family to the room.

ANS: A

Showing respect for the client and family’s preferences and needs is essential to ensure a holistic or “whole-person” approach to care. By assessing the effect of the client’s culture on health care, this nurse is practicing client-focused care. Providing for basic needs does not demonstrate this competence. Simply telling the client about all upcoming tests is not providing empowering education. Orienting the client and family to the room is an important safety measure, but not directly related to demonstrating client-centered care.

DIF: Understanding KEY: Client-centered care, Culture

TOP: Integrated Process: Culture and Spirituality MSC: Client Needs Category: Psychosocial Integrity

5. A client is going to be admitted for a scheduled surgical procedure. Which action does the

nurse explain is the most important thing the client can do to protect against errors? a. Bring a list of all medications and what they are for. b. Keep the provider’s phone number by the telephone. c. Make sure that all providers wash hands before entering the room. d. Write down the name of each caregiver who comes in the room.

ANS: A

Medication reconciliation is a formal process in which the client’s actual current medications are compared to the prescribed medications at the time of admission, transfer, or discharge.

This National client Safety Goal is important to reduce medication errors. The client would not have to be responsible for providers washing their hands, and even if the client does so, this is too narrow to be the most important action to prevent errors. Keeping the provider’s phone number nearby and documenting everyone who enters the room also do not guarantee safety.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Client safety, Informatics MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

6. Which action by the nurse working with a client best demonstrates respect for autonomy? a. Asks if the client has questions before signing a consent. b. Gives the client accurate information when questioned. c. Keeps the promises made to the client and family. d. Treats the client fairly compared to other clients.

ANS: A

Autonomy is self-determination. The client would make decisions regarding care. When the nurse obtains a signature on the consent form, assessing if the client still has questions is vital, because without full information the client cannot practice autonomy. Giving accurate information is practicing with veracity. Keeping promises is upholding fidelity. Treating the client fairly is providing social justice.

DIF: Applying TOP: Integrated Process: Caring KEY: Ethics, Autonomy MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 7. A nurse asks a more seasoned colleague to explain best practices when communicating with a

person from the lesbian, gay, bisexual, transgender, and questioning/queer (LGBTQ) community. What answer by the faculty is most accurate? a. Avoid embarrassing the client by asking questions. b. Don’t make assumptions about his or her health needs. c. Most LGBTQ people do not want to share information. d. No differences exist in communicating with this population.

ANS: B

Many members of the LGBTQ community have faced discrimination from health care providers and may be reluctant to seek health care. The nurse would never make assumptions about the needs of members of this population. Rather, respectful questions are appropriate. If approached with sensitivity, the client with any health care need is more likely to answer honestly.

DIF: Understanding KEY: Health care disparities, LGBTQ

TOP: Integrated Process: Teaching/Learning MSC: Client Needs Category: Psychosocial Integrity

8. A nurse is calling the on-call health care provider about a client who had a hysterectomy 2

days ago and has pain that is unrelieved by the prescribed opioid pain medication. Which statement comprises the background portion of the SBAR format for communication? a. “I would like you to order a different pain medication.” b. “This client has allergies to morphine and codeine.” c. “Dr. Smith doesn’t like nonsteroidal anti-inflammatory meds.” d. “This client had a vaginal hysterectomy 2 days ago.”

ANS: B

SBAR is a recommended form of communication, and the acronym stands for Situation, Background, Assessment, and Recommendation. Appropriate background information includes allergies to medications the on-call health care provider might order. Situation describes what is happening right now that must be communicated; the client’s surgery 2 days ago would be considered background. Assessment would include an analysis of the client’s problem; none of the options has assessment information. Asking for a different pain medication is a recommendation. Recommendation is a statement of what is needed or what outcome is desired.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Teamwork and collaboration, SBAR MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 9. A nurse working on a cardiac unit delegated taking vital signs to an experienced assistive

personnel (AP). Four hours later, the nurse notes that the client’s blood pressure taken by the AP was much higher than previous readings, and the client’s mental status has changed. What action by the nurse would most likely have prevented this negative outcome? a. Determining if the AP knew how to take blood pressure b. Double-checking the AP by taking another blood pressure c. Providing more appropriate supervision of the AP d. Taking the blood pressure instead of delegating the task ANS: C

Supervision is one of the five rights of delegation and includes directing, evaluating, and following up on delegated tasks. The nurse would either have asked the AP about the vital signs or instructed the AP to report them right away. An experienced AP would know how to take vital signs and the nurse would not have to assess this at this point. Double-checking the work defeats the purpose of delegation. Vital signs are within the scope of practice for a AP and are permissible to delegate. The only appropriate answer is that the nurse did not provide adequate instruction to the AP. DIF: Analyzing TOP: Integrated Process: Communication and Documentation KEY: Teamwork and collaboration, Delegation MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 10. A newly graduated nurse in the hospital states that because of being so new, participation in

quality improvement (QI) projects is not wise. What response by the precepting nurse is best? a. “All staff nurses are required to participate in quality improvement here.” b. “Even being new, you can implement activities designed to improve care.” c. “It’s easy to identify what indicators would be used to measure quality.” d. “You should ask to be assigned to the research and quality committee.”

ANS: B

The preceptor would try to reassure the nurse that implementing QI measures is not out of line for a newly licensed nurse. Simply stating that all nurses are required to participate does not help the nurse understand how that is possible and is dismissive. Identifying indicators of quality is not an easy, quick process and would not be the best place to suggest a new nurse to start. Asking to be assigned to the QI committee does not give the nurse information about how to implement QI in daily practice.

DIF: Applying

TOP: Integrated Process: Communication and Documentation

KEY: Systems thinking, Quality improvement MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 11. A nurse is talking with a co-worker who is moving to a new state and needs to find new

employment there. What advice by the nurse is best? a. Ask the hospitals there about standard nurse–client ratios. b. Choose the hospital that has the newest technology. c. Find a hospital that has achieved Magnet status. d. Work in a facility affiliated with a medical or nursing school.

ANS: C

Client Magnet status is awarded by The Joint Commission (TJC) and certifies that nurses can demonstrate how best current evidence guides their practice. New technology doesn’t necessarily mean that the hospital is safe. Affiliation with a health profession school has several advantages, but safety is most important.

DIF: Understanding TOP: Integrated Process: Communication and Documentation KEY: Evidence-based practice, Magnet status MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control MULTIPLE RESPONSE 1. A nurse manager wishes to ensure that the nurses on the unit are practicing at their highest

levels of competency. Which areas would the manager assess to determine if the nursing staff demonstrate competency according to the Institute of Medicine (IOM) report Health Professions Education: A Bridge to Quality? (Select all that apply.) a. Collaborating with an interprofessional team b. Implementing evidence-based care c. Providing family-focused care d. Routinely using informatics in practice e. Using quality improvement in client care f. Formalizing systems thinking when implementing care ANS: A, B, D, E

The IOM report lists five broad core competencies that all health care providers should practice. These include collaborating with the interprofessional team, implementing evidence-based practice, providing patient-focused care, using informatics in client care, and using quality improvement in client care. Systems thinking is required for quality improvement but is not a specified part of the IOM report.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Competencies, Institute of Medicine (IOM) MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 2. A nurse is interested in making interprofessional work a high priority. Which actions by the

nurse best demonstrate this skill? (Select all that apply.) a. Consults with other disciplines on client care. b. Coordinates discharge planning for home safety. c. Participates in comprehensive client rounding. d. Routinely asks other disciplines about client progress.

e. Shows the nursing care plans to other disciplines. f. Delegate tasks to unlicensed personnel appropriately.

ANS: A, B, C, D, F

Collaborating with the interprofessional team involves planning, implementing, and evaluating client care as a team with all other involved disciplines included. Simply showing other caregivers the nursing care plan is not actively involving them or collaborating with them.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Teamwork and collaboration, Interprofessional team MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 3. The nurse utilizing evidence-based practice (EBP) considers which factors when planning

care? (Select all that apply.) a. Cost-saving measures b. Nurse’s expertise c. Client preferences d. Research findings e. Values of the client f. Plan-do-study-act model ANS: B, C, D, E

EBP consists of utilizing current evidence, the client’s values and preferences, and the nurse’s expertise when planning care. It does not include cost-saving measures. The PDSA model is a systematic model for quality improvement, but is not a specific component of EBP. DIF: Remembering TOP: Integrated Process: Nursing Process: Planning KEY: Evidence-based practice (EBP) MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 4. A nurse manager wants to improve hand-off communication among the staff. What actions by

the manager would best help achieve this goal? (Select all that apply.) a. Attend hand-off rounds to coach and mentor. b. Create a template of suggested topics to include in report. c. Encourage staff to ask questions during hand-off. d. Give raises based on compliance with reporting. e. Provide education on the SBAR method of communication ANS: A, B, C, E

The SBAR method of communication has been identified as an excellent method of communication between health care professionals. It is a formalized structure consisting of Situation, Background, Assessment, and Recommendation/Request. Using a formalized mechanism for communication helps ensure successful hand-off and fewer client errors. When establishing this new format for report, the most helpful actions by the manager would be to provide initial education on the process, develop a template with suggested topics under each heading, attend rounds to coach and mentor, and encourage staff to ask questions to clarify information. Basing raises on compliance would not be the most helpful method because raises are often determined only once a year and are based on multiple criteria.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Teamwork and collaboration, Communication

MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care

Chapter 02: Clinical Judgment and Systems Thinking Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse asks the charge nurse to explain the difference between critical thinking and clinical

judgment. What statement by the charge nurse is best? a. “Clinical judgment is often clouded by erroneous hypotheses.” b. “Clinical judgment is the observable outcome of critical thinking.” c. “Critical thinking requires synthesizing interactions within a situation.” d. “Critical thinking is the highest level of nursing judgment.”

ANS: B

Clinical judgment is the observable outcome of critical thinking and decision making. It can be, but most often is not, clouded by erroneous hypotheses. Recognizing, understanding, and synthesizing interactions and interdependencies in a set of components designed for a specific purpose is systems thinking. Critical thinking is not the highest level of nursing judgment.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Clinical judgment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 2. The nurse understands which information regarding patient-centered care? a. A competency recognizing the client as the source of control of his or her care b. A project addressing challenges in implementing patient-centered care c. Purposeful, informed, and outcome-focused care of clients or families d. The ability to use best evidence and practice when making care-related decisions ANS: A

Patient-centered care is a QSEN competency that recognizes the patient or caregiver as the source of control and full partner in providing compassionate and coordinated care based on respect for the patient’s preferences, values, and needs. QSEN is a project addressing the challenge of preparing future nurses with the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality and safety of the health care systems in which they work. Critical thinking is the application of purposeful, informed, and outcome-focused care. The ability to use best evidence and practice when making care-related decisions is evidence-based practice.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Patient-centered care MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 3. A nurse wishes to participate in an activity that will influence health outcomes. What action

by the nurse best meets this objective? a. Creating a transportation system for health care appointments b. Lobbying with a national organization for health care policy c. Organizing a food pantry in an impoverished community d. Running for election to the county public health board ANS: B

All options are good choices for an altruistic nurse wishing to influence health outcomes; however, being involved in policy creation and health care reform is an activity specifically recognized to improve health outcomes. This action will also affect a wider population than the more local options.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Health outcomes MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 4. What factor best predicts a nurse’s willingness to employ critical thinking? a. Caring b. Knowledge c. Presence d. Skills ANS: A

All attributes are important in nursing, however; the nurse’s willingness to think critically is predicted by caring behaviors, self-reflection, and insight.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Critical thinking MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 5. To demonstrate clinical reasoning skills, what action does the nurse take? a. Collaborating with co-workers to buddy up for lunch breaks b. Delegating frequent vital signs on a new postoperative patient c. Documenting a complete history and physical on an admission d. Requesting the provider order medication for a client with high potassium ANS: D

The components of clinical reasoning include assessing, analyzing, planning, implementing, and evaluating. This nurse shows the ability to analyze by interpreting the meaning of the lab value, to plan by anticipating the consequences of the lab value, and to implement by taking action.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Implementation KEY: Clinical judgment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 6. The new nurse asks the preceptor how context affects clinical judgment. What response by the

preceptor is best? a. “Context considers the whole of the patient’s story and circumstances.” b. “It shouldn’t, only nursing knowledge would affect clinical judgment.” c. “Outside influences such as environment in which you provide care, influence your decisions.” d. “The context of the situation provides an extra layer of complexity to consider.”

ANS: C

The context of a situation considers and supports clinical judgment. The factors within this layer—such as environment, time pressure, availability or content of electronic health records, resources, and individual nursing knowledge—have a direct impact on clinical judgment. The other two options are too vague to provide appropriate information.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Clinical judgment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 7. Once the nurse has considered all possible collaborative and client problems, what action does

the nurse take next? a. Act on the observed cues. b. Determine desired outcomes. c. Generate solutions. d. Prioritize the hypotheses.

ANS: D

Analyzing cues lead to a list of potential hypotheses. The nurse prioritizes them, determines the desired outcomes, generates solutions, and acts. This is part of the six-step clinical judgment model.

DIF: Understanding TOP: Integrated Process: Nursing Process: Diagnosis KEY: Clinical judgment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 8. A nurse working in a medical home would do which of the following as part of the job? a. Advocate with insurance companies. b. Coordinate interprofessional care. c. Hold monthly team meetings. d. Provide out-of-network specialty referrals.

ANS: B

The medical home concept came into being to decrease the fragmentation of care. On a daily basis, this nurse would expect to coordinate with the interprofessional care team. Advocating with insurance companies would not be a daily function. Monthly team meetings may or may not be needed. Out of network referrals would not be needed as the interprofessional team strives to provide comprehensive care.

DIF: Remembering TOP: Integrated Process: Nursing Process: Implementation KEY: Medical home MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 9. A nurse is confused on why systems thinking is important since working on the unit involves

caring for a few specific clients. What explanation by the nurse manager is best? a. “It’s a good way to conduct root-cause analysis.” b. “It is important for quality improvement and safety.” c. “Systems thinking helps you see the bigger picture.” d. “You may enter management 1 day and need to know this.”

ANS: B

A systems thinking approach to care reinforces the nurse’s role in safety and quality improvement while expanding clinical judgment to include the patient’s place within the greater health care system in the context of care decisions. Root-cause analyses would be a small portion of systems thinking. It does give the nurse a big-picture view, but this answer is vague. The nurse may or may not ever join management.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Systems thinking MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. The expert nurse understands that critical thinking requires which elements to be present?

(Select all that apply.) a. Based on logic, creativity, and intuition b. Driven by needs c. Focused on safety and quality d. Grounded in a specific theory e. Guided by standards f. Requires forming options about evidence ANS: A, B, C, E

Critical thinking must be based on logic, creativity, and intuition; driven by patient, family, or community needs; focused on safety and quality; guided by standards, policies, ethics, and laws; based on principles of nursing process, problem-solving, and the scientific method (requires forming opinions and making decisions based on evidence); centered on identification of the key problems, issues, and risks; and grounded in strategies that make the most of human potential. It is not dependent on using a specific theory.

DIF: Understanding TOP: Integrated Process: Nursing Process: Planning KEY: Critical thinking MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 2. The nurse manager is conducting an annual evaluation of a staff nurse and is appraising the

nurse’s clinical reasoning. What nurse actions does the manager observe to help form this judgment? (Select all that apply.) a. Anticipating consequences of actions b. Delegating appropriately c. Interpreting data d. Noticing cues e. Setting priorities ANS: A, C, D, E

The phases of clinical reasoning include assessing (noticing cues), analyzing (interpreting data), planning (anticipating consequences and setting priorities), implementing, and evaluating. Delegating appropriately is not included in this model.

DIF: Applying TOP: Integrated Process: Nursing Process: Evaluation KEY: Clinical reasoning MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 3. According to the WHO, what does primary care involve? (Select all that apply.) a. Empowered people and communities b. Essential public functions c. Multisectoral policy and action d. Primary care e. Priority consideration of chronic diseases

f.

Elimination of chronic diseases

ANS: A, B, C, D

According to the WHO, primary care involves three main areas: empowered people and communities, primary care and essential public functions, and multisectoral policy and action.

Primary care focuses on both prevention and management of chronic disease.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Primary care, Systems thinking MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 4. A nurse wishes to work in a community-based practice setting. Which areas would this nurse

explore for employment? (Select all that apply.) a. Hospice facility b. “Minute clinic” c. Mobile mammography unit d. Small community hospital e. Telehealth f. Home health care ANS: A, B, C, E, F

The multiple avenues providing community-based care include hospice, “minute” or retail clinics, mobile screening and diagnostic services, telehealth, private medical practices, outpatient services, freestanding points of care, home health care, long-term ambulatory care, public health, and free clinics. Inpatient services in a hospital are not considered primary care sites.

DIF: Remembering TOP: Integrated Process: NA KEY: Community-based care MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care

Chapter 03: Overview of Health Concepts for Medical-Surgical Nursing Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse is caring for a client who is acidotic. The nurse asks the charge nurse why the client is

breathing rapidly. What response by the charge nurse is best? a. Anxiety is causing the client to breathe rapidly. b. The client is trying to get rid of excess body acids. c. The rapid respirations cause buildup of bicarbonate. d. An increased respiratory rate is due to increased metabolism.

ANS: B

The client is acidotic, and the respiratory system is attempting to compensate by “blowing off” excess acid in the form of carbon dioxide. The increased respiratory rate is not due to anxiety or increased metabolism. An increased respiratory rate does not cause a buildup of bicarbonate.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Acid-base balance MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A client had a recent thromboembolism and must resume work which requires frequent car

and plane travel. What self-care measure does the nurse teach to reduce the risk of impaired clotting in this client? a. Get up and walk around at least every 2 hours while traveling. b. Use a soft toothbrush and an electric razor for safety. c. Be sure to sit with the legs elevated as much as possible. d. Increase fiber in the diet so as not to strain to move the bowels.

ANS: A

Clients who are at risk of increased clotting (as evidenced by prior thromboembolic event) can take several measures to reduce their risk of further problems. One measure is to get up and walk frequently when sitting for a long period of time. Using a soft toothbrush and an electric razor and needing to prevent constipation would be important for a client at risk of bleeding.

Elevating the legs is not as beneficial as ambulating.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Clotting, Health teaching MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. A nurse is caring for four clients. Which client does the nurse assess first for impaired

cognition? a. A 28-year-old client 2 days post-open cholecystectomy b. An 88-year-old client 3 days post-hemorrhagic stroke c. A 32-year-old client with a 20–pack-year history of smoking d. A 42-year-old client with a serum sodium of 134 mEq/L (134 mmol/L) ANS: B

There are many risk factors for impaired cognition including advanced age and diseases and disorders that affect the brain. The 88-year-old client who is recovering from a stroke has two such risk factors and is at highest risk for impaired cognition. The nurse assesses this client first. The other clients have a much lower risk of developing impaired cognition.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Cognition, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 4. The assistive personnel (AP) reports to the registered nurse that a postoperative client has a

pulse of 132 beats/min and a blood pressure of 168/90 mm Hg. What response by the nurse is most appropriate? a. Ask the AP to repeat the client’s vital signs in 15 minutes. b. Assess the client for pain. c. Ask the client if something is bothersome. d. Instruct the AP to reposition the client.

ANS: B

The “fight-or-flight” syndrome can occur from sympathetic nervous stimulation due to acute pain. Symptoms can include nausea, vomiting, diaphoresis, tachycardia, tachypnea, hypertension, and dilated pupils. Since this client is postoperative, it is reasonable to believe that he or she might be in pain. The nurse first assesses for pain or discomfort and treats it. If the client is not in pain, the nurse would conduct further assessments to determine the cause of the abnormal vital signs.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Pain, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. A client has urinary incontinence. Which assessment finding indicates that outcomes for a

priority nursing diagnosis have been met? a. Client reports satisfaction with undergarments for incontinence. b. Client reports drinking 8 to 9 glasses of water each day. c. Skin in perineal area is intact without redness on inspection. d. Family states that client is more active and socializes more.

ANS: C

Urinary incontinence can lead to skin breakdown and possibility of infection. Skin that is intact without redness shows that a major goal for this client has been met. Becoming more social is a positive finding as many adults with incontinence limit their social activities, but this psychosocial outcome is not the priority over a physical outcome. Being satisfied with undergarments is also not the priority. Drinking adequate water can sometimes help with incontinence and is important for general health, but is not directly related to an important goal for this client.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Tissue integrity, Incontinence MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

6. The registered nurse asks the nursing assistant why a cardiac client’s morning weight has not

yet been done. The nursing assistant says, “I’ll get to it, what’s the big deal?” When deciding how to respond, the nurse considers what information about weight? a. Decisions on treatment often depend on the daily weight. b. The nursing assistant needs to ensure that tasks are done on time. c. Weight is the most accurate noninvasive indicator of fluid status. d. A change in weight may indicate the need to change IV fluids.

ANS: C

Weight is the best (noninvasive) indicator of fluid status. Primary health care providers may base treatment decisions on weight, because the weight reflects fluid balance, but this answer does not explain why. IV fluid rates or solutions may change for the same reason. The nursing assistant would perform tasks on a timely basis, but this is not related to information about weight.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Fluid and electrolytes MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 7. The nurse in the emergency department (ED) is caring for four clients. Which client does the

nurse assess for gas exchange abnormalities first? a. Involved in motor vehicle crash, has broken femur. b. Brought in unconscious by roommate after opioid overdose. c. Asthmatic client being discharged after bronchodilator therapy. d. History of COPD, presents to ED after being bitten by a dog.

ANS: B

Opioid medications can cause respiratory depression, so this client is most at risk for gas exchange problems. Diminished respirations will allow a buildup of carbon dioxide in the blood. The clients with asthma and COPD have the potential for gas exchange problems but this is not indicated in answer option as he or she is being discharged. The client with a broken femur does not have information suggesting gas exchange problems.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Gas exchange, Risk factors MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 8. The nurse caring for a client with malnutrition assesses which laboratory value as the

priority? a. Albumin b. Prealbumin c. Prothrombin time d. Serum sodium ANS: B

Both albumin and prealbumin are indicators for nutrition. However, prealbumin changes more rapidly with decreased nutrition, so it is the better test. Prothrombin time and serum sodium are not directly related to nutritional status.

DIF: Remembering KEY: Nutrition, Laboratory values

TOP: Integrated Process: Nursing Process: Assessment

9. A nurse is planning primary prevention measures for community-dwelling adults to prevent

visual impairment. What action by the nurse will best meet this objective? a. Provide glaucoma screening. b. Assess visual acuity. c. Teach clients about instilling eyedrops. d. Offer a healthy lifestyle class.

ANS: D

Primary prevention activities are those designed to actually prevent the onset of a disease or health problem. Secondary prevention focuses on screening and early diagnosis/detection.

Tertiary measures are those that offer treatment and rehabilitation. Encouraging a healthy lifestyle through classes may help prevent diabetes, a common cause of visual impairment, and is a primary prevention measure. Assessing for glaucoma and visual acuity is a secondary prevention measure. Teaching clients how to instill eyedrops is tertiary.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning KEY: Sensory perception, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 10. The nurse tells the staff development nurse he/she is very uncomfortable discussing sexuality

with clients, especially those who are older. What suggestion by the staff development nurse is most appropriate? a. “Find a trusted friend and role play.” b. “Don’t worry it will get easier.” c. “A sexual assessment is usually not needed.” d. “It’s hard for me to do, too.”

ANS: A

Discussing sexuality and sex is difficult for most people. Since it is important to be able to assess this aspect of people’s lives, the nurse needs to become comfortable. Role-playing with a trusted friend will build confidence and comfort. Saying that it will get easier and that it is hard for the staff development nurse too does not give the nurse any ideas for improvement.

Sexuality is important to assess.

DIF: Applying TOP: Integrated Process: Caring KEY: Sexuality, Nursing assessment MSC: Client Needs Category: Psychosocial Integrity MULTIPLE RESPONSE 1. A nurse is planning a community education event-related to impaired cellular regulation.

What teaching topics would the nurse include in this event? (Select all that apply.) a. Ways to minimize exposure to sunlight b. Resources available for smoking cessation c. Strategies to remain hydrated during hot weather d. Use of indoor tanning beds instead of sunbathing e. Creative cooking techniques to increase dietary fiber f. How to determine sodium content in food?

ANS: A, B, E

Disrupted cellular regulation can lead to both benign and malignant tumors (cancer). Ways to minimize the risk of developing cancer include decreasing exposure to sunlight, smoking cessation, and increasing dietary fiber. Tanning beds do not reduce the risk of cancer as opposed to sunbathing. While staying hydrated is a good health measure, it is not related to cellular regulation. Maintaining a normal intake of sodium is also not related to cellular regulation.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning KEY: Cellular regulation, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 2. A nurse is caring for clients on an inclient surgical unit. Which clients does the nurse identify

as having a risk for impaired immunity? (Select all that apply.) a. 86 years old b. Has type 2 diabetes c. Taking prednisone d. Has many allergies e. Drinks a beer a day f. Low socioeconomic status ANS: A, B, C, F

Risk factors for impaired immunity include but are not limited to: older adults (diminished immunity due to normal aging changes), low socioeconomic groups (inability to obtain proper immunizations), nonimmunized adults, adults with chronic illnesses that weaken the immune system, adults taking chronic drug therapy such as corticosteroids and chemotherapeutic agents, adults experiencing substance use disorder, adults who do not practice a healthy lifestyle, and adults who have a genetic risk for decreased or excessive immunity. Allergies and one beer a day are not risk factors.

DIF: Remembering TOP: Integrated Process: Nursing Process: Planning KEY: Immunity MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 3. The nurse is caring for a client with severely impaired mobility. What actions does the nurse

place on the care plan to address potential complications? (Select all that apply.) a. Perform a depression screen once a day. b. Consult physical therapy for range of motion. c. Increase fiber in the client’s diet. d. Decrease fluid intake. e. Allow client to stay in a position of comfort.

ANS: A, B, C

There are many complications of immobility including depression, pressure injuries, constipation, urinary calculi, and muscle atrophy. The nurse would address these by assessing for depression, consulting physical therapy for activities such as range of motion the client can do, and increase fiber so the client does not become constipated. Decreasing fluid intake would increase the possibility of calculi and allowing the client to stay in one position would increase the risk of pressure injuries.

DIF: Applying KEY: Mobility

TOP: Integrated Process: Nursing Process: Implementation

MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 4. A client has impaired tissue integrity and a nonhealing wound. The nurse has taught the client

about diet changes to improve wound healing. What diet selections does the nurse evaluate as good understanding by the client? (Select all that apply.) a. Chicken breast b. Orange juice c. Boost supplement d. Spinach salad e. Cantaloupe f. Whole wheat bread ANS: A, B, C, D

Protein and vitamin C are important for wound healing. Foods high in protein include meat sources such as chicken and nutritional supplements. Foods high in vitamin C include orange juice and spinach. Cantaloupe is a good source of vitamin A. Whole wheat bread, while healthy, does not contribute directly to wound healing.

DIF: Remembering TOP: Integrated Process: Nursing Process: Evaluation KEY: Nutrition MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

Chapter 04: Common Health Problems of Older Adults Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse learns that the fastest growing subset of the older population is which group? a. Elite old b. Middle old c. Old old d. Young old ANS: C

The old old is the fastest growing subset of the older population. This is the group comprising those 85 to 99 years of age. The young old are between 65 and 74 years of age; the middle old are between 75 and 84 years of age; and the elite old are over 100 years of age.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Older adults MSC: Client Needs Category: Health Promotion and Maintenance 2. A nurse working with older adults in the community plans programming to improve morale

and emotional health in this population. What activity would best meet this goal? a. Exercise program to improve physical function b. Financial planning seminar series for older adults c. Social events such as dances and group dinners d. Workshop on prevention from becoming an abuse victim ANS: A

All activities would be beneficial for the older population in the community. However, failure in performing one’s own activities of daily living and participating in society has direct effects on morale and life satisfaction. Those who lose the ability to function independently often feel worthless and empty. An exercise program designed to maintain and/or improve physical functioning would best address this need.

DIF: Applying KEY: Older adult

TOP: Integrated Process: Nursing Process: Planning MSC: Client Needs Category: Psychosocial Integrity

3. A nurse caring for an older client on a medical-surgical unit notices the client reports frequent

constipation and only wants to eat softer foods such as rice, bread, and puddings. What assessment would the nurse perform first? a. Auscultate bowel sounds. b. Check skin turgor. c. Perform an oral assessment. d. Weigh the client.

ANS: C

Poorly fitting dentures and other dental problems are often manifested by a preference for soft foods and constipation from the lack of fiber. The nurse would perform an oral assessment to determine if these problems exist. The other assessments are important, but will not yield information specific to the client’s food preferences as they relate to constipation.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Older adult, Nutrition MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 4. A nurse caring for an older adult has provided education on high-fiber foods. Which menu

selection by the client demonstrates a need for further review? a. Barley soup b. Black beans c. White rice d. Whole-wheat bread ANS: C

Older adults need 35 to 50 g of fiber a day. White rice is low in fiber. Foods high in fiber include barley, beans, and whole-wheat products.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Older adult, Nutrition MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. A nurse is working with an older client admitted with mild dehydration. What teaching does

the nurse provide to best address this issue? a. “Cut some sodium out of your diet.” b. “Dehydration can cause incontinence.” c. “Have something to drink every 1 to 2 hours.” d. “Take your diuretic in the morning.”

ANS: C

Older adults often lose their sense of thirst. Plus older adults have less body water than younger people. Since they should drink 1 to 2 L of water a day, the best remedy is to have the older adult drink something each hour or two, whether or not he or she is thirsty. Cutting “some” sodium from the diet will not address this issue and is vague. Although dehydration can cause incontinence from the irritation of concentrated urine, this information will not help prevent the problem of dehydration. Instructing the client to take a diuretic in the morning rather than in the evening also will not directly address this issue.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Older adult, Fluid and electrolyte balance MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. A home health care nurse is planning an exercise program with an older adult who lives at

home independently but whose mobility issues prevent much activity outside the home.

Which exercise regimen would be most beneficial to this adult? a. Building strength and flexibility b. Improving exercise endurance c. Increasing aerobic capacity d. Providing personal training ANS: A

This older adult is mostly homebound. Exercise regimens for homebound clients include things to increase functional fitness and ability for activities of daily living. Strength and flexibility will help the client to be able to maintain independence longer. The other plans are good but will not specifically maintain the client’s functional abilities.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning KEY: Older adult, Functional ability MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 7. An older adult recently retired and reports “being depressed and lonely.” What information

would the nurse assess as a priority? a. History of previous depression b. Previous stressful events c. Role of work in the adult’s life d. Usual leisure time activities ANS: C

Establishing and maintaining relationships with others throughout life are especially important to the older person’s happiness. When people retire, they may lose much of their social network, leading them to feeling depressed and lonely. This loss from a sudden change in lifestyle can easily lead to depression. The nurse would first assess the role that work played in the client’s life. The other factors can be assessed as well, but this circumstance is commonly seen in the older population.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Older adult, Depression MSC: Client Needs Category: Psychosocial Integrity 8. A nurse is assessing coping in older women in a support group for recent widows. Which

statement by a participant best indicates potential for successful coping? a. “I have had the same best friend for decades.” b. “I think I am coping very well on my own.” c. “My kids come to see me every weekend.” d. “Oh, I have lots of friends at the senior center.”

ANS: A

Friendship and support enhance coping. The quality of the relationship is what is most important, however. People who have close, intimate, stable relationships with others in whom they confide are more likely to cope with crisis. The person who is “coping well on my own” may actually need resources to help with this transition. Having children visit is important but not as important as intimate, long-term friendships. “Friends at the senior center” may refer to good acquaintances and not real friends.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Older adult, Coping MSC: Client Needs Category: Psychosocial Integrity 9. A home health care nurse has conducted a home safety assessment for an older adult. There

are five concrete steps leading out from the front door. Which intervention would be most helpful in keeping the older adult safe on the steps? a. Have the client use a walker or cane on the steps. b. Teach the client to hold the handrail when using the steps c. Instruct the client to use the garage door instead. d. Tell the client to use a two-footed gait on the steps.

ANS: B

As a person ages, he or she may experience a decreased sense of touch. The older adult may not be aware of where his or her foot is on the step. Combined with diminished visual acuity, this can create a fall hazard. Holding the handrail would help keep the person safer. If the client does not need an assistive device, he or she would not use a cane or walker just on stairs. Using an alternative door may be necessary but does not address making the front steps safer. A two-footed gait may not help if the client is unaware of where the foot is on the step.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Older adult, Safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 10. An older adult is brought to the emergency department because of sudden onset of confusion.

After the client is stabilized and comfortable, what assessment by the nurse is most important? a. Assess for orthostatic hypotension. b. Determine if there are new medications. c. Evaluate the client for gait abnormalities. d. Perform a delirium screening test.

ANS: B

Medication side effects and adverse effects are common in the older population. Something as simple as a new antibiotic can cause confusion and memory loss. The nurse would determine if the client is taking any new medications. Assessments for orthostatic hypotension, gait abnormalities, and delirium may be important once more is known about the client’s condition.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Older adult, Medication safety MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 11. An older adult client takes medication three times a day and becomes confused about which

medication should be taken at which time. The client refuses to use a pill sorter with slots for different times, saying “Those are for old people.” What action by the nurse would be most helpful? a. Arrange medications by time in a drawer. b. Encourage the client to use easy-open tops. c. Put color-coded stickers on the bottle caps. d. Write a list of when to take each medication.

ANS: C

Color-coded stickers are a fast, easy-to-remember system. One color is for morning meds, one for evening meds, and the third color is for nighttime meds. Arranging medications by time in a drawer might be helpful if the person doesn’t accidentally put them back in the wrong spot.

Easy-open tops are not related. Writing a list might be helpful, but not if it gets misplaced.

With stickers on the medication bottles themselves, the reminder is always with the medication.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Older adult, Medication safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

12. An older adult client is in the hospital. The client is ambulatory and independent. What

intervention by the nurse would be most helpful in preventing falls in this client? a. Keep the light on in the bathroom at night. b. Order a bedside commode for the client. c. Put the client on a toileting schedule. d. Use side rails to keep the client in bed.

ANS: A

Although this older adult is independent and ambulatory, being hospitalized can create confusion. Getting up in a dark, unfamiliar environment can contribute to falls. Keeping the light on in the bathroom will help reduce the likelihood of falling. The client does not need a commode or a toileting schedule. Side rails used to keep the client in bed are considered restraints and would not be used in that fashion.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Older adult, Fall prevention MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 13. An older client had hip replacement surgery and the surgeon prescribed morphine sulfate for

pain. The client is allergic to morphine and reports pain and muscle spasms. When the nurse calls the surgeon, which medication would he or she suggest in place of the morphine? a. Cyclobenzaprine b. Hydromorphone hydrochloride c. Ketorolac d. Meperidine ANS: B

Cyclobenzaprine (used for muscle spasms), ketorolac, and meperidine (both used for pain) are all on the Beers list of potentially inappropriate medications for use in older adults and would not be suggested. The nurse would suggest hydromorphone hydrochloride.

DIF: Remembering TOP: Integrated Process: Communication and Documentation KEY: Older adult, Medication safety MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 14. A nurse admits an older adult from a home environment. The client lives with an adult son

and daughter-in-law. The client has urine burns on the skin, no dentures, and several pressure injuries. What action by the nurse is most appropriate? a. Ask the family how these problems occurred. b. Call the police department and file a report. c. Notify Adult Protective Services. d. Report the findings as per agency policy.

ANS: D

These findings are suspicious for abuse. Health care providers are mandatory reporters for suspected abuse. The nurse would notify social work, case management, or whomever is designated in facility policies. That person can then assess the situation further. If the police need to be notified, that is the person who will notify them. Adult Protective Services is notified in the community setting.

DIF: Applying

TOP: Integrated Process: Communication and Documentation

KEY: Older adult, Abuse MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 15. A nurse caring for an older client in the hospital is concerned the client is not competent to

give consent for upcoming surgery. What action by the nurse is best? a. Call Adult Protective Services. b. Discuss concerns with the health care team. c. Do not allow the client to sign the consent. d. Have the client’s family sign the consent.

ANS: B

In this situation, each facility will have a policy designed for assessing competence. The nurse would bring these concerns to an interprofessional care team meeting. There may be physiologic reasons for the client to be temporarily too confused or incompetent to give consent. If an acute condition is ruled out, the staff would follow the legal procedure and policies in their facility and state for determining competence. The key is to bring the concerns forward. Calling Adult Protective Services is not appropriate at this time. Signing the consent would wait until competence is determined unless it is an emergency, in which case the next of kin can sign if there are grave doubts as to the client’s ability to provide consent. Simply not allowing the client to sign does not address the problem.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Older adult, Autonomy MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. A nurse working in an Acute Care of the Elderly unit learns that frailty in the older population

includes which components? (Select all that apply.) a. Dementia b. Exhaustion c. Slowed physical activity d. Weakness e. Weight gain f. Frequent illness ANS: B, C, D

Frailty is a syndrome consisting of unintentional weight loss, slowed physical activity and exhaustion, and weakness. Weight gain and dementia are not part of this syndrome. Frequent illness could occur due to frailty, but is also not part of the syndrome.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Older adult, Frailty MSC: Client Needs Category: Health Promotion and Maintenance 2. A home health care nurse assesses an older adult for the intake of nutrients needed in larger

amounts than in younger adults. Which foods found in an older adult’s kitchen might indicate an adequate intake of these nutrients? (Select all that apply.) a. 1% milk b. Carrots c. Lean ground beef

d. Oranges e. Vitamin D supplements f. Cheese sticks ANS: A, B, D, E

Older adults need increased amounts of calcium; vitamins A, C, and D; and fiber. Milk and cheese have calcium; carrots have vitamin A; vitamin D supplement has vitamin D; and oranges have vitamin C. Lean ground beef is healthier than more fatty cuts, but does not contain these needed nutrients.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Older adults, Nutrition MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 3. A nurse working with older adults assesses them for common potential adverse medication

effects. For what does the nurse assess? (Select all that apply.) a. Constipation b. Dehydration c. Mania d. Urinary incontinence e. Weakness f. Anorexia ANS: A, B, E, F

Common adverse medication effects include constipation/impaction, dehydration, anorexia, and weakness. Mania and incontinence are not among the common adverse effects, although urinary retention is.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Older adult, Adverse medication effects MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. A nurse manager institutes the Fulmer SPICES Framework as part of the routine assessment

of older adults in the hospital. The nursing staff assesses for which factors? (Select all that apply.) a. Confusion b. Evidence of abuse c. Incontinence d. Problems with behavior e. Sleep disorders ANS: A, C, E

SPICES stands for sleep disorders, problems with eating or feeding, incontinence, confusion, and evidence of falls.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Older adult, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 5. A visiting nurse is in the home of an older adult and notes a 7-lb weight loss since last

month’s visit. What actions would the nurse perform first? (Select all that apply.) a. Assess the client’s ability to drive or transportation alternatives.

b. c. d. e.

Determine if the client has dentures that fit appropriately.

Encourage the client to continue the current exercise plan.

Have the client complete a 3-day diet recall diary.

Teach the client about proper nutrition in the older population.

ANS: A, B, D

Assessment is the first step of the nursing process and would be completed prior to intervening. Asking about transportation to get food, dentures, and normal food patterns would be part of an appropriate assessment for the client. There is no information in the question about the older adult needing to lose weight, so encouraging him or her to continue the current exercise regimen is premature and may not be appropriate. Teaching about proper nutrition is a good idea, but teaching needs to be tailored to the client’s needs, which the nurse does not yet know.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Older adult, Nutrition MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. A hospitalized older adult has been assessed at high risk for skin breakdown. Which actions

does the registered nurse (RN) delegate to the assistive personnel (AP)? (Select all that apply.) a. Assess skin redness when turning. b. Document Braden Scale results. c. Keep the client’s skin dry. d. Obtain a pressure-relieving mattress. e. Turn the client every 2 hours.

ANS: C, D, E

The nurses’ aide or AP can assist in keeping the client’s skin dry, order a special mattress on direction of the RN, and turn the client on a schedule. Assessing the skin is a nursing responsibility, although the aide would be directed to report any redness noticed.

Documenting the Braden Scale results is the RN’s responsibility as the RN is the one who performs that assessment.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Older adult, Tissue integrity MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 7. A nurse admits an older adult to the hospital who lives at home with family. The nurse

assesses that the client is malnourished. What actions by the nurse are best? (Select all that apply.) a. Contact Adult Protective Services or hospital social work. b. Request the primary health care provider prescribes tube feedings. c. Perform and document results of a Braden Scale assessment. d. Request a dietary consultation from the health care provider. e. Suggest a high-protein oral supplement between meals. f. Assess the client’s own teeth or the dentures for proper fit.

ANS: C, D, E, F

Malnutrition in the older population is multifactorial and has several potential adverse outcomes. Appropriate actions by the nurse include assessing the client’s risk for skin breakdown with the Braden Scale, requesting a consultation with a dietitian, suggesting a high-protein meal supplement, and assessing the client’s dentures or own teeth. There is no evidence that the client is being abused or needs a feeding tube at this time.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Older adult, Nutrition MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care

Chapter 05: Assessment and Care of Patients With Pain Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A new nurse asks the precepting nurse “What is the best way to assess a client’s pain?” Which

response by the nurse is best? a. Numeric pain scale b. Behavioral assessment c. Client’s self-report d. Objective observation ANS: C

Many ways to measure pain are in use, including numeric pain scales, behavioral assessments, and other objective observations. However, the most accurate way to assess pain is to get a self-report from the client.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Pain, Nursing assessment MSC: Client Needs Category: Health Promotion and Maintenance 2. A new nurse reports to the nurse preceptor that a client requested pain medication, and when

the nurse brought it, the client was sound asleep. The nurse states the client cannot possibly sleep with the severe pain the client described. Which response by the experienced nurse is best? a. “Being able to sleep doesn’t mean pain doesn’t exist.” b. “Have you ever experienced any type of pain?” c. “The client should be assessed for drug addiction.” d. “You’re right; I would put the medication back.”

ANS: A

A client’s description is the most accurate assessment of pain. The nurse would believe the client and provide pain relief. Physiologic changes due to pain vary from client to client, and assessments of them would not supersede the client’s descriptions, especially if the pain is chronic in nature. Asking if the new nurse has had pain is judgmental and flippant and does not provide useful information. This amount of information does not warrant an assessment for drug addiction. Putting the medication back and ignoring the client’s report of pain serves no useful purpose and is unethical.

DIF: Understanding TOP: Integrated Process: Communication and Documentation KEY: Pain, Nursing assessment MSC: Client Needs Category: Health Promotion and Maintenance 3. The nurse in the outpatient surgery clinic is discussing an upcoming surgical procedure with a

client. Which information provided by the nurse is most appropriate for the client’s long-term outcome? a. “At least you know that the pain after surgery will diminish quickly.” b. “Discuss acceptable pain control after your operation with the surgeon.” c. “Opioids often cause nausea but you won’t have to take them for long.” d. “The nursing staff will give you pain medication when you ask them for it.”

ANS: B

The best outcome after a surgical procedure is timely and satisfactory pain control, which diminishes the likelihood of chronic pain afterward. The nurse suggests that the client advocate for himself or herself and discuss acceptable pain control with the surgeon. Stating that pain after surgery is usually short lived does not provide the client with options to have personalized pain control. To prevent or reduce nausea and other side effects from opioids, a multimodal pain approach is desired. For acute pain after surgery, giving pain medications around the clock instead of waiting until the client requests it is a better approach.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Pain, Acute pain MSC: Client Needs Category: Health Promotion and Maintenance 4. A nurse is assessing pain on a confused older client who has difficulty with verbal expression.

Which pain assessment tool would the nurse choose for this assessment? a. Numeric rating scale b. Verbal Descriptor Scale c. FACES Pain Scale-Revised d. Wong-Baker FACES Pain Scale ANS: C

All are valid pain rating scales; however, some research has shown that the FACES Pain Scale-Revised is preferred by both cognitively intact and cognitively impaired adults. A confused client with difficulty speaking would not be a good candidate for the numeric rating scale or the verbal descriptor scale. The cartoon images on the Wong-Baker FACES Pain Scale may not be appropriate for an adult client.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Pain, Nursing assessment MSC: Client Needs Category: Health Promotion and Maintenance 5. The nurse is assessing a client’s pain and has elicited information on the location, quality,

intensity, effect on functioning, aggravating and relieving factors, and onset and duration.

Which question by the nurse would be best to ask the client for completing a comprehensive pain assessment? a. “Are you worried about addiction to pain pills?” b. “Do you attach any spiritual meaning to pain?” c. “How high would you say your pain tolerance is?” d. “What pain rating would be acceptable to you?”

ANS: D

A comprehensive pain assessment includes the items listed in the question plus the client’s opinion on a comfort-function outcome, such as what pain rating would be acceptable to him or her. Asking about addiction is not warranted in an initial pain assessment. Asking about spiritual meanings for pain may give the nurse important information, but getting the basics first is more important. Asking about pain tolerance may give the client the idea that pain tolerance is being judged.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Pain, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

6. A nurse is assessing pain in an older adult. Which action by the nurse is best? a. Ask only “yes-or-no” questions so the client doesn’t get too tired. b. Give the client a picture of the pain scale and come back later. c. Question the client about new pain only, not normal pain from aging. d. Sit down, ask one question at a time, and allow the client to answer.

ANS: D

Some older clients do not report pain because they think it is a normal part of aging or because they do not want to be a bother. Sitting down conveys time, interest, and availability.

Ask only one question at a time and allow the client enough time to answer it. Yes-or-no questions are an example of poor communication technique. Giving the client a pain scale, and then leaving, might give the impression that the nurse does not have time for the client.

Also, the client may not know how to use it. There is no normal pain from aging.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Pain, Nursing assessment MSC: Client Needs Category: Psychosocial Integrity 7. The nurse receives a hand-off report. One client is described as a drug seeker who is obsessed

with even tiny changes in physical condition and is “on the light constantly” asking for more pain medication. When assessing this client’s pain, which statement or question by the nurse is most appropriate? a. “Help me understand how pain is affecting you right now.” b. “I wish I could do more; is there anything I can get for you?” c. “You cannot have more pain medication for 3 hours.” d. “Why do you think the medication is not helping your pain?”

ANS: A

A client who is preoccupied with physical symptoms and is “demanding” may have some psychosocial impact from the pain that is not being addressed. The nurse is providing the client the chance to explain the emotional effects of pain in addition to the physical ones.

Saying the nurse wishes he or she could do more is very empathetic, but this response does not attempt to learn more about the pain. Simply telling the client when the next medication is due also does not help the nurse understand the client’s situation. “Why” questions are probing and often make clients defensive, plus the client may not have an answer for this question.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Pain, Nursing assessment MSC: Client Needs Category: Psychosocial Integrity 8. A nurse on the medical-surgical unit has received a hand-off report. Which client would the

nurse see first? a. Client being discharged later on a complicated analgesia regimen. b. Client with new-onset abdominal pain, rated as an 8 on a 0-10 scale. c. Postoperative client who received oral opioid analgesia 45 minutes ago. d. Client who has returned from physical therapy and is resting in the recliner.

ANS: B

Acute pain often serves as a physiologic warning signal that something is wrong. The client with new-onset abdominal pain needs to be seen first. The postoperative client needs at least 30 minutes for the oral medication to become effective and would be seen shortly to assess for effectiveness. The client going home requires teaching, which would be done after the first two clients have been seen and cared for, as this teaching will take some time. The client resting comfortably can be checked on quickly before spending time teaching the client who is going home.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Acute pain, Nursing assessment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 9. A nurse uses the Checklist of Nonverbal Pain Indicators to assess pain in a nonverbal client

with advanced dementia but no other medical history except well-controlled hypertension and high cholesterol. The client scores a zero. Which action by the nurse is best? a. Assess physiologic indicators and vital signs. b. Do not give pain medication as no pain is indicated. c. Document the findings and continue to monitor. d. Try a small dose of analgesic medication for pain.

ANS: A

Assessing pain in a nonverbal client is difficult despite the use of a scale specifically designed for this population. The hierarchy for assessing pain consists of (1) obtaining a verbal report, which is not possible in this client, (2) consider conditions that might reasonably be painful, (3) observe behaviors, (4) evaluate physiologic indicators, and (5) attempt an analgesic trial.

The client is not known to have any conditions that reasonably would cause pain. The nurse would next look at physiologic indicators of pain and vital signs for clues to the presence of pain. Even a low score on this index does not mean that the client does not have pain; he or she may be holding very still to prevent more pain. Documenting pain is important but not the most important action in this case until the nurse has conducted a full assessment. The nurse can try a small dose of analgesia, but without having indices to monitor, it will be difficult to assess for effectiveness.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Pain, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 10. A nurse asks why several clients are getting more than one type of pain medication instead of

very high doses of one medication. Which response by the charge nurse is best? a. “A multimodal approach is the preferred method of control.” b. “Clients are consumers and they demand lots of pain medicine.” c. “We are all much more liberal with pain medications now.” d. “Pain is so complex it takes different approaches to control it.”

ANS: D

Pain is a complex phenomenon and often responds best to a regimen that uses different types of analgesia. This is called a multimodal approach. Using this terminology, however, may not be clear to the newer nurse if the terminology is not understood. Primary health care providers and nurses may be more liberal with different types of pain medications, but that is not the best reason for this approach, especially in light of the opioid epidemic. Saying that clients are consumers who demand medications sounds as if the charge nurse is discounting their pain experiences.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Pain, Pharmacologic pain management MSC: Client Needs Category: Physiological Adaptation: Pharmacological and Parenteral Therapies 11. A client who had surgery has extreme postoperative pain that is worsened when trying to

participate in physical therapy. Which intervention for pain management does the nurse include in the client’s care plan? a. As-needed pain medication after therapy b. Pain medications prior to therapy only c. Patient-controlled analgesia with a basal rate d. Round-the-clock analgesia with PRN analgesics ANS: D

Severe pain related to surgery or tissue trauma is best managed with round-the-clock dosing.

Breakthrough pain associated with specific procedures is managed with additional medication.

An as-needed regimen will not control postoperative pain. A patient-controlled analgesia pump might be a good idea but needs bolus (intermittent) settings to accomplish adequate pain control, with or without a basal rate. Pain control needs to be continuous, not just administered prior to therapy.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Pain, Pharmacologic pain management MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 12. A nurse on the postoperative inpatient unit receives hand-off report on four clients using

patient-controlled analgesia (PCA) pumps. Which client would the nurse see first? a. Client who appears to be sleeping soundly. b. Client with no bolus request in 6 hours. c. Client who is pressing the button every 10 minutes. d. Client with a respiratory rate of 8 breaths/min.

ANS: D

Continuous delivery of opioid analgesia can lead to respiratory depression and extreme sedation. A respiratory rate of 8 breaths/min is below normal, so the nurse would first check this client. The client “sleeping soundly” could be comfortable (no indicators of respiratory distress) and would be checked next. Pressing the button every 10 minutes indicates that the client has a high level of pain, but the device has a lockout determining how often a bolus can be delivered. Therefore, the client cannot overdose. The nurse would next assess that client’s pain. The client who has not needed a bolus of pain medicine in several hours has well-controlled pain.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Pain, Pharmacologic pain management

MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 13. A registered nurse is caring for a client who is receiving pain medication via

patient-controlled analgesia (PCA). Which action by the nurse indicates the need for further education on pain control with PCA? a. Assesses the client’s pain level per agency policy. b. Monitors the client’s respiratory rate and sedation. c. Presses the button when the client cannot reach it. d. Reinforces client teaching about using the PCA pump.

ANS: C

The client is the only person who should press the PCA button. If the client cannot reach it, the nurse would either reposition the client or the button, and would not press the button for the client. Pressing the button for the client (“PCA by proxy”) indicates the need to review the information about this treatment modality. The other actions are appropriate.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Pain, Pharmacologic pain management MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 14. A client is put on twice-daily acetaminophen for osteoarthritis. Which finding in the client’s

health history would lead the nurse to consult with the primary health care provider over the choice of medication? a. 25–pack-year smoking history b. Drinking 3 to 5 beers a day c. Previous peptic ulcer d. Taking warfarin ANS: B

The major serious side effect of acetaminophen is hepatotoxicity and liver damage. Drinking 3 to 5 beers each day may indicate underlying liver disease, which would be investigated prior to prescribing chronic acetaminophen. The nurse would relay this information to the primary health care provider. Smoking is not related to acetaminophen side effects. Acetaminophen does not cause bleeding, so a previous peptic ulcer or taking warfarin would not be a problem.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Pharmacologic pain management, Adverse drug reactions MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 15. A nurse is preparing to give a client ketorolac intravenously for pain. Which assessment

findings would lead the nurse to consult with the primary health care provider? a. Bilateral lung crackles b. Hypoactive bowel sounds c. Self-reported pain of 3/10 d. Urine output of 20 mL/2 hr ANS: D

Drugs in this category can affect renal function. Clients need to be adequately hydrated and demonstrate good renal function prior to administering ketorolac. A urine output of 20 mL/2 hr is well below normal, and the nurse would consult with the primary health care provider (PHCP) about the choice of drug. Crackles and hypoactive bowel sounds are not related. A pain report of 3 does not warrant a call to the PHCP.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Pharmacologic pain management, Adverse drug reactions MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 16. A hospitalized client has a history of depression for which sertraline is prescribed. The client

also has a morphine allergy and a history of alcoholism. After surgery, several opioid analgesics are prescribed. Which one would the nurse choose? a. Hydrocodone and acetaminophen b. Hydromorphone c. Meperidine d. Tramadol ANS: B

Hydromorphone is a good alternative to morphine for moderate to severe pain. The nurse would not choose the combination with acetaminophen because it contains acetaminophen and the client has a history of alcoholism. Tramadol would not be used due to the potential for interactions with the client’s sertraline. Meperidine is rarely used and is often restricted.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Analysis KEY: Pharmacologic pain management, Opioid analgesics MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 17. A client has received an opioid analgesic for pain. The nurse assesses that the client has a

Pasero Scale score of 3 and a respiratory rate of 7 shallow breaths/min. The client’s oxygen saturation is 87%. Which action would the nurse perform first? a. Apply oxygen at 4 L/min. b. Attempt to arouse the client. c. Give naloxone (Narcan). d. Notify the Rapid Response Team.

ANS: B

The Pasero Opioid-Induced Sedation Scale is used to assess for unwanted opioid-associated sedation. A Pasero Scale score of 3 is unacceptable but is managed by trying to arouse the client in order to take deep breaths and staying with the client until he or she is more alert.

Administering oxygen will not help if the client’s respiratory rate is 7 breaths/min. Giving naloxone and calling for a Rapid Response Team would be appropriate for a higher Pasero Scale score.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Pharmacologic pain management, Opioid analgesics MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 18. An older adult has diabetic neuropathy and often reports unbearable foot pain. About which

medication would the nurse plan to educate the client? a. Desipramine b. Duloxetine c. Morphine sulfate d. Nortriptyline ANS: B

Antidepressants and anticonvulsants often are used for neuropathic pain relief. Morphine would not be used for this client. However, SNRIs are better tolerated than tricyclics, which eliminate desipramine and nortriptyline. Duloxetine would be the best choice for this older client.

DIF: Applying TOP: Integrated Process: Nursing Process: Analysis KEY: Pharmacologic pain management, Adjuvant analgesics MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 19. A nurse is caring for four clients receiving pain medication. After the hand-off report, which

client would the nurse see first? a. Client who is crying and agitated b. Client with a heart rate of 104 beats/min c. Client with a Pasero Scale score of 4 d. Client with a verbal pain report of 9 ANS: C

The Pasero Opioid-Induced Sedation Scale has scores ranging from S to 1 to 4. A score of 4 indicates unacceptable somnolence and is an emergency. The nurse would see this client first.

The nurse can delegate visiting with the crying client to a nursing assistant; the client may be upset and might benefit from talking or a comforting presence. The client whose pain score is 9 needs to be seen next, or the nurse can delegate this assessment to another nurse while working with the priority client. A heart rate of 104 beats/min is slightly above normal, and that client can be seen after the other two clients are cared for.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Pharmacologic pain management, Critical rescue MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 20. A nurse is caring for a client who received intraspinal analgesia. Which action by the nurse is

most important to ensure client safety? a. Assess and record vital signs every 4 hours. b. Instruct the client to report any unrelieved pain. c. Monitor for numbness and tingling in the legs. d. Perform frequent neurologic assessments.

ANS: B

Complications from intraspinal anesthesia are rare, but can be life threatening. The nurse would perform frequent neurologic assessments and notify the primary health care provider for abnormal findings. Vital signs are taken every 1 to 2 hours for at least 12 hours.

Unreported pain is managed, but this is not a safety concern. Numbness and tingling outside of the surgical site is not normal, but can usually be abated by decreasing the opioid dose. The nurse can also keep the client on bedrest, decreasing safety concerns, while reporting to the primary health care provider.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Implementation KEY: Pharmacologic pain management, Epidural analgesia MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control MULTIPLE RESPONSE

1. Nurses at a conference learn the process by which pain is perceived by the client. Which

processes are included in the discussion? (Select all that apply.) a. Induction b. Modulation c. Sensory perception d. Transduction e. Transmission f. Transition ANS: B, C, D, E

The four processes involved in making pain a conscious experience are modulation, sensory perception, transduction, and transmission.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Pain, Physiology MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A nurse learns the concepts of addiction, tolerance, and dependence. Which information is

accurate? (Select all that apply.) a. Addiction is a chronic physiologic disease process. b. Physical dependence and addiction are the same thing. c. Pseudoaddiction can result in withdrawal symptoms. d. Tolerance is a normal response to regular opioid use. e. Tolerance is said to occur when opioid effects decrease. f. Physical dependence occurs after repeated doses of an opioid.

ANS: A, D, E, F

Addiction, tolerance, and dependence are important concepts. Addiction is a chronic, treatable disease with a neurologic and biologic basis. Tolerance occurs with regular administration of opioid analgesics and is seen when the effect of the analgesic decreases (either therapeutic effect or side effects). Dependence and addiction are not the same; dependence occurs with regular administration of analgesics and can result in withdrawal symptoms when they are discontinued abruptly. Pseudoaddiction is the mistaken diagnosis of addictive disease.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Pharmacological pain management MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. A postoperative client has an epidural infusion of morphine and bupivacaine. Which actions

does the nurse delegate to the assistive personnel (AP)? (Select all that apply.) a. Ask the client to point out any areas of numbness or tingling. b. Determine how many people are needed to ambulate the client. c. Perform a bladder scan if the client is unable to void after 4 hours. d. Remind the client to use the incentive spirometer every hour. e. Take and record the client’s vital signs per agency protocol.

ANS: C, D, E

The AP can assess and record vital signs, perform a bladder scan and report the results to the nurse, and remind the client to use the spirometer. The nurse is legally responsible for assessments and would ask the client about areas of numbness or tingling, and assess if the client is able to bear weight and walk.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Pharmacologic pain management, Opioid analgesics MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 4. A client with a broken arm had ice placed on it for 20 minutes. A short time after the ice was

removed, the client reports that the effect has worn off and requests pain medication, which cannot be given yet. Which actions by the nurse are most appropriate? (Select all that apply.) a. Ask for a physical therapy consult. b. Educate the client on cold therapy. c. Offer to provide a heating pad. d. Repeat the ice application. e. Teach the client relaxation techniques. f. Offer the client headphones with music.

ANS: B, D, E

Nonpharmacologic pain management can be very effective. These modalities include ice, heat, pressure, massage, vibration, and transcutaneous electrical stimulation. Since the client is unable to have more pain medication at this time, the nurse would focus on nonpharmacologic modalities. First the client must be educated; the effects of ice wear off quickly once it is removed, and the client may have had unrealistic expectations. The nurse can repeat the ice application and teach relaxation techniques if the client is open to them.

Other nonpharmacologic methods to reduce pain include distraction, imagery, and mindfulness. A physical therapy consult will not help relieve acute pain of a fracture. Heat would not be a good choice for this type of injury.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Pain, Nonpharmacologic pain management MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 5. A nurse learns that there are physical consequences to unrelieved pain. Which factors are

included in this problem? (Select all that apply.) a. Decreased immune response b. Development of chronic pain c. Increased gastrointestinal (GI) motility d. Possible immobility e. Slower healing f. Negative quality of life ANS: A, B, D, E, F

There are many physiologic impacts of unrelieved pain, including decreased immune response; development of chronic pain; decreased GI motility; immobility; slower healing; prolonged stress response; and increased heart rate, blood pressure, and oxygen demand.

Decreased quality of life includes depression, anxiety, fear, anger, hopelessness, and insomnia; impaired family, work, and social relationships; and difficulty with ADLs. DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Pain MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

6. A nurse is studying pain sources. Which statements accurately describe different types of

pain? (Select all that apply.) a. Neuropathic pain sometimes accompanies amputation. b. Nociceptive pain originates from abnormal pain processing. c. Deep somatic pain is pain arising from bone and connective tissues. d. Somatic pain originates from skin and subcutaneous tissues. e. Visceral pain is often diffuse and poorly localized.

ANS: A, C, D, E

Neuropathic pain results from abnormal pain processing and is seen in amputations and neuropathies. Somatic pain can arise from superficial sources such as skin, or deep sources such as bone and connective tissues. Visceral pain originates from organs or their linings and is often diffuse and poorly localized. Nociceptive pain is normal pain processing and consists of somatic and visceral pain.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Pain, Physiology MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 7. A nurse on the postoperative unit administers many opioid analgesics. Which actions by the

nurse are best to prevent unwanted sedation as a complication of these medications? (Select all that apply.) a. Avoid using other medications that cause sedation. b. Delay giving medication if the client is sleeping. c. Give the lowest dose that produces good control. d. Identify clients at high risk for unwanted sedation. e. Use an oximeter to monitor clients receiving analgesia.

ANS: A, C, D, E

Sedation is a side effect of opioid analgesics. Some sedation can be expected, but protecting the client against unwanted and dangerous sedation is a critical nursing responsibility. The nurse would identify clients at high risk for unwanted sedation and give the lowest possible dose that produces satisfactory pain control. Avoid using other sedating medications such as antihistamines to treat itching. An oximeter can alert the nurse to a decrease in the client’s oxygen saturation, which often follows sedation. A postoperative client frequently needs to be awakened for pain medication in order to avoid waking to out-of-control pain later.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Pain, Pharmacological pain management MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 8. A client reports a great deal of pain following a fairly minor operation. The surgeon leaves a

prescription for the nurse to administer a placebo instead of pain medication. Which actions by the nurse are most appropriate? (Select all that apply.) a. Consult with the surgeon and voice objections. b. Delegate administration of the placebo to another nurse. c. Give the placebo and reassess the client’s pain. d. Notify the nurse manager of the placebo prescription. e. Tell the client what medications were prescribed.

ANS: A, D

Nurses would never give placebos to treat a client’s pain (unless the client is in a research study). This practice is unethical and, in many states, illegal. The nurse would voice concerns with the prescriber and, if needed, contact the nurse manager. The nurse would not delegate giving the placebo to someone else, nor would the nurse give it. Telling the client about the placebo prescription before voicing objections would not be beneficial.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Pharmacological pain management, Ethics MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care

Chapter 06: Concepts of Genetics and Genomics Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse is educating a client about genetic screening. The client asks why red-green color

blindness, an X-linked recessive disorder noted in some family members, is expressed more frequently in males than females. How would the nurse respond? a. “Females have a decreased penetrance rate for this gene mutation and are therefore less likely to express the trait.” b. “Females have two X chromosomes and one is always inactive. This inactivity decreases the effect of the gene.” c. “The incidence of X-linked recessive disorders is higher in males because they do not have a second X chromosome to balance expression of the gene.” d. “Males have only one X chromosome, which allows the X-linked recessive disorder to be transmitted from father to son.”

ANS: C

Because the number of X chromosomes in males and females is not the same (1:2), the number of X-linked chromosome genes in the two genders is also unequal. Males have only one X chromosome, a condition called hemizygosity, for any gene on the X chromosome. As a result, X-linked recessive genes have a dominant expressive pattern of inheritance in males and a recessive expressive pattern of inheritance in females. This difference in expression occurs because males do not have a second X chromosome to balance the expression of any recessive gene on the first X chromosome. It is incorrect to say that one X chromosome of a pair is always inactive in females, or that females have a decreased penetrance rate for this gene mutation. X-linked recessive disorders cannot be transmitted from father to son, but the trait is transmitted from father to all daughters who will be carriers.

DIF: Understanding KEY: Genetics, Patterns of inheritance

TOP: Integrated Process: Teaching/Learning MSC: Client Needs Category: Physiological Integrity

2. A client is typed and crossmatched for a unit of blood. Which statement by the nurse indicates

a need for further genetic education? a. “Blood type is formed from three gene alleles: A, B, and O.” b. “Each blood type allele is inherited from the mother or the father.” c. “If the patient’s blood type is AB, then the client is homozygous for that trait.” d. “If the client has dominant and recessive alleles, the dominant will be expressed.”

ANS: C

There are three possible gene alleles for blood type: A, B, and O, which are inherited from the parents. If both a dominant and recessive gene allele are present, the dominant one is always expressed. Blood type AB is a heterozygous type, meaning the two alleles are different. The nurse stating that type AB is homozygous needs further education.

DIF: Understanding TOP: Integrated Process: Nursing Process: Intervention KEY: Genetics, Patterns of inheritance MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

3. A nurse obtains health histories when admitting clients to a medical-surgical unit. With which

client would the nurse discuss predisposition genetic testing? a. Middle-age woman whose mother died at age 48 of breast cancer. b. Young man who has all the symptoms of rheumatoid arthritis. c. Pregnant woman whose father has sickle cell disease. d. Middle-age man of Eastern European Jewish ancestry.

ANS: A

A client with a family history of breast cancer would be provided information about predisposition testing. Predisposition testing would be discussed with clients who are at high risk of hereditary breast, ovarian, and colorectal cancers so that the client can engage in heightened screening activities or interventions that reduce risk. The client with symptoms of rheumatoid arthritis would be given information about symptomatic diagnostic testing. The client with a familial history of sickle cell disease and the client who is of Eastern European Jewish ancestry would be given information about carrier testing.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Genetics, Genetic testing MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 4. A client who tests positive for a mutation in the BRCA1 gene allele asks a nurse to be present

when she discloses this information to her adult daughter. How would the nurse respond? a. “I will request a genetic counselor who is more qualified to be present for this conversation.” b. “The test results can be confusing; I will help you interpret them for your daughter.” c. “Are you sure you want to share this information with your daughter, who may not test positive for this gene mutation?” d. “This conversation may be difficult for both of you; I will be there to provide support.”

ANS: D

A nurse would provide emotional support while the client tells her daughter the information she has learned about the test results. The nurse would not interpret the results or counsel the client or her daughter. The nurse would refer the client for counseling or support, if necessary.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Genetics, Coping MSC: Client Needs Category: Psychosocial Integrity 5. A nurse consults a genetic counselor for a client whose mother has Huntington disease and is

considering genetic testing. The client states, “I know I want this test. Why do I need to see a counselor?” How would the nurse respond? a. “The counselor will advise you on whether you can have children or need to adopt.” b. “Genetic testing can be a stressful experience. Counseling can provide support and education throughout the process.” c. “There is no cure for this disease. The counselor will determine if there is any benefit to genetic testing.” d. “Genetic testing is expensive. The counselor will advocate for you and help you obtain financial support.”

ANS: B

Genetic testing is a stressful experience, and clients would be provided with support, education, and assistance with coping. Genetic testing would be performed only after genetic counseling has occurred. The client has the right to decide whether to have children or to participate in genetic testing. Nursing staff would provide both benefits and risks to genetic testing so that the client can make an informed decision. Financial support is not part of genetic counseling.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Genetics, Coping MSC: Client Needs Category: Psychosocial Integrity 6. A primary health care provider prescribes genetic testing for a client who has a family history

of colorectal cancer. Which action would the nurse take before scheduling the client for the procedure? a. Confirm that informed consent was obtained and placed on the patient’s chart. b. Provide genetic counseling to the client and the patient’s family members. c. Assess if the client is prepared for the risk of psychological side effects. d. Respect the patient’s right not to share the results of the genetic test.

ANS: A

Informed consent is required before genetic testing. The person tested is the one who gives consent. An advanced practice provider would explain the procedure and provide genetic counseling. Although the client would be prepared for the risk of psychological side effects and the patient’s rights would be respected, the procedure cannot occur without informed consent.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Genetics, Informed consent MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 7. A nurse cares for an adult client who has received genetic testing. The patient’s mother asks to

receive the results of the genetic tests. Which action would the nurse take? a. Obtain a signed consent from the client allowing test results to be released to the mother. b. Invite the mother and other family members to participate in genetic counseling with the client. c. Encourage the mother to undergo genetic testing to determine if she has the same risks as her child. d. Direct the mother to speak with the client and support the client’s decision to share or not share the results.

ANS: D

All conversations and test results must be kept confidential. The client has the right to determine who may be involved in discussions related to diagnosis and genetic testing, who may participate in genetic counseling with the patient, and what information may be disclosed to family members. It is the nurse’s responsibility to provide a private environment for discussions and protect the patient’s information from improper disclosure. The nurse would support the patient’s right to disclose or not disclose information.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Genetics, Confidentiality

MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 8. A nurse cares for a client who has a genetic mutation that increases the risk for colon cancer.

The client states that he/she does not want any family to know about this result. How would the nurse respond? a. “It is required by law that you inform your siblings and children about this result so that they also can be tested and monitored for colon cancer.” b. “It is not necessary to tell your siblings because they are adults, but you would tell your children so that they can be tested before they decide to have children of their own.” c. “It is not required that you tell anyone about this result. However, your siblings and children may also be at risk for colon cancer and this information might help them.” d. “It is your decision to determine with whom, if anyone, you discuss this test result.

However, you may be held liable if you withhold this information and a family member gets colon cancer.”

ANS: C

This situation represents an ethical dilemma. It is the client’s decision whether to disclose the information. However, the information can affect others in the client’s family. The law does not require the client to tell family members about the results, nor can the client be held liable for not telling them. The nurse may consider it ethically correct for clients to tell family members so that they can take action to prevent the development of cancer, but the nurse must respect the client’s decision.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Genetics, Confidentiality MSC: Client Needs Category: Psychosocial Integrity 9. A nurse cares for a client who has a specific mutation in the a1AT (alpha1-antitrypsin) gene.

What action would the nurse take? a. Teach the client to perform monthly breast self-examinations and schedule an annual mammogram. b. Support the client when sharing test results and encourages family members to be screened for cancer. c. Advise the client to limit exposure to secondhand smoke and other respiratory irritants. d. Obtain a complete health history to identify other genetic problems associated with this gene mutation.

ANS: C

The a1AT gene mutation increases risk for developing early-onset emphysema. Clients would be advised to limit exposure to smoke and other respiratory irritants as a means of decreasing environmental influences that may aggravate an early onset of emphysema. This gene mutation does not promote cancer, nor does it occur with other identified genetic problems.

The BRCA1 gene mutation gives the client a higher risk for developing breast cancer.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Genetics, Genetic mutations MSC: Client Needs Category: Health Promotion and Maintenance

10. A nurse cares for a pregnant client who has a family history of sickle cell disease. The client is

unsure if she wants to participate in genetic testing. What action would the nurse take? a. Provide information about the risks and benefits of genetic testing. b. Empathize with the client and share a personal story about a hereditary disorder. c. Teach the client that early detection can minimize transmission to the fetus. d. Advocate for the client and her baby by encouraging genetic testing.

ANS: A

Genetic counseling is to be nondirective. The nurse would provide as much information as possible about the risks and benefits but would not influence the patient’s decision to test or not test. Once the client has made a decision, the nurse would support the client in that decision. Carrier testing will determine if a client without symptoms has an allele for a recessive disorder that could be transmitted to his or her child. Genetic testing will not minimize transmission of the disorder.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Genetics, Genetic counseling MSC: Client Needs Category: Psychosocial Integrity 11. A nurse cares for a client who recently completed genetic testing and received a negative

result. The client states, “I feel guilty because so many of my family members are carriers of this disease and I am not.” How would the nurse respond? a. “You are not genetically predisposed for this disease but you could still become ill.

Let’s discuss a plan for prevention.” b. “Since many of your family members are carriers, you would undergo further testing to verify the results are accurate.” c. “We usually encourage clients to participate in counseling after receiving test results. Can I arrange this for you?” d. “It is normal to feel this way. I think you would share this news with your family so that they can support you.”

ANS: C

Clients who have negative genetic test results need counseling and support. Some clients may have an unrealistic view of what a negative result means for their general health. Others may feel guilty that they were “spared” when some family members were not. The client will not be symptomatic if he or she is not a carrier of the disease. A second round of testing is not recommended, because false negatives are rare with this type of testing. It is the client’s choice to reveal test results to family members; the nurse would not encourage this.

DIF: Applying TOP: Integrated Process: Caring KEY: Genetics, Genetic counseling MSC: Client Needs Category: Psychosocial Integrity MULTIPLE RESPONSE 1. A nurse cares for a client who recently completed genetic testing that revealed that she has a

BRCA1 gene mutation. What actions would the nurse take next? (Select all that apply.) a. Assess the patient’s response to the test results. b. Assist the client to make a plan for prevention and risk reduction. c. Disclose the information to the medical insurance company. d. Discuss potential risks for other members of her family. e. Encourage support by sharing the results with family members.

f.

Recommend the client complete weekly breast self-examinations.

ANS: A, B, D

The medical-surgical nurse can assess the patient’s response to the test results, discuss potential risks for other family members, encourage genetic counseling, and assist the client to make a plan for prevention, risk reduction, and early detection. For some positive genetic test results, such as having a BRCA1 gene mutation, the risk for developing breast cancer is high but is not a certainty. Because the risk is high, the client would have a plan for prevention and risk reduction. One form of prevention is early detection. Breast self-examinations may be helpful when performed monthly, but those performed every week may not be useful, especially around the time of menses. A client who tests positive for a BRCA1 mutation would have at least yearly mammograms and ovarian ultrasounds to detect cancer at an early stage, when it is more easily cured. Owing to confidentiality, the nurse would never reveal any information about a client to an insurance company or family members without the patient’s permission.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning KEY: Genetics, Genetic testing MSC: Client Needs Category: Health Promotion and Maintenance 2. A nurse completes pedigree charts for clients at a community health center. Which diagnoses

would the nurse refer for carrier genetic testing? (Select all that apply.) a. Breast cancer b. Colorectal cancer c. Cystic fibrosis d. Hemophilia e. Huntington disease f. Sickle cell disease ANS: C, D, F

Of the disease processes listed, the ones that would make the client a candidate for carrier genetic testing would be hemophilia, sickle cell disease, and cystic fibrosis. Although Huntington disease, breast cancer, and colorectal cancer all have genetic components, there is no evidence that carrier genetic testing would be beneficial in diseases such as these.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Genetics, Genetic testing MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. A nurse teaches clients about patterns of inheritance for genetic disorders among adults.

Which disorders have an autosomal dominant pattern of inheritance? (Select all that apply.) a. Breast cancer b. Alzheimer disease c. Hemophilia d. Huntington disease e. Marfan syndrome f. Cystic fibrosis ANS: A, D, E

Breast cancer, Huntington disease, and Marfan syndrome have an autosomal dominant pattern of inheritance. Alzheimer disease is a complex disorder with familial clustering, hemophilia is a sex-linked recessive disorder, and cystic fibrosis has an autosomal recessive pattern of inheritance.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Genetics, Patterns of inheritance MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. A nurse cares for a client who is scheduled for genetic testing. What actions would the nurse

include in the patient’s pretesting assessment? (Select all that apply.) a. Assess the client’s understanding of the genetic test. b. Obtain physical assessment data relevant to the at-risk disorder. c. Discuss prevention, early detection, and treatment options. d. Assess the client’s perception of the test results. e. Discuss client rights and obligations regarding disclosure of information.

ANS: A, B, E

During the pretesting assessment, the nurse would evaluate the patient’s understanding of the genetic test being sought and obtain relevant information including physical assessment, family history, psychosocial status, and social support. The nurse would also discuss client rights and obligations regarding disclosure of information, risks and benefits of testing, and testing options. Discussion of prevention, early detection and treatment options, and an assessment of the patient’s perception of the test results would occur after genetic testing is complete.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Genetics, Patterns of inheritance MSC: Client Needs Category: Health Promotion and Maintenance

Chapter 07: Concepts of Rehabilitation for Chronic and Disabling Health Problems Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse assesses a client recovering from coronary artery bypass graft surgery in an inpatient

rehabilitation unit. Which assessment would the nurse complete to evaluate the client’s activity tolerance? a. Vital signs before, during, and after activity b. Body image and self-care abilities c. Ability to use assistive or adaptive devices d. Client’s electrocardiography readings ANS: A

Alterations in the cardiac system can affect a client’s ability to tolerate activity. Signs of this include changes in blood pressure and pulse since they are directly affected by cardiac output.

A body image assessment is not necessary before basic activities are performed. Self-care abilities and ability to use assistive or adaptive devices is an important assessment when planning rehabilitation activities, but will not provide essential information about the client’s activity tolerance. Electrocardiography is not used to monitor clients in a rehabilitation setting.

DIF: Applying TOP: Integrated Process: Nursing Process: Evaluation KEY: Rehabilitation care, Activity tolerance MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A nurse teaches a client with a past history of angina who has had a total knee replacement.

Which statement would the nurse include in this client’s teaching prior to beginning rehabilitation activities? a. “Use analgesics before and after activity, even if you are not experiencing pain.” b. “Let me know if you start to experience shortness of breath, chest pain, or fatigue.” c. “Do not take your prescribed beta blocker until after you exercise with physical therapy.” d. “If you experience knee pain, ask the physical therapist to reschedule your therapy.”

ANS: B

Participation in exercise may increase myocardial oxygen demand beyond the ability of the coronary circulation to deliver enough oxygen to meet the increased need. The nurse must determine the client’s ability to tolerate different activity levels. Asking the client to notify the nurse if symptoms of shortness of breath, chest pain, or fatigue occur will assist the nurse in developing an appropriate rehabilitation plan the client can tolerate. Analgesics before and after activity are not warranted. The rehabilitation nurse would not change the client’s medication schedule without consulting the physiatrist or primary health care provider.

Therapy would not be cancelled if this client had knee pain postoperatively.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Rehabilitation care, Activity tolerance MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

3. A rehabilitation nurse prepares to move a client who has new bilateral leg amputations. Which

is the best approach? a. Use the bear-hug method to transfer the client safely. b. Ask several members of the health care team to carry the client. c. Utilize the facility’s mechanical lift to move the client. d. Consult physical therapy before performing all transfers.

ANS: C

Use mechanical lifts to minimize staff work-related musculoskeletal injuries. Many facilities have implemented no-lift or minimal-lift policies to reduce staff and client injury. The bear-hug method does not eliminate staff injuries. Staff would not carry the client. Physical therapy would be consulted but cannot be depended upon for all transfers. Nursing staff must be capable of transferring a client safely.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Rehabilitation care, Safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 4. A rehabilitation nurse in a skilled nursing facility (SNF) cares for a client who has generalized

weakness and needs assistance with activities of daily living. Which exercise would the nurse implement? a. Passive range of motion b. Active range of motion c. Resistive range of motion d. Aerobic exercise ANS: B

Active range of motion is a part of a restorative nursing program. Active range of motion will promote strength, range of motion, and independence with activities of daily living. Passive range of motion will not increase the client’s strength. Performing range of motion against resistance may be too advanced for the client. This client is not yet ready for aerobic exercise.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Rehabilitation care, Functional ability MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. A nurse plans care for a client who is bedridden. Which assessment would the nurse complete

to ensure to prevent pressure injury formation? a. Nutritional intake and serum albumin levels b. Pressure injury diameter and depth c. Wound drainage, including color, odor, and consistency d. Dressing site and antibiotic ointment application ANS: A

Assessing serum albumin levels helps determine the client’s nutritional status and allows care providers to alter the diet, as needed, to provide protein to prevent pressure injuries. All other options are treatment oriented rather than prevention oriented.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Rehabilitation care, Tissue integrity MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

6. A nurse teaches a client about performing intermittent self-catheterization. The client states, “I

am not sure if I will be able to afford these catheters.” How would the nurse respond? a. “I will try to find out whether you qualify for money to purchase these necessary supplies.” b. “Even though it is expensive, the cost of taking care of urinary tract infections would be even higher.” c. “Instead of purchasing new catheters, you can boil the catheters and reuse them up to 10 times each.” d. “I will contact the social worker who will discuss potential resources with you.”

ANS: D

Social workers help patients identify support services and resources, including financial assistance. The nurse would refer the client to the social worker to explore financial concerns.

The nurse would not threaten the client, nor would the client be instructed to boil the catheters.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Rehabilitation care, Interprofessional team MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 7. A nurse delegates the ambulation of an older adult client to a nursing assistant. Which

statement would the nurse include when delegating this task? a. “The client has skid-proof socks, so there is no need to use your gait belt.” b. “Teach the client how to use the walker while you are ambulating up the hall.” c. “Sit the client on the edge of the bed with legs dangling before ambulating.” d. “Ask the client if pain medication is needed before you walk the client.”

ANS: C

Before the client gets out of bed, have the client sit on the bed with legs dangling on the side.

This will enhance safety for the client because it gives the body time to adjust after changing position and can prevent safety concerns from orthostatic hypotension. A gait belt would be used for all clients. The nursing assistant cannot teach the client to use a walker or assess the client’s pain.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Rehabilitation care, Fall prevention MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 8. A nurse assesses a client who is admitted to the inpatient rehabilitation unit with hip

problems. The client asks, “Why are you asking about my bowels and bladder?” How would the nurse respond? a. “To plan your care based on your normal elimination routine.” b. “So we can help prevent side effects of your medications.” c. “We need to evaluate your ability to function independently.” d. “To schedule your activities around your elimination pattern.”

ANS: A

Bowel and bladder elimination varies from client to client and must be evaluated on the basis of the client’s normal routine. The nurse asks about bowel and bladder habits to develop a client-centered plan of care. The other answers are correct but are not the best responses. Oral analgesics may cause constipation, but they do not interfere with bladder control. The client is in rehabilitation to assist his or her ability to function independently.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Rehabilitation care, Elimination MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 9. A nurse is caring for a client who has a flaccid bladder after a spinal cord injury. Which

intervention would the nurse implement to assist with bladder dysfunction? a. Insert an indwelling urinary catheter. b. Stroke the medial aspect of the thigh. c. Use the Credé maneuver every 3 hours. d. Apply an external (condom) catheter with a leg bag.

ANS: C

When the patient has a lower motor neuron problem, the voiding reflex arc is not intact (flaccid bladder pattern), and additional stimulation may be needed to initiate voiding. Two techniques are used to facilitate voiding in a client with a flaccid bladder: the Valsalva maneuver and the Credé maneuver. Indwelling urinary catheters generally are not used because of the increased incidence of urinary tract infection. Stroking the medial aspect of the thigh facilitates voiding in clients with upper motor neuron problems. An external catheter is not ideal for this lesion which causes urinary retention and overflow.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Rehabilitation care, Elimination MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation: Basic Care and Comfort 10. A nurse teaches a client who has a reflex (spastic) bladder after a spinal cord injury. Which

bladder training technique would the nurse teach? a. Stroking the medial aspect of the thigh b. Valsalva maneuver c. Self-catheterization d. Frequent toileting ANS: A

If there is an upper motor neuron problem but the reflex arc is intact (reflex bladder pattern), the voiding response can be initiated by any stimulus that sends the message to the spinal cord level S2-4 that the bladder might be full. Such techniques include stroking the medial aspect of the thigh, pinching the area above the groin, massaging the peno-scrotal area, pinching the posterior aspect of the glans penis, and providing digital anal stimulation. The Valsalva maneuver is used for a flaccid bladder. Intermittent catheterization may be necessary if nothing else works. A consistent toileting schedule may be included in the regimen.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Rehabilitation care, Elimination MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

11. A rehabilitation nurse cares for a client who is wheelchair bound. Which intervention would

the nurse implement to prevent skin breakdown? a. Place pillows under the client’s heels. b. Have the client do wheelchair push-ups. c. Perform wound care as prescribed. d. Massage the client’s calves and feet with lotion.

ANS: B

Clients who sit for prolonged periods in a wheelchair would perform wheelchair push-ups for at least 20 seconds every hour. Chair-bound clients also need to be repositioned at least every 1 to 2 hours. The lower legs, where the wheelchair could rub against the legs, also need to be assessed. Pillows under the heels may or may not be beneficial, but repositioning and redistributing weight are more important. Performing wound care as prescribed is important to improve the healing of pressure injuries, but this intervention will not prevent skin breakdown. The calves of a client with no or decreased lower extremity mobility would not be massaged because of the risk of embolization or thrombus.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Rehabilitation care, Tissue integrity MSC: Client Needs Category: Health Promotion and Maintenance MULTIPLE RESPONSE 1. A nurse collaborates with an occupational therapist when providing care for a rehabilitation

client. With which activities would the occupational therapist assist the client? (Select all that apply.) a. Achieving mobility b. Attaining independence with dressing c. Using a walker in public d. Learning techniques for transferring e. Performing activities of daily living (ADLs) f. Completing job training ANS: B, E

The role of the occupational therapist is to assist the client with fine motor control activities, such as ADLs and dressing. The physical therapist assists with gross motor function, muscle strength development, and ambulation. Vocational counselors assist with job placement, training, and further education.

DIF: Understanding TOP: Integrated Process: Nursing Process: Implementation KEY: Rehabilitation care, Interprofessional team MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 2. An interprofessional team is caring for a client on a rehabilitation unit. Which team members

are paired with the correct roles and responsibilities? (Select all that apply.) a. Speech–language pathologist—evaluates and retrains clients with swallowing problems b. Physical therapist—assists clients with ambulation and walker training c. Recreational therapist—assists physical therapists to complete rehabilitation therapy

d. Vocational counselor—works with clients who have experienced head injuries e. Registered dietitian—develops client-specific diets to ensure that client needs are f.

met Clinical psychologist—assesses and diagnoses mental health/behavioral health or cognition issues resulting from the disability or chronic condition and help both the patient and family identify strategies to foster coping.

ANS: A, B, E, F

Speech–language pathologists evaluate and retrain clients with speech, language, or swallowing problems. Physical therapists help clients to achieve self-management by focusing on gross mobility. Registered dietitians develop client-specific diets to ensure that clients meet their needs for nutrition. Recreational therapists work to help clients continue or develop hobbies or interests. Vocational counselors assist with job placement, training, or further education. The clinical psychologist assesses and diagnoses mental health/behavioral health or cognition issues resulting from the disability or chronic condition and help both the patient and family identify strategies to foster coping.

DIF: Remembering TOP: Integrated Process: Nursing Process: Implementation KEY: Rehabilitation care, Intraprofessional team MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 3. A rehabilitation nurse is caring for an older adult client who states, “I tire easily.” How would

the nurse respond? (Select all that apply.) a. “Schedule all of your tasks for the morning when you have the most energy.” b. “Try to rest before and after eating or going to the bathroom.” c. “Your family could hire someone who can assist you with daily chores.” d. “Plan to gather all of the supplies needed for a chore prior to starting the activity.” e. “Try to break large activities into smaller parts to allow rest periods between activities.”

ANS: A, B, D, E

Resting before and after eating or going to the bathroom reduces strain and fatigue. Gathering equipment before performing a chore decreases unneeded steps. Breaking larger chores into smaller ones allows rest periods between activities and still gives the client a sense of completion even if the client is unable to complete the whole task. Major tasks would be performed in the morning, when energy levels are high, while lesser tasks would be done throughout the day after frequent rest periods. Someone would be hired to do the chores only if the client cannot do them. The outcome would be achieving independence as close to the predisability level as possible.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Rehabilitation care, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 4. A nurse is caring for clients as a member of the rehabilitation team. Which activities would

the nurse complete as part of the nurse’s role? (Select all that apply.) a. Maintain the function of assistive technology by making needed repairs. b. Coordinate rehabilitation team activities to ensure implementation of the plan of care. c. Assist clients to identify support services and resources for the coordination of

services. d. Counsel clients and family members on strategies to cope with disability. e. Support the client’s choices by acting as an advocate for the client and family.

ANS: B, E

The rehabilitation nurse’s role includes coordination of rehabilitation activities to ensure that the client’s plan of care is effectively implemented and advocating for the client and family.

Assistive technology (computer keyboards, door locks) would be maintained by the vendor, not the nurse. The social worker assists clients with support services and resources. The clinical psychologist counsels clients and families on their psychological problems and on strategies to cope with disability.

DIF: Understanding TOP: Integrated Process: Nursing Process: Implementation KEY: Rehabilitation care MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 5. A rehabilitation nurse assesses a client upon admission. Which assessments would the nurse

complete to determine actual or potential interruption in skin and tissue integrity? (Select all that apply.) a. Oxygen saturation b. Cognitive abilities c. Functional mobility d. Spiritual needs e. Urinary output f. Nutrition ANS: A, B, C, E, F

To identify actual or potential interruptions in skin and tissue integrity, the nurse would assess for adequate oxygenation, cognition, bladder and bowel patterns and incontinence, sensation, adequate nutrition, and functional ability. The client’s spiritual needs do not impact skin integrity.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Rehabilitation care, Tissue integrity MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 6. A nurse begins discharge planning for a rehabilitation client who will be discharged in a

wheelchair. Which would the nurse include in this predischarge assessment? (Select all that apply.) a. Doorway widths within the client’s home b. Nutritional status including laboratory results c. Feelings and concerns related to the discharge d. Vital signs before, during, and after exercise activities e. Client’s ability to perform activities of daily living ANS: A, C, E

In preparation for discharge, the nurse in collaboration with the health care team would assess the client’s home to ensure accessibility given the client’s mobility impairments, psychological and mental readiness for discharge, ability to perform ADLs and IADLs, and support resources needed. Vital signs and nutritional status would be assessed during the rehabilitation stay but are not part of the predischarge assessment.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Rehabilitation care, Transition management MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

Chapter 08: Concepts of Care for Patients at End of Life Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse cares for a dying client. Which manifestation of dying does the nurse treat first? a. Anorexia b. Pain c. Nausea d. Hair loss ANS: B

Only symptoms that cause distress for a dying client would be treated. Such symptoms include pain, nausea and vomiting, dyspnea, and agitation. These problems interfere with the client’s comfort. Even when symptoms, such as anorexia or hair loss, disturb the family, they would be treated only if the client is distressed by their presence. The nurse would treat the client’s pain first.

DIF: Applying TOP: Integrated Process: Caring MSC: Client Needs Category: Psychosocial Integrity

KEY: End-of-life care, Comfort

2. A nurse plans care for a client who is nearing end of life. Which question will the nurse ask

when developing this client’s plan of care? a. “Is your advance directive up to date and notarized?” b. “Do you want to be at home at the end of your life?” c. “Would you like a physical therapist to assist you with range-of-motion activities?” d. “Have your children discussed resuscitation with your primary health care provider?”

ANS: B

When developing a plan of care for a dying client, consideration would be given for where the client wants to die. Different states have different laws regarding legal requirements for advance directives, but this would not take priority over establishing client preferences. A physical therapist would not be involved in end-of-life care. The client would discuss resuscitation with the primary health care provider and children; do-not-resuscitate status would be the client’s decision, not the family’s decision.

DIF: Applying TOP: Integrated Process: Caring KEY: End-of-life care, Advance directives MSC: Client Needs Category: Psychosocial Integrity 3. A nurse is caring for a client who has lung cancer and is dying. Which prescription does the

nurse question? a. Morphine 10 mg sublingual every 6 hours PRN for pain level greater than 5 b. Albuterol metered dose inhaler every 4 hours PRN for wheezes c. Atropine solution 1% sublingual every 4 hours PRN for excessive oral secretions d. Sodium biphosphate enema once a day PRN for impacted stool ANS: A

Pain medications would be scheduled around the clock to maintain comfort and prevent reoccurrence of pain. The dying client should not have to request medications for serious pain.

The other medications are appropriate for this client.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning KEY: End-of-life care, Pharmacologic pain management MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. A nurse is caring for a dying client whose adult child confides frequent crying episodes to the

nurse. How does the nurse respond? a. “It’s normal. Most people move on within a few months.” b. “Whenever you start to cry, distract yourself with pleasant thoughts of your parent.” c. “You should try not to cry. Your parent will be in a better place soon.” d. “Your feelings are completely normal and may continue for a long time.”

ANS: D

Everyone grieves and mourns differently. The nurse would offer support to the client and family during this time. By telling the adult child that the feelings are normal and may continue, the nurse is providing support to whatever the person is feeling. The other statements all show lack of compassion and respect to the family member’s feelings.

DIF: Applying TOP: Integrated Process: Caring MSC: Client Needs Category: Psychological Integrity

KEY: End-of-life care, Caring

5. After teaching a client about advance directives, a nurse assesses the client’s understanding.

Which statement indicates that the client correctly understands the teaching? a. “An advance directive will keep my children from selling my home when I’m old.” b. “An advance directive will be completed as soon as I’m incapacitated and can’t think for myself.” c. “An advance directive will specify what I want done when I can no longer make decisions about health care.” d. “An advance directive will allow me to keep my money out of the reach of my family.”

ANS: C

An advance directive is a written document prepared by a competent individual that specifies what, if any, extraordinary actions a person would want to be taken when he or she can no longer make decisions about personal health care. It does not address issues such as the client’s residence or financial matters.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: End-of-life care, Advance directives MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 6. A nurse teaches a client who is considering being admitted to hospice. Which statement does

the nurse include in this client’s teaching? a. “Hospice admission has specific criteria. You may not be a viable candidate, so we will look at alternative plans for your discharge.” b. “Hospice care focuses on a holistic approach to health care. It is not designed to

hasten death, but rather to relieve symptoms.” c. “Hospice care will not help with your symptoms of depression. I will refer you to

the facility’s counseling services instead.” d. “You seem to be experiencing some difficulty with this stage of the grieving

process. Let’s talk about your feelings.”

ANS: B

As both a philosophy and a system of care, hospice care uses an interprofessional approach to assess and address the holistic needs of clients and families to facilitate quality of life and a peaceful death. This holistic approach neither hastens nor postpones death but provides relief of symptoms experienced by the dying client.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: End-of-life care, Palliative, hospice care MSC: Client Needs Category: Psychosocial Integrity 7. A nurse is caring for a dying client. The client’s spouse states, “I think he is choking to

death.” How would the nurse respond? a. “Do not worry. The choking sound is normal during the dying process.” b. “I will administer more morphine to keep your spouse comfortable.” c. “I can ask the respiratory therapist to suction secretions out through his nose.” d. “I will have another nurse assist me to turn your spouse onto the side.”

ANS: D

The choking sound or “death rattle” is common in dying clients. The nurse acknowledges the spouse’s concerns and provides interventions that will reduce the choking sounds.

Repositioning the client onto one side with a towel under the mouth to collect secretions is the best intervention. The nurse would not minimize the spouse’s concerns. Morphine will assist with comfort but will not decrease the choking sounds. Nasotracheal suctioning is not appropriate in a dying client and may cause agitation.

DIF: Applying TOP: Integrated Process: Caring MSC: Client Needs Category: Psychosocial Integrity

KEY: End-of-life care, Comfort

8. The nurse is teaching a family member about various types of complementary therapies that

might be effective for relieving the dying client’s anxiety and restlessness. Which statement made by the family member indicates understanding of the nurse’s teaching? a. “Maybe we should just hire an around-the-clock sitter to stay with Grandmother.” b. “I have some of her favorite hymns on a CD that I could bring for music therapy.” c. “I don’t think that she’ll need pain medication along with her herbal treatments.” d. “I will burn therapeutic incense in the room so we can stop the anxiety pills.”

ANS: B

Music therapy is a complementary therapy that may produce relaxation by quieting the mind and removing a client’s inner restlessness. Hiring an around-the-clock sitter does not demonstrate that the client’s family understands complementary therapies. Complementary therapies are used in conjunction with traditional therapy. Complementary therapy would not replace pain or anxiety medication but may help decrease the need for these medications.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: End-of-life care, Nonpharmacologic comfort measures MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort

9. A nurse is caring for a terminally ill client who has just died in a hospital setting with family

members at the bedside. Which action will the nurse take first? a. Call for emergency assistance so that resuscitation procedures can begin. b. Ask family members if they would like to spend time alone with the client. c. Ensure the primary health care provider completed the death certificate. d. Request family members to prepare the client’s body for the funeral home.

ANS: B

Before moving the client’s body to the funeral home, the nurse asks family members if they would like to be alone with the client. Emergency assistance will not be necessary. Although it is important to ensure that a death certificate has been completed before the client is moved to the mortuary, the nurse first would ask family members if they would like to be alone with the client. The client’s family would not be expected to prepare the body for the funeral home but they could be asked if they wish to provide some care such as brushing the hair.

DIF: Applying TOP: Integrated Process: Caring KEY: End-of-life care, Postmortem care MSC: Client Needs Category: Psychosocial Integrity 10. A nurse assesses a client who is dying. Which sign or symptoms does the nurse assess to

determine whether the client is near death? a. Level of consciousness b. Respiratory rate c. Bowel sounds d. Pain level on a 0-10 scale ANS: B

Although all of these assessments would be performed during the dying process, periods of apnea and Cheyne-Stokes respirations indicate that death is near. As peripheral circulation decreases, the client’s level of consciousness and bowel sounds decrease, and the client would be unable to provide a numeric number on a pain scale. Even with these other symptoms, the nurse would continue to assess respiratory rate throughout the dying process. As the rate drops significantly and breathing becomes agonal, death is near.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: End-of-life care MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 11. A nurse is caring for a client who is terminally ill. The client’s spouse states, “I am concerned

because he does not want to eat.” How does the nurse respond? a. “Let him know that food is available if he wants it, but do not insist that he eat.” b. “A feeding tube can be placed in the nose to provide important nutrients.” c. “Force him to eat even if he does not feel hungry, or he will die sooner.” d. “He is getting all the nutrients he needs through his intravenous catheter.”

ANS: A

Anorexia often causes distress in family members. When family members understand that the client is not suffering from hunger and is not “starving to death,” they may allow the client to determine when, what, or if to eat. Often, as death approaches, metabolic needs decrease and clients do not feel the sensation of hunger. Forcing them to eat frustrates the client and the family and contributes to client discomfort.

DIF: Applying TOP: Integrated Process: Caring KEY: End-of-life care, Comfort MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 12. A nurse discusses palliative care with a client and the client’s family. A family member

expresses concern that the loved one will receive only custodial care. How will the nurse respond? a. “The goal of palliative care is to provide the greatest degree of comfort possible and help the dying person enjoy whatever time is left.” b. “Palliative care will release you from the burden of having to care for someone in the home. It does not mean that curative treatment will stop.” c. “A palliative care facility is like a nursing home and costs less than a hospital because only pain medications are given.” d. “Your relative is unaware of her surroundings and will not notice the difference between her home and a palliative care facility.”

ANS: A

Palliative care provides an increased level of personal care designed to manage symptom distress. It does not specifically relieve the family’s burden of caring for a client at home. It is not a place where only pain medications are given. The client is involved in this discussion so the nurse would not state he or she is unaware of surroundings. The goal of palliative care is to improve the quality of life for the patient and the family.

DIF: Understanding TOP: Integrated Process: Caring KEY: End-of-life care, Palliative, hospice care MSC: Client Needs Category: Psychosocial Integrity 13. An intensive care nurse discusses withdrawal of care with a client’s family. The family

expresses concerns related to discontinuation of therapy. How will the nurse respond? a. “I understand your concerns, but in this state, discontinuation of care is not a form of active euthanasia.” b. “You will need to talk to the primary health care provider because I am not legally allowed to participate in the withdrawal of life support.” c. “I realize this is a difficult decision. Discontinuation of therapy will allow the client to die a natural death.” d. “There is no need to worry. Most religious organizations support the client’s decision to stop medical treatment.”

ANS: C

The nurse validates the family’s concerns and provides accurate information about the discontinuation of therapy. The other statements address specific issues related to the withdrawal of care but do not provide appropriate information about their purpose. If the client’s family asks for specific information about euthanasia, legal, or religious issues, the nurse would provide unbiased information about these topics.

DIF: Applying TOP: Integrated Process: Caring KEY: End-of-life care, Withdrawal of care MSC: Client Needs Category: Psychosocial Integrity 14. A hospice nurse is caring for a variety of clients who are dying. Which end-of-life and death

ritual is paired with the correct religion?

a. Roman Catholic—autopsies are not allowed except under special circumstances. b. Christian—upon death, a religious leader should perform rituals of bathing and

wrapping the body in cloth. c. Judaism—a person who is extremely ill and dying should not be left alone. d. Islam—an ill or a dying person should receive the Sacrament of the Sick.

ANS: C

According to Jewish law, a person who is extremely ill or dying should not be left alone.

Orthodox Jews do not allow autopsies except under special circumstances. The Islamic faith requires a religious leader to perform rituals of bathing and wrapping the body in cloth upon death. A Catholic priest usually performs the Sacrament of the Sick for ill or dying people.

DIF: Remembering TOP: Integrated Process: Caring KEY: End-of-life care, Religion, spirituality MSC: Client Needs Category: Psychosocial Integrity MULTIPLE RESPONSE 1. A hospice nurse is caring for a dying client and family members. Which interventions does

the nurse implement? (Select all that apply.) a. Teach family members about physical signs of impending death. b. Encourage the management of adverse symptoms. c. Assist family members by offering an explanation for their loss. d. Encourage reminiscence by both client and family members. e. Avoid spirituality because the client’s and the nurse’s beliefs may not be congruent. f. Allow the client and family to voice concerns and fears.

ANS: A, B, D, F

The nurse would teach family members about the physical signs of death, because family members often become upset when they see physiologic changes in their loved one. Palliative care includes management of symptoms so that the peaceful death of the client is facilitated.

Reminiscence will help both the client and family members cope with the dying process. The nurse is not expected to explain why this is happening to the family’s loved one. The nurse can encourage spirituality if the client is agreeable, regardless of whether the client’s religion is the same. The nurse shows presence by allowing the client and family members to voice their fears and concerns openly.

DIF: Applying TOP: Integrated Process: Caring MSC: Client Needs Category: Psychosocial Integrity

KEY: End-of-life care

2. A nurse admits an older adult client to the hospital. Which criteria does the nurse use to

determine if the client can make his or her own medical decisions? (Select all that apply.) a. Can communicate treatment preferences. b. Is able to read and write at an eighth-grade level. c. Is oriented enough to understand information provided. d. Can evaluate and deliberate information. e. Has completed an advance directive. f. The family states the client can make decisions.

ANS: A, C, D

To have decision-making ability, a person must be able to perform three tasks: receive information (but not necessarily oriented  4); evaluate, deliberate, and mentally manipulate information; and communicate a treatment preference. The client does not have to read or write at a specific level. Education can be provided at the client’s level so that he can make the necessary decisions. The client does not need to complete an advance directive to make his own medical decisions. An advance directive will be necessary if he wants to designate someone to make medical decisions when he is unable to. The family may or may not be correct in stating the client is capable, but the nurse would listen openly to their statements.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: End-of-life care, Advance directives MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 3. A hospice nurse plans care for a client who is experiencing pain. Which complementary

therapies does the nurse incorporate in this client’s pain management plan? (Select all that apply.) a. Play music that the client enjoys. b. Massage tissue that is tender from radiation therapy. c. Rub lavender lotion on the client’s feet. d. Ambulate the client in the hall twice a day. e. Administer intravenous morphine. f. Involve the client in guided imagery.

ANS: A, C, F

Complementary therapies for pain management include massage therapy, music therapy, therapeutic touch, guided imagery, and aromatherapy. Nurses would not massage over sites of tissue damage from radiation therapy. Ambulation and intravenous morphine are not complementary therapies for pain management.

DIF: Understanding TOP: Integrated Process: Nursing Process: Implementation KEY: End-of-life care, Complementary therapy MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 4. A nurse teaches a client’s family members about signs and symptoms of approaching death.

Which of the following does the nurse include in this teaching? (Select all that apply.) a. Warm and flushed extremities b. Long periods of insomnia c. Increased respiratory rate d. Decreased appetite e. Congestion and gurgling f. Incontinence ANS: D, E, F

Common physical signs and symptoms of approaching death include coolness of extremities, increased sleeping, irregular and slowed breathing rate, a decrease in fluid and food intake, congestion and gurgling, incontinence, disorientation, and restlessness.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: End-of-life care MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

Chapter 09: Concepts of Care for Perioperative Patients Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A preoperative nurse is assessing a client prior to surgery. Which information would be most

important for the nurse to relay to the surgical team? a. Allergy to bee and wasp stings b. History of lactose intolerance c. No previous experience with surgery d. Use of multiple herbs and supplements ANS: D

Some herbs and supplements can interact with medications, so this information needs to be reported as the priority. An allergy to bee and wasp stings should not affect the client during surgery. Lactose intolerance should also not affect the client during surgery but will need to be noted before a postoperative diet is ordered. Lack of experience with surgery may increase anxiety and may require higher teaching needs, but client safety is more important.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Perioperative nursing, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 2. A nurse works on the postoperative floor and has four clients who are being discharged

tomorrow. Which one has the greatest need for the nurse to consult other members of the health care team for postdischarge care? a. Married young adult who is the primary caregiver for children. b. Middle-age client who is post-knee replacement, and needs physical therapy. c. Older adult who lives alone at home despite some memory loss. d. Young client who lives alone, and has family and friends nearby.

ANS: C

The older adult has the most potentially complex discharge needs. With memory loss, the client may not be able to follow the prescribed home regimen. The client’s physical abilities may be limited by chronic illness. This client has several safety needs that should be assessed.

The other clients all have evidence of a support system and no known potential for serious safety issues.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Perioperative nursing, Interprofessional team MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 3. A clinic nurse is teaching a client prior to surgery. The client does not seem to comprehend

the teaching, forgets a lot of what is said, and asks the same questions again and again. What action by the nurse is best? a. Assess the client for anxiety. b. Break the information into smaller bits. c. Give the client written information. d. Review the information again.

ANS: A

Anxiety can interfere with learning, coping, and cooperation. The nurse should assess the client for anxiety. The other actions are appropriate too, and can be included in the teaching plan, but effective teaching cannot occur if the client is highly anxious.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Perioperative nursing, Psychosocial response MSC: Client Needs Category: Psychosocial Integrity 4. A preoperative nurse is reviewing morning laboratory values on four clients waiting for

surgery. Which result warrants immediate communication with the surgical team? a. Creatinine: 1.2 mg/dL (106.1 umol/L) b. Hemoglobin: 14.8 mg/dL (148 mmol/L) c. Potassium: 2.9 mEq/L (2.9 mmol/L) d. Sodium: 134 mEq/L (134 mmol/L) ANS: C

The potassium level is critically low and can affect cardiac and respiratory status. The nurse would communicate this laboratory value immediately. The creatinine is at the high end of normal, the hemoglobin is normal, and the sodium is only slightly low so these values do not need to be reported immediately.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Perioperative nursing, Laboratory values MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 5. An inpatient nurse brings an informed consent form to a client for an operation scheduled for

tomorrow. The client asks about possible complications from the operation. What response by the nurse is best? a. Answer the questions and document that teaching was done. b. Do not have the client sign the consent and call the primary health care provider. c. Have the client sign the consent, and then call the primary health care provider. d. Remind the client of what teaching the primary health care provider has done.

ANS: B

In order to give informed consent, the client needs sufficient information. Questions about potential complications should be answered by the primary health care provider. The nurse can repeat some facts taught by the primary health care provider, but this topic is too broad for the nurse to address alone. The nurse should notify the primary health care provider to come back and answer the client’s questions before the client signs the consent form. The other actions are not appropriate.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Perioperative nursing, Informed consent MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 6. A client has a great deal of pain when coughing and deep breathing after abdominal surgery

despite having pain medication. What action by the nurse is best? a. Call the primary health care provider to request more analgesia. b. Demonstrate how to splint the incision. c. Have the client take shallower breaths.

d. Tell the client that a little pain is expected.

ANS: B

Splinting an incision provides extra support during coughing and activity and helps decrease pain. If the client is otherwise comfortable, no more analgesia is required. Shallow breathing can lead to atelectasis and pneumonia. The client should know that some pain is normal and expected after surgery, but that answer alone does not provide any interventions to help the client.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Perioperative nursing, Nonpharmacologic pain management MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 7. A nurse is giving a client instructions for showering the night before surgery. What instruction

is most appropriate? a. “After you wash the surgical site, shave that area with your own razor.” b. “Use the prescribed solution and wash the area where you will have surgery very thoroughly.” c. “Use a washcloth to wash the surgical site; do not take a full shower or bath.” d. “Use warm water and scrub the surgical area vigorously.”

ANS: B

One or two days before the scheduled surgery, the surgeon may ask the patient to shower using an antiseptic solution, often chlorhexidine gluconate. This cleaning reduces contamination of the surgical field and the number of organisms at the site. Hair removal if needed is done in the operating suite using evidence-based practices such as clipping or a depilatory agent. While the client should wash the area thoroughly, vigorous scrubbing might scrape the skin, increasing the risk of infection.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Perioperative nursing, Health teaching MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 8. A postoperative client has an abdominal drain. What assessment by the nurse indicates that

goals for the priority client problems related to the drain are being met? a. Drainage from the surgical site is 30 mL less than yesterday. b. There is no redness, warmth, or drainage at the insertion site. c. The client reports adequate pain control with medications. d. Urine is clear yellow and urine output is greater than 40 mL/hr.

ANS: B

The skin is the body’s first line of defense against infection and a drain of any type increases this risk. The priority client problem related to a surgical drain is the potential for infection.

An insertion site that is free of redness, warmth, and drainage indicates that goals for this client problem are being met. The other assessments are normal, but not related to the drain.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Perioperative nursing, Infection MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

9. The perioperative nurse manager and the postoperative unit manager are concerned about the

increasing number of surgical infections in their hospital. What action by the managers is best? a. Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met. b. Encourage staff on both units to provide peer pressure to adhere to hand hygiene policy. c. Hold educational meetings with the nursing and surgical staff on infection prevention. d. Monitor staff on both units for consistent adherence to established hand hygiene practices.

ANS: A

The SCIP project contains core measures to reduce surgical complications. Examples of focus included administration of prophylactic antibiotics, correct hair removal processes, the timing of discontinuation of urinary catheterization after surgery, and venous thromboembolism prophylaxis. These practices are now standard in surgical care. Prevention of infection is a heavy emphasis, so the managers would start by reviewing charts to see if the guidelines of this project were implemented. The other actions may be necessary too, but first the managers need to assess the situation.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Perioperative nursing, Surgical Care Improvement Project (SCIP) MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 10. A nurse assesses a client in the preoperative holding area and finds brittle nails and hair, dry

skin turgor, and muscle wasting. What action by the nurse is best? a. Consult the primary health care provider about a dietitian referral. b. Document the findings thoroughly in the client’s chart. c. Encourage the client to eat more after recovering from surgery. d. Refer the client to Meals on Wheels after discharge.

ANS: A

This client has signs of malnutrition, which can impact recovery from surgery. The nurse should consult the primary health care provider about prescribing a consultation with a dietitian in the postoperative period. The nurse should document the findings but needs to do more. Encouraging the client to eat more may be helpful, but the client needs a professional nutritional assessment so that the appropriate diet and supplements can be ordered. The client may or may not need Meals on Wheels after discharge.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Perioperative nursing, Nutrition MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 11. A client has arrived in the inpatient postoperative unit. What action by the inpatient nurse

takes priority? a. Assessing fluid and blood output b. Checking the surgical dressings c. Ensuring the client is warm d. Participating in hand-off report

ANS: D

Hand-offs are a critical time in client care, and poor communication during this time can lead to serious errors. The inpatient nurse and postanesthesia care nurse participate in hand-off report as the priority. Assessing fluid losses and dressings can be done together as part of the report. Ensuring the client is warm is a lower priority.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Perioperative nursing, Hand-off communication MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 12. The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative

clients. Which client would the nurse assess first? a. Client with a blood pressure of 100/50 mm Hg b. Client with a pulse of 118 beats/min c. Client with a respiratory rate of 6 breaths/min d. Client with a temperature of 96° F (35.6° C) ANS: C

The respiratory rate is the most important vital sign for any client who has undergone general anesthesia or moderate sedation, or has received opioid analgesia. This respiratory rate is too low and indicates respiratory depression. The nurse would assess this client first. A blood pressure of 100/50 mm Hg is slightly low and may be within that client’s baseline. A pulse of 118 beats/min is slightly fast, which could be due to several causes, including pain and anxiety. A temperature of 96° F (35.6° C) is slightly low and the client needs to be warmed.

But none of these other vital signs take priority over the respiratory rate.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Perioperative nursing, Nursing assessment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 13. A client had a surgical procedure with spinal anesthesia. The client’s blood pressure was

122/78 mm Hg 30 minutes ago and is now 138/60 and the client reports nausea. What action by the nurse is best? a. Call the Rapid Response Team. b. Increase the IV fluid rate. c. Notify the primary health care provider. d. Nothing; this is expected.

ANS: C

A widening pulse pressure (44 to 78 mm Hg) and nausea may indicate autonomic blockade, a complication of spinal anesthesia causing widespread vasodilation. The nurse would notify the primary health care provider. The Rapid Response Team is not yet warranted; the nurse would not increase the IV rate without a prescription.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Implementation KEY: Perioperative nursing, Adverse drug effects MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 14. A postoperative client vomited. After cleaning and comforting the client, which action by the

nurse is most important? a. Allow the client to rest.

b. Auscultate lung sounds. c. Document the episode. d. Encourage the client to eat dry toast.

ANS: B

Vomiting after surgery has several complications, including aspiration. The nurse would listen to the client’s lung sounds. The client should be allowed to rest after an assessment.

Documenting is important, but the nurse needs to be able to document fully, including an assessment. The client should not eat until nausea has subsided.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Perioperative nursing, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 15. A postoperative client has just been admitted to the postanesthesia care unit (PACU). What

assessment by the PACU nurse takes priority? a. Airway b. Bleeding c. Breathing d. Cardiac rhythm ANS: A

Assessing the airway always takes priority, followed by breathing and circulation. Bleeding is part of the circulation assessment, as is cardiac rhythm.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Perioperative nursing, Nursing assessment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 16. A postoperative client has respiratory depression after receiving morphine for pain. Which

medication and dose does the nurse prepare to administer? a. Flumazenil 0.2 to 1 mg b. Flumazenil 2 to 10 mg c. Naloxone 0.4 to 2 mg d. Naloxone 4 to 20 mg ANS: C

The nurse would prepare to administer naloxone, an opioid antagonist, at a dose of between 0.04 and 0.05 mg up to 2 mg, depending on the client’s symptoms. Flumazenil is a benzodiazepine antagonist.

DIF: Remembering TOP: Integrated Process: Nursing Process: Implementation KEY: Perioperative nursing, Critical rescue MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 17. A nurse on the postsurgical inpatient unit is observing a client perform leg exercises. What

action by the client indicates a need for further instruction? a. Client states “This will help prevent blood clots in my legs.” b. Bends both knees, pushes against the bed until calf and thigh muscles contract. c. Dorsiflexes and plantar flexes each foot several times an hour. d. Makes several clockwise then counterclockwise ankle circles with each foot.

ANS: B

The client should perform this leg exercise one leg at a time. The other actions are correct.

DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Perioperative nursing, Health teaching MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 18. A registered nurse (RN) is watching a new nurse change a dressing and perform care around a

Penrose drain. What action by the new nurse warrants intervention? a. Cleaning around the drain per agency protocol b. Placing a new sterile gauze under the drain c. Securing the drain’s safety pin to the sheets d. Using sterile technique to empty the drain ANS: C

The safety pin that prevents the drain from slipping back into the client’s body would not be pinned to the client’s bedding. Pinning it to the sheets will cause it to pull out when the client turns. The other actions are appropriate.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Implementation KEY: Postoperative nursing, Drains MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 19. A postoperative nurse is caring for a client who received a neuromuscular blocking agent

during surgery. On assessment the nurse notes the client has weak hand grasps. What assessment does the nurse conduct next? a. Ability to raise head off the bed b. Blood pressure and pulse c. Signs of oxygenation d. Level of orientation ANS: C

When neuromuscular blocking agents are retained, muscle weakness could affect the diaphragm and impair gas exchange. Symptoms include the inability to maintain a head lift, weak hand grasps, and an abdominal breathing pattern. Since the client has weak hand grasps, the nurse would assess for signs of systemic oxygenation next. The nurse would assess head lift ability, but this does not take priority over oxygenation. Blood pressure, pulse, and level of orientation are all important in the postoperative period, but oxygenation would come first.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Perioperative nursing, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 20. The postanesthesia care unit (PACU) nurse is caring for an older client following a lengthy

surgery. The client’s pulse is 48 beats/min which is 20 beats/min lower than the preoperative baseline. What assessment does the nurse make next? a. Temperature b. Level of consciousness c. Blood pressure d. Rate of IV infusion

ANS: A

Bradycardia in the immediate postoperative client can indicate anesthesia effect or hypothermia. Older adults are at higher risk for hypothermia because of age-related changes in temperature regulation, decreased body fat, or prolonged exposure to cool environments, such as an OR suite. The nurse would first assess the client’s temperature and take measures to correct any existing hypothermia. Level of consciousness, blood pressure, and IV infusion rate are not related, although all are important assessments in the postoperative period.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Perioperative nursing, Older adult MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 21. The postoperative nurse is caring for a client who reports feeling “something popped” after

vomiting. What action by the nurse is best? a. Administer an antiemetic medication. b. Call the primary health care provider. c. Instruct client to avoid coughing. d. Gather sterile nonadherent dressings.

ANS: D

The client may have a wound dehiscence. The nurse would gather needed supplies and assess the wound under the dressing. If the incision has dehisced, the nurse would cover it with a sterile nonadherent dressing or saline-moistened gauze dressing then call the primary health care provider. The client may need an antiemetic, but this is not the most important action at this time.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Perioperative nursing, Wound dehiscence MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. A new perioperative nurse is receiving orientation to the surgical area and learns about the

Surgical Care Improvement Project (SCIP) goals. What major areas do these measures focus on? (Select all that apply.) a. Hemorrhage prevention b. Infection prevention c. Malignant hyperthermia testing d. Stroke recognition e. Thromboembolism prevention f. Correct hair removal ANS: B, E, F

The Surgical Care Improvement Project (SCIP), a set of core compliance measures, was initiated in 2006 to reduce surgical complications. Examples of focus included administration of prophylactic antibiotics to prevent infection, correct hair removal processes, the timing of discontinuation of urinary catheterization after surgery, and venous thromboembolism prophylaxis. These practices are now standard in surgical care.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Perioperative nursing, Surgical Care Improvement Project (SCIP)

MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 2. A nurse is learning about different surgical procedures and their classifications. Which

examples below does this include? (Select all that apply.) a. Rhinoplasty: curative b. Liver biopsy: diagnostic c. Arthroscopy: preventative. Ileostomy: palliative. Total shoulder replacement: reconstructive d. Body contouring: cosmetic ANS: B, C, D

A cosmetic procedure is designed to improve the client’s appearance or self-confidence; a body contouring procedure is an example. A diagnostic procedure is performed to determine the origin and cause of a disorder by taking a tissue sample with the intention of diagnosing (and staging, if applicable) a condition, such as a liver biopsy. A preventative procedure is performed with the intention that a specific condition will not occur. An example of this is a prophylactic bilateral mastectomy in a woman who carries the BRCA 1 or BRCA 2 gene to prevent the development of breast cancer. A palliative procedure is designed to improve quality of life; an example is an ileostomy. A reconstructive operation improves functional ability is an abnormal or damaged structure. A total shoulder replacement would be an example. A curative operation is performed to resolve a health problem by repairing or removing the cause; a gallbladder removal is an example.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Perioperative nursing, Surgical procedures MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. A nurse is caring for several clients in the morning prior to surgery. Which medications taken

by the clients require the nurse to consult with the primary health care provider about their administration? (Select all that apply.) a. Insulin b. Omega-3 fatty acids c. Phenytoin d. Metoprolol e. Warfarin f. Prednisone ANS: A, C, D, E, F

Although the client will be on NPO status before surgery, the nurse should check with the primary health care provider about allowing the client to take medications prescribed for diabetes, hypertension, cardiac disease, seizure disorders, depression, glaucoma, anticoagulation, or depression and steroids. Metformin is used to treat diabetes; phenytoin is for seizures; metoprolol is for cardiac disease and/or hypertension; and warfarin is an anticoagulant. The omega-3 fatty acids can be held the day of surgery.

DIF: Understanding TOP: Integrated Process: Nursing Process: Analysis KEY: Perioperative nursing, Medication safety MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

4. A nurse recently hired to the preoperative area learns that certain clients are at higher risk for

venous thromboembolism (VTE). Which clients are considered to be at high risk? (Select all that apply.) a. Client with a humerus fracture b. Morbidly obese client c. Client who smokes d. Client with severe heart failure e. Wheelchair-bound client f. 50 years of age or older ANS: B, C, D, E

All surgical clients should be assessed for VTE risk. Those considered to be at higher risk include those who are obese; are over 40; have cancer; have decreased mobility, immobility, or a spinal cord injury; have a history of any thrombotic event, varicose veins, or edema; take oral contraceptives or smoke; have decreased cardiac output; have a hip fracture; or are having total hip or knee surgery.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Perioperative nursing, Venous thromboembolism MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 5. A client has received several doses of midazolam. The nurse assesses the client to be difficult

to arouse with respirations of 6 breaths/min. What actions by the nurse are most important?

(Select all that apply.) a. Administer oxygen per protocol. b. Obtain one dose of flumazenil. c. Obtain naloxone, 0.04 mg for IV push. d. Ensure suction is working e. Transfer the client to intensive care. f. Monitor client every 10 to 15 minutes for the next 2 hours.

ANS: A, D, E

Midazolam is a benzodiazepine and its reversal agent is flumazenil. Naloxone is for opioid reversal. The nurse would apply oxygen as prescribed or by policy and obtain several doses at once because the drug can be given every 2 to 3 minutes if needed. Flumazenil can cause vomiting, so the nurse ensures suction equipment is present and working. Since flumazenil is metabolized more quickly than the midazolam, the client must be monitored every 10 to 15 minutes for the next 2 hours. The client may or may not need to be transferred.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Perioperative nursing, Critical rescue MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. A nurse learns older adults are at higher risk for complications after surgery. What reasons for

this does the nurse understand? (Select all that apply.) a. Decreased cardiac output b. Decreased oxygenation c. Frequent nocturia d. Mobility alterations e. Inability to adapt to changes f. Slower reaction times

ANS: A, B, C, D, F

Older adults have many age-related physiologic changes that put them at higher risk of falling and other complications after surgery. Some of these include decreased cardiac output, decreased oxygenation of tissues, nocturia, mobility alterations, and slower reaction times.

They also have a decreased ability to adapt to new surroundings, but that is not the same as being unable to adapt.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Perioperative nursing, Older adult MSC: Client Needs Category: Health Promotion and Maintenance 7. A nurse working in the preoperative holding area performs which functions to ensure client

safety? (Select all that apply.) a. Allow small sips of plain water. b. Check that consent is on the chart. c. Ensure that the client has an armband on. d. Have the client help mark the surgical site. e. Allow the client to use the toilet before giving sedation. f. Assess the client for fall risks.

ANS: B, C, D, E, F

Providing for client safety is a priority function of the preoperative nurse. Checking for appropriately completed consent, verifying the client’s identity, having the client assist in marking the surgical site if applicable, assessing for fall risk, and allowing the client to use the toilet prior to sedating him or her are just some examples of important safety measures. The preoperative client should be NPO, so water should not be provided unless an oral medication is ordered to be given in pre-op.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Perioperative nursing, Safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 8. A nurse orienting to the postoperative area learns which principles about the postoperative

period? (Select all that apply.) a. All phases require the client to be in the hospital. b. Phase I care may last for several days in some clients. c. Phase I requires intensive care unit monitoring. d. Phase II ends when the client is stable and awake. e. Vital signs may be taken only once a day in phase III. f. Some clients may be discharged directly after phase I. ANS: C, D, E

There are three phases of postoperative care. Phase I is the most intense, with clients coming right from surgery until they are completely awake and hemodynamically stable. This may take hours or days and can occur in the intensive care unit or the postoperative care unit.

Some patients achieve this level of recovery in phase I and can be discharged directly to home. Phase II ends when the client is at a pre-surgical level of consciousness and baseline oxygen saturation, and vital signs are stable. Phase III involves the extended-care environment and may continue at home or in an extended-care facility if needed.

DIF: Remembering

TOP: Integrated Process: Teaching/Learning

KEY: Perioperative nursing, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 9. A postanesthesia care unit (PACU) nurse is assessing a postoperative client with a nasogastric

(NG) tube. What laboratory values would warrant intervention by the nurse? (Select all that apply.) a. Blood glucose: 120 mg/dL (6.7 mmol/L) b. Hemoglobin: 7.8 mg/dL (78 mmol/L) c. pH: 7.68 d. Potassium: 2.9 mEq/L (2.9 mmol/L) e. Sodium: 142 mEq/L (142 mmol/L) ANS: B, C, D

Fluid and electrolyte balance are assessed carefully in the postoperative client because many imbalances can occur. The low hemoglobin may be from blood loss in surgery. The higher pH level indicates alkalosis, possibly from losses through the NG tube. The potassium is very low. The blood glucose is within normal limits for a postsurgical client who has been fasting.

The sodium level is normal.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Perioperative nursing, Laboratory values MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 10. A nurse on the postoperative nursing unit provides care to reduce the incidence of surgical

wound infection. What actions are best to achieve this goal? (Select all that apply.) a. Administering antibiotics for 72 hours b. Disposing of dressings properly c. Leaving draining wounds open to air d. Performing proper hand hygiene e. Removing and replacing wet dressings ANS: B, D, E

Interventions necessary to prevent surgical wound infection include proper disposal of soiled dressings, performing proper hand hygiene, and removing wet dressings as they can be a source of infection. Prophylactic antibiotics may be given to clients at risk for infection, but not all clients need them for 72 hours. Draining wounds would always be covered.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Perioperative nursing, Infection control MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

Chapter 10: Concepts of Emergency and Trauma Nursing Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. An emergency department nurse assesses a client who has been raped. With which health care

team member would the nurse collaborate when planning this client’s care? a. Primary health care provider b. Case manager c. Forensic nurse examiner d. Psychiatric crisis nurse ANS: C

All other members of the health care team listed may be used in the management of this client’s care. However, the forensic nurse examiner is educated to obtain client histories and collect evidence dealing with the assault, and can offer the counseling and follow-up needed when dealing with the victim of an assault.

DIF: Understanding TOP: Integrated Process: Nursing Process: Planning KEY: Emergency nursing, Interprofessional team MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 2. The emergency department team is performing cardiopulmonary resuscitation on a client

when the client’s spouse arrives. Which action would the nurse take first? a. Request that the client’s spouse sit in the waiting room. b. Ask the spouse if he or she wishes to be present during the resuscitation. c. Suggest that the spouse begin to pray for the patient. d. Refer the client’s spouse to the hospital’s crisis team.

ANS: B

If resuscitation efforts are still under way when the family arrives, one or two family members may be given the opportunity to be present during lifesaving procedures. The other options do not give the spouse the opportunity to be present for the client or to begin to have closure.

DIF: Applying TOP: Integrated Process: Caring MSC: Client Needs Category: Psychosocial Integrity

KEY: Emergency nursing

3. An emergency department nurse is triaging victims of a multi-casualty event. Which client

would receive care first? a. A 30-year-old distraught mother holding her crying child b. A 65-year-old conscious male with a head laceration c. A 26-year-old male who has pale, cool, clammy skin d. A 48 year old with a simple fracture of the lower leg ANS: C

The client with pale, cool, clammy skin may be in shock and needs immediate medical attention. The mother does not have injuries and so would be the lowest priority. The other two people need medical attention soon, but not at the expense of a person in shock.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Emergency nursing, Triage

MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 4. While triaging clients in a crowded emergency department, a nurse assesses a client who

presents with symptoms of tuberculosis. Which action would the nurse take first? a. Apply oxygen via nasal cannula. b. Administer intravenous 0.9% saline solution. c. Transfer the client to a negative-pressure room. d. Obtain a sputum culture and sensitivity.

ANS: C

A client with signs and symptoms of tuberculosis or other airborne pathogens would be placed in a negative-pressure room to prevent contamination of staff, clients, and family members in the crowded emergency department. The client may or may not need oxygen or an IV. A sputum culture would be obtained but is not the priority.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Emergency nursing, Transmission-Based Precautions MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 5. A nurse is triaging clients in the emergency department (ED). Which client would the nurse

prioritize to receive care first? a. A 22 year old with a painful and swollen right wrist b. A 45 year old reporting chest pain and diaphoresis c. A 60 year old reporting difficulty swallowing and nausea d. An 81 year old, respiratory rate 28 breaths/min and temperature of 101° F (38.8° C) ANS: B

A client experiencing chest pain and diaphoresis would be classified as emergent and would be triaged immediately to a treatment room in the ED. The other clients are more stable.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning KEY: Emergency nursing, Triage MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 6. A nurse is evaluating levels and functions of trauma centers. Which function is appropriately

paired with the level of the trauma center? a. Level I—located within remote areas and provides advanced life support within resource capabilities b. Level II—located within community hospitals and provides care to most injured clients c. Level III—located in rural communities and provides only basic care to clients d. Level IV—located in large teaching hospitals and provides a full continuum of trauma care for all clients ANS: B

Level I trauma centers are usually located in large teaching hospital systems and provide a full continuum of trauma care for all clients. Both Level II and Level III facilities are usually located in community hospitals. These trauma centers provide care for most clients and transport to Level I centers when client needs exceed resource capabilities. Level IV trauma centers are usually located in rural and remote areas. These centers provide basic care, stabilization, and advanced life support while transfer arrangements to higher level trauma centers are made.

DIF: Remembering TOP: Integrated Process: Nursing Process: Planning KEY: Emergency nursing, Levels of trauma centers MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 7. Emergency medical technicians arrive at the emergency department with an unresponsive

client who has an oxygen mask in place. Which action would the nurse take first? a. Assess that the client is breathing adequately. b. Insert a large-bore intravenous line. c. Place the client on a cardiac monitor. d. Assess for the best neurologic response.

ANS: A

After establishing an airway, the highest priority intervention in the primary survey is to establish that the client is breathing adequately. Even though this client has an oxygen mask on, he or she may not be breathing, or may be breathing inadequately with the device in place.

Inserting an IV line and placing the client on a monitor would come after ensuring a patent airway and effective breathing.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Emergency nursing, Primary survey MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 8. A trauma client with multiple open wounds is brought to the emergency department in cardiac

arrest. Which action would the nurse take prior to providing advanced cardiac life support? a. Contact the on-call orthopedic surgeon. b. Don personal protective equipment. c. Notify the Rapid Response Team. d. Obtain a complete history from the paramedic.

ANS: B

Nurses must recognize and plan for a high risk of contamination with blood and body fluids when engaging in trauma resuscitation. Standard Precautions would be taken in all resuscitation situations and at other times when exposure to blood and body fluids is likely.

Proper attire consists of an impervious cover gown, gloves, eye protection, a facemask, a surgical cap, and shoe covers. It is not known if this client has orthopedic injuries. The Rapid Response Team is not needed in the ED. A complete history is needed but the staff’s protection comes first.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning KEY: Emergency nursing, Standard Precautions MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

9. A nurse is triaging clients in the emergency department. Which client would be considered

“urgent”? a. A 20-year-old female with a chest stab wound and tachycardia b. A 45-year-old homeless man with a skin rash and sore throat c. A 75-year-old female with a cough and a temperature of 102° F (38.9° C) d. A 50-year-old male with new-onset confusion and slurred speech ANS: C

A client with a cough and a temperature of 102° F (38.9° C) is urgent. This client is at risk for deterioration and needs to be seen quickly, but is not in an immediately life-threatening situation. The client with a chest stab wound and tachycardia and the client with new-onset confusion and slurred speech would be triaged as emergent. The client with a skin rash and a sore throat is not at risk for deterioration and would be triaged as nonurgent.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning KEY: Emergency nursing, Triage MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 10. An emergency department nurse is caring for a client who has died from a suspected

homicide. Which action does the nurse take? a. Remove all tubes and wires in preparation for the medical examiner. b. Limit the number of visitors to minimize the family’s trauma. c. Consult the bereavement committee to follow up with the grieving family. d. Communicate the client’s death to the family in a simple and concrete manner.

ANS: D

When dealing with clients and families in crisis, communicate in a simple and concrete manner to minimize confusion. Tubes must remain in place for the medical examiner. Family would be allowed to view the body. Offering to call for additional family support during the crisis is suggested. The bereavement committee would be consulted, but this is not the priority at this time.

DIF: Applying TOP: Integrated Process: Caring MSC: Client Needs Category: Psychosocial Integrity

KEY: Emergency nursing, Death

11. An emergency department (ED) case manager is consulted for a client who is homeless.

Which intervention would the case manager provide? a. Communicate client needs and restrictions to support staff. b. Prescribe low-cost antibiotics to treat community-acquired infection. c. Provide referrals to subsidized community-based health clinics. d. Offer counseling for substance abuse and mental health disorders.

ANS: C

Case management interventions include facilitating referrals to primary care providers who are accepting new clients or to subsidized community-based health clinics for clients or families in need of routine services. The ED nurse is accountable for communicating pertinent staff considerations, client needs, and restrictions to support staff (e.g., physical limitations, Isolation Precautions) to ensure that ongoing client and staff safety issues are addressed. The ED provider prescribes medications and treatments. The psychiatric nurse team evaluates clients with emotional behaviors or mental illness and facilitates the follow-up treatment plan, including possible admission to an appropriate psychiatric facility.

DIF: Understanding TOP: Integrated Process: Nursing Process: Planning KEY: Emergency nursing, Interprofessional team MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 12. An emergency department nurse is caring for a client who is homeless. Which action would

the nurse take to gain the client’s trust? a. Speak in a quiet and monotone voice. b. Avoid eye contact with the patient. c. Listen to the client’s concerns and needs. d. Ask security to store the client’s belongings.

ANS: C

To demonstrate behaviors that promote trust with homeless clients, the emergency department nurse makes eye contact (if culturally appropriate), speaks calmly, avoids any prejudicial or stereotypical remarks, shows genuine care and concern by listening, and follows through on promises. The nurse would also respect the client’s belongings and personal space.

DIF: Understanding TOP: Integrated Process: Nursing Process: Planning KEY: Emergency nursing, Psychosocial response MSC: Client Needs Category: Psychosocial Integrity 13. A nurse is triaging clients in the emergency department. Which client would the nurse classify

as “nonurgent?” a. A 44 year old with chest pain and diaphoresis b. A 50 year old with chest trauma and absent breath sounds c. A 62 year old with a simple fracture of the left arm d. A 79 year old with a temperature of 104° F (40.0° C) ANS: C

A client in a nonurgent category can tolerate waiting several hours for health care services without a significant risk of clinical deterioration. The client with a simple arm fracture and palpable radial pulses is currently stable, is not at significant risk of clinical deterioration, and would be considered nonurgent. The client with chest pain and diaphoresis and the client with chest trauma are emergent owing to the potential for clinical deterioration and would be seen immediately. The client with a high fever may be stable now but also has a risk of deterioration.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning KEY: Emergency nursing, Triage MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 14. What is the primary goal of a triage system used by the nurse with clients presenting to the

emergency department? a. Determine the acuity of the client’s condition to determine priority of care. b. Assess the status of the airway, breathing, circulation, or presence of deficits. c. Determine whether the client is responsive enough to provide needed information. d. Evaluate the emergency department’s resources to adequately treat the patient.

ANS: A

ED triage is an organized system for sorting and classifying clients into priority levels depending on illness or injury severity. The primary goal of the triage system is to facilitate the ED nurse’s ability to prioritize care according to the acuity of the patient, having the clients with the more severe illness or injury seen first. Airway, breathing, and circulation are part of the primary survey. Determining responsiveness is done during the disability phase of the primary survey and is not the primary goal. Evaluating the ED’s resources is also not a goal of triage.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning KEY: Emergency nursing, Triage MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 15. An elderly client who has fallen from a roof is transported to the emergency department by

ambulance. The client was unconscious at the scene but is conscious on arrival and is triaged as urgent. What is the priority assessment the nurse includes during the primary survey of the patient? a. A full set of vital signs b. Cardiac rhythm c. Neurologic status d. Client history ANS: C

The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. Injuries from this type of fall have a high risk for cervical spine injuries. In addition, with the loss of consciousness at the scene the client would be at risk for head trauma. A full set of vital signs is obtained as part of the secondary survey. The cardiac rhythm is important but not specifically related to this client’s presentation. Client history would be obtained as able.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Emergency nursing, Primary survey MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. A nurse is caring for clients in a busy emergency department. What actions would the nurse

take to ensure client and staff safety? (Select all that apply.) a. Leave the stretcher in the lowest position with rails down so that the client can access the bathroom. b. Use two identifiers before each intervention and before mediation administration. c. Attempt de-escalation strategies for clients who demonstrate aggressive behaviors. d. Search the belongings of clients with altered mental status to gain essential medical information. e. Use facility policy identification procedures for “Jane/John Doe” clients. f. Check clients for a medical alert bracelets or necklaces. g. Avoid using Security personnel to prevent escalation of client behaviors.

ANS: B, C, D, E, F

Best practices for client and staff safety in the emergency department include leaving beds in the lowest position with side rails up, using two unique identifiers for medications and procedures, using de-escalation strategies for clients or visitors showing hostile or aggressive behaviors, searching the belongings of confused clients for medical information, using facility identification systems for Jane/John Doe clients, observing for medical alert jewelry, and using security staff as needed.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Emergency nursing, Safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 2. An emergency department (ED) nurse is preparing to transfer a client to the trauma intensive

care unit. Which information would the nurse include in the nurse-to-nurse hand-off report?

(Select all that apply.) a. Mechanism of injury b. Diagnostic test results c. Immunizations d. List of home medications e. Isolation Precautions f. Safety concerns ANS: A, B, E, F

Hand-off communication would be comprehensive so that the receiving nurse can continue care for the client fluidly. Communication would be concise and would include only the most essential information for a safe transition in care. Hand-off communication would include the client’s situation (reason for being in the ED), brief medical history, assessment and diagnostic findings, Transmission-Based Precautions needed, safety concerns interventions provided, and response to those interventions. Immunization history is not usually considered critical unless it relates to the reason for admission. Medication reconciliation will occur when the client reaches the inpatient unit.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Emergency nursing, Hand-off communication MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 3. An emergency department nurse is caring for a trauma patient. Which interventions does the

nurse perform during the primary survey? (Select all that apply.) a. Foley catheterization b. Needle decompression c. Initiating IV fluids d. Splinting open fractures e. Endotracheal intubation f. Removing wet clothing g. Laceration repair ANS: B, C, E, F

The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. The primary survey is based on the standard mnemonic ABC, with an added D and E: Airway and cervical spinal motion restriction; Breathing; Circulation; Disability; and Exposure. After the completion of primary diagnostic and laboratory studies, and the insertion of gastric and urinary tubes, the secondary survey (a complete head-to-toe assessment) can be carried out.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Emergency nursing, Primary survey MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. The complex care provided during an emergency requires interprofessional collaboration.

Which team members are paired with the correct responsibilities? (Select all that apply.) a. Psychiatric crisis nurse—interacts with clients and families when sudden illness, serious injury, or death of a loved one may cause a crisis b. Forensic nurse examiner—performs rapid assessments to ensure that clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources c. Triage nurse—provides basic life support interventions such as oxygen, basic wound care, splinting, spinal motion restriction, and monitoring of vital signs d. Emergency medical technician—obtains client histories, collects evidence, and offers counseling and follow up care for victims of rape, child abuse, and domestic violence e. Paramedic—provides prehospital advanced life support, including cardiac monitoring, advanced airway management, and medication administration ANS: A, E

The psychiatric crisis nurse evaluates clients with emotional behaviors or mental illness and facilitates follow-up treatment plans. The psychiatric crisis nurse also works with clients and families when experiencing a crisis. Paramedics are advanced life support providers who can perform advanced techniques that may include cardiac monitoring, advanced airway management and intubation, establishing IV access, and administering drugs en route to the emergency department. The forensic nurse examiner is trained to recognize evidence of abuse and to intervene on the client’s behalf. The forensic nurse examiner will obtain client histories, collect evidence, and offer counseling and follow up care for victims of rape, child abuse, and domestic violence. The triage nurse performs rapid assessments to ensure that clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources. The emergency medical technician is usually the first caregiver and provides basic life support and transportation to the emergency department.

DIF: Understanding TOP: Integrated Process: Nursing Process: Planning KEY: Emergency nursing, Interprofessional team MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 5. A nurse prepares to discharge an older adult client home from the emergency department

(ED). What actions does the nurse take to prevent future ED visits? (Select all that apply.) a. Provide medical supplies to the family. b. Consult a home health agency. c. Encourage participation in community activities. d. Screen for depression and suicide.

e. Complete a functional assessment.

ANS: D, E

Due to the high rate of suicide among older adults, a nurse would assess all older adults for depression and suicide. The nurse would also screen older adults for functional assessment, cognitive assessment, and risk for falls to prevent future ED visits.

DIF: Understanding TOP: Integrated Process: Nursing Process: Implementation KEY: Emergency nursing, Older adult MSC: Client Needs Category: Health Promotion and Maintenance

Chapter 11: Concepts of Care for Patients With Common Environmental Emergencies Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. On a hot humid day, an emergency department nurse is caring for a client who is confused

and has these vital signs: temperature 104.1° F (40.1° C), pulse 132 beats/min, respirations 26 breaths/min, and blood pressure 106/66 mm Hg. What action would the nurse take? a. Encourage the client to drink cool water or sports drinks. b. Start an intravenous line and infuse 0.9% saline solution. c. Administer acetaminophen (Tylenol) 650 mg orally. d. Encourage rest and reassess in 15 minutes.

ANS: B

The client demonstrates signs of heat stroke. This is a medical emergency and priority care includes oxygen therapy, IV infusion with 0.9% saline solution, insertion of a urinary catheter, and aggressive interventions to cool the patient, including external cooling and internal cooling methods. Oral hydration would not be appropriate for a client who has symptoms of heat stroke because oral fluids would not provide necessary rapid rehydration, and the confused client would be at risk for aspiration. Acetaminophen would not decrease this patient’s temperature or improve the patient’s symptoms. The client needs immediate medical treatment; therefore, rest and reassessing in 15 minutes are inappropriate.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Environmental emergencies, Heat-related illness MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. While at a public park, a nurse encounters a person immediately after a bee sting. The

person’s lips are swollen, and wheezes are audible. What action would the nurse take first? a. Elevate the site and notify the person’s next of kin. b. Remove the stinger with tweezers and encourage rest. c. Administer diphenhydramine and apply ice. d. Administer an epinephrine autoinjector and call 911.

ANS: D

The client’s swollen lips indicate that anaphylaxis may be developing, and this is a medical emergency. The nurse would call 911 would immediately, and the client transported to the emergency department as quickly as possible. If an EpiPen is available, it would be administered at the first sign of an anaphylactic reaction. The other answers do not provide adequate interventions to treat airway obstruction due to anaphylaxis, although the nurse would remove the stinger as soon as possible after administering the autoinjector.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Environmental emergencies, Bee and insect stings MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. A client presents to the emergency department after prolonged exposure to the cold. The client

is difficult to arouse and speech is incoherent. What action would the nurse take first? a. Reposition the client into a prone position. b. Administer warmed intravenous fluids to the client.

c. Wrap the client’s extremities in warm blankets. d. Initiate extracorporeal rewarming via hemodialysis.

ANS: B

Moderate hypothermia manifests with muscle weakness, increased loss of coordination, acute confusion, apathy, incoherence, stupor, and impaired clotting. Moderate hypothermia is treated by core rewarming methods, which include administration of warm IV fluids; heated oxygen; and heated peritoneal, pleural, gastric, or bladder lavage. The client’s trunk would be warmed prior to the extremities to prevent peripheral vasodilation. Extracorporeal warming with cardiopulmonary bypass or hemodialysis is a treatment for severe hypothermia.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Environmental emergencies, Cold-related illness MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. An emergency department nurse cares for a middle-age mountain climber who is confused,

ataxic, and exhibits impaired judgement. After administering oxygen, which intervention would the nurse implement next? a. Administer dexamethasone. b. Complete a mini mental state examination. c. Prepare the client for computed tomography of the brain. d. Request a psychiatric consult.

ANS: A

The client is exhibiting signs of mountain sickness and high-altitude cerebral edema (HACE).

Dexamethasone reduces cerebral edema by acting as an anti-inflammatory in the central nervous system. The other interventions will not specifically treat HACE, although a thorough mental status exam would be performed.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning KEY: Environmental emergencies, Altitude-related illness MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 5. An emergency department nurse assesses a client admitted after a lightning strike. The client

is awake but somewhat confused. Which assessment would the nurse complete first? a. Electrocardiogram (ECG) b. Wound inspection c. Creatinine kinase d. Computed tomography of head ANS: A

Clients who survive a lightning strike can have serious myocardial injury, which can be manifested by ECG and myocardial perfusion abnormalities. The nurse would prioritize the ECG over the other assessments which would be completed later.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Environmental emergencies, Lightning injury MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. A nurse teaches a community health class about water safety. Which statement by a

participant indicates that additional teaching is needed? a. “I can go swimming all by myself because I am a certified lifeguard.”

b. “I cannot leave my toddler alone in the bathtub for even a minute.” c. “I will appoint one adult to supervise the pool at all times during a party.” d. “I will make sure that there is a phone near my pool in case of an emergency.”

ANS: A

People would never swim alone, regardless of lifeguard status. The other statements indicate good understanding of the teaching.

DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Environmental emergencies, Drowning, Health teaching MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 7. A primary health care provider prescribes a rewarming bath for a client who presents with

Grade 3 frostbite. What action would the nurse take prior to starting this treatment? a. Administer intravenous morphine. b. Wrap the limb with a compression dressing. c. Massage the frostbitten areas. d. Assess the limb for compartment syndrome.

ANS: A

Rapid rewarming in a water bath is recommended for all instances of partial-thickness and full-thickness frostbite. Patients experience severe pain during the rewarming process and nurses would administer intravenous analgesics.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Environmental emergencies, Cold-related illness MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 8. A nurse assesses a client recently bitten by a coral snake. Which assessment would the nurse

complete first? a. Unilateral peripheral swelling b. Clotting times c. Cardiopulmonary status d. Electrocardiogram rhythm ANS: C

Signs and symptoms of coral snake envenomation are the result of its neurotoxic properties.

The physiologic effect is to block neurotransmission, which produces ascending paralysis, reduced perception of pain, and, ultimately, respiratory paralysis. The nurse would monitor for respiratory rate and depth. Severe swelling and clotting problems do not occur with coral snakes but do occur with pit viper snakes. Electrocardiogram rhythm is not affected by neurotoxins.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Environmental emergencies, Snakebites MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 9. A nurse plans care for a client admitted with a snakebite to the right leg. With whom would

the nurse collaborate? a. The facility’s neurologist b. The poison control center c. The physical therapy department

d. A herpetologist (snake specialist) ANS: B

For the client with a snakebite, the nurse would contact the regional poison control center immediately for specific advice on antivenom administration and client management.

DIF: Remembering TOP: Integrated Process: Nursing Process: Planning KEY: Environmental emergencies, Snakebites MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 10. While on a camping trip, a nurse cares for an adult client who had a drowning incident in a

lake and is experiencing agonal breathing with a palpable pulse. What action would the nurse take first? a. Deliver rescue breaths. b. Wrap the client in dry blankets. c. Assess for signs of bleeding. d. Check for a carotid pulse.

ANS: A

In this emergency situation, the nurse immediately initiates airway clearance and ventilator support measures, including delivering rescue breaths.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Environmental emergencies, Drowning MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 11. A nurse assesses a client admitted with a brown recluse spider bite. Which assessment does

the nurse perform to identify complications of this bite? a. Ask the client about pruritus at the bite site. b. Inspect the bite site for a bluish purple vesicle. c. Assess the extremity for redness and swelling. d. Monitor the client’s temperature every 4 hours.

ANS: D

Fever and chills indicate systemic toxicity, which can lead to hemolytic anemia, thrombocytopenia, DIC, and death. Assessing for a fever would indicate this complication.

All other symptoms are normal for a brown recluse bite and would be assessed, but they do not provide information about complications from the bite.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Environmental emergencies, Arthropod bites MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 12. A primary health care provider prescribes diazepam to a client who was bitten by a black

widow spider. The client asks, “What is this medication for?” How does the nurse respond? a. “This medication is an antivenom for this type of bite.” b. “It will relieve your muscle rigidity and spasms.” c. “It prevents respiratory difficulty from excessive secretions.” d. “This medication will prevent respiratory failure.”

ANS: B

Black widow spider venom can produce muscle rigidity and spasms, which are treated with the muscle relaxant, diazepam. It does not prevent respiratory difficulty or failure nor is it antivenom.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Environmental emergencies, Arthropod bites MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 13. After teaching a client how to prevent altitude-related illnesses, a nurse assesses the client’s

understanding. Which statement indicates that the client needs additional teaching? a. “If my climbing partner can’t think straight, we should descend to a lower altitude.” b. “I will ask my primary health care provider about medications to help prevent acute mountain sickness.” c. “My partner and I will plan to sleep at a higher elevation to acclimate more quickly.” d. “I will drink plenty of fluids to stay hydrated while on the mountain.”

ANS: C

Teaching to prevent altitude-related illness would include descending when symptoms start, staying hydrated, and taking acetazolamide, which is commonly used to prevent and treat acute mountain sickness. The nurse would teach the client to sleep at a lower elevation.

DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Environmental emergencies, Altitude-related illness, Health teaching MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 14. A client admitted to the emergency department following a lightning strike. What is the

priority assessment the nurse focuses on? a. Cardiopulmonary b. Integumentary c. Peripheral vascular d. Renal ANS: A

Lightning strikes can profoundly affect the cardiopulmonary and the central nervous system as a serious cardiac and/or respiratory arrest. The nurse would be alert for reports of chest pain and would watch for dysrhythmias on the cardiac monitor. As impairment of the respiratory center can also be affected, the nurse would assess the respiratory system second.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Environmental emergencies, Lightning injuries MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 15. A middle-age mountain hiker is admitted to the emergency department exhibiting a cough

with pink, frothy sputum and cyanosis of lips and nail beds. What priority action would the nurse implement? a. Administer acetazolamide. b. Administer oxygen via a nonrebreather mask. c. Complete a thorough pulmonary assessment. d. Obtain arterial blood gas (ABG) specimen for analysis.

ANS: B

The client is exhibiting signs of AMS with high-altitude pulmonary edema (HAPE). Cyanosis indicates hypoxia and must be treated immediately. A complete pulmonary assessment and ABG analysis are indicated but the priority is oxygen administration. Acetazolamide is used to prevent AMS. DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Environmental emergencies, Altitude-related illness MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 1. A nurse is teaching a wilderness survival class. Which statements would the nurse include

about the prevention of hypothermia and frostbite? (Select all that apply.) a. “Wear synthetic clothing instead of cotton to keep your skin dry.” b. “Drink plenty of fluids. Brandy can be used to keep your body warm.” c. “Remove your hat when exercising to prevent overheating.” d. “Wear sunglasses to protect skin and eyes from harmful rays.” e. “Know your physical limits. Come in out of the cold when limits are reached.” f. “Change your gloves and socks if they become wet.”

ANS: A, D, E, F

To prevent hypothermia and frostbite, the nurse would teach patients to wear synthetic clothing (which moves moisture away from the body and dries quickly), layer clothing, and a hat, facemask, sunscreen, and sunglasses. The client would also be taught to drink plenty of fluids, but to avoid alcohol when participating in winter activities. Clients need to know their physical limits and come in out of the cold when these limits have been reached. Wet clothing contributes to heat loss so clients would be taught to change any clothing that becomes wet.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Environmental emergencies, Cold-related illness, Health teaching MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A nurse teaches a client who has severe allergies ways to prevent insect bites. Which

statements does the nurse include in this client’s teaching? (Select all that apply.) a. “Consult an exterminator to control bugs in and around your home.” b. “Do not swat at insects or wasps.” c. “Wear sandals whenever you go outside.” d. “Keep your prescribed epinephrine autoinjector in a bedside drawer.” e. “Use screens in your windows and doors to prevent flying insects from entering.” f. “Identify and remove potential nesting sites in your yard.”

ANS: A, B, E, F

To prevent arthropod bites and stings, patients should wear protective clothing, cover garbage cans, use screens in windows and doors, inspect clothing and shoes before putting them on, consult an exterminator, remove nests, avoid swatting at insects, and carry a prescription epinephrine autoinjector at all times if they are known to be allergic to bee or wasp stings.

Shoes are needed when working in areas known or suspected to harbor arthropods, but sandals will not protect the feet. Removing nesting sites may help eliminate the population.

DIF: Understanding

TOP: Integrated Process: Teaching/Learning

KEY: Environmental emergencies, Bee and insect sting, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 3. A nurse is providing health education at a community center. Which instructions does the

nurse include in teaching about prevention of lightning injuries during a storm? (Select all that apply.) a. Seek shelter inside a building or vehicle. b. Hide under a tall tree. c. Do not take a bath or shower. d. Turn off the television. e. Remove all body piercings. f. Put down golf clubs or gardening tools.

ANS: A, C, D, F

When thunder is heard, individuals should seek shelter in a safe area such as a building or an enclosed vehicle. Electrical equipment such as TVs and stereos should be turned off. Stay away from plumbing, water, and metal objects such as golf clubs or gardening tools. Do not stand under an isolated tall tree or a structure such as a flagpole. Body piercings will not increase a person’s chances of being struck by lightning.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Environmental emergencies, Lightning injuries MSC: Client Needs Category: Health Promotion and Maintenance 4. An emergency department nurse moves to a new city where heat-related illnesses are

common. Which clients does the nurse anticipate being at highest risk for heat-related illnesses? (Select all that apply.) a. Homeless individuals b. People with substance abuse disorders c. Caucasians d. Hockey players e. Older adults f. Obese individuals ANS: A, B, E, F

Some of the most vulnerable, at-risk populations for heat-related illness include older adults; people who work outside, such as construction and agricultural workers; homeless people; people who abuse substances; outdoor athletes (recreational and professional); and members of the military who are stationed in countries with hot climates (e.g., Iraq, Afghanistan).

Hockey is generally a cold-air game whether played indoors or outdoors and wouldn’t have as much risk for heat-related illness as other sports.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Environmental emergencies, Heat-related illness MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 5. An emergency department nurse plans care for a client who is admitted with heat stroke.

Which interventions does the nurse include in this patient’s plan of care? (Select all that apply.) a. Administer oxygen via mask or nasal cannula. b. Administer ibuprofen, an antipyretic medication.

c. Apply cooling techniques until core body temperature is less than 101° F (38.3°

C). d. Infuse 0.9% sodium chloride via a large-bore intravenous cannula. e. Obtain baseline serum electrolytes and cardiac enzymes. f. Insert an indwelling urinary catheter for urine output measurements.

ANS: A, D, E

Heat stroke is a medical emergency. Oxygen therapy and intravenous fluids would be provided, and baseline laboratory tests would be performed as quickly as possible. Urinary output is measured via an indwelling urinary catheter. The client would be cooled until core body temperature is reduced to 102° F (38.9° C). Antipyretics would not be administered.

DIF: Understanding TOP: Integrated Process: Nursing Process: Planning KEY: Environmental emergencies, Heat-related illness MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. A nurse is in charge of a first-aid tent at an all-day outdoor sports event on a hot and humid

day. A participant comes to the tent reporting a headache, weakness, and nausea. What actions would the nurse take? (Select all that apply.) a. Have the client lie down in a cool place. b. Force fluids with large quantities of plain water. c. Administer acetaminophen and send home. d. Apply cold packs to neck, arm pits, and groin. e. Encourage drinking a sports drink. f. Remove all clothing and cover with a towel.

ANS: A, D, E

Heat exhaustion manifests as flulike symptoms with headache, weakness, nausea, and/or vomiting. Treatment includes stopping the activity, moving to a cool place, and using cooling measures such as cold packs, cool water soaks, or fanning while spraying cool water on skin.

Sodium deficits may occur from drinking plain water, so sports drinks or an oral rehydration therapy solution would be provided. The nurse would remove constrictive clothing only.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Environmental emergencies, Heat-related illness MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 7. Which assessment findings would indicate to the nurse that a client has suffered from a heat

stroke? (Select all that apply.) a. Confusion and bizarre behavior b. Headache and fatigue c. Hypotension d. Presence of perspiration e. Tachycardia and tachypnea f. Body temperature more than 104° F (40° C) ANS: A, C, E, F

Signs and symptoms of heat stroke include as elevated body temperature (above 104° F [40° C]), mental status changes such as confusion and decreasing level of consciousness, hypotension, tachycardia, and tachypnea. Perspiration is an inconsistent finding.

DIF: Applying

TOP: Integrated Process: Nursing Process: Assessment

KEY: Environmental emergencies, Heat-related illness MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 8. An emergency department nurse is caring for a client who had been hiking in the mountains

for the past 2 days. What are the most important indicators that a client is experiencing high-altitude pulmonary edema (HAPE)? (Select all that apply.) a. Ataxia b. Confusion c. Crackles in both lung fields d. Decreased level of consciousness e. Persistent dry cough f. Reports “feeling hung over” ANS: C, E

Signs and symptoms of high-altitude pulmonary edema (HAPE) include poor exercise tolerance, prolonged recovery time after exertion, fatigue, and weakness that progresses to a persistent dry cough and cyanosis of lips and nail beds. Crackles may be auscultated in one or both lung fields. A late sign of HAPE is pink, frothy sputum. Ataxia and confusion or decreased level of consciousness are seen in HACE—high-altitude cerebral edema. Acute mountain sickness produces a syndrome similar to an alcohol-induced hangover.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Environmental emergencies, Altitude-related illness MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 9. A client resuscitated after drowning is admitted to the emergency department. What

assessment findings does the nurse recognize as symptoms of a drowning? (Select all that apply.) a. Bilateral crackles b. Bradycardia c. Cyanosis of the lips d. Hypotension e. Flushed, diaphoretic skin ANS: A, B, C, D

Drowning victims will exhibit signs of pulmonary edema which includes crackles in one or both lungs, persistent dry cough, and cyanosis of the lips and/or nail beds. The diving reflex as a response to asphyxia produces bradycardia, signs of decreased cardiac output with hypotension, and vasoconstriction of vessels in the intestine, skeletal muscles, and kidneys.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Environmental emergencies, Drowning MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 10. The nurse is teaching participants in a family-oriented community center ways to prevent their

older relatives and friends from getting heat-related illnesses. What information does the nurse include? (Select all that apply.) a. Use sunscreen with an SPF of at least 15 when outdoors. b. Take cool baths or showers after outdoor activities. c. Check on the older adult daily in hot weather. d. Drink plenty of liquids throughout the day.

e. Wear light-colored, snugly-fitting clothing to wick sweat away.

ANS: B, C, D

To best prevent heat-related illnesses, the nurse would teach individuals to use sunscreen with at least an SPF of 30 for both UVA and UVB rays, to shower or bathe in cool water after being outdoors to reduce body heat, to remain hydrated, and to wear light-colored, loose-fitting clothes. Families and friends should check older adults at least twice a day during a heat wave; however, this may not prevent heat-related illness but could catch it quickly and limit its severity.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Environmental emergencies, Heat-related illness MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

Chapter 12: Concepts of Disaster Preparedness Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A hospital responds to a local mass casualty event. What action would the nurse supervisor

take to prevent staff posttraumatic stress disorder during and after the event? a. Provide water and healthy snacks for energy throughout the event. b. Schedule 16-hour shifts to allow for greater rest between shifts. c. Encourage counseling upon deactivation of the emergency response plan. d. Assign staff to different roles and units within the medical facility.

ANS: A

To prevent staff posttraumatic stress disorder during a mass casualty event, the nurses would use available counseling, encourage and support co-workers, monitor each other’s stress level and performance, take breaks when needed, talk about feelings with staff and managers, and drink plenty of water and eat healthy snacks for energy. Nurses would also keep in touch with family, friends, and significant others, and not work for more than 12 hours/day. Encouraging counseling upon deactivation of the plan, or after the emergency response is over, does not prevent stress during the casualty event. Assigning staff to unfamiliar roles or units may increase situational stress and is not an approach to prevent posttraumatic stress disorder.

These actions also help mitigate PTSD after the event.

DIF: Remembering TOP: Integrated Process: Communication and Documentation KEY: Emergency and Disaster Preparedness, Psychosocial response MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 2. A client who is hospitalized with burns after losing the family home in a fire becomes angry

and screams at a nurse when dinner is served late. How would the nurse respond? a. “Do you need something for pain right now?” b. “Please stop yelling. I brought dinner as soon as I could.” c. “I suggest that you get control of yourself.” d. “You seem upset. I have time to talk if you’d like.”

ANS: D

Clients would be allowed to ventilate their feelings of anger and despair after a catastrophic event. The nurse establishes rapport through active listening and honest communication and by recognizing cues that the client wishes to talk. Asking whether the client is in pain as the first response closes the door to open communication and limits the client’s options. Simply telling the client to stop yelling and to gain control does nothing to promote therapeutic communication.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Emergency and Disaster Preparedness, Psychosocial response MSC: Client Needs Category: Psychosocial Integrity 3. A nurse is field-triaging clients after an industrial accident. Which client condition would the

nurse triage with a red tag? a. Dislocated right hip and an open fracture of the right lower leg

b. Large contusion to the forehead and a bloody nose c. Closed fracture of the right clavicle and arm numbness d. Multiple fractured ribs and shortness of breath ANS: D

Clients who have an immediate threat to life are given the highest priority, are placed in the emergent or class I category, and are given a red triage tag. The client with multiple rib fractures and shortness of breath has a threat to oxygenation and is the most critical. The client with the hip and leg problem and the client with the clavicle fracture would be classified as class II (urgent, yellow tag); these major but stable injuries can wait for 30 minutes to 2 hours for definitive care. The client with facial wounds would be considered the “walking wounded” and classified as nonurgent (class III, green tag).

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Emergency and Disaster Preparedness, Triage MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 4. An emergency department (ED) charge nurse prepares to receive clients from a mass casualty

within the community. What is the role of this nurse during the event? a. Ask nursing staff to discharge clients from the medical-surgical units in order to make room for critically injured victims. b. Call additional medical-surgical and critical care nursing staff to come to the hospital to assist when victims are brought in. c. Inform the incident commander at the mass casualty scene about how many victims may be handled by the ED. d. Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims.

ANS: D

The ED charge nurse would direct additional nursing staff to help care for current ED clients while the ED staff prepares to receive mass casualty victims; however, they would not be assigned to the most critically ill or injured clients. The hospital incident commander’s role is to take a global view of the entire situation and facilitate patient movement through the system, while bringing in personnel and supply resources to meet patient needs. The medical command physician would kept the incident commander informed about victims and capacity of the ED. DIF: Applying TOP: Integrated Process: Nursing Process: Planning KEY: Emergency and Disaster Preparedness, Interprofessional team MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 5. An emergency department manager wants to mitigate the possible acute and chronic stress

after mass casualty events in the staff. What action would the manager take? a. Encourage all staff to join a Disaster Medical Assistance Team. b. Instruct all staff members to prepare go bags for all family members. c. Use available resources for broad education and training in disaster management. d. Provide incentives and bonuses for responding to mass casualty events.

ANS: C

Research indicates that education and training in disaster management before an incident occurs is associated with improved confidence and better coping after the incident. Go bags are important to maintain for all family members but would not be effective in mitigating stress. A DMAT is a medical relief team made up of civilian medical, paraprofessional, and support personnel that is deployed to a disaster area with enough medical equipment and supplies to sustain operations for 72 hours. Incentives and bonuses will not help mitigate stress.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Emergency and Disaster Preparedness, Psychosocial response MSC: Client Needs Category: Psychosocial Integrity 6. A nurse is caring for a client whose spouse died in a recent mass casualty accident. The client

says, “I can’t believe that my spouse is gone and I am left to raise my children all by myself.”

How would the nurse respond? a. “Please accept my sympathies for your loss.” b. “I can call the hospital chaplain if you wish.” c. “You sound anxious about being a single parent.” d. “At least your children still have you in their lives.”

ANS: C

Therapeutic communication includes active listening and honesty. This statement demonstrates that the nurse recognizes the client’s distress and has provided an opening for discussion. Extending sympathy and offering to call the chaplain do not give the client the opportunity to discuss feelings. Stating that the children still have one parent discounts the client’s feelings and situation.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Emergency and Disaster Preparedness, Psychosocial response MSC: Client Needs Category: Psychosocial Integrity 7. A nurse cares for victims during a community-wide disaster drill. One of the victims asks,

“Why are the individuals with black tags not receiving any care?” How does the nurse respond? a. “To do the greatest good for the greatest number of people, it is necessary to sacrifice some.” b. “Not everyone will survive a disaster, so it is best to identify those people early and move on.” c. “In a disaster, extensive resources are not used for one person at the expense of many others.” d. “With black tags, volunteers can identify those who are dying and can give them comfort care.”

ANS: C

In a disaster, military-style triage is used; this approach identifies the dead or expectant dead with black tags. This practice helps to maintain the goal of triage, which is doing the most good for the most people. Precious resources are not used for those with overwhelming critical injury or illness, so that they can be allocated to others who have a reasonable expectation of survival. Victims are not “sacrificed.” Telling victims that is important to move on after identifying the expectant dead does not provide an adequate explanation and is callous. Victims are not black-tagged to allow volunteers to give comfort care.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Emergency and Disaster Preparedness, Triage MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 8. A nurse wants to become involved in community disaster preparedness and is interested in

helping setup and staff first-aid stations or community acute care centers in the event of a disaster. Which organization is the best fit for this nurse’s interests? a. The Medical Reserve Corps b. The National Guard c. The health department d. A Disaster Medical Assistance Team ANS: A

The Medical Reserve Corps (MRC) consists of volunteer medical and public health care professionals who support the community during times of need. They may help staff hospitals, establish first-aid stations or special needs shelters, or set up acute care centers in the community. The National Guard often performs search-and-rescue operations and law enforcement. The health department focuses on communicable disease tracking, treatment, and prevention. A Disaster Medical Assistance Team is deployed to a disaster area for up to 72 hours, providing many types of relief services.

DIF: Remembering TOP: Integrated Process: Nursing Process: Implementation KEY: Emergency and Disaster Preparedness, Emergency nursing MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 9. A nurse wants to become part of a Disaster Medical Assistance Team (DMAT) but is

concerned about maintaining licensure in several different states. Which statement best addresses these concerns? a. “Deployed DMAT providers are federal employees, so their licenses are good in all 50 states.” b. “The government has a program for quick licensure activation wherever you are deployed.” c. “During a time of crisis, licensure issues would not be the government’s priority concern.” d. “If you are deployed, you will be issued a temporary license in the state in which you are working.”

ANS: A

When deployed, DMAT health care providers act as agents of the federal government, and so are considered federal employees. Thus their licenses are valid in all 50 states. Licensure is an issue that the government would be concerned with, but no programs for temporary licensure or rapid activation are available.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Emergency and Disaster Preparedness, Emergency nursing MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

10. After a hospital’s emergency department (ED) has efficiently triaged, treated, and transferred

clients from a community disaster to appropriate units, the hospital incident command officer wants to “stand down” from the emergency plan. Which question would the nursing supervisor ask at this time? a. “Are you sure no more victims are coming into the ED?” b. “Do all areas of the hospital have the supplies and personnel they need?” c. “Have all ED staff had the chance to eat and rest recently?” d. “Does the Chief Medical Officer agree this disaster is under control?”

ANS: B

Before “standing down,” the incident command officer ensures that the needs of the other hospital departments have been taken care of because they may still be stressed and may need continued support to keep functioning. Many more “walking wounded” victims may present to the ED; that number may not be predictable. Giving staff the chance to eat and rest is important, but all areas of the facility need that too. Although the Chief Medical Officer (CMO) may be involved in the incident, the CMO does not determine when the hospital can “stand down.”

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Emergency and Disaster Preparedness, Interprofessional team MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 11. A nurse is volunteering in a temporary shelter for survivors of a hurricane. Which client does

the nurse anticipate has the highest need for further assessment and referral? a. Client who is still trying to locate relatives who are missing b. Family awaiting the ability to travel out of state for temporary housing c. Client with a score of 48 on the Impact of Event Scale-Revised (IES-R) d. Client who has trouble sleeping and who startles easily ANS: C

The IES-R is an assessment tool is a 22-item self-administered questionnaire that scores individuals on signs and symptoms of acute stress disorder or posttraumatic stress disorder. A score of 33 or higher out of 88 is a positive finding and this client would be referred a psychiatrist or other licensed mental health care provider. The nurse would administer the assessment to the client with difficulty sleeping after ensuring he or she can read at the 10th grade level, which is the reading level of the tool. The other two clients do not show evidence of particular needs for referral beyond what is usually provided in a natural disaster.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Emergency and Disaster Preparedness, Interprofessional team MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 12. An emergency department charge nurse notes an increase in sick calls and bickering among

the staff after a week with multiple trauma incidents. What action would the nurse take? a. Organize a pizza party for each shift. b. Remind the staff of the facility’s sick-leave policy. c. Arrange for postincident crisis support. d. Talk individually with staff members.

ANS: C

The staff may be suffering from stress related to the multiple traumas and needs to have crisis support. A crisis support team can assist the staff with developing appropriate coping methods. Speaking with staff members individually does not provide the same level of support as trained health care providers who can offer emotional first aid. Organizing a party and revisiting the sick-leave policy may be helpful, but are not as important and beneficial as formalized crisis support.

DIF: Applying TOP: Integrated Process: Caring KEY: Emergency and Disaster Preparedness, Psychosocial response MSC: Client Needs Category: Psychosocial Integrity 13. A nurse is constructing a personal preparedness plan in case of a disaster. What does the nurse

consider in making this plan? a. Store basic supplies to last for at least 3 days. b. Have short-term arrangements for child care. c. Store enough frozen foods in freezer for 5 days. d. Keep cooking utensils needed in a separate bag.

ANS: A

Concerns for their home and family can impact the willingness to report in an emergency and can be diminished by being prepared with a personal preparedness plan with enough supplies for 3 days. Any food needs to be nonperishable with no cooking required. Arrangements for children, pets, or older adults would be made for extended period of time.

DIF: Remembering TOP: Integrated Process: Nursing Process: Planning KEY: Emergency and Disaster Preparedness MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. Emergency medical services (EMS) brings a large number of clients to the emergency

department following a mass casualty incident. The nurse identifies the clients with which injuries with yellow tags? (Select all that apply.) a. Partial-thickness burns covering both legs b. Open fractures of both legs with absent pedal pulses c. Neck injury and numbness of both legs d. Small pieces of shrapnel embedded in both eyes e. Head injury and difficult to arouse f. Bruising and pain in the right lower abdomen ANS: A, C, D, F

Clients with burns, spine injuries, eye injuries, and stable abdominal injuries would be treated within 30 minutes to 2 hours, and therefore would be identified with yellow tags. The client with the open fractures and the client with the head injury would be classified as urgent with red tags.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Implementation KEY: Emergency and Disaster Preparedness, Triage MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care

2. A nurse triages clients arriving at the hospital after a mass casualty. Which clients are

correctly classified? (Select all that apply.) a. A 35-year-old female with severe chest pain: red tag b. A 42-year-old male with full-thickness body burns: green tag c. A 55-year-old female with a scalp laceration: black tag d. A 60-year-old male with an open fracture with distal pulses: yellow tag e. An 88-year-old male with shortness of breath and chest bruises: green tag f. A 33-year-old male unconscious with bilateral leg amputations: yellow tag ANS: A, D

Red-tagged clients need immediate care due to life-threatening injuries. A client with severe chest pain would receive a red tag. Yellow-tagged clients have major injuries that need to be treated within 30 minutes to 2 hours. A client with an open fracture with distal pulses would receive a yellow tag. The client with full-thickness body burns would receive a black tag. The client with a scalp laceration would receive a green tag, and the client with shortness of breath would receive a red tag. The client with the amputated legs will probably be black tagged if the unconsciousness is from massive blood loss.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Emergency and Disaster Preparedness, Triage MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 3. A hospital prepares to receive large numbers of casualties from a community disaster. Which

clients would the nurse identify as appropriate for discharge or transfer to another facility?

(Select all that apply.) a. Older adult in the medical decision unit for evaluation of chest pain b. Client who had open reduction and internal fixation of a femur fracture 3 days ago c. Client admitted last night with community-acquired pneumonia d. Infant who has a fever of unknown origin e. Client on the medical unit for wound care f. Client with symptoms of influenza after traveling abroad ANS: B, E

The client with the femur fracture could be transferred to a rehabilitation facility, and the client on the medical unit for wound care could be transferred home with home health or to a long-term care facility for ongoing wound care. The client in the medical decision unit would be identified for dismissal if diagnostic testing reveals a noncardiac source of chest pain. The newly admitted client with pneumonia would not be a good choice because culture results are not yet available and antibiotics have not been administered long enough. The infant does not have a definitive diagnosis. The client who has recently traveled abroad may have either seasonal influenza or may have a novel or potential pandemic respiratory virus and should not be transferred to avoid spreading the illness.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Emergency and Disaster Preparedness, Nursing assessment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 4. A hospital prepares for a mass casualty event. Which functions are correctly paired with the

personnel role? (Select all that apply.) a. Paramedic—decides the number, acuity, and resource needs of clients b. Hospital incident commander—assumes overall leadership for implementing the

emergency plan c. Public information officer—provides advanced life support during transportation

to the hospital d. Triage officer—rapidly evaluates each client to determine priorities for treatment e. Medical command physician—serves as a liaison between the health care facility

and the media ANS: B, D

The hospital incident commander assumes overall leadership for implementing the emergency plan. The triage officer rapidly evaluates each client to determine priorities for treatment. The paramedic provides advanced life support during transportation to the hospital. The public information officer serves as a liaison between the health care facility and the media. The medical command physician decides the number, acuity, and resource needs of clients.

DIF: Remembering TOP: Integrated Process: Nursing Process: Implementation KEY: Emergency and Disaster Preparedness, Interprofessional team MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 5. A new graduate nurse has started working on a medical-surgical unit. What actions would the

nurse take to be prepared for a disaster? (Select all that apply.) a. Know the institution’s Emergency Response Plan. b. Participate in the institution’s disaster drill. c. Develop a personal preparedness plan. d. Understand that nurses play a role in every phase of a disaster. e. Be prepared to report immediately to the emergency department. f. Be willing to be flexible working during a crisis situation.

ANS: A, B, C, D, F

Nurses play a major role in disaster and need to be prepared for any type of disaster. Knowing the institution’s emergency management plan and participating in disaster drills will help the nurse be prepared for a disaster. Concerns for their home and family can impact the willingness to report in an emergency and can be diminished by being prepared with a personal preparedness plan. Nurses play key roles before, during, and after a disaster in the development of emergency management plan in defining specific nursing roles. During a crisis, nurses may be assigned to different areas of the facility or to different job functions and must remain flexible while working to their best ability.

DIF: Remembering TOP: Integrated Process: Nursing Process: Planning KEY: Emergency and Disaster Preparedness, Interprofessional team MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care

Chapter 13: Concepts of Fluid and Electrolyte Balance Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse assesses clients at a family practice clinic for risk factors that could lead to

dehydration. Which client is at greatest risk for dehydration? a. A 36 year old who is prescribed long-term steroid therapy. b. A 55 year old who recently received intravenous fluids. c. A 76 year old who is cognitively impaired. d. An 83 year old with congestive heart failure.

ANS: C

Older adults, because they have less total body water than younger adults, are at greater risk for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his or her need for fluids known is at high risk for dehydration.

The client with heart failure has a risk for both fluid imbalances. Long-term steroids and recent IV fluid administration do not increase the risk of dehydration.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Fluid and electrolyte imbalances, Dehydration MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 2. A nurse is caring for an older client who exhibits dehydration-induced confusion. Which

intervention by the nurse is best? a. Measure intake and output every 4 hours. b. Assess client further for fall risk. c. Increase the IV flow rate to 250 mL/hr. d. Place the client in a high-Fowler position.

ANS: B

Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing confusion. The client with dehydration is at risk for falls because of this confusion, orthostatic hypotension, dysrhythmia, and/or muscle weakness. The nurse’s best response is to do a more thorough evaluation of the client’s risk for falls. Measuring intake and output may need to occur more frequently than every 4 hours, but does not address a critical need. The nurse would not adjust the IV flow rate without a prescription or standing protocol. For an older adult, this rapid an infusion rate could lead to fluid overload. Sitting the client in a high-Fowler position may or may not be comfortable but still does not address the most important issue which is safety.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Fluid and electrolyte imbalances, Dehydration MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 3. After teaching a client who is being treated for dehydration, a nurse assesses the client’s

understanding. Which statement indicates that the client correctly understood the teaching? a. “I must drink a quart (liter) of water or other liquid each day.” b. “I will weigh myself each morning before I eat or drink.” c. “I will use a salt substitute when making and eating my meals.”

d. “I will not drink liquids after 6 p.m. so I won’t have to get up at night.”

ANS: B

One liter of water weighs 1 kg; therefore, a change in body weight is a good measure of excess fluid loss or fluid retention. Weight loss greater than 0.5 lb (0.2 kg) daily is indicative of excessive fluid loss. One liter of fluid a day is insufficient. A salt substitute is not related to dehydration. Clients may want to limit fluids after dinner so they won’t have to get up, but this does not address dehydration if the patient drinks the recommended amount of fluid during the earlier parts of the day.

DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Fluid and electrolyte imbalances, Dehydration, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 4. A nurse is assessing clients on a medical-surgical unit. Which adult client does the nurse

identify as being at greatest risk for insensible water loss? a. Client taking furosemide. b. Anxious client who has tachypnea. c. Client who is on fluid restrictions. d. Client who is constipated with abdominal pain.

ANS: B

Insensible water loss is water loss through the skin, lungs, and stool. Clients at risk for insensible water loss include those being mechanically ventilated, those with rapid respirations, and those undergoing continuous GI suctioning. Clients who have thyroid crisis, trauma, burns, states of extreme stress, and fever are also at increased risk. The client taking furosemide will have increased fluid loss, but not insensible water loss. The other two clients on a fluid restriction and with constipation are not at risk for insensible fluid loss.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Fluid and electrolyte imbalances, Dehydration MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. A nurse is evaluating a client who is being treated for dehydration. Which assessment result

does the nurse correlate with a therapeutic response to the treatment plan? a. Increased respiratory rate from 12 to 22 breaths/min b. Decreased skin turgor on the client’s posterior hand and forehead c. Increased urine specific gravity from 1.012 to 1.030 g/mL d. Decreased orthostatic changes when standing ANS: D

The focus of management for clients with dehydration is to increase fluid volumes to normal.

When blood volume is normal, orthostatic blood pressure and pulse changes will not occur.

This assessment finding shows a therapeutic response to treatment. Increased respirations, decreased skin turgor, and higher urine specific gravity all are indicators of continuing dehydration.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Fluid and electrolyte imbalances, Dehydration MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

6. After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client’s

understanding. Which food choice for lunch indicates that the client correctly understood the teaching? a. Slices of smoked ham with potato salad b. Bowl of tomato soup with a grilled cheese sandwich c. Salami and cheese on whole-wheat crackers d. Grilled chicken breast with glazed carrots ANS: D

Clients on restricted sodium diets generally avoid processed, smoked, and pickled foods and those with sauces and other condiments. Foods lowest in sodium include fish, poultry, and fresh produce. The ham, tomato soup, salami, and crackers are usually high in sodium.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Fluid and electrolyte imbalances, Sodium imbalances MSC: Client Needs Category: Health Promotion and Maintenance 7. A nurse is assessing clients for fluid and electrolyte imbalances. Which client will the nurse

assess first for potential hyponatremia? a. A 34 year old who is NPO and receiving rapid intravenous D5W infusions. b. A 50 year old with an infection who is prescribed a sulfonamide antibiotic. c. A 67 year old who is experiencing pain and is prescribed ibuprofen. d. A 73 year old with tachycardia who is receiving digoxin.

ANS: A

Dextrose 5% in water (D5W) contains no electrolytes. The dextrose is rapidly metabolized when infused, leaving the solution hypotonic. Aggressive ingestion (or infusion) of hypotonic solutions can lead to hyponatremia. Because the client is not taking any food or fluids by mouth (NPO), normal sodium excretion can also lead to hyponatremia. The sulfonamide antibiotic, ibuprofen, and digoxin will not put a client at risk for hyponatremia.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Fluid and electrolyte imbalances, Sodium imbalances MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 8. A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse

include in this client’s teaching? a. “Have you spouse watch you for irritability and anxiety.” b. “Notify the clinic if you notice muscle twitching.” c. “Call your primary health care provider for diarrhea.” d. “Bake or grill your meat rather than frying it.”

ANS: C

One sign of hyponatremia is diarrhea due to increased intestinal motility. The client would be taught to call the primary health care provider if this is noticed. Irritability and anxiety are common neurologic signs of hypokalemia. Muscle twitching is related to hypernatremia.

Cooking methods are not a cause of hyponatremia.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Fluid and electrolyte imbalances, Sodium imbalances, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance

9. A nurse is caring for a client who has the following laboratory results: potassium 2.4 mEq/L

(2.4 mmol/L), magnesium 1.8 mEq/L (0.74 mmol/L), calcium 8.5 mEq/L (2.13 mmol/L), and sodium 144 mEq/L (144 mmol/L). Which assessment does the nurse complete first? a. Depth of respirations b. Bowel sounds c. Grip strength d. Electrocardiography ANS: A

A client with a low serum potassium level may exhibit hypoactive bowel sounds, cardiac dysrhythmias, and muscle weakness resulting in shallow respirations and decreased handgrips. The nurse would assess the client’s respiratory status first to ensure that respirations are sufficient. The respiratory assessment would include rate and depth of respirations, respiratory effort, and oxygen saturation. The other assessments are important but are secondary to the client’s respiratory status.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Fluid and electrolyte imbalances, Potassium imbalances MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 10. A nurse cares for a client who has a serum potassium of 6.5 mEq/L (6.5 mmol/L) and is

exhibiting cardiovascular changes. Which intervention will the nurse implement first? a. Prepare to administer patiromer by mouth. b. Provide a heart-healthy, low-potassium diet. c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push. d. Prepare the client for hemodialysis treatment.

ANS: C

A client with a critically high serum potassium level and cardiac changes would be treated immediately to reduce the extracellular potassium level. Potassium movement into the cells is enhanced by insulin by increasing the activity of sodium-potassium pumps. Insulin will decrease both serum potassium and glucose levels and therefore would be administered with dextrose to prevent hypoglycemia. Patiromer may be ordered, but this therapy may take hours to reduce potassium levels. Dialysis may also be needed, but this treatment will take much longer to implement and is not the first intervention the nurse would implement. Decreasing potassium intake may help prevent hyperkalemia in the future but will not decrease the client’s current potassium level.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Fluid and electrolyte imbalances, Potassium imbalances MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 11. The nurse is caring for a client who has fluid overload. What action by the nurse takes

priority? a. Administer high-ceiling (loop) diuretics. b. Assess the client’s lung sounds every 2 hours. c. Place a pressure-relieving overlay on the mattress. d. Weigh the client daily at the same time on the same scale.

ANS: B

All interventions are appropriate for the client who is overhydrated. However, client safety is the priority. A client with fluid overload can easily go into pulmonary edema, which can be life threatening. The nurse would closely monitor the client’s respiratory status.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Fluid and electrolyte imbalances, Overhydration MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 12. A nurse is assessing a client with hypokalemia, and notes that the client’s handgrip strength

has diminished since the previous assessment 1 hour ago. What action does the nurse take first? a. Assess the client’s respiratory rate, rhythm, and depth. b. Measure the client’s pulse and blood pressure. c. Document findings and monitor the client. d. Call the health care primary health care provider.

ANS: A

In a client with hypokalemia, progressive skeletal muscle weakness is associated with increasing severity of hypokalemia. The most life-threatening complication of hypokalemia is respiratory insufficiency. It is imperative for the nurse to perform a respiratory assessment first to make sure that the client is not in immediate jeopardy. Cardiac dysrhythmias are also associated with hypokalemia. The client’s pulse and blood pressure would be assessed after assessing respiratory status. Next, the nurse would call the health care primary health care provider to obtain orders for potassium replacement. Documenting findings and continuing to monitor the client would occur during and after potassium replacement therapy.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Fluid and electrolyte imbalances, Potassium imbalances MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 13. A new nurse is preparing to administer IV potassium to a client with hypokalemia. What

action indicates the nurse needs to review this procedure? a. Notifies the pharmacy of the IV potassium order. b. Assesses the client’s IV site every hour during infusion. c. Sets the IV pump to deliver 30 mEq of potassium an hour. d. Double-checks the IV bag against the order with the precepting nurse.

ANS: C

IV potassium should not be infused at a rate exceeding 20mEq/hr under any circumstances.

This action shows a need for further knowledge. The other actions are acceptable for this high-alert drug.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Fluid and electrolyte imbalances, Potassium imbalances MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 14. A nurse is caring for a client with hypocalcemia. Which action by the nurse shows poor

understanding of this condition? a. Assesses the client’s Chvostek and Trousseau sign. b. Keeps the client’s room quiet and dimly lit. c. Moves the client carefully to avoid fracturing bones.

d. Administers bisphosphonates as prescribed.

ANS: D

Bisphosphonates are used to treat hypercalcemia. The Chvostek and Trousseau signs are used to assess for hypocalcemia. Keeping the client in a low stimulus environment is important because the excitable nervous system cells are overstimulated. Long-standing hypocalcemia can cause fragile, brittle bones which can be fractured.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Fluid and electrolyte imbalances, Calcium imbalances MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 15. A nurse is caring for a client who has a serum calcium level of 14 mg/dL (3.5 mmol/L).

Which primary health care provider order does the nurse implement first? a. Encourage oral fluid intake. b. Connect the client to a cardiac monitor. c. Assess urinary output. d. Administer oral calcitonin.

ANS: B

This client has hypercalcemia. Elevated serum calcium levels can decrease cardiac output and cause cardiac dysrhythmias. Connecting the client to a cardiac monitor is a priority to assess for lethal cardiac changes. Encouraging oral fluids, assessing urine output, and administering calcitonin are treatments for hypercalcemia, but are not the highest priority.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Fluid and electrolyte imbalances, Calcium imbalances MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 16. A nurse is caring for an older adult client who is admitted with moderate dehydration. Which

intervention will the nurse implement to prevent injury while in the hospital? a. Ask family members to speak quietly to keep the client calm. b. Assess urine color, amount, and specific gravity each day. c. Encourage the client to drink at least 1 L of fluids each shift. d. Dangle the client on the bedside before ambulating.

ANS: D

An older adult with moderate dehydration may experience orthostatic hypotension. The client needs to dangle on the bedside before ambulating. Although dehydration in an older adult may cause confusion, speaking quietly will not help the client remain calm or decrease confusion.

Assessing the client’s urine may assist with the diagnosis of dehydration but would not prevent injury. Clients are encouraged to drink fluids, but 1 L of fluid each shift for an older adult may cause respiratory distress and symptoms of fluid overload, especially if the client has heart failure or renal insufficiency.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Fluid and electrolyte imbalances, Dehydration MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control MULTIPLE RESPONSE

1. A nurse assesses a client who is admitted for treatment of fluid overload. Which signs and

symptoms does the nurse expect to find? (Select all that apply.) a. Increased pulse rate b. Distended neck veins c. Decreased blood pressure d. Warm and pink skin e. Skeletal muscle weakness f. Visual disturbances ANS: A, B, E, F

Signs and symptoms of fluid overload include increased pulse rate, distended neck veins, increased blood pressure, pale and cool skin, skeletal muscle weakness, and visual disturbances. Decreased blood pressure would be seen in dehydration. Warm and pink skin is a normal finding.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Fluid and electrolyte imbalances, Overhydration MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion

and release. For which potential complications will the nurse assess? (Select all that apply.) a. Urine output of 25 mL/hr b. Serum potassium level of 5.4 mEq/L (5.4 mmol/L) c. Urine specific gravity of 1.02 g/mL d. Serum sodium level of 128 mEq/L (128 mmol/L) e. Blood osmolality of 250 mOsm/kg (250 mmol/kg) ANS: B, E

Aldosterone is a naturally occurring hormone of the mineralocorticoid type that increases the reabsorption of water and sodium in the kidney at the same time that it promotes excretion of potassium. Any drug or condition that disrupts aldosterone secretion or release increases the client’s risk for excessive water loss (increased urine output), increased potassium reabsorption, decreased blood osmolality, and increased urine specific gravity. The client would not be at risk for sodium imbalance.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Fluid and electrolyte imbalances MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 3. A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For

which potential complications of this electrolyte imbalance does the nurse assess? (Select all that apply.) a. Reports of palpitations b. Slow, shallow respirations c. Orthostatic hypotension d. Paralytic ileus e. Skeletal muscle weakness f. Tall, peaked T waves on ECG ANS: A, E, F

Electrolyte imbalances associated with acute renal failure include hyperkalemia. The nurse would assess for electrocardiogram changes, including tall, peaked T waves, reports of palpitations or “skipped beats,” diarrhea, and skeletal muscle weakness in clients with hyperkalemia. The other choices are potential complications of hypokalemia. Respiratory muscles may be affected with lethally high hyperkalemia.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Fluid and electrolyte imbalances, Potassium imbalances MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 4. A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which

clinical signs and symptoms are correctly paired with the contributing electrolyte imbalance?

(Select all that apply.) a. Hypokalemia—muscle weakness with respiratory depression b. Hypermagnesemia—bradycardia and hypotension c. Hyponatremia—decreased level of consciousness d. Hypercalcemia—positive Trousseau and Chvostek signs e. Hypomagnesemia—hyperactive deep tendon reflexes f. Hypernatremia—weak peripheral pulses ANS: A, B, C, E, F

Hypokalemia is associated with muscle weakness and respiratory depression.

Hypermagnesemia manifests with bradycardia and hypotension. Hyponatremia can present with decreased level of consciousness. Hypomagnesemia can be assessed through hyperactive deep tendon reflexes. Weak peripheral pulses are felt in hypernatremia. Positive Trousseau and Chvostek signs are seen in hypocalcemia.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Fluid and electrolyte imbalances MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. After administering potassium chloride, a nurse evaluates the client’s response. Which signs

and symptoms indicate that treatment is improving the client’s hypokalemia? (Select all that apply.) a. Respiratory rate of 8 breaths/min b. Absent deep tendon reflexes c. Strong productive cough d. Active bowel sounds e. U waves present on the electrocardiogram (ECG) ANS: C, D

A strong, productive cough indicates an increase in muscle strength and improved potassium imbalance. Active bowel sounds also indicate that treatment is working. A respiratory rate of 8 breaths/min, absent deep tendon reflexes, and U waves present on the ECG are all signs and symptoms of hypokalemia and do not demonstrate that treatment is working.

DIF: Understanding TOP: Integrated Process: Nursing Process: Evaluation KEY: Fluid and electrolyte imbalances, Potassium imbalances MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

6. A nurse develops a plan of care for an older client who has a fluid overload. What

interventions will the nurse include in this client’s care plan? (Select all that apply.) a. Calculate pulse pressure with each blood pressure reading. b. Assess skin turgor using the back of the client’s hand. c. Assess for pitting edema in dependent body areas. d. Monitor trends in the client’s daily weights. e. Assist the client to change positions frequently. f. Teach client and family how to read food labels for sodium.

ANS: A, C, D, E, F

Appropriate interventions for the client who has overhydration include calculating the pulse pressure with each BP reading as this is a sign of cardiovascular involvement, assessing for pitting edema in the client’s dependent body areas, monitoring trends in the client’s daily weight as fluid retention is not always visible, protecting the client’s skin by helping him or her change positions, and teaching the client and family to read food labels some type of sodium restriction may be required at home. The nurse assesses skin turgor on the chest or forehead.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Fluid and electrolyte imbalances, Overhydration MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 7. A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which

common causes are correctly paired with the corresponding electrolyte imbalance? (Select all that apply.) a. Hypomagnesemia—kidney failure b. Hyperkalemia—salt substitutes c. Hyponatremia—heart failure d. Hypernatremia—hyperaldosteronism e. Hypocalcemia—diarrhea f. Hypokalemia—loop diuretics ANS: B, C, D, E, F

Salt substitutes contain potassium and are a cause of hyperkalemia. Hyponatremia can be caused by heart failure with fluid overload. Hyperaldosterone is a cause of hypernatremia and diarrhea causes actual calcium deficits. Loop diuretics excrete potassium. Decreased kidney function is a cause of magnesium excess, not deficit.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Fluid and electrolyte imbalances MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 8. A nurse is caring for several clients at risk for fluid imbalances. Which laboratory results are

paired with the correct potential imbalance? (Select all that apply.) a. Sodium: 160 mEq/L (mmol/L): Overhydration b. Potassium: 5.4 mEq/L (mmol/L): Dehydration c. Osmolarity: 250 mOsm/L: Overhydration d. Hematocrit: 68%: Dehydration e. BUN: 39 mg/dL: Overhydration f. Magnesium: 0.8 mg/dL: Dehydration

ANS: B, C, D, F

In dehydration, hemoconcentration usually results in higher levels of hemoglobin, hematocrit, serum osmolarity, glucose, protein, blood urea nitrogen, and electrolytes. The opposite is true of overhydration. The sodium level is high, indicating dehydration. The potassium level is high, also indicating possible dehydration. The osmolarity is low, indicating overhydration, the hematocrit is high indicating dehydration, the BUN is high indicating dehydration, and the magnesium level is low, indicating possible dehydration and malnutrition from diarrhea-causing diseases.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Fluid and electrolyte imbalances MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

Chapter 14: Concepts of Acid–Base Balance Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse assesses a client with diabetes mellitus who is admitted with an acid–base imbalance.

The client’s arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 mEq/L (18 mmol/L). Which sign or symptom does the nurse identify as an example of the client’s compensatory mechanisms? a. Increased rate and depth of respirations b. Increased urinary output c. Increased thirst and hunger d. Increased release of acids from the kidneys ANS: A

This client has metabolic acidosis. The respiratory system compensates by increasing its activity and blowing off excess carbon dioxide. Increased urinary output, thirst, and hunger are signs and symptoms of hyperglycemia but are not compensatory mechanisms for acid– base imbalances. The kidneys do not release acids.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Acid-base imbalances, Acidosis MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A nurse assesses a client who is experiencing an acid–base imbalance. The client’s arterial

blood gas values are pH 7.2, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L (19 mmol/L). Which assessment would the nurse perform first? a. Cardiac rate and rhythm b. Skin and mucous membranes c. Musculoskeletal strength d. Level of orientation ANS: A

Early cardiovascular changes for a client experiencing moderate acidosis include increased heart rate and cardiac output. As the acidosis worsens, the heart rate decreases and electrocardiographic changes will be present. The nurse responds by performing a thorough cardiovascular assessment. Changes will occur in the integumentary system, musculoskeletal system, and neurologic system, but assessing for the cardiovascular complications comes first.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Acid-base imbalance, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 3. A nurse assesses a client who is prescribed furosemide for hypertension. For which acid–base

imbalance does the nurse assess to prevent complications of this therapy? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

ANS: D

Many diuretics, especially loop and thiazide diuretics, increase the excretion of hydrogen ions, leading to excess acid loss through the renal system. This situation is an actual acid deficit.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Acid-base imbalance, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. A nurse is caring for a client who is experiencing moderate metabolic alkalosis. What action

would the nurse take? a. Monitor daily hemoglobin and hematocrit values. b. Administer furosemide intravenously. c. Encourage the client to take deep breaths. d. Teach the client fall prevention measures.

ANS: D

The most important nursing care for a client who is experiencing moderate metabolic alkalosis is providing client safety. Client’s with metabolic alkalosis have muscle weakness and are at risk for falling. The other nursing interventions are not appropriate for metabolic alkalosis.

DIF: Remembering TOP: Integrated Process: Nursing Process: Implementation KEY: Acid-base imbalance, Client safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 5. A nurse is assessing a client who has acute pancreatitis and is at risk for an acid–base

imbalance. For which manifestation of this acid–base imbalance would the nurse assess? a. Agitation b. Kussmaul respirations c. Seizures d. Positive Chvostek sign ANS: B

The pancreas is a major site of bicarbonate production. Pancreatitis can cause metabolic acidosis through underproduction of bicarbonate ions. Signs and symptoms of acidosis include lethargy and Kussmaul respirations. Agitation, seizures, and a positive Chvostek sign are signs and symptoms of the electrolyte imbalances that accompany alkalosis.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Acid-base imbalances, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. A nurse assesses a client who is admitted with an acid–base imbalance. The client’s arterial

blood gas values were pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L (16 mmol/L). The most recent blood gasses show a drop in the pH. What action does the nurse take next? a. Assess client’s rate, rhythm, and depth of respiration. b. Measure the client’s pulse and blood pressure. c. Document the findings and continue to monitor. d. Notify the primary health care provider.

ANS: A

Progressive skeletal muscle weakness is associated with increasing severity of acidosis.

Muscle weakness can lead to severe respiratory insufficiency. Acidosis does lead to dysrhythmias (due to hyperkalemia), but these would best be assessed with cardiac monitoring. Findings would be documented, but simply continuing to monitor is not sufficient. Before notifying the primary care provider, the nurse must have more data to report.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Acid-base imbalances, Nursing assessment MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 7. A nurse is caring for a client who has the following arterial blood values: pH 7.12, PaO2 56

mm Hg, PaCO2 65 mm Hg, and HCO3 22 mEq/L (22 mmol/L). Which clinical situation does the nurse correlate with these values? a. Diabetic ketoacidosis in a person with emphysema b. Bronchial obstruction related to aspiration of a hot dog c. Anxiety-induced hyperventilation in an adolescent d. Diarrhea for 36 hours in an older, frail woman ANS: B

Arterial blood gas values indicate that the client has acidosis with normal levels of bicarbonate, suggesting that the problem is not metabolic. Arterial concentrations of oxygen and carbon dioxide are abnormal, with low oxygen and high carbon dioxide levels. Thus, this client has respiratory acidosis from inadequate gas exchange. The fact that the bicarbonate level is normal indicates that this is an acute respiratory problem rather than a chronic problem, because no renal compensation has occurred. The client who would have these ABG values is the one with the new onset of airway obstruction.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Analysis KEY: Acid-base imbalances, Laboratory values MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 8. A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The

client’s arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22 mEq/L (22 mmol/L). What action would the nurse take first? a. Apply oxygen by mask or nasal cannula. b. Apply a paper bag over the client’s nose and mouth. c. Administer 50 mL of sodium bicarbonate intravenously. d. Administer 50 mL of 20% glucose and 20 units of regular insulin.

ANS: A

This client is severely hypoxic and needs oxygen. Now that the seizure has ended, the client can breathe again normally, so oxygen administration will rapidly increase the PaO2.

Rebreathing carbon dioxide with a paper bag would make the acidosis worse. Bicarbonate is only indicated with extremely low pH and serum bicarbonate levels. Glucose and insulin are administered to decrease the high potassium levels associated with acidosis, but this situation should reverse itself with oxygen and breathing.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Acid-base imbalance, Critical rescue MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care

9. After teaching a client who was malnourished and is being discharged, a nurse assesses the

client’s understanding. Which statement indicates that the client correctly understood teaching to decrease risk for the development of metabolic acidosis? a. “I will drink at least three glasses of milk each day.” b. “I will eat three well-balanced meals and a snack daily.” c. “I will not take pain medication and antihistamines together.” d. “I will avoid salting my food when cooking or during meals.”

ANS: B

Starvation or a diet with too few carbohydrates can lead to metabolic acidosis by forcing cells to switch to using fats for fuel and by creating ketoacids as a by-product of excessive fat metabolism. Eating sufficient calories from all food groups helps reduce this risk. Milk, taking pain medications with antihistamines, and salting food are not related.

DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Acid-base imbalances, Health teaching MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 10. A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98 mm

Hg, PaCO2 28 mm Hg, and HCO3 22 mEq/L (22 mmol/L). Which client condition does the nurse correlate with these results? a. Diarrhea and vomiting for 36 hours b. Anxiety-induced hyperventilation c. Chronic obstructive pulmonary disease (COPD) d. Diabetic ketoacidosis and emphysema ANS: B

The elevated pH level indicates alkalosis. The bicarbonate level is normal, and so is the oxygen partial pressure. Loss of carbon dioxide is the cause of the alkalosis, which would occur in response to hyperventilation. Diarrhea and vomiting would cause metabolic acidosis and COPD would lead to respiratory acidosis. The client with emphysema most likely would have combined metabolic acidosis on top of a mild, chronic respiratory acidosis.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Acid-base imbalances, Laboratory values MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 11. After providing discharge teaching, a nurse assesses the client’s understanding regarding

increased risk for metabolic alkalosis. Which statement indicates that the client needs additional teaching? a. “I don’t drink milk because it gives me gas and diarrhea.” b. “I have been taking digoxin every day for the last 15 years.” c. “I take sodium bicarbonate after every meal to prevent heartburn.” d. “In hot weather, I sweat so much that I drink six glasses of water each day.”

ANS: C

Excessive oral ingestion of sodium bicarbonate and other bicarbonate-based antacids can cause metabolic alkalosis. Avoiding milk, taking digoxin, and sweating would not lead to increased risk of metabolic alkalosis.

DIF: Analyzing

TOP: Integrated Process: Teaching/Learning

KEY: Acid-base imbalances, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 12. A nurse is caring for a client who is experiencing excessive diarrhea. The client’s arterial

blood gas values are pH 7.18, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3 16 mEq/L (16 mmol/L). Which primary health care provider order does the nurse expect to receive? a. Furosemide 40 mg b. Sodium bicarbonate c. Mechanical ventilation d. Indwelling urinary catheter ANS: B

This client’s arterial blood gas values represent metabolic acidosis related to a loss of bicarbonate ions from diarrhea. The bicarbonate would be replaced to help restore this client’s acid–base balance as the pH is below 7.2 and the bicarbonate level is low. Furosemide would cause an increase in acid fluid and acid elimination via the urinary tract; although this may improve the client’s pH, the client has excessive diarrhea and cannot afford to lose more fluid.

Mechanical ventilation is used to treat respiratory acidosis for clients who cannot keep their oxygen saturation at 90%, or who have respiratory muscle fatigue. Mechanical ventilation and an indwelling urinary catheter would not be prescribed for that client.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Acid-base imbalances, Medications MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 13. A nurse evaluates a client’s arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg,

PaCO2 55 mm Hg, and HCO3 22 mEq/L (22 mmol/L). Which intervention does the nurse implement first? a. Assess the airway. b. Administer prescribed bronchodilators. c. Provide oxygen. d. Administer prescribed mucolytics.

ANS: A

All interventions are important for clients with respiratory acidosis; this is indicated by the ABGs. However, the priority is assessing and maintaining an airway. Without a patent airway, other interventions will not be helpful.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Acid-base imbalance, Nursing assessment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 14. A nurse is planning care for a client who is hyperventilating. The client’s arterial blood gas

values are pH 7.52, PaO2 94 mm Hg, PaCO2 31 mm Hg, and HCO3 26 mEq/L (26 mmol/L).

Which question would the nurse ask when developing this client’s plan of care? a. “Do you take any over-the-counter medications?” b. “You appear anxious. What is causing your distress?” c. “Do you have a history of anxiety attacks?” d. “You are breathing fast. Is this causing you to feel light-headed?

ANS: B

The nurse would assist the client who is experiencing anxiety-induced respiratory alkalosis to identify causes of the anxiety. The other questions will not identify the cause of the acid–base imbalance. The other three questions are also yes/no and close-ended.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Acid-base imbalance, Nursing assessment MSC: Client Needs Category: Psychosocial Integrity 15. A diabetic client becomes septic after a bowel resection and is having problems with

respiratory distress. The nurse reviews the labs and finds the following ABG results: pH 7.50, PaCO2 30, HCO3 : 24, and PaO2 68. What does the nurse recognize as the primary factor causing this the acid–base imbalance? a. Atelectasis due to respiratory muscle fatigue b. Hyperventilation due to poor oxygenation c. Hypoventilation due to morphine PCA d. Kussmaul respirations due to glucose of 102 mg/dL (5.7 mmol/L) ANS: B

The ABG results indicate respiratory alkalosis. The client has low oxygenation as indicated by low partial pressure of arterial oxygen causing a compensatory mechanism of increased respirations and hyperventilation. Respiratory muscle fatigue and hypoventilation would cause respiratory acidosis with a low pH and high PaCO2. Kussmaul respirations are characterized by deep labored breathing and are a compensatory mechanism to metabolic acidosis, not hypoxemia or alkalosis.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Acid-base imbalances, Alkalosis MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 1. A nurse is planning interventions that regulate acid–base balance to ensure that the pH of a

client’s blood remains within the normal range. Which abnormal physiologic functions may occur if the client experiences an acid–base imbalance? (Select all that apply.) a. Reduction in the function of hormones b. Fluid and electrolyte imbalances c. Increase in the function of selected enzymes d. Excitable cardiac muscle membranes e. Increase in the effectiveness of many drugs f. Changes in GI tract excitability ANS: A, B, D, F

Acid–base imbalances interfere with normal physiology, including reducing the function of hormones and enzymes, causing fluid and electrolyte imbalances, causing heart membranes and GI tract to be more or less excitable, and decreasing the effectiveness of many drugs.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Acid-base imbalances MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

2. A nurse assesses a client who is experiencing an acid–base imbalance. The client’s arterial

blood gas values are pH 7.32, PaO2 94 mm Hg, PaCO2 34 mm Hg, and HCO3 18 mEq/L (18 mmol/L). For which clinical signs and symptoms would the nurse assess? (Select all that apply.) a. Reduced deep tendon reflexes b. Drowsiness c. Increased respiratory rate d. Decreased urinary output e. Positive Trousseau sign f. Flaccid paralysis ANS: A, B, C

Metabolic acidosis causes neuromuscular changes, including reduced muscle tone and deep tendon reflexes. Clients usually present with lethargy and drowsiness. The respiratory system will attempt to compensate for the metabolic acidosis; therefore, respirations will increase rate and depth. Flaccid paralysis can occur. A positive Trousseau sign is associated with alkalosis.

Decreased urine output is not a sign of metabolic acidosis.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Acid-base imbalances, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. A nurse is assessing clients who are at risk for acid–base imbalance. Which clients are

correctly paired with the acid–base imbalance? (Select all that apply.) a. Metabolic alkalosis—young adult who is prescribed intravenous morphine sulfate for pain b. Metabolic acidosis—older adult who is following a carbohydrate-free diet c. Respiratory alkalosis—client on mechanical ventilation at a rate of 28 breaths/min d. Respiratory acidosis—postoperative client who received 6 units of packed red blood cells e. Metabolic alkalosis—older client prescribed antacids for gastroesophageal reflux disease ANS: B, C, E

Respiratory acidosis often occurs as the result of underventilation. The client who is taking opioids, especially IV opioids, is at risk for respiratory depression and respiratory acidosis.

One cause of metabolic acidosis is a strict low-calorie diet or one that is low in carbohydrate content. Such a diet increases the rate of fat catabolism and results in the formation of excessive ketoacids. A ventilator set at a high respiratory rate or tidal volume will cause the client to lose too much carbon dioxide, leading to an acid deficit and respiratory alkalosis.

Citrate is a substance used as a preservative in blood products. It is not only a base, but also a precursor for bicarbonate. Multiple units of packed red blood cells could cause metabolic alkalosis. Sodium bicarbonate antacids may increase the risk of metabolic alkalosis.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Acid-base imbalances MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. A nurse assesses a client who is receiving total parenteral nutrition. For which adverse effects

related to an acid–base imbalance would the nurse assess? (Select all that apply.) a. Positive Chvostek sign

b. c. d. e. f.

Elevated blood pressure Bradycardia Increased muscle strength Anxiety and irritability Tetany

ANS: A, E

A client receiving total parenteral nutrition is at risk for metabolic alkalosis. Signs and symptoms of metabolic alkalosis include positive Chvostek sign, normal or low blood pressure, increased heart rate, skeletal muscle weakness, possible tetany and seizures, and anxiety and irritability.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Acid-base imbalances, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 5. A nurse is planning care for a client who is lethargic and confused. The client’s arterial blood

gas values are pH 7.30, PaO2 96 mm Hg, PaCO2 43 mm Hg, and HCO3 19 mEq/L (19 mmol/L). Which questions would the nurse ask the client and spouse when developing the plan of care? (Select all that apply.) a. “Are you taking any antacid medications?” b. “Is your spouse’s current behavior typical?” c. “Do you drink any alcoholic beverages?” d. “Have you been participating in strenuous activity?” e. “Are you experiencing any shortness of breath?”

ANS: B, C, D

This client’s symptoms of lethargy and confusion are related to a state of metabolic acidosis.

The nurse would ask the client’s spouse or family members if the client’s behavior is typical for him or her, and establish a baseline for comparison with later assessment findings. The nurse would also assess for alcohol intake because alcohol can cause metabolic acidosis.

Excessive and strenuous activity can lead to overproduction of hydrogen ions. The other options are not causes of metabolic acidosis.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Acid-base imbalance, Acidosis MSC: Client Needs Category: Psychosocial Integrity

Chapter 15: Concepts of Infusion Therapy Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse is caring for a client who has just had a central venous access line inserted. What

action will the nurse take next? a. Begin the prescribed infusion via the new access. b. Ensure that an x-ray is completed to confirm placement. c. Check medication calculations with a second RN. d. Make sure that the solution is appropriate for a central line.

ANS: B

A central venous access device, once placed, needs an x-ray confirmation of proper placement before it is used. The bedside nurse would be responsible for beginning the infusion once placement has been verified. Any IV solution can be given through a central line.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Infusion therapy, Vascular access device MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 2. A nurse assesses a client who has a radial artery catheter. Which assessment will the nurse

complete first? a. Amount of pressure in fluid container b. Date of catheter tubing change c. Type of dressing over the site d. Skin color and capillary refill ANS: D

An intra-arterial catheter may cause arterial occlusion, which can lead to absent or decreased perfusion to the extremity. Assessment of color, warmth, sensation, capillary refill time, and distal pulses (if appropriate) are assessments for circulation distal to the catheter site. The nurse would note that there is enough pressure in the fluid container to keep the system flushed, and would check to see whether the catheter tubing needs to be changed. However, these are not assessments of greatest concern. The type of dressing over the site would be noted and most likely prescribed by policy.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Infusion therapy, Vascular access device MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 3. A nurse teaches a client who is being discharged home with a peripherally inserted central

catheter (PICC). Which statement will the nurse include in this client’s teaching? a. “Avoid carrying your grandchild with the arm that has the central catheter.” b. “Be sure to place the arm with the central catheter in a sling during the day.” c. “Flush the peripherally inserted central catheter line with normal saline daily.” d. “You can use the arm with the central catheter for most activities of daily living.”

ANS: A

A properly placed PICC (in the antecubital fossa or the basilic vein) allows the client considerable freedom of movement. Clients can participate in most activities of daily living; however, heavy lifting can dislodge the catheter or occlude the lumen. Although it is important to keep the insertion site and tubing dry, the client can shower. The device is flushed with heparin.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Infusion therapy, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 4. A nurse is caring for a client who is receiving an epidural infusion for pain management.

Which assessment finding requires immediate intervention from the nurse? a. Redness at the catheter insertion site b. Report of headache and stiff neck c. Temperature of 100.1° F (37.8° C) d. Pain rating of 8 on a scale of 0-10 ANS: B

Complications of epidural therapy include infection, bleeding, leakage of cerebrospinal fluid, occlusion of the catheter lumen, and catheter migration. Headache, neck stiffness, and a temperature higher than 101° F (37.8° C) are signs of meningitis and would be reported to the primary health care provider immediately. The other findings are important but do not require immediate intervention.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Infusion therapy, Complications MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 5. A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which

assessment finding is of greatest concern? a. The catheter has been in place for 20 hours. b. The client has poor vascular access in the upper extremities. c. The catheter is placed in the proximal tibia. d. The client’s left lower extremity is cool to the touch.

ANS: D

Compartment syndrome is a condition in which increased tissue pressure in a confined anatomic space causes decreased blood flow to the area. A cool extremity can signal the possibility of this syndrome. All other findings are important; however, the possible development of compartment syndrome requires immediate intervention because the client could require amputation of the limb if the nurse does not correctly assess and respond to this perfusion problem.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Infusion therapy, Complications MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 6. A nurse is assessing clients who have intravenous therapy prescribed. Which assessment

finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention? a. The initial site dressing is 3 days old.

b. The PICC was inserted 4 weeks ago. c. A securement device is absent. d. Upper extremity swelling is noted.

ANS: D

Upper extremity swelling could indicate infiltration, and the PICC will need to be removed.

The initial dressing over the PICC site would be changed within 24 hours. This does not require immediate attention, but the swelling does. The dwell time for PICCs can be months or even years. Securement devices are being used more often now to secure the catheter in place and prevent complications such as phlebitis and infiltration. The IV lacking one does not take priority over the client whose arm is swollen.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Infusion therapy, Vascular access device MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 7. A nurse assesses a client’s peripheral IV site, and notices edema and tenderness above the site.

What action will the nurse take next? a. Apply cold compresses to the IV site. b. Elevate the extremity on a pillow. c. Flush the catheter with normal saline. d. Stop the infusion of intravenous fluids.

ANS: D

Infiltration occurs when the needle dislodges partially or completely from the vein. Signs of infiltration include edema and tenderness above the site. The nurse would stop the infusion and remove the catheter. Cold compresses and elevation of the extremity can be done after the catheter is discontinued to increase client comfort. Alternatively, warm compresses may be prescribed per institutional policy and may help speed circulation to the area.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Infusion therapy, Complications MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 8. While assessing a client’s peripheral IV site, the nurse observes a streak of red along the vein

path and palpates a 1.5 inch (4-cm) venous cord. How will the nurse document this finding? a. “Grade 3 phlebitis at IV site” b. “Infection at IV site” c. “Thrombosed area at IV site” d. “Infiltration at IV site” ANS: A

The presence of a red streak and palpable cord indicates grade 3 phlebitis. No information in the description indicates that infection, thrombosis, or infiltration is present.

DIF: Understanding TOP: Integrated Process: Communication and Documentation KEY: Infusion therapy, Complications MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 9. A new nurse is caring for a client receiving drug therapy via a smart pump. What statement by

the new nurse demonstrates the need for more instruction on this technology?

a. b. c. d.

“I don’t need to manually calculate IV infusion rates with smart pumps.”

“Responding to IV pump alarms is a high priority for client safety.”

“The hospital can preprogram the pumps for high-alert drug limits.”

“These pumps have a system to prevent fluids from free-flowing into the client.”

ANS: A

The “smarter” the pump is the more programming needs to occur and errors can happen and systems can fail. Using a programmable pump does not relieve the nurse of his or her responsibility to monitor the infusion site and rates and ensure the client is receiving the fluids or medications as prescribed. The Joint Commission continues to include responding to alarms as a National Patient Safety Goal. Pumps can be preprogrammed so that upper limits exist for high-alert drugs. All electronic infusion devices have some mechanism for preventing free flow of fluids if the cassette or tubing is removed from the pump.

DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Infusion therapy, Client safety MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 10. A nurse prepares to insert a peripheral venous catheter in an older adult. What action will the

nurse take to protect the client’s skin during this procedure? a. Lower the extremity below the level of the heart. b. Apply warm compresses to the extremity. c. Tap the skin lightly and avoid slapping. d. Place a washcloth between the skin and tourniquet.

ANS: D

To protect the client’s skin, the nurse will place a washcloth or the client’s gown between the skin and tourniquet. The other interventions are methods to distend the vein but will not protect the client’s skin.

DIF: Understanding TOP: Integrated Process: Nursing Process: Implementation KEY: Infusion therapy, Older adult MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 11. A nurse delegates care to an assistive personnel (AP). Which statement will the nurse include

when delegating hygiene for a client who has a vascular access device? a. “Provide a bed bath instead of letting the client take a shower.” b. “Use sterile technique when changing the dressing.” c. “Disconnect the intravenous fluid tubing prior to the client’s bath.” d. “Use a plastic bag to cover the extremity with the device.”

ANS: D

The nurse will ask the AP to cover the extremity with the vascular access device with a plastic bag or wrap to keep the dressing and site dry. The client may take a shower or bath with a vascular device. The nurse will disconnect IV fluid tubing prior to the bath and change the dressing using sterile technique if necessary. These options are not appropriate to delegate to the AP. DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Infusion therapy, Delegation MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort

12. A nurse teaches a client who is prescribed a central vascular access device and is transferring

to a skilled facility for long-term treatment. Which statement will the nurse include in this client’s teaching? a. “You will need to wear a sling on your arm while the device is in place.” b. “There is no risk of infection because sterile technique will be used during insertion.” c. “Ask all providers to vigorously clean the connections prior to accessing the device.” d. “You will not be able to take a bath with this vascular access device.”

ANS: C

The nurse would actively engage the client in the prevention of catheter-related bloodstream infections and taught to remind all providers to perform hand hygiene and vigorously clean connections prior to accessing the device. The other statements are incorrect.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Infusion therapy, Infection control MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 13. A nurse is caring for a client with a peripheral vascular access device who is experiencing

pain, redness, and swelling at the site. After removing the device, what action will the nurse take to relieve pain? a. Administer topical lidocaine to the site. b. Place warm compresses on the site. c. Administer prescribed oral pain medication. d. Massage the site with scented oils.

ANS: B

At the first sign of phlebitis, the catheter will be removed and warm compresses used to relieve pain. The other options are not appropriate for this type of pain.

DIF: Applying TOP: Integrated Process: Caring KEY: Infusion therapy, Nonpharmacologic comfort measures MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 14. A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client

reports abdominal pain and “feeling warm.” For which complication of this therapy will the nurse assess the client? a. Allergic reaction b. Bowel obstruction c. Catheter lumen occlusion d. Infection ANS: D

Fever, abdominal pain, abdominal rigidity, and rebound tenderness may be present in the client who has peritonitis related to intraperitoneal therapy. Peritonitis is preventable by using strict aseptic technique in handling all equipment and infusion supplies. An allergic reaction would show other signs and symptoms. Bowel obstruction and catheter lumen occlusion can occur but would present clinically in different ways.

DIF: Applying TOP: Integrated Process: Nursing Process: Analysis KEY: Infusion therapy, Complications

MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 15. A medical-surgical nurse is concerned about the incidence of complications related to IV

therapy, including bloodstream infection. Which intervention will the nurse suggest to the management team to make the biggest impact on decreasing complications? a. Initiate a dedicated team to insert access devices. b. Require additional education for all nurses. c. Limit the use of peripheral venous access devices. d. Perform quality control testing on skin preparation products.

ANS: A

The Centers for Disease Control and Prevention recommends having a dedicated IV team to reduce complications, save money, and improve client satisfaction and outcomes. In-service education would always be helpful, but it would not have the same outcomes as an IV team.

Limiting the use of various access devices may not be practical. The quality of skin preparation products is only one aspect of IV insertion that could contribute to infection.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Infusion therapy, Quality improvement MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 16. A nurse prepares to flush a peripherally inserted central catheter (PICC) line with 50 units of

heparin. The pharmacy supplies a multidose vial of heparin with a concentration of 100 units/mL. Which of the syringes shown below will the nurse use to draw up and administer the heparin? a.

b.

c.

d.

ANS: D

Always use a 10-mL syringe when flushing PICC lines because a smaller syringe creates higher pressure, which could rupture the lumen of the PICC. The PICC line would be accessed with a needleless syringe.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Infusion therapy, Vascular access device MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 17. A home care nurse prepares to administer intravenous medication to a client. The nurse

assesses the site and reviews the client’s chart prior to administering the medication and notes it to have been inserted 4 months ago. The site has no redness, warmth, or swelling and flushes easily. What action does the nurse take? a. Notify the primary health care provider. b. Administer the prescribed medication. c. Discontinue the PICC. d. Switch the medication to the oral route.

ANS: B

A PICC that is functioning well without inflammation or infection may remain in place for months. Because the line shows no signs of complications, it is permissible to administer the IV antibiotic. There is no need to call the primary health care provider or to have the IV medication changed to an oral route.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Infusion therapy, Vascular access device MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies MULTIPLE RESPONSE 1. A registered nurse (RN) occasionally delegates client care to licensed practical nurses (LPNs)

or technicians. What information does the RN consider when delegating components of IV therapy? (Select all that apply.) a. Each state’s Nurse Practice Act will regulate who can perform care related to IVs. b. The nurse would check the facility’s Policies and Procedures manual. c. The LPN’s level of experience primarily guides the decision. d. Technicians cannot participate in any part of caring for IV infusions. e. The RN remains accountable for all aspects of IV care and delegated actions. f. The Infusion Nurses Society has guidelines and standards of IV therapy competency.

ANS: A, B, E, F

The state Nurse Practice Act will have the information the RN needs to determine scope of practice, and in some states, LPNs and technicians are able to perform specific aspects of IV therapy. The nurse would also be familiar with facility policies and procedures regarding delegation of IV therapy. Amount of experience is not a criterion as LPNs and technicians can have their knowledge and skills verified. The nurse remains accountable for all aspects of IV therapy include what has been delegated. The Infusion Nurses Society has published guidelines and standards related to competency for IV therapy.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Infusion therapy, Delegation MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 2. A nurse assesses a client who has a peripherally inserted central catheter (PICC). For which

common complications will the nurse assess? (Select all that apply.) a. Phlebitis b. Pneumothorax c. Thrombophlebitis d. Excessive bleeding e. Extravasation f. Pneumothorax g. Infiltration ANS: A, C

Although the complication rate with PICCs is fairly low, the most common complications are phlebitis, thrombophlebitis, and catheter-related bloodstream infection. Excessive bleeding, infiltration, and extravasation are not common complications. Pneumothorax does not occur.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Infusion therapy, Complications MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 3. A nurse prepares to administer a blood transfusion to a client, and checks the blood label with

a second registered nurse using the International Society of Blood Transfusion (ISBT) universal bar-coding system to ensure the right blood for the right client. Which components must be present on the blood label in bar code and in eye-readable format? (Select all that apply.) a. Unique facility identifier b. Lot number related to the donor c. Name of the client receiving blood d. ABO group and Rh type of the donor e. Blood type of the client receiving blood f. Signature line for 2-person verification ANS: A, B, D

The ISBT universal bar-coding system includes four components: (1) the unique facility identifier, (2) the lot number relating to the donor, (3) the product code, and (4) the ABO group and Rh type of the donor. Positive identification by two qualified health care providers is essential although automated bar coding is acceptable in some care areas. However, a signature line is not required on the blood label.

DIF: Remembering TOP: Integrated Process: Communication and Documentation KEY: Infusion therapy, Blood component transfusion, Safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 4. A nurse assists with the insertion of a central vascular access device. Which actions will the

nurse ensure are completed to prevent a catheter-related bloodstream infection? (Select all that apply.) a. Include a review for the need of the device each day in the client’s plan of care.

b. Remind the primary health care provider to perform hand hygiene prior to c. d. e. f.

insertion if he or she forgets.

Cleanse the preferred site with alcohol and let it dry completely before insertion.

Ask everyone in the room to wear a surgical mask during the procedure.

Plan to complete a sterile dressing change on the device every day.

Minimal client draping and barrier precautions as blood loss are minimal.

ANS: A, B, D

The central vascular access device bundle to prevent catheter-related bloodstream infections includes using a checklist during insertion, performing hand hygiene before inserting the catheter and anytime someone touches the catheter, using chlorhexidine to disinfect the skin at the site of insertion, using preferred sites, and reviewing the need for the catheter every day.

The practitioner who inserts the device would wear sterile gloves, gown, and mask, and anyone in the room would wear a mask. Maximal barrier precautions are used which requires the client to be draped sterilely from head to toe. The initial dressing on a central vascular access device is changed in 24 hours. Gauze and tape dressings are changed every 48 hours and transparent membrane dressings are changed every 5 to 7 days.

DIF: Remembering TOP: Integrated Process: Nursing Process: Implementation KEY: Infusion therapy, Infection control MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 5. A nurse prepares to insert a short peripheral venous catheter. What actions will the nurse take

to use best practices? (Select all that apply.) a. Choose a distal site on the client’s nondominant arm. b. Verify that the prescription is appropriate for peripheral infusion. c. Place the venous catheter near an area of joint flexion. d. Wear a surgical mask during the catheter insertion procedure. e. Perform hand hygiene before inserting the catheter. f. Limit unsuccessful attempts by up to three clinicians to one attempt each.

ANS: A, B, E

Best practices for the insertion of a short peripheral venous catheter include hand hygiene prior to the procedure, verification of the prescription for intravenous therapy and its appropriateness for infusion through a short peripheral catheter, and placement of the catheter in a distal site, away from an area of joint flexion and when possible in the client’s nondominant arm. Surgical masks are needed for central venous catheter placement but not for short peripheral venous catheter placement. Unsuccessful attempts to insert the catheter should be limited to two per person and no more than four total.

DIF: Remembering TOP: Integrated Process: Nursing Process: Implementation KEY: Infusion therapy, Vascular access device MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

Chapter 16: Concepts of Inflammation and Immunity Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. The nurse learns that the most important function of inflammation and immunity is which

purpose? a. Destroying bacteria before damage occurs b. Preventing any entry of foreign material c. Providing maximum protection against infection d. Regulating the process of self-tolerance ANS: C

Immunity and Inflammation working together are critical to maintaining health, preventing disease, and repairing tissue damage. When all the different parts and functions of immunity are working well, the adult is immunocompetent and has maximum protection against infection. Working together, their function is not limited to destroying bacteria before damage occurs. They do not prevent the entry of all foreign materials and immunity alone regulates the process of self-tolerance.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Immunity, Inflammation, Infection control MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A nurse is assessing an older client for the presence of infection. The client’s temperature is

97.6° F (36.4° C). What response by the nurse is best? a. Assess the client for more specific signs. b. Conclude that an infection is not present. c. Document findings and continue to monitor. d. Request the primary health care provider order blood cultures.

ANS: A

Because older adults have decreased immune function, including reduced neutrophil function, fever may not be present during an episode of infection. The nurse would assess the client for specific signs of infection. Documentation needs to occur, but a more thorough assessment comes first. Blood cultures may or may not be needed depending on the results of further assessment.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Inflammation, Immunity MSC: Client Needs Category: Health Promotion and Maintenance 3. A clinic nurse is working with an older client. What action is most important for preventing

infections in this client? a. Assessing vaccination records for booster shot needs b. Encouraging the client to eat a nutritious diet c. Instructing the client to wash minor wounds carefully d. Teaching hand hygiene to prevent the spread of microbes ANS: A

Older adults may have insufficient antibodies that have already been produced against microbes to which they have been exposed. Therefore, older adults need booster shots for many vaccinations they received as younger people. A nutritious diet, proper wound care, and hand hygiene are relevant for all populations.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Immunity, Inflammation MSC: Client Needs Category: Health Promotion and Maintenance 4. A client has a leg wound that is in Stage II of the inflammatory response. For what sign or

symptom does the nurse assess? a. Noticeable rubor b. Purulent drainage c. Swelling and pain d. Warmth at the site ANS: B

During the second phase of the inflammatory response, neutrophilia occurs, producing pus.

Rubor (redness), swelling, pain, and warmth are cardinal signs of the general inflammatory process.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Inflammation, Inflammatory response MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 5. A nurse learning about antibody-mediated immunity learns that the cell with the most direct

role in this process begins development in which tissue or organ? a. Bone marrow b. Spleen c. Thymus d. Tonsils ANS: A

The B-cell is the primary cell in antibody-mediated immunity and is released from the bone marrow. These cells then travel to other organs and tissues, known as the secondary lymphoid tissues for B-cells.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Immunity, Antibody-mediated immunity MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. The nurse understands that which type of immunity is the longest acting? a. Artificial active b. Inflammatory c. Natural active d. Natural passive ANS: C

Natural active immunity is the most effective and longest acting type of immunity. Artificial and natural passive do not last as long. “Inflammatory” is not a type of immunity.

DIF: Remembering

TOP: Integrated Process: Teaching/Learning

KEY: Immunity, Antibody-mediated immunity MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 7. The nurse working with clients who have autoimmune diseases understands that what

component of cell-mediated immunity is the problem? a. CD4+ cells b. Cytotoxic T-cells c. Natural killer cells d. Regulator T-cells ANS: D

Regulator T-cells help prevent hypersensitivity to one’s own cells, which is the basis for autoimmune disease. CD4+ cells are also known as helper/inducer cells, which secrete cytokines. Natural killer cells have direct cytotoxic effects on some non-self cells without first being sensitized. Regulator T-cells have an inhibitory action on the immune system. Cytotoxic T-cells are effective against self cells infected by parasites such as viruses or protozoa.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Immunity, Cell-mediated immunity MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 8. A primary health care provider notifies the nurse that a client has a “bandemia.” What action

does the nurse anticipate? a. Administer antibiotics. b. Place the client in isolation. c. Administer IV leukocytes. d. Obtain an immunization history.

ANS: A

A bandemia, or shift to the left, in the white count differential means that an acute, continuing infection has placed so much stress on the immune system that the most numerous type of neutrophil in circulation are immature, or band cells. The nurse would anticipate administering antibiotics. The client may or may not need isolation. Leukocyte infusion and immunization history are not relevant.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Immunity, Decreased immunity, Older adult risk factors MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 9. What does the nurse learn about the function of colony-stimulating factor? a. Triggers the bone marrow to shorten the time needed to produce mature WBCs. b. Causes capillary leak in acute inflammation. c. Responsible for creating exudate (pus) at infectious sites. d. Dilates blood vessels at the site of inflammation leading to hyperemia.

ANS: A

Colony-stimulating factor triggers the bone marrow to shorten the time needed to produce mature WBCs from about 14 days to hours. Increased blood flow to the local area of inflammation produces hyperemia, or redness. Exudate is formed by neutrophils and consists of dead WBCs, necrotic tissue, and fluids that escape from damaged cells. Histamine, serotonin, and kinins dilate arterioles leading to redness and warmth.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Immunity, Older adult risk factors MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 10. The older client’s adult child questions the nurse as to why the client is at higher risk for

infection when the client’s white cell count is within the normal range. What response by the nurse is best? a. “The white cell count does not tell us everything about immunity.” b. “White blood cells are less active in older people so they are not as efficient.” c. “Older people typically have poor nutrition which makes them prone to infection.” d. “As one ages, immunoglobulins cease to be produced in response to illness.”

ANS: B

An age-related change in immunity is that neutrophils in the older adult are less active and therefore less effective in immunity. The white blood cell count is not the only thing that can inform about immunity, but this response is too vague to be useful. Many older adults do have poor nutrition that does affect immunity, but this is not true for everyone and the stem does not contain information stating that is problematic for this older adult. Immunoglobulins do not cease to be produced with age.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Immunity, Older adult risk factors MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 1. For a person to be immunocompetent, which processes need to be functional and interact

appropriately with each other? (Select all that apply.) a. Antibody-mediated immunity b. Cell-mediated immunity c. Inflammation d. Red blood cells e. White blood cells ANS: A, B, C

The three processes that need to be functional and interact with each other for a person to be immunocompetent are antibody-mediated immunity, cell-mediated immunity, and inflammation. Red and white blood cells are not processes.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Immunity, Inflammation MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A nurse is learning about the types of different cells involved in the inflammatory response.

Which principles does the nurse learn? (Select all that apply.) a. Basophils are only involved in the general inflammatory process. b. Eosinophils increase during allergic reactions and parasitic invasion. c. Macrophages can participate in many episodes of phagocytosis. d. Monocytes turn into macrophages after they enter body tissues. e. Neutrophils can only take part in one episode of phagocytosis.

ANS: B, C, D, E

Eosinophils do increase during allergic and parasitic invasion. Macrophages participate in many episodes of phagocytosis. Monocytes turn into macrophages after they enter body tissues. Neutrophils only take part in one episode of phagocytosis. Basophils are involved in both the general inflammatory response and allergic or hypersensitivity responses.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Inflammation, Immunity MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. The nurse assesses clients for the cardinal signs of inflammation. Which signs/symptoms does

this include? (Select all that apply.) a. Edema b. Pulselessness c. Pallor d. Redness e. Warmth f. Decreased function ANS: A, D, E, F

The five cardinal signs of inflammation include redness, warmth, pain, swelling, and decreased function.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Inflammation, Immunity, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. Which are steps in the process of making an antigen-specific antibody? (Select all that apply.) a. Antibody-antigen binding b. Invasion c. Opsonization d. Recognition e. Sensitization f. Production ANS: A, B, D, E, F

The seven steps in the process of making antigen-specific antibodies are: exposure/invasion, antigen recognition, sensitization, antibody production and release, antigen-antibody binding, antibody binding actions, and sustained immunity. Opsonization is the adherence of an antibody to the antigen, marking it for destruction.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Immunity, Antibody-mediated immunity MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. The nurse is learning about immunoglobulins. . Which principles does the nurse learn? (Select

all that apply.) a. IgA is found in high concentrations in secretions from mucous membranes. b. IgD is present in the highest concentrations in mucous membranes. c. IgE is associated with antibody-mediated hypersensitivity reactions. d. IgG comprises the majority of the circulating antibody population.

e. IgM is the first antibody formed by a newly sensitized B-cell.

ANS: A, C, D, E

Immunoglobulin A (IgA) is found in high concentrations in secretions from mucous membranes. Immunoglobulin E (IgE) is associated with antibody-mediated hypersensitivity reactions. The majority of the circulating antibody population consists of immunoglobulin G (IgG). The first antibody formed by a newly sensitized B-cell is immunoglobulin M (IgM).

Immunoglobulin D (IgD) is typically present in low concentrations.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Immunity, Antibodies MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. The nurse learns that which risk factors can affect immunity? (Select all that apply.) a. Age b. Environmental factors c. Ethnicity d. Drugs e. Nutritional status ANS: A, B, D, E

Immunity changes during an adult’s life as a result of nutritional status, environmental conditions, drugs, disease, and age. Immunity is most efficient in young adults and older adults have decreased immune function. Ethnicity does not affect immunity.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Immunity, Older adult risk factors MSC: Client Needs Category: Health Promotion and Maintenance 7. The nurse is teaching an elderly client the risks of infection for older adults. Which of the

following factors would the nurse include in the education? (Select all that apply.) a. Higher risk for respiratory tract and genitourinary infections. b. May not have a fever with severe infection. c. Show expected changes in white blood cell counts. d. Should receive influenza, pneumococcal, and shingles vaccinations. e. Skin tests for tuberculosis may be falsely negative. f. Booster vaccinations are not likely needed as one ages.

ANS: A, B, D, E

Immunity changes during an adult’s life and older adults have decreased immune function.

The number and function of neutrophils and macrophages are reduced leading to reduced response to infection and injury, such as temperature elevation. The usual response of an increased white blood cell count is delayed or absent. Older adults are less able to make new antibodies in response to the presence of new antigens requiring repeat vaccinations and immunizations. Skin tests for tuberculosis may be falsely negative and there is an increased risk for bacterial and fungal infections due to the decreased number of circulating T-lymphocytes.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Immunity, Older adult risk factors MSC: Client Needs Category: Health Promotion and Maintenance

8. A nurse is studying the functions of specific leukocytes. Which leukocytes are matched

correctly with their function? (Select all that apply.) a. Monocyte: matures into a macrophage. b. Basophil: releases vasoactive amines during an allergic reaction. c. Plasma cell: secretes immunoglobulins in response to the presence of a specific antigen. d. Cytotoxic T-cells: attacks and destroys ingested poisons and toxins. e. Natural killer cell: nonselectively attacks non-self cells. f. Regulator T-cells: become sensitized for self-recognition in the bone marrow.

ANS: A, C, E

Monocytes mature into macrophages, plasma cells secrete immunoglobulin in the presence of specific antigens, and natural killer cells nonselectively attack non-self cells. Basophils release histamines, kinins, and heparin in areas of tissue damage. Cytotoxic T-cells selectively attack and destroy non-self cells, including virally infected cells, grafts, and transplanted organs.

Regulator T-cells become sensitized for self-recognition in the thymus.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Immunity, Leukocytes MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 9. A nurse is studying the function of immunoglobulins. Which immunoglobulins are correctly

matched to their function? (Select all that apply.) a. IgA: most responsible for preventing infection in the respiratory tracts, the GI tract, and the genitourinary tract. b. IgD: provides protection against parasite infestations, especially helminths. c. IgE: associated with antibody-mediated immediate hypersensitivity reactions. d. IgG: activates classic complement pathway and enhances neutrophil and macrophage actions. e. IgM: first antibody formed by a newly sensitized B-lymphocyte plasma cell.

ANS: A, C, D, E

All options are true except IgD acts as a B-cell antigen receptor. IgE provides protection against parasite infestations, especially helminths.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Immunity, Immunoglobulins MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 10. The nurse caring for clients assesses their daily laboratory profiles. Which lab results are

considered to be in the normal range? (Select all that apply.) a. Segmented neutrophils: 68% b. Bands: 19% c. Monocytes: 12% d. Lymphocytes: 38% e. Eosinophils: 2% f. Basophils: 1% ANS: A, D, E, F

The normal range for segmented neutrophils is 55% to 70%. The normal range for bands is 5%. The normal range for monocytes is 2% to 8%. The normal range for lymphocytes is 20% to 40%. The normal range for eosinophils is 1% to 4%. The normal range for basophils is 0.5% to 1%.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Immunity, White blood cells MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 11. What statements about the complement system are correct? (Select all that apply.) a. Comprised of 20 types of inactive plasma proteins. b. Act as enzymes when activated to enhance innate immunity. c. Phagocytize foreign invaders quickly by destroying their membranes. d. Sticks to the antigen and forms a membrane attack complex. e. Maintain and prolong inflammation from non-self cells. f. Is part of the innate immune system.

ANS: A, B, D, F

The complement system is made up of 20 different types of inactive plasma proteins that, when activated, act as enzymes to enhance (or complement) cell actions in innate immunity.

They join other proteins to surround antigens and “fix” or stick to the antigen quickly forming a membrane attack complex on the antigen surface. This action makes immune cell attachment to antigens and phagocytosis more efficient. They are part of innate immunity.

They do not phagocytize invaders themselves nor do they maintain and prolong inflammation from allergens.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Immunity, Complement System MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

Chapter 17: Concepts of Care for Patients With HIV Disease Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. The nurse is caring for a client diagnosed with HIV-II. The client’s CD4+ cell count is

399/mm3 (0.399  109/L). What action by the nurse is best? a. Counsel the client on safer sex practices/abstinence. b. Encourage the client to abstain from alcohol. c. Facilitate genetic testing for CD4+ CCR5/CXCR4 co-receptors. d. Help the client plan high-protein/iron meals.

ANS: A

This client is in the Centers for Disease Control and Prevention HIV-II case definition group.

He or she remains highly infectious and would be counseled on either safer sex practices or abstinence. Abstaining from alcohol is healthy but not required, although some medications may need to be taken while abstaining. Genetic testing is not commonly done, but an alteration on the CCR5/CXCR4 co-receptors is seen in long-term nonprogressors.

High-protein/iron meals are important for people who are immunosuppressed, but helping to plan them does not take precedence over stopping the spread of the disease.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: HIV disease, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 2. The nurse is presenting information to a community group on safer sex practices. The nurse

would teach that which sexual practice is the riskiest? a. Anal intercourse b. Masturbation c. Oral sex d. Vaginal intercourse ANS: A

Anal intercourse is the riskiest sexual practice because the fragile anal tissue can tear, creating a portal of entry for human immune deficiency virus in addition to providing mucus membrane contact with the virus.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: HIV disease, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 3. The nurse providing direct client care uses specific practices to reduce the chance of acquiring

infection with human immune deficiency virus (HIV) from clients. Which practice is most effective? a. Consistent use of Standard Precautions b. Double-gloving before body fluid exposure c. Labeling charts and armbands “HIV+” d. Wearing a mask within 3 feet (1 m) of the client ANS: A

According to The Joint Commission, the most effective preventative measure to avoid HIV exposure is consistent use of Standard Precautions. Standard Precautions are required by the CDC. Double-gloving is not necessary. Labeling charts and armbands in this fashion is a violation of the Health Information Portability and Accountability Act (HIPAA). Wearing a mask within 3 feet (1 m) of the client is not necessary with every client contact.

DIF: Remembering TOP: Integrated Process: Nursing Process: Implementation KEY: HIV disease, Standard precautions MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 4. A client with known HIV-II is admitted to the hospital with fever, night sweats, and severe

cough. Laboratory results include a CD4+ cell count of 180/mm3 and a negative tuberculosis (TB) skin test 4 days ago. What action would the nurse take first? a. Initiate Droplet Precautions for the client. b. Notify the primary health care provider about the CD4+ results. c. Place the client under Airborne Precautions. d. Use Standard Precautions to provide care.

ANS: C

Since this client’s CD4+ cell count is so low, he or she may have energy, or the inability to mount an immune response to the TB test. The client also appears to have progressed to HIV-III. The nurse would first place the client on Airborne Precautions to prevent the spread of TB if it is present. Next the nurse notifies the primary health care provider about the low CD4+ count and requests alterative testing for TB. Droplet Precautions are not used for TB. Standard Precautions are not adequate in this case.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: HIV disease, Transmission-based precautions MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 5. A nurse is talking with a client about a negative enzyme-linked immunosorbent assay

(ELISA) test for human immune deficiency virus (HIV). The test is negative and the client states “Whew! I was really worried about that result.” What action by the nurse is most important? a. Assess the client’s sexual activity and patterns. b. Express happiness over the test result. c. Remind the client about safer sex practices. d. Tell the client to be retested in 3 months.

ANS: A

The ELISA test can be falsely negative if testing occurs after the client has become infected but prior to making antibodies to HIV. This period of time is known as the window period and can last up to 21 days. The confirmatory Western Blot test takes an additional 7 days, so using that testing algorithm, the client’s status may not truly be known for up to 28 days. The client may have had exposure that has not yet been confirmed. The nurse needs to assess the client’s sexual behavior further to determine the proper response. The other actions are not the most important, but discussing safer sex practices is always appropriate. Testing would be recommended every 3 months for someone engaging in high risk behaviors.

DIF: Applying

TOP: Integrated Process: Nursing Process: Assessment

KEY: HIV disease, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 6. A client with HIV-II has had a sudden decline in status with a large increase in viral load.

What action would the nurse take first? a. Ask the client about travel to any foreign countries. b. Assess the client for adherence to the drug regimen. c. Determine if the client has any new sexual partners. d. Request information about new living quarters or pets.

ANS: B

Adherence to the complex drug regimen needed for HIV treatment can be daunting. Clients must take their medications on time and correctly at a minimum of 90% of the time to be effective. Since this client’s viral load has increased dramatically, the nurse would first assess this factor. After this, the other assessments may or may not be needed.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: HIV disease, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 7. A client is hospitalized with Pneumocystis jiroveci pneumonia. The client reports shortness of

breath with activity and extreme fatigue. What intervention is best to promote comfort? a. Administer sleeping medication. b. Perform most activities for the client. c. Increase the client’s oxygen during activity. d. Pace activities, allowing for adequate rest.

ANS: D

This client has two major reasons for fatigue: decreased oxygenation and systemic illness. The nurse would not do everything for the client but rather let the client do as much as possible within limits and allow for adequate rest in between. Sleeping medications may be needed but not as the first step, and only with caution. Increasing oxygen during activities may or may not be warranted, but first the nurse must try pacing the client’s activity.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: HIV disease, Fatigue MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 8. A client with HIV-III and wasting syndrome has inadequate nutrition. What assessment

finding by the nurse best indicates that goals have been met for this client problem? a. Chooses high-protein food. b. Has decreased oral discomfort. c. Eats 90% of meals and snacks. d. Has a weight gain of 2 lb (1 kg)/1 mo.

ANS: D

The weight gain is the best indicator that goals for this client problem have been met because it demonstrates that the client not only is eating well but also is able to absorb the nutrients.

Choosing high-protein food is important, but only if the client eats and absorbs the nutrients.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: HIV disease, Nutrition

MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 9. A client with HIV-III is hospitalized and has weeping Kaposi sarcoma lesions. The nurse

dresses them with sterile gauze. When changing these dressings, which action is most important for the nurse’s safety? a. Adhering to Standard Precautions b. Assessing tolerance to dressing changes c. Performing hand hygiene before and after care d. Disposing of soiled dressings properly ANS: A

All of the actions are important, but due to the infectious nature of this illness, the nurse would ensure he or she is following Standard Precautions (and Transmission-Based Precautions when necessary) to avoid a potential exposure.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: HIV disease, Standard precautions MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 10. A client with HIV-III is admitted to the hospital with Toxoplasma gondii infection. Which

action by the nurse is most appropriate? a. Initiate Contact Precautions. b. Conduct frequent neurologic assessments. c. Conduct frequent respiratory assessments. d. Initiate Protective Precautions.

ANS: D

Toxoplasma gondii infection is an opportunistic infection that causes an encephalitis but poses only a rare threat to immunocompetent individuals The nurse would perform ongoing neurologic assessments. Contact and Protective Precautions are not needed. Good respiratory assessments are important to the client, but toxoplasmosis will demonstrate neurologic signs and symptoms.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: HIV disease, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 11. A client has just been informed of a positive HIV test. The client is distraught and does not

know what to do. What intervention by the nurse is best? a. Assess the client for support systems. b. Determine if a clergy member would help. c. Explain legal requirements to tell sex partners. d. Offer to tell the family for the client.

ANS: A

This client needs the assistance of support systems. The nurse would help the client identify them and what role they can play in supporting him or her. A clergy member may or may not be welcome. Positive HIV test results are reportable in all 50 states, Washington, D.C., and Canada but the nurse works with the client to support his or her choices in disclosure. The nurse would not tell the family for the client.

DIF: Applying

TOP: Integrated Process: Caring

KEY: HIV disease, Psychosocial response MSC: Client Needs Category: Psychosocial Integrity 12. A nurse is caring for a client with HIV-III who was admitted with HAND. What sign or

symptom would be most important for the nurse to report to the primary health care provider? a. Nausea b. Change in pupil size c. Weeping open lesions d. Cough ANS: B

HIV-associated neurocognitive disorder (HAND) is a sign of neurologic involvement. The nurse would report any sign of increasing intracranial pressure immediately, including change in pupil size, level of consciousness, vital signs, or limb strength. The other signs and symptoms are not life threatening and would be documented and reported appropriately.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: HIV disease MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 13. A client has been hospitalized with an opportunistic infection secondary to HIV-III. The

client’s partner is listed as the emergency contact, but the client’s mother insists that she should be listed instead. What action by the nurse is best? a. Contact the social worker to assist the client with advance directives. b. Ignore the mother; the client does not want her to be involved. c. Let the client know, gently, that nurses cannot be involved in these disputes. d. Tell the client that, legally, the mother is the emergency contact.

ANS: A

The client should make his or her wishes known and formalize them through advance directives. The nurse would help the client by contacting someone to help with this process.

Ignoring the mother or telling the client that nurses cannot be involved does not help the situation. Legal statutes vary by state, but the nurse would be the client’s advocate and help ensure his or her wishes are met.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: HIV disease, Ethics MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 14. A client with HIV-II is hospitalized for an unrelated condition, and several medications are

prescribed in addition to the regimen already being used. What action by the nurse is most important? a. Consult with the pharmacy about drug interactions. b. Ensure that the client understands the new medications. c. Give the new drugs without considering the old ones. d. Schedule all medications at standard times.

ANS: A

The drug regimen for someone with HIV/AIDS is complex and consists of many medications that must be given at specific times of the day, and that have many interactions with other drugs and food. The nurse would consult with a pharmacist about possible interactions. Client teaching is important but does not take precedence over ensuring the medications do not interfere with each other, which could lead to drug resistance or a resurgence of symptoms.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: HIV disease, Medication safety MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 15. A client with HIV-III has been hospitalized with suspected cryptosporidiosis. What physical

assessment would be most important with this condition? a. Auscultating the lungs b. Assessing mucous membranes c. Listening to bowel sounds d. Performing a neurologic examination ANS: B

Cryptosporidiosis can cause diarrhea and wasting with extreme loss of fluids and electrolytes.

The nurse would assess signs of hydration/dehydration as the priority, including checking the client’s mucous membranes for dryness. The nurse will perform the other assessments as part of a comprehensive assessment.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: HIV disease, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 16. A client with HIV-III asks the nurse why gabapentin is part of the drug regimen when the

client does not have a history of seizures. What response by the nurse is best? a. “Gabapentin can be used as an antidepressant too.” b. “I have no idea why you would be taking this drug.” c. “This drug helps treat the pain from nerve irritation.” d. “You are at risk for seizures due to fungal infections.”

ANS: C

Many classes of medications are used for neuropathic pain, including tricyclic antidepressants and anticonvulsants such as gabapentin. It is not being used to prevent seizures from fungal infections. If the nurse does not know the answer, he or she would find out for the client.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: HIV disease, Pharmacologic pain management MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 17. An HIV-negative client who has an HIV-positive partner asks the nurse about receiving

tenofovir/emtricitabine. What information is most important to teach the client about this drug? a. Does not reduce the need for safe sex practices. b. Has been taken off the market due to increases in cancer. c. Reduces the number of HIV tests you will need. d. Is only used for postexposure prophylaxis.

ANS: A

Tenofovir/emtricitabine is a newer drug used for preexposure prophylaxis and appears to reduce transmission of human immune deficiency virus (HIV) from known HIV-positive people to HIV-negative people. The drug does not reduce the need for practicing safe sex.

Since the drug can lead to drug resistance if used, clients will still need HIV testing every 3 months. This drug has not been taken off the market and is not used for postexposure prophylaxis.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: HIV disease, Health teaching MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies MULTIPLE RESPONSE 1. A nurse is learning about human immune deficiency virus (HIV) infection. Which statements

about HIV infection are correct? (Select all that apply.) a. CD4+ cells begin to create new HIV virus particles. b. Antibodies produced are incomplete and do not function well. c. Macrophages stop functioning properly. d. Opportunistic infections and cancer are leading causes of death. e. People with HIV-I disease are not infectious to others. f. The CD4+ T-cell is only affected when the disease has progressed to HIV-III ANS: A, B, C, D

In HIV, CD4+ cells begin to create new HIV particles. Antibodies the client produce are incomplete and do not function well. Macrophages also stop functioning properly.

Opportunistic infections and cancer are the two leading causes of death in client’s with HIV infection. People infected with HIV are infectious in all stages of the disease. The CD4+ T-cell is the immune system cell most affected by infection with the HIV virus.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: HIV disease, Pathophysiology MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. Which findings are AIDS-defining characteristics? (Select all that apply.) a. CD4+ cell count less than 200/mm3 (0.2  109/L) or less than 14% b. Infection with P. jiroveci c. Positive enzyme-linked immunosorbent assay (ELISA) test for human immune

deficiency virus (HIV) d. Presence of HIV wasting syndrome e. Taking antiretroviral medications f. Confusion, dementia, or memory loss ANS: A, B, D, F

A diagnosis of AIDS requires that the person be HIV positive and have either a CD4+ T-cell count of less than 200 cells/mm3 (0.2  109/L) or less than 14% (even if the total CD4+ count is above 200 cells/mm3) or an opportunistic infection such as P. jiroveci and HIV wasting syndrome. Confusion, dementia, and memory loss are central nervous system indications.

Having a positive ELISA test and taking antiretroviral medications are not AIDS-defining characteristics.

DIF: Remembering

TOP: Integrated Process: Teaching/Learning

KEY: HIV disease MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. The nurse is teaching a client about medications for HIV-II treatment. What drugs are paired

with the correct information? (Select all that apply.) a. Abacavir: avoid fatty and fried foods. b. Efavirenz: take 1 hour before or 2 hours after antacids. c. Atazanavir: check pulse daily and report pulse greater than 100 beats/min. d. Dolutegravir: do not take this medication if you become pregnant. e. Enfuvirtide: teach client how to operate syringe infusion pump for administration. f. All drugs: you must adhere to the drug schedule at least 90% of the time for effectiveness.

ANS: A, B, F

Abacavir is a nucleoside reverse transcriptase inhibitor and clients are taught to avoid fried and fatty foods because they can lead to digestive upsets and even pancreatitis. Efavirenz is a nonnucleoside reverse transcriptase inhibitor and clients are taught to take them (doraverene) all except spaced 1 hour before or 2 hours after antacids to avoid inhibiting drug absorption.

Atazanavir is a protease inhibitor and can cause bradycardia which should be reported.

Dolutegravir is an integrase inhibitor and can cause birth defects. Enfuvirtide is a fusion inhibitor and is given subcutaneously. All drugs must be taken as scheduled 90% of the time in order to remain effective.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: HIV disease, Medications MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. A client with HIV-III is hospitalized with P. jiroveci pneumonia and is started on the drug of

choice for this infection. What laboratory values would be most important for the nurse report to the primary health care provider? (Select all that apply.) a. Aspartate transaminase, alanine transaminase: elevated b. CD4+ cell count: 180/mm3 c. Creatinine: 1.0 mg/dL (88 mcmol/L) d. Platelet count: 80,000/mm3 (80  109/L) e. Serum sodium: 120 mEq/L (120 mmol/L) f. Serum potassium: 3.4 mEq/L (3.4 mmol/L) ANS: A, D, E

The drug of choice to treat P. jiroveci pneumonia is trimethoprim with sulfamethoxazole. Side effects of this drug include hepatitis, hyponatremia, and thrombocytopenia. The elevated liver enzymes, low platelet count, and low sodium would all be reported. The CD4+ cell count is within the expected range for a client with an AIDS-defining infection. The creatinine level is normal and the potassium is just below normal.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Analysis KEY: HIV disease, Medication side effects MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 5. A client with HIV-III has oral thrush and difficulty eating. What actions does the nurse

delegate to the assistive personnel (AP)? (Select all that apply.) a. Apply oral anesthetic gels before meals.

b. c. d. e. f.

Assist the client with oral care every 2 hours.

Offer the client frequent sips of cool drinks.

Provide the client with alcohol-based mouthwash.

Remind the client to use only a soft toothbrush.

Offer the client soft foods like gelatin or pudding.

ANS: B, C, E, F

The AP can help the client with oral care, offer fluids, and remind the client of things the nurse (or other professional) has already taught. Soft foods and liquids are tolerated better than harder foods. Applying medications is performed by the nurse. Alcohol-based mouthwashes are harsh and drying and would not be used.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: HIV disease, Delegation MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 6. A client with HIV-III is in the hospital with severe diarrhea. What actions does the nurse

delegate to assistive personnel (AP)? (Select all that apply.) a. Assessing the client’s fluid and electrolyte status b. Assisting the client to get out of bed to prevent falls c. Obtaining a bedside commode if the client is weak d. Providing gentle perianal cleansing after stools e. Reporting any perianal abnormalities ANS: B, C, D, E

The AP can assist the client with getting out of bed, obtain a bedside commode for the client’s use, cleanse the client’s perianal area after bowel movements, and report any abnormal observations such as redness or open areas. The nurse assesses fluid and electrolyte status.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: HIV disease, Delegation MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 7. The nurse is educating a client with HIV-II and the partner on self-care measures to prevent

infection when blood counts are low. What information does the nurse provide? (Select all that apply.) a. Do not work in the garden or with houseplants. b. Do not empty the kitty litter boxes. c. Clean your toothbrush in the dishwasher daily. d. Bathe daily using antimicrobial soap. e. Avoid people who are sick and large crowds. f. Make sure meat, fish, and eggs are cooked well.

ANS: A, B, D, E, F

Ways to avoid infection when immunocompromised include not working in the garden or with houseplants; not emptying litter boxes; running the toothbrush through the dishwasher at least weekly; bathing daily using antimicrobial soap; avoiding sick people and large crowds; and making sure meat, fish, and eggs are cooked well prior to eating them.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: HIV disease, Health teaching MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

8. A nurse is providing education about HIV risks at a health fair. What groups would the nurse

include as needing to be tested for HIV on an annual basis? (Select all that apply.) a. Anyone who received a blood product in 1989 b. Couples planning on getting married c. Those who are sexually active with multiple partners d. Injection drugs users e. Sex workers and their customers f. Adults over the age of 65 years ANS: B, C, D, E

The CDC recommends that HIV testing would be performed on those who received a transfusion between 1978 and 1985 only. People planning on getting married should be tested and all sexually active people should know their HIV status. Those engaged in sex work and their customers should also be tested, as well as injection drug users. Those over the age of 65 years need a one-time screen.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: HIV disease, Secondary prevention MSC: Client Needs Category: Health Promotion and Maintenance 9. A nurse begins a job at a Veterans Administration Hospital and asks why so much emphasis is

on HIV testing for the veterans. What reasons is this nurse given? (Select all that apply.) a. Veterans have a high prevalence of substance abuse. b. Many veterans may engage in high risk behaviors. c. Many older veterans may not know their risks. d. Everyone should know their HIV status. e. Belief that the VA has tested them and would notify them if positive.

ANS: A, B, C, D, E

All options are correct for the veteran population. The nurse interacting with veteran would ensure they know about the HIV testing offered by the VA. DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: HIV disease, Veterans' health considerations MSC: Client Needs Category: Health Promotion and Wellness

Chapter 18: Concepts of Care for Patients With Hypersensitivity (Allergy) and Autoimmunity Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse is teaching the client with systemic lupus erythematosus about prednisone. What

information is the priority? a. Might make the client feel jittery or nervous. b. Can cause sodium and fluid retention. c. Long-term effects include fat redistribution. d. Never stop prednisone abruptly.

ANS: D

The nurse teaches the client to avoid stopping the drug abruptly as the priority because this can lead to a life-threatening adrenal crisis. Short-term side effects do include jitteriness or nervousness, sodium and water retention. One long-term side effect is fat redistribution resulting in “moon face” and “buffalo hump.”

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: SLE, Health teaching MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. The nurse is caring for clients on the medical-surgical unit. What action by the nurse will help

prevent a client from having a type II hypersensitivity reaction? a. Administering steroids for a positive TB test b. Correctly identifying the client prior to a blood transfusion c. Keeping the client free of the offending agent d. Providing a latex-free environment for the client ANS: B

A classic example of a type II hypersensitivity reaction is a blood transfusion reaction. These can be prevented by correctly identifying the client and cross-checking the unit of blood to be administered. A positive type IV response is a positive TB test. Avoidance therapy is the cornerstone of treatment for a type IV hypersensitivity to substances that are known and can be avoided such as poison ivy and insect stings. Latex allergies are a type I hypersensitivity.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Hypersensitivities, Immunity MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 3. A client has been newly diagnosed with systemic lupus erythematosus and is reviewing

self-care measures with the nurse. Which statement by the client indicates a need to review the material? a. “I will avoid direct sunlight as much as possible.” b. “Baby powder is good for the constant sweating.” c. “Grouping errands will help prevent fatigue.” d. “Rest time will have to become a priority.”

ANS: B

Constant sweating is not a sign of SLE and powders are drying so they should not be used, at least not in excess. The client is correct in stating he/she should avoid direct sunlight, that grouping errands can prevent or reduce fatigue, and that rest will have to become a priority.

DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: SLE, Health teaching MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. A client calls the clinic to report exposure to poison ivy and an itchy rash that is not helped

with over-the-counter antihistamines. What response by the nurse is most appropriate? a. “Antihistamines do not help poison ivy.” b. “There are different antihistamines to try.” c. “You should be seen in the clinic right away.” d. “You will need to take some IV steroids.”

ANS: A

Since histamine is not the mediator of a type IV reaction such as with poison ivy, antihistamines will not provide relief. The nurse would educate the client about this. The client does not need to be seen right away. The client may or may not need steroids; they may be given either IV or orally.

DIF: Understanding TOP: Integrated Process: Communication and Documentation KEY: Hypersensitivities, Immunity MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 5. A nurse has educated a client on an epinephrine autoinjector. What statement by the client

indicates additional instruction is needed? a. “I don’t need to go to the hospital after using it.” b. “I must carry two autoinjectors with me at all times.” c. “I will write the expiration date on my calendar.” d. “This can be injected right through my clothes.”

ANS: A

Clients would be instructed to call 911 and go to the hospital for monitoring after using the autoinjector. The medication may wear off before the offending agent has cleared the client’s system. The other statements show good understanding of this treatment.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Allergic response, Drug therapy MSC: Client Needs Category: Health Promotion and Maintenance 6. A nurse has presented an educational program to a community group on Lyme disease. What

statement by a participant indicates the need to review the material? a. “I should take precautions against ticks, especially in the summer.” b. “A red rash that looks like a bull’s-eye may be one of the symptoms.” c. “If Lyme disease is not treated successfully, it is usually fatal.” d. “For Stage I disease, antibiotics are usually needed for 14 to 21 days.”

ANS: C

Untreated Lyme disease can lead to chronic complications, or Stage III Lyme disease, such as arthritis, chronic fatigue, memory/thinking problems. It is not usually a fatal disease so this information would need to be corrected by the nurse. The other participant statements are correct.

DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Lyme disease, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 7. A client is in the hospital and has received two doses of an angiotensin-converting enzyme for

hypertension. When the nurse answers the client’s call light, the client presents an appearance as shown below:

What action by the nurse takes is most appropriate? a. Administer epinephrine 1:1000, 0.3 mg IV push immediately. b. Apply oxygen by facemask at 100% and a pulse oximeter. c. Ensure a patent airway while calling the Rapid Response Team. d. Reassure the client that these symptoms will go away.

ANS: C

This client has angioedema which is a severe type I hypersensitivity reaction and is most commonly caused by ACE-inhibitors. The nurse would ensure the client’s airway is patent and either call the Rapid Response Team or delegate this to someone else. Epinephrine needs to be administered right away, but not without a prescription by the primary health care provider unless standing orders exist. The client may need oxygen, but a patent airway comes first. Reassurance is important, but airway and calling the Rapid Response Team are the priorities.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Implementation KEY: Rapid Response Team, Critical rescue MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE

1. The nurse is studying hypersensitivity reactions. Which reactions are correctly matched with

their hypersensitivity types? (Select all that apply.) a. Type I—examples include hay fever and anaphylaxis. b. Type II—mediated by action of immunoglobulin M (IgM). c. Type III—immune complex deposits in blood vessel walls. d. Type IV—examples are poison ivy and transplant rejection. e. Type IV—involve both antibodies and complement.

ANS: A, C, D

Type I reactions are mediated by immunoglobulin E (IgE) and include hay fever, anaphylaxis, and allergic asthma. Type III reactions consist of immune complexes that form and deposit in the walls of blood vessels. Type IV reactions include responses to poison ivy exposure, positive tuberculosis tests, and graft rejection. Type II reactions are mediated by immunoglobulin G, not IgM. Type IV hypersensitivity reactions do not involve either antibodies or complement.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Hypersensitivities, Immunity MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. The nurse is assessing a client for signs and symptoms of systemic lupus erythematosus

(SLE). Which of the following would be consistent with this disorder? (Select all that apply.) a. Discoid rash on skin exposed to sunlight b. Urinalysis positive for casts and protein c. Painful, deformed small joints d. Pain on inspiration e. Thrombocytosis f. Serum positive for antinuclear antibodies (ANA) ANS: A, B, D, F

Signs and symptoms of SLE include (but are not limited to) a discoid rash on skin exposed to the sun, urinalysis with casts and protein, pleurisy as manifested by pain on inspiration, and positive ANA titers in the blood. Nonerosive arthritis in peripheral joints can occur but does not lead to deformity. Thrombocytopenia is another sign.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: SLE, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. A client is being administered the first dose of belimumab for a systemic lupus erythematosus

flare. What actions by the nurse are most appropriate? (Select all that apply.) a. Observe the client for at least 2 hours afterward. b. Instruct the client about the monthly infusion schedule. c. Inform the client not to drive or sign legal papers for 24 hours. d. Ensure emergency equipment is working and nearby. e. Make a follow-up appointment for a lipid panel in 2 months. f. Instruct the client to hold other medications for 72 hours.

ANS: A, D

This drug is a monoclonal antibody to tumor necrosis factor. The first dose would be administered in a place where severe allergic reactions and/or anaphylaxis can be managed.

This includes having emergency equipment nearby. The client would be observed for at least 2 hours after this first dose. This drug does not cause drowsiness, so there would be no restrictions on driving or signing legal documents. Elevated lipids are not associated with this drug. This drug is used in combination with other therapies, especially during a flare.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: SLE, Drug therapy MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 4. A nurse caring for clients with systemic lupus erythematosus (SLE) plans care understanding

the most common causes of death for these clients is which of the following? (Select all that apply.) a. Infection b. Cardiovascular impairment c. Vasculitis d. Chronic kidney disease e. Liver failure f. Blood dyscrasias ANS: B, D

Any and all organs and tissues may be affected in SLE but the most common causes of death in clients with SLE include cardiovascular impairment and chronic kidney disease.

DIF: Remembering TOP: Integrated Process: Nursing Process: Planning KEY: SLE, Complications MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

Chapter 19: Concepts of Cancer Development Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. The nurse learning about cellular regulation understands that which process occurs during the

S phase of the cell cycle? a. Actual division (mitosis) b. Doubling of DNA c. Growing extra membrane d. No reproductive activity ANS: B

During the S phase, the cell must double its DNA content through DNA synthesis. Actual division, or mitosis, occurs during the M phase. Growing extra membrane occurs in the G1 phase. During the G0 phase, the cell is working but is not involved in any reproductive activity.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Cancer development MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A nurse asks the staff development nurse what “apoptosis” means. What response best? a. Growth by cells enlarging b. Having the normal number of chromosomes c. Inhibition of cell growth d. Programmed cell death ANS: D

Apoptosis is programmed cell death. With this characteristic, organs and tissues function with cells that are at their peak of performance. Growth by cells enlarging is hyperplasia. Having the normal number of chromosomes is euploidy. Inhibition of cell growth is contact inhibition.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Cancer development MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. A nurse is learning the difference between normal cells and benign tumor cells. What

information does this include? a. Benign tumors grow through invasion of other tissue. b. Benign tumors have lost their cellular regulation from contact inhibition. c. Growing in the wrong place or time is typical of benign tumors. d. The loss of characteristics of the parent cells is called anaplasia.

ANS: C

Benign tumors are basically normal cells growing in the wrong place or at the wrong time.

Benign cells grow through hyperplasia, not invasion. Benign tumor cells retain contact inhibition. Anaplasia is a characteristic of cancer cells.

DIF: Understanding

TOP: Integrated Process: Teaching/Learning

KEY: Cancer development MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. A nurse learns that which of the following is the single biggest risk factor for developing

cancer? a. Exposure to tobacco b. Advancing age c. Occupational chemicals d. Oncovirus infection ANS: B

The single biggest risk factor for developing cancer is advancing age. As one ages, immunity decreases and exposures increase. Tobacco use is the single most preventable cause of cancer.

Exposure to chemicals and oncoviruses cause fewer cancers.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Cancer development MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. Which statement about carcinogenesis is accurate? a. An initiated cell will always become clinical cancer. b. Cancer becomes a health problem once it is 1 cm in size. c. Normal hormones and proteins do not promote cancer growth. d. Tumor cells need to develop their own blood supply.

ANS: D

Tumors need to develop their own blood supply through a process called angiogenesis. An initiated cell needs a promoter to continue its malignant path. Normal hormones and proteins in the body can act as promoters. A 1-cm tumor is a detectable size, but other events have to occur for it to become a health problem.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Cancer development MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. The nurse caring for oncology clients knows that which form of metastasis is the most

common? a. Bloodborne b. Direct invasion c. Lymphatic spread d. Via bone marrow ANS: A

Bloodborne metastasis is the most common way for cancer to metastasize. Direct invasion and lymphatic spread are other methods. Bone marrow is not a medium in which cancer spreads, although cancer can occur in the bone marrow.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Cancer development MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 7. A nurse is assessing a client with glioblastoma. What assessment is most important?

a. b. c. d.

Abdominal palpation Abdominal percussion Lung auscultation Neurologic examination

ANS: D

A glioblastoma arises in the brain. The most important assessment for this client is the neurologic examination.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Cancer development MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 8. A nurse has taught a client about dietary changes that can reduce the chances of developing

cancer. What statement by the client indicates the nurse needs to provide additional teaching? a. “Foods high in vitamin A and vitamin C are important.” b. “I’ll have to cut down on the amount of bacon I eat.” c. “I’m so glad I don’t have to give up my juicy steaks.” d. “Vegetables, fruit, and high-fiber grains are important.”

ANS: C

To decrease the risk of developing cancer, one should cut down on the consumption of red meats and animal fat. The other statements are correct.

DIF: Remembering TOP: Integrated Process: Nursing Process: Evaluation KEY: Cancer development, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 9. A client is in the oncology clinic for a first visit since being diagnosed with cancer. The nurse

reads in the client’s chart that the cancer classification is TISN0M0. What does the nurse conclude about this client’s cancer? a. The primary site of the cancer cannot be determined. b. Regional lymph nodes could not be assessed. c. There are multiple lymph nodes involved already. d. There are no distant metastases noted in the report.

ANS: D

TIS stands for carcinoma in situ; N0 stands for no regional lymph node metastasis; and M0 stands for no distant metastasis.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Cancer development, Diagnostic testing MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 10. A client asks the nurse if eating only preservative- and dye-free foods will decrease cancer

risk. What response by the nurse is best? a. “Maybe; preservatives, dyes, and preparation methods may be risk factors.” b. “No; research studies have never shown those things to cause cancer.” c. “There are other things you can do that will more effectively lower your risk.” d. “Yes; preservatives and dyes are well known to be carcinogens.”

ANS: A

Dietary factors related to cancer development are poorly understood, although dietary practices are suspected to alter cancer risk. Suspected dietary risk factors include low-fiber intake and a high intake of red meat or animal fat. Preservatives, preparation methods, and additives (dyes, flavorings, sweeteners) may have cancer-promoting effects. It is correct to say that other things can lower risk more effectively, but this does not give the client concrete information about how to do so, and also does not answer the client’s question.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Cancer development, Health teaching MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 1. The nurse learning about cancer development remembers characteristics of normal cells.

Which characteristics does this include? (Select all that apply.) a. Differentiated function b. Large nucleus-to-cytoplasm ratio c. Loose adherence d. Nonmigratory e. Specific morphology f. Orderly and specific growth ANS: A, D, E, F

Normal cells have the characteristics of differentiated function, nonmigratory, specific morphology, a smaller nucleus-to-cytoplasm ratio, tight adherence, and orderly and well-regulated growth.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Cancer development MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. The nurse working with oncology clients understands that interacting factors affect cancer

development. Which factors does this include? (Select all that apply.) a. Exposure to carcinogens b. Genetic predisposition c. Immune function d. Normal doubling time e. State of euploidy ANS: A, B, C

The three interacting factors needed for cancer development are exposure to carcinogens, genetic predisposition, and immune function.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Cancer development MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. A nurse is participating in primary prevention efforts directed against cancer. In which

activities is this nurse most likely to engage? (Select all that apply.) a. Demonstrating breast self-examination methods to women b. Instructing people on the use of chemoprevention

c. d. e. f.

Providing vaccinations against certain cancers Screening teenage girls for cervical cancer Teaching teens the dangers of tanning booths Educating adults about healthy eating habits

ANS: B, C, E, F

Primary prevention aims to prevent the occurrence of a disease or disorder, in this case cancer.

Secondary prevention includes screening and early diagnosis. Primary prevention activities include teaching people about chemoprevention, providing approved vaccinations to prevent cancer, teaching teens the dangers of tanning beds, and educating adults on eating habits to reduce the risk of getting cancer. Breast examinations and screening for cervical cancer are secondary prevention methods.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Cancer development, Primary prevention MSC: Client Needs Category: Health Promotion and Maintenance 4. A nurse is providing community education on the seven warning signs of cancer. Which signs

are included? (Select all that apply.) a. A sore that does not heal b. Changes in menstrual patterns c. Indigestion or trouble swallowing d. Near-daily abdominal pain e. Obvious change in a mole f. Frequent indigestion ANS: A, B, C, E, F

The seven warning signs for cancer can be remembered with the acronym CAUTION: changes in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, thickening or lump in the breast or elsewhere, indigestion or difficulty swallowing, obvious change in a wart or mole, and nagging cough or hoarseness. Abdominal pain is not a warning sign.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Cancer development, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance

Chapter 20: Concepts of Care for Patients With Cancer Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse in the oncology clinic is providing preoperative education to a client just diagnosed

with cancer. The client has been scheduled for surgery in 3 days. What action by the nurse is best? a. Call the client at home the next day to review teaching. b. Give the client information about a cancer support group. c. Provide all the preoperative instructions in writing. d. Reassure the client that surgery will be over soon.

ANS: A

Clients are often overwhelmed at a sudden diagnosis of cancer and may be more overwhelmed at the idea of a major operation so soon. This stress significantly impacts the client’s ability to understand, retain, and recall information. The nurse would call the client at home the next day to review the teaching and to answer questions. The client may or may not be ready to investigate a support group, but this does not help with teaching. Giving information in writing is important (if the client can read it), but in itself will not be enough.

Telling the client that surgery will be over soon is giving false reassurance and does nothing for teaching.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Cancer, Psychosocial response MSC: Client Needs Category: Psychosocial Integrity 2. A nurse is caring for a client admitted for Non-Hodgkin’s lymphoma and chemotherapy. The

client reports nausea, flank pain, and muscle cramps. What action by the nurse is most important? a. Request an order for serum electrolytes and uric acid. b. Increase the client’s IV infusion rate. c. Instruct assistive personnel to strain all urine. d. Administer an IV antiemetic.

ANS: A

This client’s reports are consistent with tumor lysis syndrome, for which he or she is at risk due to the diagnosis. Early symptoms of TLS stem from electrolyte imbalances and can include lethargy, nausea, vomiting, anorexia, flank pain, muscle weakness, cramps, seizures, and altered mental status. The nurse would notify the primary health care provider and request an order for serum electrolytes. Hydration is important in both preventing and managing this syndrome, but the nurse would not just increase the IV rate. Assistive personnel may need to strain the client’s urine and the client may need an antiemetic, but first the nurse would assess the situation further by obtaining pertinent lab tests.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Cancer, Oncologic emergencies MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 3. A new nurse has been assigned a client who is in the hospital to receive iodine-131 treatment.

Which action by the nurse is best?

a. b. c. d.

Ensure the client is placed in protective isolation.

Have pregnant visitors stay 6 feet from the client No special action is necessary to care for this client.

Read the policy on handling radioactive excreta.

ANS: D

This type of radioisotope is excreted in body fluids and excreta (urine and feces) and would not be handled directly. The nurse would read the facility’s policy for handling and disposing of this type of waste. The other actions are not warranted.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Cancer, Radiation therapy MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 4. A client in the oncology clinic reports her family is frustrated at her ongoing fatigue 4 months

after radiation therapy for breast cancer. What response by the nurse is most appropriate? a. “Are you getting adequate rest and sleep each day?” b. “It is normal to be fatigued even for months afterward.” c. “This is not normal and I’ll let the primary health care provider know.” d. “Try adding more vitamins B and C to your diet.”

ANS: B

Radiation-induced fatigue can be debilitating and may last for months after treatment has ended. Rest and adequate nutrition can affect fatigue, but it is most important that the client (and family) understands this is normal.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Cancer, Radiation therapy MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. A client tells the oncology nurse about an upcoming vacation to the beach to celebrate

completing radiation treatments for cancer. What response by the nurse is most appropriate? a. “Avoid getting salt water on the radiation site.” b. “Do not expose the radiation area to direct sunlight.” c. “Have a wonderful time and enjoy your vacation!” d. “Remember you should not drink alcohol for a year.”

ANS: B

The skin overlying the radiation site is extremely sensitive to sunlight after radiation therapy has been completed. The nurse would inform the client to avoid sun exposure to this area.

This advice continues for 1 year after treatment has been completed. The other statements are not appropriate.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Cancer, Radiation therapy MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 6. A client is receiving chemotherapy through a peripheral IV line. What action by the nurse is

most important? a. Assessing the IV site and blood return every hour b. Educating the client on side effects c. Monitoring the client for nausea

d. Providing warm packs for comfort ANS: A

Intravenous chemotherapy can cause local tissue destruction if it extravasates into the surrounding tissues. Peripheral IV lines are more prone to this than centrally placed lines. The most important intervention is prevention, so the nurse would check hourly to ensure the IV site is patent, or frequently depending on facility policy. Education and monitoring for side effects such as nausea are important for all clients receiving chemotherapy. Warm packs may be helpful for some drugs, whereas for others ice is more comfortable. would monitor the site and check for blood return to prevent injury from infiltration or extravasation.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Cancer, Chemotherapy MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 7. A client with cancer is admitted to a short-term rehabilitation facility. The nurse prepares to

administer the client’s oral chemotherapy medications. What action by the nurse is most appropriate? a. Crush the medications if the client cannot swallow them. b. Give one medication at a time with a full glass of water. c. No special precautions are needed for these medications. d. Wear personal protective equipment when handling the medications.

ANS: D

During the administration of oral chemotherapy agents, nurses must take the same precautions that are used when administering IV chemotherapy. This includes using personal protective equipment. These medications cannot be crushed, split, or chewed. Giving one at a time is not needed.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Cancer, Medication administration MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 8. The nurse working with oncology clients understands that which age-related change increases

the older client’s susceptibility to infection during chemotherapy? a. Decreased immune function b. Diminished nutritional stores c. Existing cognitive deficits d. Poor physical reserves ANS: A

As people age, there is an age-related decrease in immune function, causing the older adult to be more susceptible to infection than other clients. Not all older adults have diminished nutritional stores, cognitive dysfunction, or poor physical reserves.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Cancer, Older adult MSC: Client Needs Category: Health Promotion and Maintenance 9. The nurse has educated a client on precautions to take with thrombocytopenia. What

statement by the client indicates a need to review the information? a. “I will be careful if I need enemas for constipation.”

b. “I will use an electric shaver instead of a razor.” c. “I should only eat soft food that is either cool or warm.” d. “I won’t be able to play sports with my grandkids.”

ANS: A

The thrombocytopenic client is at high risk for bleeding even from minor trauma. Due to the risk of injuring rectal and anal tissue, the client should not use enemas or rectal thermometers.

This statement would indicate the client needs more information. The other statements are appropriate for the thrombocytopenic client.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Cancer, Client safety MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 10. A client has a platelet count of 9800/mm3 (9800  109/L). What action by the nurse is most

appropriate? a. Assess the client for calf pain, warmth, and redness. b. Instruct the client to call for help to get out of bed. c. Obtain cultures as per the facility’s standing policy. d. Place the client on protective Isolation Precautions.

ANS: B

A client with a platelet count this low is at high risk for serious bleeding episodes. To prevent injury, the client would be instructed to call for help prior to getting out of bed. Calf pain, warmth, and redness might indicate a deep vein thrombosis, not associated with low platelets.

Cultures and isolation relate to low white cell counts.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Cancer, Client safety MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 11. A client hospitalized for chemotherapy has a hemoglobin of 6.1 mg/dL (61 mmol/L). The

client is symptomatic but refuses blood transfusions. What medication does the nurse prepare to administer? a. Epoetin alfa b. Filgrastim c. Mesna d. Dexrazoxane ANS: A

The client’s hemoglobin is very low, so the nurse prepares to administer epoetin alfa, a colony-stimulating factor that increases production of red blood cells. Filgrastim is for neutropenia. Mesna is used to decrease bladder toxicity from some chemotherapeutic agents.

Dexrazoxane helps protect the heart from cardiotoxicity from other agents.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Cancer, Medications MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 12. A nurse works with clients who have alopecia from chemotherapy. What action by the nurse

takes priority? a. Helping clients adjust to their appearance

b. Reassuring clients that this change is temporary c. Referring clients to a reputable wig shop d. Teaching measures to prevent scalp injury ANS: D

All of the actions are appropriate for clients with alopecia. However, the priority is client safety, so the nurse would first teach ways to prevent scalp injury.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Cancer, Injury prevention MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 13. A client is receiving rituximab. What assessment by the nurse takes priority? a. Blood pressure b. Temperature c. Oral mucous membranes d. Pain ANS: A

Rituximab can cause infusion-related reactions, including hypotension, so monitoring blood pressure is the priority. Other complications of this drug include fever with chills/rigors, headache and abdominal pain, shortness of breath, bronchospasm, nausea and vomiting, and rash. Assessing the client’s temperature and for pain are both pertinent assessments, but do not take priority over the blood pressure. Oral mucus membrane assessment is important for clients with cancer, but are not specific for this treatment.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Cancer, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 14. A client is receiving rituximab and asks how it works. What response by the nurse is best? a. “It causes rapid lysis of the cancer cell membranes.” b. “It destroys the enzymes needed to create cancer cells.” c. “It prevents the start of cell division in the cancer cells.” d. “It sensitizes certain cancer cells to chemotherapy.”

ANS: C

Rituximab prevents the initiation of cancer cell division. The other statements are not accurate.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Cancer, Biological response modifiers MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 15. Four clients are receiving tyrosine kinase inhibitors (TKIs). Which of these four clients would

the nurse assess first? a. Dry, itchy, peeling skin b. Serum calcium of 9.2 mg/dL (2.3 mmol/L) c. Serum potassium of 2.8 mEq/L (2.8 mmol/L) d. Weight gain of 0.5 lb (1.1 kg) in 1 day ANS: C

TKIs can cause electrolyte imbalances. This potassium level is very low, so the nurse would assess this client first. Dry, itchy, peeling skin can be a problem in clients receiving cancer treatments, and the nurse would assess that client next because of the potential for discomfort and infection. This calcium level is normal. TKIs can also cause weight gain, but the client with the low potassium level is more critical.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Cancer, Biological response modifiers MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 16. A nurse is assessing a female client who is taking hormone therapy for breast cancer. What

assessment finding requires the nurse to notify the primary health care provider immediately? a. Irregular menses b. Edema in the lower extremities c. Ongoing breast tenderness d. Red, warm, swollen calf ANS: D

Clients receiving hormone therapy are at risk for thromboembolism. A red, warm, swollen calf is indicative of deep vein thrombosis and would be reported to the provider. Irregular menses, edema in the lower extremities, and breast tenderness are not as urgent as the possible thromboembolism.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Cancer, Hormone therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 17. A client with a history of prostate cancer is in the clinic and reports new onset of severe low

back pain. What action by the nurse is most important? a. Assess the client’s gait and balance. b. Ask the client about the ease of urine flow. c. Document the report completely. d. Inquire about the client’s job risks.

ANS: A

This client has symptoms of spinal cord compression, which can be seen with prostate cancer.

This may affect both gait and balance and urinary function. For client safety, assessing gait and balance is most important. Documentation would be complete. The client may or may not have occupational risks for low back pain, but with his history of prostate cancer, this would not be where the nurse starts investigating.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Cancer, Oncologic emergencies MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 18. The nurse has taught a client with cancer ways to prevent infection. What statement by the

client indicates that more teaching is needed? a. “I should take my temperature daily and when I don’t feel well.” b. “I will discard perishable liquids after sitting out for over an hour.” c. “I won’t let anyone share any of my personal toiletries.” d. “It’s alright for me to keep my pets and change the litter box.”

ANS: D

Clients should wash their hands after touching their pets and would not empty or scoop the cat litter box. The other statements are appropriate for self-management.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Cancer, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 19. A client with long-standing heart failure being treated for cancer has received a dose of

ondansetron for nausea. What action by the nurse is most important? a. Assess the client for a headache or dizziness. b. Request a prescription for cardiac monitoring c. Instruct the client to change positions slowly. d. Weigh the client daily before eating.

ANS: B

5-HT3 antagonists, such as ondansetron, can prolong the QT interval within the cardiac conduction cycle. ECG monitoring is recommended in patients with electrolyte abnormalities (e.g., hypokalemia or hypomagnesemia), heart failure, bradyarrhythmias or patients taking other medications that can cause QT prolongation. The nurse would contact the primary health care provider and request cardiac monitoring. The nurse would assess the client for any other reported changes, but this is not a critical safety factor. Weight is not related directly to this drug.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Cancer, Client safety MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 20. A nurse working with clients who experience alopecia knows that which is the best method of

helping clients manage the psychosocial impact of this problem? a. Assisting the client to pre-plan for this event b. Reassuring the client that alopecia is temporary c. Teaching the client ways to protect the scalp d. Telling the client that there are worse side effects ANS: A

Alopecia does not occur for all clients who have cancer, but when it does, it can be devastating. The best action by the nurse is to teach the client about the possibility and to give the client multiple choices for preparing for this event. Not all clients will have the same reaction, but some possible actions the client can take are buying a wig ahead of time, buying attractive hats and scarves, and having a hairdresser modify a wig to look like the client’s own hair. Teaching about scalp protection is important but does not address the psychosocial impact. Reassuring the client that hair loss is temporary and telling him or her that there are worse side effects are both patronizing and do not give the client tools to manage this condition.

DIF: Applying TOP: Integrated Process: Caring KEY: Cancer, Psychosocial response MSC: Client Needs Category: Psychosocial Integrity 21. A client is admitted with superior vena cava syndrome. What action by the nurse is most

appropriate?

a. b. c. d.

Administer a dose of allopurinol.

Assess the client’s serum potassium level.

Gently inquire about advance directives.

Prepare the client for emergency surgery.

ANS: C

Superior vena cava syndrome is often a late-stage manifestation. After the client is stabilized and comfortable, the nurse would initiate a conversation about advance directives. Allopurinol is used for tumor lysis syndrome. Potassium levels are important in tumor lysis syndrome, in which cell destruction leads to large quantities of potassium being released into the bloodstream. Surgery is rarely done for superior vena cava syndrome.

DIF: Applying TOP: Integrated Process: Caring KEY: Cancer, Oncologic emergencies MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 22. A client is having a catheter placed to deliver chemotherapy beads into a liver tumor via the

femoral artery. What action by the nurse is most important? a. Assessing the client’s abdomen beforehand b. Ensuring that informed consent is on the chart c. Marking the client’s bilateral pedal pulses d. Reviewing client teaching done previously ANS: B

This is an invasive procedure requiring informed consent. The nurse would ensure that consent is on the chart. The other actions are also appropriate but not as important as ensuring the client has given consent.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Cancer, Informed consent MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 23. A nurse works on an oncology unit and delegates personal hygiene to assistive personnel

(AP). What action by the AP requires intervention from the nurse? a. Allowing a very tired client to skip oral hygiene and sleep b. Assisting clients with washing the perianal area every 12 hours c. Helping the client use a soft-bristled toothbrush for oral care d. Reminding the client to rinse the mouth with water or saline ANS: A

Even though clients may be tired, they still need to participate in hygiene to help prevent infection. The nurse would intervene and explain this to AP. The other options are all appropriate.

DIF: Remembering TOP: Integrated Process: Communication and Documentation KEY: Cancer, Infection, Delegation (UAP) MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 24. A client with cancer has anorexia and mucositis, and is losing weight. The client’s family

members continually bring favorite foods to the client and are distressed when the client won’t eat them. What action by the nurse is best?

a. b. c. d.

Explain the pathophysiologic reasons behind the client not eating.

Help the family show other ways to demonstrate love and caring.

Suggest foods and liquids the client might be willing to try to eat.

Tell the family the client isn’t able to eat now no matter what they bring.

ANS: B

Families often become distressed when their loved ones won’t eat. Providing food is a universal sign of caring, and to some people the refusal to eat signifies worsening of the condition. The best option for the nurse is to help the family find other ways to demonstrate caring and love, because with treatment-related anorexia and mucositis, the client is not likely to eat anything right now. Explaining the rationale for the problem is a good idea but does not suggest to the family anything that they can do for the client. Simply telling the family the client is not able to eat does not give them useful information and is dismissive of their concerns.

DIF: Applying TOP: Integrated Process: Caring MSC: Client Needs Category: Psychosocial Integrity

KEY: Cancer, Nutrition

25. A client in the emergency department reports difficulty breathing. The nurse assesses the

client’s appearance as depicted below:

What action by the nurse is most important? a. Assess blood pressure and pulse. b. Attach the client to a pulse oximeter. c. Have the client rate his or her pain. d. Facilitate urgent radiation therapy.

ANS: A

This client has superior vena cava syndrome, in which venous return from the head, neck, and trunk is blocked. Decreased cardiac output can occur. The nurse would assess indicators of cardiac output, including blood pressure and pulse, as the priority. The other actions are also appropriate but are not as important. The ED nurse may or may not be able to facilitate radiation therapy.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Cancer, Oncologic emergencies MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE

1. The nurse caring for clients who have cancer understands that the general consequences of

cancer include which client problems? (Select all that apply.) a. Clotting abnormalities from thrombocythemia b. Increased risk of infection from white blood cell deficits c. Nutritional deficits such as early satiety and cachexia d. Potential for reduced gas exchange e. Various motor and sensory deficits f. Increased risk of bone fractures ANS: A, B, C, D, E, F

The general consequences of cancer include reduced immunity and blood-producing functions, altered GI structure and function, decreased respiratory function, and motor and sensory deficits. Clotting problems often occur due to thrombocytopenia (not enough platelets), not thrombocythemia (too many platelets).

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Cancer MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A nurse is preparing to administer IV chemotherapy. What supplies does this nurse need?

(Select all that apply.) a. “Chemo” gloves b. Face mask c. Impervious gown d. N95 respirator e. Shoe covers f. Eye protection ANS: A, B, C, F

The Occupational Safety and Health Administration (OSHA) and the Oncology Nurses Society have developed safety guidelines for those preparing or administering IV chemotherapy. These include double gloves (or “chemo” gloves), eye protection, a face mask, and a gown. An N95 respirator and shoe covers are not required.

DIF: Remembering TOP: Integrated Process: Nursing Process: Implementation KEY: Cancer, Medication safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 3. A client receiving radiation therapy reports severe skin itching and irritation. What actions

does the nurse delegate to assistive personnel (AP)? (Select all that apply.) a. Apply approved moisturizers to dry skin. b. Apply steroid creams to the skin. c. Bathe the client using mild soap. d. Help the client pat skin dry after a bath. e. Teach the client to avoid sunlight. f. Make sure no clothing is rubbing the site.

ANS: A, C, D, F

The nurse can delegate applying moisturizer approved by the radiation oncologist using mild soap for bathing, and helping the client pat wet skin dry after bathing. Any clothing worn over the site should be soft and not create friction. Steroid creams are not used for this condition.

Hot water will worsen the irritation. Client teaching is a nursing function.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Cancer, Skin care, Delegation MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 4. A client has thrombocytopenia. What actions does the nurse delegate to assistive personnel

(AP)? (Select all that apply.) a. Apply the client’s shoes before getting the client out of bed. b. Assist the client with ambulation. c. Shave the client with a safety razor only. d. Use a lift sheet to move the client up in bed. e. Use a water pressure device be set on low for oral care.

ANS: A, B, D

Clients with thrombocytopenia are at risk of significant bleeding even with minor injuries.

The nurse instructs the AP to put the client’s shoes on before getting the client out of bed, assist with ambulation, shave the client with an electric razor, use a lift sheet when needed to reposition the client, and use a soft-bristled toothbrush for oral care. All of these measures help prevent client injury.

DIF: Understanding TOP: Integrated Process: Communication and Documentation KEY: Cancer, Client safety, Delegation MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 5. A client has mucositis. What actions by the nurse will improve the client’s nutrition? (Select

all that apply.) a. Assist with rinsing the mouth with saline frequently. b. Encourage the client to eat room-temperature foods. c. Give the client hot liquids to hold in the mouth. d. Provide local anesthetic medications to swish and spit. e. Remind the client to brush teeth gently after each meal. f. Offer the client fluids to drink each hour.

ANS: A, B, D, F

Mucositis can interfere with nutrition. The nurse can help with rinsing the mouth frequently with water or saline; encouraging the client to eat cool, slightly warm, or room-temperature foods; providing swish-and-spit anesthetics; and reminding the client to keep the mouth clean by brushing gently after each meal. Drinking plenty of fluids (unless contraindicated for another condition) is another beneficial measure. Hot liquids would be painful for the client.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Cancer, Oral care, Delegation MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort

6. A client’s family members are concerned that telling the client about a new finding of cancer

will cause extreme emotional distress. They approach the nurse and ask if this can be kept from the client. What actions by the nurse are most appropriate? (Select all that apply.) a. Ask the family to describe their concerns more fully. b. Consult with a social worker, chaplain, or ethics committee. c. Explain the client’s right to know and ask for their assistance. d. Have the unit manager take over the care of this client and family. e. Tell the family that this secret will not be kept from the client.

ANS: A, B, C

The client’s right of autonomy means that the client must be fully informed as to his or her diagnosis and treatment options. The nurse cannot ethically keep this information from the client. The nurse can ask the family to explain their concerns more fully so everyone understands them. A social worker, chaplain, or ethics committee can become involved to assist the nurse, client, and family. The nurse would explain the client’s right to know and ask the family how best to proceed. Enlisting their help might reduce their reluctance for the client to be informed. The nurse would not abdicate responsibility for this difficult situation by transferring care to another nurse. Simply telling the family that he or she will not keep this secret sets up an adversarial relationship. Explaining this fact along with the concept of autonomy would be acceptable, but this by itself is not.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Cancer, Ethical principles MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 7. A client receiving chemotherapy has a white blood cell count of 1000/mm3 (1  109/L). What

actions by the nurse are most appropriate? (Select all that apply.) a. Assess all mucous membranes every 4 to 8 hours. b. Do not allow the client to eat meat or poultry. c. Listen to lung sounds and monitor for cough. d. Monitor the venous access device appearance hourly. e. Take and record vital signs every 4 to 8 hours. f. Encourage activity the client can tolerate.

ANS: A, C, D, E

Depending on facility protocol, the nurse would assess this client for infection every 4 to 8 hours by assessing all mucous membranes, listening to lung sounds, monitoring for cough, monitoring the appearance of the venous access device, and recording vital signs. Assisting the client with mobilization will also help prevent infection. Eating meat and poultry is allowed.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Cancer, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

Chapter 21: Concepts of Care for Patients With Infection Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. The nurse learning about infection discovers that which factor is the best and most important

barrier to infection? a. Colonization by host bacteria b. Gastrointestinal secretions c. Inflammatory processes d. Skin and mucous membranes ANS: D

The skin and mucous membranes are two of the most important barriers against infection. The other options are also barriers, but are considered secondary to skin and mucous membranes.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Infection MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A nursing manager is concerned about the number of infections on the hospital unit. What

action by the manager would best help prevent these infections? a. Auditing staff members’ hand hygiene practices b. Ensuring clients are placed in appropriate isolation c. Establishing a policy to remove urinary catheters quickly d. Teaching staff members about infection control methods ANS: A

All methods will help prevent infection; however, health care workers’ lack of hand hygiene is the biggest cause of health care–associated infections. The manager can start with a hand hygiene audit to see if this is a contributing cause.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Infection, Infection control MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 3. An assistive personnel asks why brushing client s’ teeth with a toothbrush in the intensive care

unit is important to infection control. What response by the registered nurse is best? a. “It mechanically removes biofilm on teeth.” b. “It’s easier to clean all surfaces with a brush.” c. “Oral care is important to all our clients.” d. “Toothbrushes last longer than oral swabs.”

ANS: A

Biofilms are a complex group of bacteria that function within a slimy gel on surfaces such as teeth. Mechanical disruption (i.e., toothbrushing with friction) is the best way to control them.

The other answers are not accurate.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Infection, Infection control MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

4. A client is admitted with possible sepsis. Which action will the nurse perform first? a. Administer antibiotics. b. Give an antipyretic. c. Place the client in isolation. d. Obtain specified cultures.

ANS: D

Prior to administering antibiotics, the nurse obtains the prescribed cultures. Broad-spectrum antibiotics will be administered until the culture and sensitivity results are known.

Antipyretics are given if the client is uncomfortable; fever is a defense mechanism. Giving antipyretics does not occur before obtaining cultures. The client may or may not need isolation.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Infection, Medication administration MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 5. A client is hospitalized and on multiple antibiotics. The client develops frequent diarrhea.

What action by the nurse is most important? a. Consult with the primary health care provider about obtaining stool cultures. b. Delegate frequent perianal care to assistive personnel. c. Place the client on NPO status until the diarrhea resolves. d. Request a prescription for an antidiarrheal medication.

ANS: A

Hospitalized clients who have three or more stools a day for 2 or more days are suspected of having infection with Clostridium difficile. The nurse will inform the primary health care provider and request stool cultures. Frequent perianal care is important and can be delegated but is not the most important action. The client does not necessarily need to be NPO; if the client is NPO, the nurse ensures he or she is getting appropriate IV fluids to prevent dehydration. Antidiarrheal medication may or may not be appropriate as the diarrhea serves as the portal of exit for the infection.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Infection, Diagnostic testing MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 6. A nurse is observing as an assistive personnel (AP) performs hygiene and provides comfort

measures to a client with an infection. What action by the AP requires intervention by the nurse? a. Not using gloves while combing the client’s hair b. Rinsing the client’s commode pan after use c. Ordering an oscillating fan for the client d. Wearing gloves when providing perianal care ANS: C

Fans in client care areas are discouraged because they can disperse airborne or droplet-borne pathogens. The other actions are appropriate. If the client has a scalp infection or infestation, the AP will wear gloves; otherwise, it is not required for grooming the hair.

DIF: Analyzing

TOP: Integrated Process: Communication and Documentation

KEY: Infection, Infection control MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 7. A client is to receive a fecal microbiota transplantation tomorrow (FMT). What action by the

nurse is best? a. Administer bowel cleansing as prescribed. b. Educate the client on immunosuppressive drugs. c. Inform the client he/she will drink a thick liquid. d. Place a nasogastric tube to intermittent suction.

ANS: A

The usual route of delivering an FMT is via colonoscopy, so the client would have a bowel cleansing as prescribed for that procedure. The client will not need immunosuppressant drugs, to drink the material, or have an NG tube inserted.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Infection MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 8. A nurse manager is preparing an educational session for floor nurses on drug-resistant

organisms. Which statement below indicates the need to review this information? a. “Methicillin-resistant Staphylococcus aureus can be hospital- or community-acquired.” b. “Vancomycin-resistant Enterococcus can live on surfaces and be infectious for weeks.” c. Carbapenem-resistant Enterobacteriaceae is hard to treat due to enzymes that break down antibiotics.” d. “If you leave work wearing your scrubs, go directly home and wash them right away.”

ANS: D

To help prevent the transmission of an MDRO, wear scrubs and change clothes before leaving work. Keep work clothes separate from personal clothes. The nursing manager would need to correct his or her knowledge if he or she is letting staff know that wearing scrubs home is alright. The other statements are correct about multi-drug resistant organisms.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Implementation KEY: Infection, Infection control MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 9. The nurse caring for clients admitted for infectious diseases understands what information

about emerging global diseases and bioterrorism? a. Many infections are or could be spread by international travel. b. Safer food preparation practices have decreased foodborne illnesses. c. The majority of Americans have adequate innate immunity to smallpox. d. Plague produces a mild illness and generally has a low mortality rate.

ANS: A

Increased global travel has resulted in the spread of many emerging diseases and has the potential to spread diseases caused by bioterrorism. Foodborne illnesses are on the increase.

Many people in the United States have never been vaccinated against smallpox, and those who have are not guaranteed life-long protection. Plague can be fatal.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Implementation KEY: Infection, Infection control MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 10. A client has been placed on Contact Precautions. The client’s family is very afraid to visit for

fear of being “contaminated” by the client. What action by the nurse is best? a. Explain to them that these precautions are mandated by law. b. Show the family how to avoid spreading the disease. c. Reassure the family that they will not get the infection. d. Tell the family it is important that they visit the client.

ANS: B

Visitors may be apprehensive about visiting a client in Transmission-Based Precautions. The nurse would reassure the visitors that taking appropriate precautions will minimize their risks.

The nurse would then demonstrate what precautions were needed. The other options do nothing to ease the family’s fears.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Infection, Transmission-based precautions MSC: Client Needs Category: Psychosocial Integrity 11. A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA)

infection cultured from the urine. What action by the nurse is most appropriate? a. Prepare to administer vancomycin. b. Strictly limit visitors to immediate family only. c. Wash hands only after taking off gloves after care. d. Wear a respirator when handling urine output.

ANS: A

Vancomycin is one of a few drugs approved to treat MRSA. The others include linezolid and ceftaroline fosamil. Delafloxacin is a new antibiotic approved to treat MRSA. Visitation does not need to be limited to immediate family only. Hand hygiene is performed before and after wearing gloves. A respirator is not needed, but if splashing is anticipated, a face shield can be used.

DIF: Remembering TOP: Integrated Process: Nursing Process: Implementation KEY: Infection, Antibiotics MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 12. A hospitalized client is placed on Contact Precautions. The client needs to have a computed

tomography (CT) scan. What action by the nurse is most appropriate? a. Ensure that the radiology department is aware of the Isolation Precautions. b. Plan to travel with the client to ensure appropriate precautions are used. c. No special precautions are needed when this client leaves the unit. d. Notify the primary health care provider that the client cannot leave the room.

ANS: A

Clients in isolation will leave their rooms only when necessary, such as for a CT scan that cannot be done portably in the room. The nurse will ensure that the receiving department is aware of the Isolation Precautions needed to care for the client. The other options are not needed.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Infection, Transmission-based precautions MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 13. A nurse receives report from the laboratory on a client who was admitted for fever. The

laboratory technician states that the client has “a shift to the left” on the white blood cell count. What action by the nurse is most important? a. Document findings and continue monitoring. b. Notify the primary health care provider and request antibiotics. c. Place the client in protective isolation. d. Tell the client this signifies inflammation.

ANS: B

A shift to the left indicates an increase in immature neutrophils and is often seen in infections, especially those caused by bacteria. The nurse will notify the primary health care provider and request antibiotics (and cultures). Documentation and teaching need to be done, but the nurse needs to do more. The client does not need protective isolation.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Infection, Laboratory values MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential MULTIPLE RESPONSE 1. The nurse caring for clients understands that which factors must be present to transmit

infection? (Select all that apply.) a. Colonization b. Host c. Mode of transmission d. Portal of entry e. Reservoir f. Poor hygiene ANS: B, C, D, E

Factors that must be present in order to transmit an infection include a host with a portal of entry, a mode of transmission, and a reservoir. Colonization is not one of these factors. Poor hygiene may or may not contribute to infection.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Infection MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. Which statements are true regarding Standard Precautions? (Select all that apply.) a. Always wear a gown when performing hygiene on clients. b. Sneeze into your sleeve or into a tissue that you throw away. c. Remain 3 feet (1 m) away from any client who has an infection. d. Use personal protective equipment as needed for client care. e. Wear gloves when touching clients’ excretions or secretions. f. Cohorting clients who have infections caused by the same organism.

ANS: D, E

Standard Precautions implies that contact with bodily secretions, excretions, and moist mucous membranes and tissues (excluding perspiration) is potentially infectious. Always wear gloves when coming into contact with such material. Other personal protective equipment is used based on the care being given. For example, if face splashing is expected, you will also wear a mask. Wearing a gown for hygiene is not required. Sneezing into your sleeve or tissue is part of respiratory etiquette. Remaining 3 feet (1 m) away from client is also not part of Standard Precautions. Cohorting infectious clients can be used for deciding room/bed placement, but is not part of Standard Precautions.

DIF: Remembering TOP: Integrated Process: Nursing Process: Implementation KEY: Infection, Standard precautions MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 3. The nurse learns that effective antimicrobial therapy requires which factors to be present?

(Select all that apply.) a. Appropriate drug b. Proper route of administration c. Standardized peak levels d. Sufficient dose e. Sufficient length of treatment f. Appropriate trough levels ANS: A, B, D, E

In order to be effective, antimicrobial therapy must use the appropriate drug in a sufficient dose, for a sufficient length of time, and given via the appropriate route. Some antimicrobials do require monitoring for peak and trough levels, but not all.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Infection, Antibiotics MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. A client is being admitted with suspected tuberculosis (TB). What actions by the nurse are

best? (Select all that apply.) a. Admit the client to a negative-airflow room. b. Maintain a distance of 3 feet (1 m) from the client at all times. c. Obtain specialized respirators for caregiving. d. Other than wearing gloves, no special actions are needed. e. Wash hands with chlorhexidine after providing care. f. Assure client has a respirator for moving between departments.

ANS: A, C

A client with suspected TB is admitted to Airborne Precautions, which includes a negative-airflow room and special N95 or PAPR masks to be worn when providing care. A 3-foot (1 m) distance without a mask is required for Droplet Precautions (a nurse providing direct care cannot ensure that he or she will never need to be within 3 feet of the client).

Chlorhexidine is used for clients with a high risk of infection. When moving between departments, the client wears a surgical mask.

DIF: Applying

TOP: Integrated Process: Nursing Process: Implementation

KEY: Infection, Transmission-based precautions MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 5. A nurse asks the supervisor why older adults are more prone to infection than other adults.

What reasons does the supervisor give? (Select all that apply.) a. Age-related decrease in immune function b. Decreased cough and gag reflexes c. Diminished acidity of gastric secretions d. Increased lymphocytes and antibodies e. Thinning skin that is less protective f. Higher rates of chronic illness ANS: A, B, C, E, F

Older adults have several age-related changes making them more susceptible to infection, including decreased immune function, decreased cough and gag reflex, decreased acidity of gastric secretions, thinning skin, fewer lymphocytes and antibodies, and higher rates of chronic illness.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Infection, Older adult MSC: Client Needs Category: Health Promotion and Maintenance 6. A client with an infection has a fever. What actions by the nurse help increase the client’s

comfort? (Select all that apply.) a. Administer antipyretics around the clock. b. Change the client’s gown and linens when damp. c. Offer cool fluids to the client frequently. d. Place ice bags in the armpits and groin. e. Provide a fan to help cool the client. f. Sponging the client with tepid water.

ANS: B, C, F

Comfort measures appropriate for this client include offering frequent cool drinks, and changing linens or the gown when damp. Fever is a defense mechanism, and antipyretics will be administered only when the client is uncomfortable. Ice bags can help cool the client quickly but are not comfort measures. Fans are discouraged because they can disperse microbes. Sponging the client’s body with tepid water is also helpful.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Infection, Comfort measures MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 7. A nurse plans care for a client who is at risk for infection. Which interventions will the nurse

implement to prevent infection? (Select all that apply.) a. Administer prophylactic antibiotics. b. Monitor white blood cell count and differential. c. Screen all visitors for infections. d. Implement Transmission-Based Precautions. e. Promote sufficient nutritional intake.

ANS: B, C, E

Nursing interventions for clients at risk for infection include monitoring white blood cell count and differential, screening visitors for infections and infectious disease, and promoting sufficient nutritional intake. Standard Precautions are required but not Transmission-Based Precautions. Prophylactic antibiotics are not generally used to prevent infections.

DIF: Understanding TOP: Integrated Process: Nursing Process: Implementation KEY: Infection, Infection control MSC: Client Needs Category: Health Promotion and Maintenance 8. A nurse cares for several clients on an inpatient unit. Which infection control measures will

the nurse implement? (Select all that apply.) a. Wear a gown when contact of clothing with body fluids is anticipated. b. Teach clients and visitors respiratory hygiene techniques. c. Obtain powered air purifying respirators for all staff members. d. Do not use alcohol-based hand rub between client contacts. e. Disinfect frequently touched surfaces in client-care areas.

ANS: A, B, E

Infection control measures appropriate to all clients include hand hygiene with alcohol-based hand rub or soap between client contact, procedures for routine care, cleaning and disinfection of frequently contaminated surfaces, and wearing personal protective equipment when contamination is anticipated. Client and visitors would be instructed on appropriate respiratory hygiene and cough etiquette. No information in the stem indicates the clients need anything more than Standard Precautions.

DIF: Understanding TOP: Integrated Process: Nursing Process: Implementation KEY: Infection, Infection control MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

Chapter 22: Assessment of the Skin, Hair, and Nails Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. While assessing a client, a nurse detects a bluish tinge to the client’s palms, soles, and mucous

membranes. Which action will the nurse take next? a. Ask the client about current medications he or she is taking. b. Use pulse oximetry to assess the patient’s oxygen saturation. c. Auscultate the patient’s lung fields for adventitious sounds. d. Palpate the patient’s bilateral radial and pedal pulses.

ANS: B

Cyanosis can be present when impaired gas exchange occurs. In a client with dark skin, cyanosis can be seen because the palms, soles, and mucous membranes have a bluish tinge.

The nurse will assess for systemic oxygenation before continuing with other assessments.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Skin, hair, and nail, Assessment MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 2. A nurse assesses a client who has inflamed soft-tissue folds around the nail plates. Which

question will the nurse ask to elicit useful information about the possible condition? a. “What do you do for a living?” b. “Are your nails professionally manicured?” c. “Do you have diabetes mellitus?” d. “Have you had a recent fungal infection?”

ANS: A

The condition chronic paronychia is common in people with frequent intermittent exposure to water, such as homemakers, bartenders, and laundry workers. The other questions would not provide information specifically related to this assessment finding.

DIF: Applying TOP: Integrated Process: Nursing Process: Analysis KEY: Skin, hair, and nail, Assessment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 3. A nurse assesses a client who has multiple areas of ecchymosis on both arms. Which question

will the nurse ask first? a. “Are you using lotion on your skin?” b. “Do you have a family history of this?” c. “Do your arms itch?” d. “What medications are you taking?”

ANS: D

Certain drugs such as aspirin, warfarin, and corticosteroids can lead to easy or excessive bruising, which can result in ecchymosis. The other options would not provide information about bruising.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Skin, hair, and nail, Assessment, Medication side effects

MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. After teaching a client who expressed concern about a rash located beneath her breast, a nurse

assesses the client’s understanding. Which statement indicates the client has a good understanding of this condition? a. “This rash is probably due to fluid overload.” b. “I need to wash this daily with antibacterial soap.” c. “I can use powder to keep this area dry.” d. “I will schedule a mammogram as soon as I can.”

ANS: C

Rashes limited to skinfold areas (e.g., on the axillae, beneath the breasts, in the groin) may reflect problems related to excessive moisture. The client needs to keep the area dry; one option is to use powder. Good hygiene is important, but the rash does not need an antibacterial soap. Fluid overload and breast cancer are not related to rashes in skinfolds.

DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Skin, hair, and nail, Assessment MSC: Client Needs Category: Health Promotion and Maintenance 5. A nurse assesses an older client who has two skin lesions on the chest. Each lesion is the size

of a nickel, flat, and darker in color than the rest of the client’s skin. What does the nurse tell the client regarding these lesions? a. “Monitor these spots for any changes.” b. “You don’t need to worry about these.” c. “I will ask for a dermatology referral for you.” d. “We need to schedule you for a skin biopsy.”

ANS: A

Because of melanocyte hyperplasia, the older adult frequently has “age spots,” or darker spots on the skin. The nurse would teach the client to monitor the spots and report any changes indicative of cancer. Stating the client does not need to worry is inaccurate and dismissive.

The client does not necessarily need a dermatology referral and does not need a skin biopsy at this point.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Skin, hair, and nail, Assessment MSC: Client Needs Category: Health Promotion and Maintenance 6. A nurse cares for an older adult client who has a chronic skin disorder. The client states, “I

have not been to church in several weeks because of the discoloration of my skin.” How will the nurse respond? a. “I will consult the chaplain to provide you with spiritual support.” b. “You do not need to go to church; God is everywhere.” c. “Tell me more about your concerns related to your skin.” d. “Religious people are nonjudgmental and will accept you.”

ANS: C

Clients with chronic skin disorders often become socially isolated related to the fear of rejection by others. Nurses will assess how the client’s skin changes are affecting his or her body image and encourage the client to express feelings about a change in appearance. The other statements are dismissive of the client’s concerns.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Skin, hair, and nail, Assessment, Psychosocial response MSC: Client Needs Category: Psychosocial Integrity 7. A nurse assesses a client who has open skin lesions. Which action by the nurse is most

important? a. Put on gloves. b. Ask the client about his or her occupation. c. Assess the client’s pain. d. Obtain vital signs.

ANS: A

Nurses wear gloves as part of Standard Precautions when examining skin that is not intact.

The other options are part of the full assessment but adhering to Standard Precautions is important for safety and infection control.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Skin, hair, and nail, Assessment, Standard Precautions MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 8. The nurse reads on a chart that a client has lichenification. What assessment finding confirms

this description? a. Increased skin thickness b. Excessive facial hair c. Purple skin patches d. Tightly stretched skin ANS: A

Lichenification is increased skin thickness as the result of scarring. Excessive facial hair (or body hair) is hirsutism. Purple patches on the skin are purpura. Tightly stretched skin is from edema.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Skin, hair, and nail, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 9. A nurse assesses a client and identifies that the client has pale conjunctivae. Which focused

assessment will the nurse complete next? a. Partial thromboplastin time b. Hemoglobin and hematocrit c. Liver enzymes d. Basic metabolic panel ANS: B

Pale conjunctivae signify anemia. The nurse will assess the client’s hemoglobin and hematocrit to confirm anemia. The other laboratory results do not relate to this client’s potential anemia.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Skin, hair, and nail, Assessment, Laboratory results MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

10. During skin inspection, the nurse observes lesions with wavy borders that are widespread

across the client’s chest. Which descriptors will the nurse use to document these observations? a. Clustered and annular b. Linear and circinate c. Diffuse and serpiginous d. Coalesced and circumscribed ANS: C

“Diffuse” is used to describe lesions that are widespread. “Serpiginous” describes lesions with wavy borders. “Clustered” describes lesions grouped together. “Linear” describes lesions occurring in a straight line. Annular lesions are ring like with raised borders, circinate lesions are circular, and circumscribed lesions have well-defined sharp borders. “Coalesced” describes lesions that merge with one another and appear confluent.

DIF: Remembering TOP: Integrated Process: Communication and Documentation KEY: Skin, hair, and nail, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 11. A nurse assesses an older adult client with the skin disorder shown below:

How will the nurse document this finding? a. Petechiae b. Ecchymoses c. Actinic lentigo d. Senile angiomas ANS: A

Petechiae, or small, reddish purple nonraised lesions that do not fade or blanch with pressure, are pictured here. Ecchymoses are larger areas of hemorrhaging, commonly known as bruising. Actinic lentigo presents as paper-thin, transparent skin. Senile angiomas, also known as cherry angiomas, are red raised lesions.

DIF: Remembering TOP: Integrated Process: Communication and Documentation KEY: Skin, hair, and nail, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

MULTIPLE RESPONSE 1. A nurse assesses an older adult’s skin. Which findings require immediate referral? (Select all

that apply.) a. Excessive moisture under axilla b. Increased hair thinning c. Presence of toenail fungus d. Lesion with various colors e. Spider veins on legs f. Asymmetric 6-mm dark lesion on forehead ANS: D, F

The lesion with various colors, as well as the asymmetric 6-mm dark lesion, fits two of the Skin Cancer Foundation’s hallmark signs for cancer according to the ABCDE method. Other signs and symptoms, while not normal, are not cause for concern.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Skin, hair, and nail, Assessment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 2. A nurse plans care for a client who has a wound that is not healing. Which focused

assessments will the nurse complete to develop the patient’s plan of care? (Select all that apply.) a. Height b. Allergies c. Alcohol use d. Prealbumin laboratory results e. Liver enzyme laboratory results f. Weight ANS: A, C, D, E

Nutritional status can have a significant impact on skin health and wound healing. The care plan for a client with poor nutritional status will include a high-protein, high-calorie diet. To determine the patient’s nutritional status, the nurse will assess height and weight, alcohol use, and prealbumin laboratory results. These data will provide information related to vitamin and protein deficiencies, and body mass. Allergies and liver enzyme laboratory results will not provide information about nutrition status or wound healing.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Skin, hair, and nail, Assessment, Nutrition MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. A client has multiple lesions all over the body and a family history of skin cancer. The nurse

teaches the client to perform a total skin self-examinations on a monthly basis. Which statements will the nurse include in this patient’s teaching? (Select all that apply.) a. “Look for asymmetry of shape and irregular borders.” b. “Assess for color variation within each lesion.” c. “Examine the distribution of lesions over a section of the body.” d. “Monitor for edema or swelling of tissues.” e. “Focus your assessment on skin areas that itch.” f. “Report any lesions that change over time in any way.”

ANS: A, B, F

Patients will be taught to examine each lesion following the ABCDE features associated with skin cancer: asymmetry of shape, border irregularity, color variation within one lesion, diameter greater than 6 mm, and evolving or changing in any feature.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Skin, hair, and nail, Assessment, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 4. A nurse assesses a client who presents with early koilonychias. Which assessments will the

nurse complete next? (Select all that apply.) a. Review the client’s health history for a diagnosis of iron deficiency anemia. b. Palpate the client’s nail base for potential edemata and sponginess. c. Ask the client about prolonged contact with chemical irritants. d. Assess the client for signs of chronic obstructive pulmonary disease. e. Request a prescription to assess the client’s hemoglobin A1C. ANS: A, E

Early koilonychias manifests as flattening of the nail plate with an increased smoothness of the nail. This is caused by iron deficiency with or without anemia, poorly controlled diabetes, and local injury. Nails with visible edema and sponginess when palpated are associated with clubbing. Chronic obstructive pulmonary disease may cause clubbing of the nails and chemical irritants are associated with late koilonychias.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Skin, hair, and nail, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

Chapter 23: Concepts of Care for Patients With Skin Problems Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse teaches a client who has pruritus. Which statement by the client shows a need to

review the information? a. “I will shower daily using a super-fatted soap.” b. “I can try taking a bath with colloidal oatmeal.” c. “I will pat my skin dry instead of rubbing it with a towel.” d. “I will be careful to keep my nails filed smoothly.”

ANS: D

The client with pruritus should shower only every other day, although super-fatted soap is an appropriate choice. Colloidal oatmeal baths are very soothing. Patting the skin dry avoids trauma and injury. Keeping nails filed smoothly also prevents injury.

DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Skin disorders, Health teaching MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 2. A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for pressure

injury development? a. A 44 year old prescribed IV antibiotics for pneumonia b. A 26 year old who is bedridden with a fractured leg c. A 65 year old with hemiparesis and incontinence d. A 78 year old requiring assistance to ambulate with a walker ANS: C

Risk factors for development of a pressure injury include lack of mobility, exposure of skin to excessive moisture (e.g., urinary or fecal incontinence), malnourishment, and aging skin. The client with hemiparesis and incontinence has two risk factors. The client with pneumonia has no identified risk factors. The other two are at lower risk if they are not very mobile, but having two risk factors is a higher risk.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Pressure injuries, Risk factors MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 3. A nurse is caring for a client with an electrical burn. The client has entrance wounds on the

hands and exit wounds on the feet. What information is most important to include when planning care? a. The client may have memory and cognitive issues postburn. b. Everything between the entry and exit wounds can be damaged. c. The respiratory system requires close monitoring for signs of swelling. d. Electrical burns increase the risk of developing future cancers.

ANS: B

As the electricity enters the body, travels through various tissues, and exits, it damages all the tissue it flows through. There may be severe internal injury that is not yet apparent. The client may have cognitive issues postburn but this is not as important as vigilant monitoring for complications. Respiratory system swelling is associated with thermal burns and smoke inhalation. Exposure to radiation increases cancer risk.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning KEY: Burns MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 4. A nurse cares for a client who has a stage 3 pressure injury with copious exudate. What type

of dressing does the nurse use on this wound? a. Wet-to-damp saline moistened gauze b. None, the wound is left open to the air c. A transparent film d. Multi-fiber superabsorbent dressing ANS: D

This pressure injury requires a superabsorbent dressing that will collect the exudate but not stick to the wound itself. A wet-to-damp gauze dressing provides mechanical removal of necrotic tissue. A draining wound would not be left open. A transparent film is a good choice for a noninfected stage 2 pressure injury.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Pressure injuries, Wound care MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. A nurse is caring for a client who has a nonhealing pressure injury on the right ankle. Which

action would the nurse take first? a. Draw blood for albumin, prealbumin, and total protein. b. Prepare for and assist with obtaining a wound culture. c. Instruct the client to elevate the foot. d. Assess the right leg for pulses, skin color, and temperature.

ANS: D

A client with an ulcer on the foot would be assessed for interruption in arterial flow to the area. This begins with the assessment of pulses and color and temperature of the skin. The nurse can also assess for pulses noninvasively with a Doppler flowmeter if unable to palpate with his or her fingers. Tests to determine nutritional status and risk assessment would be completed after the initial assessment is done. Wound cultures are done after it has been determined that drainage, odor, and other risks for infection are present. Elevation of the foot would impair the ability of arterial blood to flow to the area.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Pressure injuries, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. A client has been brought to the emergency department after being covered in fertilizer after

an explosion and fire at a warehouse. What action by the nurse is best? a. Assess the client’s airway. b. Irrigate the client’s skin.

c. Brush any visible dust off the skin. d. Call poison control for guidance ANS: A

With any burn client, assessing and maintaining the airway is paramount. Airway tissues can swell quickly, cutting off the airway. The fertilizer would then be brushed off before irrigation. Poison control may or may not need to be called.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Burns MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 7. After teaching a client who has a stage 2 pressure injury, a nurse assesses the client’s

understanding. Which dietary choice by the client indicates a good understanding of the teaching? a. Green salad, a banana, whole wheat dinner roll, coffee b. Chicken breast, broccoli, baked potato, ice water c. Vegetable lasagna and green salad, iced tea d. Hamburger, fruit cup, cookie, diet pop ANS: B

Successful healing of pressure injuries depends on adequate intake of calories, protein, vitamins, minerals, and water. The dinner with the chicken breast meets all these criteria. The other dinners while having some healthy items each, are not as nutritious.

DIF: Evaluating TOP: Integrated Process: Teaching/Learning KEY: Pressure injuries, Nutrition MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 8. A nurse assesses clients on a medical-surgical unit, all of whom have stage 2 or 3 pressure

injuries. Which client would the nurse evaluate further for a wound infection? a. WBC 9200 mm/L3 (9.2  109) b. Boggy feel to granulation tissue c. Increased size after debridement d. Requesting pain medication ANS: B

Wound infection may or may not occur in the presence of signs of systemic infection, but a change in the appearance, texture, color, drainage, or size of a wound (except after debridement) is indicative of possible infection. The nurse would assess the client with boggy granulation tissue further. The WBC is normal. After debridement, the wound may look larger. If the client needs a sudden increase in the amount or frequency of pain medication that would be another indicator, but there is no evidence this client has more pain than usual.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Pressure injuries, Infection MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 9. A nurse is teaching a client and family about self-care at home for the client’s wound infected

with methicillin-resistant Staphylococcus aureus. What statement by the client indicates a need to review the information? a. “I will keep dry bandages on the wound and change them when drainage appears.”

b. “I will shower instead of taking a bath in the bathtub each day.” c. “If the dressing is dry, I can sit or sleep anywhere in the house.” d. “I will clean exposed household surfaces with a bleach and water mixture.”

ANS: C

The client should not sit on upholstered furniture or sleep in the same bed as another person until the infection has cleared. The other statements show good understanding.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Skin disorders, Health teaching MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 10. A nurse is assessing a client who has a recent diagnosis of melanoma for understanding of

treatment choices. What statement by the client indicates good understanding of the information? a. “Dermabrasion or chemical peels can be done in the office.” b. “I may need lymph node resection during Mohs surgery.” c. “This needs only a small excision with local anesthetic.” d. “After surgery I will need 8 weeks of radiation therapy.”

ANS: B

Melanoma is usually treated with Mohs micrographic surgery, in which tissue is sectioned horizontally in layers and examined histologically, layer by layer, to assess for cancer cells.

Dermabrasion and chemical peels can be used on actinic keratoses. Local anesthetic for small excisions is generally used on basal or squamous cell carcinomas. Radiation is usually not used with melanoma.

DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Skin cancer MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 11. A nurse assesses an older client who is scratching and rubbing white ridges on the skin

between the fingers and on the wrists. Which action would the nurse take? a. Request a prescription for permethrin. b. Administer an antihistamine. c. Assess the client’s airway. d. Apply gloves to minimize friction.

ANS: A

The client’s presentation is most likely to be scabies, a contagious mite infestation. The drugs used to treat this infestation are ivermectin and permethrin. The nurse would contact the primary care provider to request a prescription for one of the medications. Secondary interventions may include medication to decrease the itching. The client’s airway is not at risk with this skin disorder. Applying gloves will help prevent transmission.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Skin disorders, Medications MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 12. A client contacts the clinic to report a life-long mole has developed a crust with occasional

bleeding. What instruction by the nurse is most appropriate? a. “Take monthly photographs of it so you can document any changes.”

b. “Wash daily with warm water and gentle soap to prevent infection.” c. “Keep the lesion covered with a bandage and triple antibiotic ointment.” d. “Please make an appointment to be seen here as soon as possible.”

ANS: D

A lesion demonstrating a change in characteristics, such as oozing, crusting, bleeding, or scaling, is suspicious for skin cancer. The nurse would instruct the client to come in for evaluation. Monthly photographs are a good way to document skin changes, but the client needs an assessment for skin cancer. The lesion can be washed and covered with a bandage and ointment, but again, the client needs an evaluation for skin cancer.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Skin cancer MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 13. A nurse is teaching a client who has itchy, raised red patches covered with a silvery white

scale how to care for this disorder. What statement by the client shows a need for further information? a. “At the next family reunion, I’m going to ask my relatives if they have anything similar.” b. “I have to make sure I keep my lesions covered, so I do not spread this to others.” c. “I must avoid large crowds and sick people while I am taking adalimumab.” d. “I will buy a good quality emollient to put on my skin each day.”

ANS: B

This client has plaque psoriasis which is not a contagious disorder. The client does not have to worry about spreading the condition to others. It is a condition that has hereditary links so it would be correct for the client to inquire about other family members who are affects.

Adalimumab is a drug used to treat psoriasis and it has a black box warning about serious infection risk and cancer risk, so the client needs to take precautions to avoid infectious individuals. Emollients help keep the plaques soft and reduce itching.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Skin disorders, Psoriasis MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 14. A nurse performs a skin screening for a client who has numerous skin lesions. Which lesion

does the nurse evaluate first? a. Beige freckles on the backs of both hands. b. Irregular mole with multiple colors on the leg. c. Large cluster of pustules in the right axilla. d. Thick, reddened papules covered by white scales.

ANS: B

This mole fits two of the criteria for being cancerous or precancerous: variation of color within one lesion, and an indistinct or irregular border. Freckles are a benign condition.

Pustules could mean an infection, but it is more important to assess the potentially cancerous lesion first. Psoriasis vulgaris manifests as thick reddened papules covered by white scales.

This is a chronic disorder and is not the priority.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Skin cancer, Nursing assessment

MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 15. A nurse assesses a young female client who is prescribed tazarotene. Which question should

the nurse ask prior to starting this therapy? a. “Do you spend a great deal of time in the sun?” b. “Have you or any family members ever had skin cancer?” c. “Which method of contraception are you using?” d. “Do you drink alcoholic beverages?”

ANS: C

Tazarotene has many side effects. It is a known teratogen and can cause severe birth defects.

Strict birth control measures must be used during therapy. The other questions are not directly related to this medication.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Skin disorders, Medications MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 16. A nurse is assessing clients with pressure injuries. Which wound description is correctly

matched to its description? a. Suspected deep tissue injury: nonblanchable deep purple or maroon. b. Stage 2: may have visible adipose tissue and slough. c. Stage 3: may have a pink or red wound bed. d. Stage 4: wound bed is obscured with eschar or slough.

ANS: A

A suspected deep tissue injury is characterized by persistent, nonblanchable purple or maroon discoloration. A stage 2 wound may have a pink of red would bed with granulation tissue. The stage 3 wound may have visible adipose tissue and slough. A stage 4 wound is full-thickness skin loss with exposed or palpable fascia, muscle, tendon, ligament, cartilage, or bone. An unstageable wound is obscured by eschar or slough making assessment impossible.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Pressure injuries, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 17. A new nurse reads a client has a wound “healing by second intention” and asks what that

means. Which description by the charge nurse is most accurate? a. “The wound edges have been approximated and stitched together.” b. “The wound was stapled together after an infection was cleared up.” c. “The wound is an open cavity that will fill in with granulation tissue.” d. “The wound was contaminated by debris and can’t be closed at all.”

ANS: C

Wounds healing by second intention are deeper wounds that leave open cavities. These wounds heal as connective tissue fills in the dead space. A wound that has its edges brought together (approximated) and sutured or stapled together is said to be healing by first intention.

A wound that was left open while an infection healed and then is closed is an example of healing by third intention. A wound that cannot be closed at all would be left to heal by second intention.

DIF: Understanding

TOP: Integrated Process: Teaching/Learning

KEY: Skin disorders, Wounds MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 18. A nurse assesses a client who has psoriasis. Which action would the nurse take first? a. Don gloves and an isolation gown. b. Shake the client’s hand and introduce self. c. Assess for signs and symptoms of infections. d. Ask the client if she might be pregnant.

ANS: B

Clients with psoriatic lesions are often self-conscious of their skin. The nurse would first provide direct contact and touch without gloves to establish a good report with the client.

Psoriasis is not an infectious disease, nor is it contagious. The nurse would not need to wear gloves or an isolation gown. Obtaining a health history and assessing for an infection and pregnancy would be completed after establishing a report with the client.

DIF: Applying TOP: Integrated Process: Caring KEY: Skin lesions, Wounds psoriasis MSC: Client Needs Category: Psychosocial Integrity 19. A nurse is caring for a client whose Braden Scale score is 9. What intervention demonstrates a

lack of evidence-based knowledge? a. Requests a referral to a registered dietitian nutritionist. b. Raises the head of the bed no more than 45 degrees. c. Performs perineal cleansing every 2 hours. d. Assesses the client’s entire skin surface daily.

ANS: B

A client with a Braden Scale score of 9 is at high risk for skin breakdown and requires moderate to maximum assistance to prevent further breakdown. The nurse needs to keep the head of the bed elevated to no more than 30 degrees to prevent shearing. An RDN consultation, frequent perineal cleaning, and assessing the client’s entire skin surface are all appropriate actions.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Pressure injuries MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 20. A nurse evaluates the following data in a client’s chart:

Admission Note A 66-year-old male with a health history of a cerebral vascular accident and left-side paralysis

Laboratory Results Wound Care Note White blood cell count: 8000/mm3 Sacral ulcer: 4  2  (8  109/L) 1.5 cm Prealbumin: 15.2 mg/dL (152 mg/L) Albumin: 4.2 mg/dL (42 mg/L) Lymphocyte count: 2000/mm3 (2  109/L) Based on this information, which action would the nurse take? a. Perform a neuromuscular assessment. b. Request a dietary consult. c. Initiate Contact Precautions. d. Assess the client’s vital signs.

ANS: B

The white blood cell count is not directly related to nutritional status. Albumin, prealbumin, and lymphocyte counts all give information related to nutritional status. The prealbumin count is a more specific indicator of nutritional status than is the albumin count. The albumin and lymphocyte counts given are normal, but the prealbumin count is low. This puts the client at risk for inadequate wound healing, so the nurse would request a dietary consult. The other interventions do not address the information provided.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Analysis KEY: Pressure injuries, Nutrition MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 21. A nurse evaluates the following data in a client’s chart:

Admission Note Prescriptions Wound Care A 78-year-old male with Warfarin sodium Negative-pressure wound a past medical history of (Coumadin) therapy (NPWT) to leg atrial fibrillation is Sotalol (Betapace) wound admitted with a chronic leg wound Based on this information, which action would the nurse take first? a. Assess the client’s vital signs and initiate continuous telemetry monitoring. b. Contact the primary health care provider to discuss the treatment c. Consult the wound care nurse to apply the VAC device. d. Obtain a prescription for a low-fat, high-protein diet with vitamin supplements.

ANS: B

A client on anticoagulants is not a candidate for NPWT because of the incidence of bleeding complications. The health care primary health care provider needs this information quickly to plan other therapy for the client’s wound. The nurse would contact the wound care nurse after alternative orders for wound care are prescribed. Vital signs and telemetry monitoring are appropriate for a client who has a history of atrial fibrillation and would be implemented as routine care for this client. A low-fat, high-protein diet with vitamin supplements will provide the client with necessary nutrients for wound healing but can be implemented after wound care, vital signs, and telemetry monitoring.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Implementation KEY: Wounds, Negative-pressure therapy MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control MULTIPLE RESPONSE 1. A nurse plans care for a client who is immobile. Which interventions would the nurse include

in this client’s plan of care to prevent pressure sores? (Select all that apply.) a. Place a small pillow between bony surfaces. b. Elevate the head of the bed to 45 degrees. c. Limit fluids and proteins in the diet. d. Use a lift sheet to assist with re-positioning. e. Re-position the client who is in a chair every 2 hours. f. Keep the client’s heels off the bed surfaces.

g. Use a rubber ring to decrease sacral pressure when up in the chair.

ANS: A, D, F

A small pillow decreases the risk for pressure between bony prominences, a lift sheet decreases friction and shear, and heels have poor circulation and are at high risk for pressure sores, so they would be kept off hard surfaces. Head-of-the-bed elevation greater than 30 degrees increases pressure on pelvic soft tissues. Fluids and proteins are important for maintaining tissue integrity. Clients would be repositioned every hour while sitting in a chair.

A rubber ring impairs capillary blood flow, increasing the risk for a pressure sore.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Pressure injuries MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 2. A nurse is working with a client who has a painful rash consisting of grouped weeping and

crusting lesions in distinct lines. What actions by the nurse are most appropriate? (Select all that apply.) a. Instruct the client to report lesions near the eyes. b. Have the client take long, hot baths to soak the lesions. c. Show the client how to make a baking soda compress. d. Advise the client to avoid exposure to UV light rays. e. Demonstrate proper use of antifungal medications. f. Review appropriate hygiene measures.

ANS: A, C

This client has herpes zoster (shingles). Eye infection is possible, so the client should be taught to report any lesions erupting near the eyes. Comfort measures can include compresses, calamine lotions, and baking soda. Long hot baths are not recommended. Avoiding UV lighting is important for herpes simplex. Herpes zoster is a viral disorder, so antifungal medications are not used. Hygiene is not an issue causing an outbreak.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Skin disorders, Herpes zoster MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. The nurse learns that which age-related changes increase the potential for complications of

burns? (Select all that apply.) a. Thinner skin b. Slower healing time c. Decreased mobility d. Hyperresponsive immune response e. Increased risk of unnoticed sepsis f. Pre-existing conditions ANS: A, B, C, E, F

Age-related differences that can increase the risk of burns and complications of burns include thinner skin, slower healing, decreased mobility, increased risk of infection that goes unnoticed, and pre-existing conditions that can complicate recovery. The older adult has decreased inflammatory and immune responses.

DIF: Understanding KEY: Burns, Age-related differences

TOP: Integrated Process: Nursing Process: Planning

MSC: Client Needs Category: Health Promotion and Maintenance 4. A nurse assesses a client who presents with an increase in psoriatic lesions. Which questions

would the nurse ask to identify a possible trigger for worsening of this client’s psoriatic lesions? (Select all that apply.) a. “Have you eaten a large amount of chocolate lately?” b. “Have you been under a lot of stress lately?” c. “Have you recently used a public shower?” d. “Have you been out of the country recently?” e. “Have you recently had any other health problems?” f. “Have you changed any medications recently?”

ANS: B, E, F

Outbreaks of psoriasis can be induced by stress, environmental triggers, certain medications, skin injuries, infections, smoking, alcohol use, and obesity. Psoriatic lesions are not triggered by chocolate, public showers, or international travel.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Skin disorders, Psoriasis MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. A nurse cares for many clients with pressure injuries. What actions by the nurse are

considered best practice? (Select all that apply.) a. Conduct ongoing assessments that include pain. b. Use normal saline to cleanse around the pressure injury. c. Soak eschar daily until it softens and can be removed. d. Consult with a registered dietitian nutritionist. e. Use antimicrobial agents to clean wounds that are infected. f. Consider the use of adjuvant therapies for nonhealing wounds.

ANS: A, B, D, E, F

Best practice for pressure injury wound management includes ongoing assessments that include pain, using normal saline to clean gently around the wound, ensuring optimal nutrition by involving a registered dietitian nutritionist, using an antimicrobial agent to clean wounds that are anticipated to become infected, and considering the use of adjuvant therapies such as stimulation, negative-pressure wound therapy, ultrasound, hyperbaric oxygen, and topical growth factors. The nurse would not disturb stable eschar.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Pressure injuries, Assistive personnel (AP) MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. A nurse cares for a client who reports discomfort related to eczematous dermatitis. Which

nonpharmacologic comfort measures would the nurse implement? (Select all that apply.) a. Cool, moist compresses b. Topical corticosteroids c. Heating pad d. Tepid bath with colloidal oatmeal e. Back rub with baby oil ANS: A, D

For a client with eczematous dermatitis, the goal of comfort measures is to decrease inflammation and help débride crusts and scales. The nurse would implement cool, moist compresses and tepid baths with additives such as colloidal oatmeal. Topical corticosteroids are a pharmacologic intervention. A heating pad and a back rub with baby oil are not appropriate for this client and could increase inflammation and discomfort.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Skin disorders, Comfort measures MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 7. The nurse in the emergency department would arrange to transfer which burned clients to a

burn center? (Select all that apply.) a. 15% partial-thickness burn b. Lightening injury c. 7% partial-thickness burn d. History of pulmonary edema e. Healthy 67 year old f. 4% partial-thickness burn to perineum ANS: A, B, D, E, F

Clients with major burns are transferred to a burn center for specialized care. These include any partial-thickness burn over 10% TBSA; any lightening injury; a burn injury in a client with a history of pre-existing conditions that could complicate care or prolong recovery; adults over the age of 60; and burns to the face, hands, feet, genitalia, perineum, or major joints. The client with a 7% partial-thickness burn could be cared for in a hospital or a burn center.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning KEY: Burns MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

Chapter 24: Assessment of the Respiratory System Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse obtains the health history of a client who is recently diagnosed with lung cancer and

identifies that the client has a 60–pack-year smoking history. Which action is most important for the nurse to take when interviewing this client? a. Tell the client that he or she needs to quit smoking to stop further cancer development. b. Encourage the client to be completely honest about both tobacco and marijuana use. c. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty. d. Avoid giving the client false hope regarding cancer treatment and prognosis.

ANS: C

Smoking assessments and cessation information can be an uncomfortable and sensitive topic among both clients and health care providers. The nurse would maintain a nonjudgmental attitude in order to foster trust with the client. Telling the client he or she needs to quit smoking is paternalistic and threatening. Assessing exposure to smoke includes more than tobacco and marijuana. The nurse would avoid giving the client false hope but when taking a history, it is most important to get accurate information.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Respiratory assessment MSC: Client Needs Category: Psychosocial Integrity 2. A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with

the correct intervention? a. Client reports being dizzy—nurse calls the Rapid Response Team. b. Client’s heart rate is 55 beats/min—nurse withholds pain medication. c. Client has reduced breath sounds—nurse calls primary health care provider immediately. d. Client’s respiratory rate is 18 breaths/min—nurse decreases oxygen flow rate.

ANS: C

A potentially serious complication after biopsy is pneumothorax, which is indicated by decreased or absent breath sounds. The primary health care provider needs to be notified immediately. Dizziness without other data would not lead the nurse to call the RRT. If the client’s heart rate is 55 beats/min, no reason is known to withhold pain medication. A respiratory rate of 18 breaths/min is a normal finding and would not warrant changing the oxygen flow rate.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Respiratory assessment, Critical rescue MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. A nurse assesses a client’s respiratory status. Which information is most important for the

nurse to obtain? a. Average daily fluid intake. b. Neck circumference.

c. Height and weight. d. Occupation and hobbies.

ANS: D

Many respiratory problems occur as a result of chronic exposure to inhalation irritants used in a client’s occupation and hobbies. Although it will be important for the nurse to assess the client’s fluid intake, height, and weight, these will not be as important as determining his occupation and hobbies. This is part of the I-PREPARE assessment model for particulate matter exposure. Determining the client’s neck circumference will not be an important part of a respiratory assessment.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Respiratory assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. A nurse observes that a client’s anteroposterior (AP) chest diameter is the same as the lateral

chest diameter. Which question would the nurse ask the client in response to this finding? a. “Are you taking any medications or herbal supplements?” b. “Do you have any chronic breathing problems?” c. “How often do you perform aerobic exercise?” d. “What is your occupation and what are your hobbies?”

ANS: B

The normal chest has an anteroposterior (AP or front-to-back) diameter ratio with the lateral (side-to-side) diameter. This ratio normally is about 1:1.5. When the AP diameter approaches the lateral diameter, and the ratio is 1:1, the client is said to have a barrel chest. Most commonly, barrel chest occurs as a result of a long-term chronic airflow limitation problem, such as chronic emphysema. It can also be seen in people who have lived at a high altitude for many years. Medications, herbal supplements, and aerobic exercise are not associated with a barrel chest. Although occupation and hobbies may expose a client to irritants that can cause chronic lung disorders and barrel chest, asking about chronic breathing problems is more direct and would be asked first.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Respiratory assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. A nurse is assessing a client who is recovering from a lung biopsy. The client’s breath sounds

are absent. While another nurse calls the Rapid Response Team, what action by the nurse takes is most important? a. Take a full set of vital signs. b. Obtain pulse oximetry reading. c. Ask the patient about hemoptysis. d. Inspect the biopsy site.

ANS: B

Absent breath sounds may indicate that the client has a pneumothorax, a serious complication after a needle biopsy or open lung biopsy. The nurse would first obtain a pulse oximetry reading and perform other respiratory assessments. Temperature is not a priority. The nurse can ask about other symptoms while conducting the assessment. The nurse would assess the biopsy site and/or dressings, but this is not the first action.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Respiratory assessment, Critical rescue MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 6. A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention

would the nurse complete prior to the procedure? a. Measure oxygen saturation before and after a 12-minute walk. b. Verify that the client understands all possible complications. c. Explain the procedure in detail to the client and the family. d. Validate that informed consent has been given by the client.

ANS: D

A thoracentesis is an invasive procedure with many potentially serious complications. The nurse would ensure signed informed consent has been obtained. Verifying that the client understands complications and explaining the procedure to be performed will be done by the primary health care provider, not the nurse. Measurement of oxygen saturation before and after a 12-minute walk is not a procedure unique to a thoracentesis.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Respiratory assessment, Diagnostic testing MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 7. A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate

action? a. The client rates pain as a 5/10 at the site of the procedure. b. A small amount of drainage from the site is noted. c. Pulse oximetry is 93% on 2 L of oxygen. d. The trachea is shifted toward the opposite side of the neck.

ANS: D

A shift of central thoracic structures toward one side is a sign of a tension pneumothorax, which is a medical emergency. The other findings are normal or near normal. The nurse would report this finding immediately or call the Rapid Response Team.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Respiratory assessment, Critical rescue MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 8. A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of

water. What action would the nurse take next? a. Call the primary health care provider and request food and water for the client. b. Provide the client with ice chips instead of a drink of water. c. Assess the client’s gag reflex before giving any food or water. d. Let the client have a small sip to see whether he or she can swallow.

ANS: C

The topical anesthetic used during the procedure will have affected the client’s gag reflex.

Before allowing the client anything to eat or drink, the nurse must check for the return of this reflex.

DIF: Applying

TOP: Integrated Process: Nursing Process: Assessment

KEY: Respiratory assessment, Diagnostic testing MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 9. A nurse plans care for a client who is experiencing dyspnea and must stop multiple times

when climbing a flight of stairs. Which intervention would the nurse include in this client’s plan of care? a. Assistance with activities of daily living b. Physical therapy activities every day c. Oxygen therapy at 2 L per nasal cannula d. Complete bedrest with frequent repositioning ANS: A

A client with dyspnea and the inability to complete activities such as climbing a flight of stairs without pausing has class IV dyspnea. The nurse would provide assistance with activities of daily living. These clients would be encouraged to participate in activities as tolerated. They would not be on complete bedrest, may not be able to tolerate daily physical therapy, and only need oxygen if hypoxia is present.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Respiratory assessment, Functional ability MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 10. A nurse teaches a client who is prescribed nicotine replacement therapy. Which statement

would the nurse include in this client’s teaching? a. “Make a list of reasons why smoking is a bad habit.” b. “Rise slowly when getting out of bed in the morning.” c. “Smoking while taking this medication will increase your risk of a stroke.” d. “Stopping this medication suddenly increases your risk for a heart attack.”

ANS: C

Clients who smoke while using drugs for nicotine replacement therapy increase the risk of stroke and heart attack. Nurses would teach clients not to smoke while taking these drugs. The nurse would encourage the client to make a list of reasons for stopping the habit but would not phrase it so judgmentally. Orthostatic hypotension is not a risk with nicotine replacement therapy. Stopping suddenly does not increase the risk of heart attack.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Respiratory assessment, Smoking cessation MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 11. A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy.

The client presents with continuous cyanosis even with oxygen therapy. What action would the nurse take next? a. Administer an albuterol treatment. b. Notify the Rapid Response Team. c. Assess the client’s peripheral pulses. d. Obtain blood and sputum cultures.

ANS: B

Cyanosis unresponsive to oxygen therapy is a sign of methemoglobinemia, which is an adverse effect of benzocaine spray. This condition can lead to death. The nurse would notify the Rapid Response Team to provide advanced care. An albuterol treatment would not address the client’s oxygenation problem. Assessment of pulses and cultures will not provide data necessary to treat the client.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Respiratory assessment, Critical rescue MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 12. A nurse auscultates a harsh hollow sound over a client’s trachea and larynx. What action

would the nurse take first? a. Document the findings. b. Administer oxygen therapy. c. Position the client in high-Fowler position. d. Administer prescribed albuterol.

ANS: A

Bronchial breath sounds, including harsh, hollow, tubular, and blowing sounds, are a normal finding over the trachea and larynx. The nurse would document this finding. There is no need to implement oxygen therapy, administer albuterol, or change the client’s position because the finding is normal.

DIF: Understanding TOP: Integrated Process: Communication and Documentation KEY: Respiratory assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 1. A nurse assesses a client who is prescribed varenicline for smoking cessation. Which signs or

symptoms would the nurse identify as adverse effects of this medication? (Select all that apply.) a. Visual hallucinations b. Tachycardia c. Decreased cravings d. Manic behavior e. Increased thirst f. Orangish urine ANS: A, D

Varenicline has a black box warning stating that the drug can cause manic behavior and hallucinations. The nurse would assess for changes in behavior and thought processes, including manic behaviors and visual hallucinations. Tachycardia, increased thirst, and orange-colored urine are not adverse effects of this medication. Decreased cravings are a therapeutic response to this medication.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Medication administration, Medication side effects MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

2. While obtaining a client’s health history, the client states, “I am allergic to avocados, molds,

and grass.” Which responses by the nurse are best? (Select all that apply.) a. “What happens when you are exposed to those things? b. “How do you treat these allergies?” c. “When was the last time you ate foods containing avocados?” d. “I will document this in your record so all so everyone knows.” e. “Have you ever been in the hospital after an allergic response?” f. “How do manage to avoid grass and mold?”

ANS: A, B, D, E

Nurses would assess clients who have allergies for the specific cause, treatment, and response to treatment. The nurse would also document the allergies in a prominent place in the client’s medical record. Asking about the last time the client ate avocados does not provide any pertinent information for the client’s plan of care. Asking how a client manages to avoid environmental allergies in this fashion also does not provide any pertinent information.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Respiratory assessment, Allergies MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 3. A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs)

for a client. Which statements would the nurse include in communications with the respiratory therapist prior to the tests? (Select all that apply.) a. “I held the client’s morning bronchodilator medication.” b. “The client is ready to go down to radiology for this examination.” c. “Physical therapy states the client can run on a treadmill.” d. “I advised the client not to smoke for 6 hours prior to the test.” e. “The client is alert and can follow your commands.”

ANS: A, D, E

To ensure that the PFTs are accurate, the therapist needs to know that no bronchodilators have been administered in the past 4 to 6 hours (depending on the suspected cause), the client did not smoke within 6 to 8 hours prior to the test, and the client can follow basic commands, including different breathing maneuvers. The respiratory therapist can perform PFTs at the bedside or the respiratory lab. A treadmill is not used for this test.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Respiratory assessment, Diagnostic testing MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 4. A nurse teaches a client who is interested in smoking cessation. Which statements would the

nurse include in this client’s teaching? (Select all that apply.) a. “Find an activity that you enjoy and will keep your hands busy.” b. “Keep snacks like potato chips on hand to nibble on.” c. “Identify a consequence for yourself in case you backslide.” d. “Drink at least eight glasses of water each day.” e. “Make a list of reasons you want to stop smoking.” f. “Set a quit date and stick to it.”

ANS: A, D, E, F

The nurse would teach a client who is interested in smoking cessation to find an activity that keeps the hands busy, to keep healthy snacks on hand to nibble on, to drink at least eight glasses of water each day, to make a list of reasons for quitting smoking, and to set a firm quit date and stick to it. The nurse would also encourage the client not to be upset if he or she backslides and has a cigarette but to try to determine what conditions caused him or her to smoke.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Smoking cessation, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 5. A nurse is assessing a client’s history of particular matter exposure. What questions are

consistent with the I PREPARE tool? (Select all that apply.) a. Investigate all history of known exposures. b. Determine if breathing problems are worse at work. c. Ask the client what type of heating is in the home. d. Gather details about the geographic location of the client’s home. e. Have client list all previous jobs and work experiences. f. Assess what hobbies the client and family enjoy.

ANS: A, B, C, D, E, F

All questions are appropriate for the I PREPARE model of particulate matter exposure. The R and final E stands for resources/referrals and educate.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Respiratory assessment, Smoking cessation MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. A nurse assesses a client who is recovering from a thoracentesis. Which assessment findings

would alert the nurse to a potential pneumothorax? (Select all that apply.) a. Bradycardia b. New-onset cough c. Purulent sputum d. Tachypnea e. Pain with respirations f. Rapid, shallow respirations ANS: B, D, E

Symptoms of a pneumothorax include tachycardia, tachypnea, new-onset “nagging” cough, and pain that is worse at the end of inhalation and the end of exhalation on the affected side.

Additional symptoms include trachea slanted to the unaffected side, cyanosis, and the affected side of the chest that does not move in and out with respirations. Purulent sputum is a symptom of infection.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Respiratory assessment, Diagnostic testing MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 7. A nurse prepares a client who is scheduled for a bronchoscopy with transbronchial biopsy

procedure at 9:00 AM (0900). What actions would the nurse take? (Select all that apply.) a. Provide a clear liquid breakfast.

b. c. d. e. f.

Verify that the informed consent was obtained.

Document the client’s allergies.

Review laboratory results.

Hold the client’s bronchodilator.

Monitor the client for at least 24 hours afterwards.

ANS: B, C, D, F

Prior to a bronchoscopy, the nurse would verify that the informed consent was obtained, keep the client NPO for 4 to 8 hours prior to the procedure or per agency policy to prevent aspiration, document allergies, and review laboratory results including complete blood count and bleeding times. There is no reason to hold the client’s bronchodilator prior to this procedure. The nurse will monitor the client at least every 4 hours for 24 hours.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Respiratory assessment, Diagnostic testing MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care

Chapter 25: Concepts of Care for Patients Requiring Oxygen Therapy or Tracheostomy Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse caring for a client removes the client’s oxygen as prescribed. The client is now

breathing what percentage of oxygen in the room air? a. 14% b. 21% c. 28% d. 31% ANS: B

Oxygen content of atmospheric or “room air” is about 21%.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Oxygen, Physiology MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is

the priority? a. Administer prescribed anxiolytic medication. b. Ensure that informed consent is on the chart. c. Reinforce any teaching done previously. d. Start the preoperative antibiotic infusion.

ANS: B

Since this is an operative procedure, the client must sign an informed consent, which must be on the chart. Giving anxiolytics and antibiotics and reinforcing teaching may also be required but do not take priority.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Informed consent, Autonomy MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 3. A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes that the

client’s face is puffy and the eyelids are swollen. What action by the nurse takes best? a. Assess the client’s oxygen saturation. b. Notify the Rapid Response Team. c. Oxygenate the client with a bag-valve-mask. d. Palpate the skin of the upper chest.

ANS: A

This client may have subcutaneous emphysema, which is air that leaks into the tissues surrounding the tracheostomy. The nurse would first assess the client’s oxygen saturation and other indicators of oxygenation. If the client is stable, the nurse can palpate the skin of the upper chest to feel for the air. If the client is unstable, the nurse calls the Rapid Response Team. Using a bag-valve-mask device may or may not be appropriate for the unstable client.

DIF: Applying

TOP: Integrated Process: Nursing Process: Assessment

KEY: Oxygenation, Tracheostomy, Nursing assessment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 4. A client has a tracheostomy tube in place. When the nurse suctions the client, food particles

are noted. What action by the nurse is best? a. Elevate the head of the client’s bed. b. Measure and compare cuff pressures. c. Place the client on NPO status. d. Request that the client have a swallow study.

ANS: B

Constant pressure from the tracheostomy tube cuff can cause tracheomalacia, leading to dilation of the tracheal passage. This can be manifested by food particles seen in secretions or by noting that larger and larger amounts of pressure are needed to keep the tracheostomy cuff inflated. The nurse would measure the pressures and compare them to previous ones to detect a trend. Elevating the head of the bed, placing the client on NPO status, and requesting a swallow study will not correct this situation.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Tracheostomy, Client safety MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. An assistive personnel (AP) was feeding a client with a tracheostomy. Later that evening, the

UAP reports that the client had a coughing spell during the meal. What action by the nurse is best? a. Assess the client’s lung sounds. b. Assign a different AP to the client. c. Report the AP to the manager. d. Request thicker liquids for meals.

ANS: A

The best action is to check the client’s oxygenation because he or she may have aspirated.

Once the client has been assessed, the nurse would notify the primary health care provider of possible aspiration and would consult with the registered dietitian about appropriately thickened liquids. The UAP should have reported the incident immediately, but addressing that issue is not the immediate priority.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Aspiration, Tracheostomy MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 6. A nurse is providing tracheostomy care. What action by the nurse requires intervention by

the charge nurse? a. Holding the device securely when changing ties b. Suctioning the client first if secretions are present c. Tying a square knot at the back of the neck d. Using half-strength peroxide for cleansing ANS: C

To prevent pressure injuries and for client safety, when ties are used that must be knotted, the knot would be placed at the side of the client’s neck, not in back. The other actions are appropriate.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Tracheostomy care, Client safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 7. A nurse is demonstrating suctioning a tracheostomy during the annual skills review. What

action by the student demonstrates that more teaching is needed? a. Applying suction while inserting the catheter b. Preoxygenating the client prior to suctioning c. Suctioning for a total of three times if needed d. Suctioning for only 10 to 15 seconds each time ANS: A

Suction would only be applied while withdrawing the catheter. The other actions are appropriate.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Tracheostomy, Suctioning MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 8. A nurse is caring for a client using oxygen while in the hospital. What assessment finding

indicates that outcomes for client safety with oxygen therapy are being met? a. 100% of meals being eaten by the client b. Intact skin behind the ears c. The client understanding the need for oxygen d. Unchanged weight for the past 3 days ANS: B

Oxygen tubing can cause pressure injuries, so clients using oxygen have a high risk of skin breakdown. Intact skin behind the ears indicates that goals for maintaining client safety with oxygen therapy are being met. Nutrition and weight are not related to using oxygen.

Understanding the need for oxygen is important but would not take priority over a physical problem.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Oxygen therapy, Skin integrity MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 9. A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy

tube is pulsing with the heartbeat as the client’s pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate? a. Call the operating room to inform them of a pending emergency case. b. No action is needed at this time; this is a normal finding in some clients. c. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask. d. Stay with the client and have someone else call the primary health care provider immediately.

ANS: D

This client may have a tracheoinnominate artery fistula, which can be a life-threatening emergency if the artery is breached and the client begins to hemorrhage. Since no bleeding is yet present, the nurse stays with the client and asks someone else to notify the primary health care provider. If the client begins hemorrhaging, the nurse removes the tracheostomy and applies pressure at the bleeding site. The client will need to be prepared for surgery.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Tracheostomy, Medical emergencies MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 10. A client with a new tracheostomy is being seen in the oncology clinic. What finding by the

nurse best indicates that goals for the client’s decrease in self-esteem are being met? a. The client demonstrates good understanding of stoma care. b. The client has joined a book club that meets at the library. c. Family members take turns assisting with stoma care. d. Skin around the stoma is intact without signs of infection.

ANS: B

The client joining a book club that meets outside the home and requires him or her to go out in public is the best sign that goals for disrupted self-esteem are being met. The other findings are all positive signs but do not relate to this client problem.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Tracheostomy, Psychosocial response MSC: Client Needs Category: Psychosocial Integrity 11. A client is receiving oxygen at 4 L per nasal cannula. What comfort measure may the nurse

delegate to assistive personnel (AP)? a. Apply water-soluble ointment to nares and lips. b. Periodically turn the oxygen down or off. c. Replaces the oxygen tubing with a different type. d. Turn the client every 2 hours or as needed.

ANS: A

Oxygen can be drying, so the UAP can apply water-soluble lubricant to the client’s lips and nares. The AP would not adjust the oxygen flow rate or replace the tubing. Turning the client is not related to comfort measures for oxygen.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Oxygen, Comfort measures, Delegation MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 12. A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived. What

action by the nurse is best? a. Assess the client’s oxygen saturation and, if normal, turn off the oxygen. b. Determine if the client can switch to a nasal cannula during the meal. c. Have the client lift the mask off the face when taking bites of food. d. Turn the oxygen off while the client eats the meal and then restart it.

ANS: B

Oxygen is a drug that needs to be delivered constantly. The nurse would determine if the primary health care provider has approved switching to a nasal cannula during meals. If not, the nurse would consult with the primary health care provider about this issue. The primary health care provider would need to prescribe discontinuing oxygen if the client’s oxygen saturation is normal. The oxygen would not be turned off. Lifting the mask to eat will alter the FiO2 delivered.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Oxygen therapy, Oxygen MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 13. The nurse assesses the client using the device pictured below to deliver 50% O2:

The nurse finds that the mask fits snugly, the skin under the mask and straps is intact, and the flow rate of the oxygen is 3 L/min. What action by the nurse is best? a. Assess the client’s oxygen saturation. b. Document these findings in the chart. c. Immediately increase the flow rate. d. Turn the flow rate down to 2 L/min.

ANS: C

For the venturi mask to deliver high flow of oxygen, the flow rate must be set correctly, usually between 4 and 10 L/min. The client’s flow rate is too low and the nurse would increase it. After increasing the flow rate, the nurse assesses the oxygen saturation and documents the findings.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Oxygen therapy, Client safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control MULTIPLE RESPONSE 1. A home health nurse is visiting a new client who uses oxygen in the home. For which factors

does the nurse assess when determining if the client is using the oxygen safely? (Select all that apply.)

a. b. c. d. e. f.

The client does not allow smoking in the house.

Electrical cords are in good working order.

Flammable liquids are stored in the garage.

Household light bulbs are the fluorescent type.

The client does not have pets inside the home.

No alcohol-based hand sanitizers are present.

ANS: A, B, C

Oxygen it enhances combustion, so precautions are needed whenever using it. The nurse would assess if the client allows smoking in the house, whether electrical cords are in good shape or are frayed, and if flammable liquids are stored (and used) in the garage away from the oxygen. Light bulbs and pets are not related to oxygen safety. Alcohol-based hand sanitizers are permitted.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Oxygen therapy, Home safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 2. A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse

delegate to assistive personnel (AP)? (Select all that apply.) a. Applying water-soluble lip balm to the client’s lips b. Ensuring that the humidification provided is adequate c. Performing oral care with alcohol-based mouthwash d. Reminding the client to cough and deep breathe often e. Suctioning excess secretions through the tracheostomy f. Holding the new tracheostomy tube while the RN changes the ties ANS: A, D

The AP can perform hygiene measures such as applying lip balm and reinforce teaching such as reminding the client to perform coughing and deep-breathing exercises. Oral care can be accomplished with normal saline, not products that dry the mouth. Ensuring that the humidity is adequate and suctioning through the tracheostomy are nursing functions. When needed, a second licensed person assists with holding the tracheostomy tube during tie changes; some hospitals require a second licensed person during the first 72 hours after placement.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Tracheostomy, Delegation MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 3. A client is being discharged home after having a tracheostomy placed. What suggestions does

the nurse offer to help the client maintain self-esteem? (Select all that apply.) a. Create a communication system. b. Don’t go out in public alone. c. Find hobbies to enjoy at home. d. Try loose-fitting shirts with collars. e. Wear fashionable scarves.

ANS: A, D, E

The client with a tracheostomy may be shy and hesitant to go out in public. The client needs to have a sound communication method to ease frustration. The nurse can also suggest ways of enhancing appearance so the client is willing to leave the house. These can include wearing scarves and loose-fitting shirts to hide the stoma. Keeping the client homebound is not good advice.

DIF: Understanding TOP: Integrated Process: Caring KEY: Tracheostomy, Psychosocial response, Client education MSC: Client Needs Category: Psychosocial Integrity 4. A nurse is planning discharge teaching on tracheostomy care for an older client. What factors

does the nurse need to assess before teaching this particular client? (Select all that apply.) a. Cognition b. Dexterity c. Hydration d. Range of motion e. Vision f. Upper arm range of motion ANS: A, B, D, E, F

The older adult is at risk for having impairments in cognition, dexterity, range of motion, and vision that could limit the ability to perform tracheostomy care and would be assessed. Upper arm mobility is required to perform tracheostomy self-care. Hydration is not directly related to the ability to perform self-care.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Tracheostomy, Older adult MSC: Client Needs Category: Health Promotion and Maintenance 5. A nurse is teaching a client about possible complications and hazards of home oxygen

therapy. About which complications does the nurse plan to teach the client? (Select all that apply.) a. Absorptive atelectasis b. Combustion c. Dried mucous membranes d. Alveolar recruitment e. Toxicity ANS: A, B, C, E

Complications of oxygen therapy include absorptive atelectasis, combustion, dried mucous membranes, and oxygen toxicity. Alveolar recruitment may be a benefit of high-flow nasal cannulas such as Vapotherm, which both humidifies and warms the oxygen.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Oxygen therapy, Health teaching MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

Chapter 26: Concepts of Care for Patients With Noninfectious Upper Respiratory Problems Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse is assessing a client who has suffered a nasal fracture. Which assessment would the

nurse perform first? a. Facial pain b. Vital signs c. Bone displacement d. Airway patency ANS: D

A patent airway is the priority. The nurse first would make sure that the airway is patent and then would determine whether the client is in pain and whether bone displacement or blood loss has occurred.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Trauma, Medical emergencies MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 2. A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a

headache, and difficulty with vision. What action would the nurse take next? a. Collect the nasal drainage on a piece of filter paper. b. Encourage the client to blow his or her nose. c. Perform a test focused on a neurologic examination. d. Palpate the nose, face, and neck.

ANS: A

The client with nasal drainage after facial trauma could have a skull fracture resulting in leakage of cerebrospinal fluid (CSF). CSF can be differentiated from regular drainage by the fact that it forms a halo when dripped on filter paper and tests positive for glucose. The other actions would be appropriate but are not as high a priority as assessing for CSF. A CSF leak would increase the patient’s risk for infection.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Trauma, Medical emergencies MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 3. A nurse teaches a client who had a supraglottic laryngectomy. Which technique would the

nurse teach the client to prevent aspiration? a. Tilt the head back as far as possible when swallowing. b. Swallow twice while bearing down. c. Breathe slowly and deeply while swallowing. d. Keep the head very still and straight while swallowing.

ANS: B

The client post supraglottic laryngectomy has a high risk for aspiration. The nurse or speech language pathologist teaches the client the supraglottic method of swallowing. This includes placing a small amount of food in the mouth, performing the Valsalva maneuver, then swallowing twice. The client sits upright. The client holds the breath while swallowing twice.

Keeping the head still and straight will not decrease the risk of aspiration.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Aspiration Precautions MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 4. A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for

development of obstructive sleep apnea? a. A 26-year-old woman who is 8 months pregnant. b. A 42-year-old man with gastroesophageal reflux disease. c. A 55-year-old woman who is 50 lb (23 kg) overweight. d. A 73-year-old man with type 2 diabetes mellitus.

ANS: C

The client at highest risk would be the one who is extremely overweight. None of the other clients have risk factors for sleep apnea. Clients with sleep apnea may develop gastroesophageal reflux.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Obstructive sleep apnea, Risk factors MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. A nurse cares for a client who has hypertension that has not responded well to several

medications. The client states compliance is not an issue. What action would the nurse take next? a. Assess the client for obstructive sleep apnea. b. Arrange a home sleep apnea test. c. Encourage the client to begin exercising. d. Schedule a polysomnography ANS: A

Hypertension not responding to medications can be a sign of obstructive sleep apnea (OSA).

The nurse would assess the client using an evidence-based tool, such as the STOP-Bang Sleep Apnea Questionnaire, the Epworth Sleepiness Scale, the Pittsburgh Sleep Quality Index, and the Multiple Sleep Latency Test. If the results of the assessment indicate OSA may be a problem, the nurse would consult the primary health care provider for further testing. An at-home sleep-study is often done prior to a polysomnography. Excessive weight can contribute to OSA so exercising is always encouraged, but this is not specific to assessing for OSA. DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Obstructive sleep apnea, Nursing assessment MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 6. A nurse cares for a client after radiation therapy for neck cancer. The client reports extreme

dry mouth. What action by the nurse is most appropriate? a. Ask the client to gargle with mouthwash containing lidocaine.

b. Administer IV fluid boluses every 2 hours. c. Explain that xerostomia may be a permanent side effect. d. Assess the client’s neck for redness and swelling.

ANS: C

Xerostomia, or dry mouth, is a potential side effect of radiation, particularly if the salivary glands were in the radiation zone. Unfortunately, this may be long term or even permanent.

Gargling with lidocaine would not help. Increasing fluids is somewhat helpful, but the client would be encouraged to drink. The client’s neck may have redness and swelling, but this finding is not related to the reported dry mouth.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Cancer, Surgical complications MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 7. A nurse cares for a client who had a partial laryngectomy 10 days ago. The client states that

all food tastes bland. How would the nurse respond? a. “I will consult the speech therapist to ensure you are swallowing properly.” b. “This is normal after surgery. What types of food do you like to eat?” c. “I will ask the dietitian to change the consistency of the food in your diet.” d. “Replacement of protein, calories, and water is very important after surgery.”

ANS: B

Many clients experience changes in taste after surgery. The nurse would identify foods that the client wants to eat to ensure that the client maintains necessary nutrition. Although the nurse would collaborate with the speech therapist and dietitian to ensure appropriate replacement of protein, calories, and water, the other responses do not address the patient’s concerns.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Surgical care, Nutrition MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 8. A nurse cares for a client who is scheduled for a total laryngectomy. What action would the

nurse take prior to surgery? a. Assess airway patency, breathing, and circulation. b. Administer prescribed intravenous pain medication. c. Assist the client to choose a communication method. d. Ambulate the client in the hallway to assess gait.

ANS: C

The client will not be able to speak after surgery. The nurse would assist the client to choose a communication method that he or she would like to use after surgery. Assessing the patient’s airway and administering IV pain medication are done after the procedure. Although ambulation promotes health and decreases the complications of any surgery, this patient’s gait would not be impacted by a total laryngectomy and therefore is not a priority.

DIF: Applying TOP: Integrated Process: Caring KEY: Surgical care, Communication MSC: Client Needs Category: Psychosocial Integrity 9. While assessing a client who has facial trauma, the nurse auscultates stridor. The client is

anxious and restless. What action would the nurse take first?

a. b. c. d.

Contact the primary health care provider and prepare for intubation.

Administer prescribed albuterol nebulizer therapy.

Place the client in high-Fowler position.

Ask the client to perform deep-breathing exercises.

ANS: A

Facial and neck tissue edema can occur in clients with facial trauma. Airway patency is the highest priority. Clients who experience stridor and hypoxia, manifested by anxiety and restlessness, would be immediately intubated to ensure airway patency. Albuterol decreases bronchi and bronchiole inflammation, not facial and neck edema. Although putting the client in high-Fowler position and asking the client to perform breathing exercises may temporarily improve the patient’s comfort, these actions will not decrease the underlying problem or improve airway patency.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Trauma, Airway MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 10. A nurse cares for a client who has packing inserted for posterior nasal bleeding. What action

would the nurse take first? a. Assess the client’s pain level. b. Keep the client’s head elevated. c. Teach the client about the causes of nasal bleeding. d. Assess the client’s airway.

ANS: D

If the packing slips out of place, it may obstruct the client’s airway. The other options are good interventions, but ensuring that the airway is patent in the priority objective.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Epistaxis, Airway MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 11. A nurse teaches a client to use a room humidifier after a laryngectomy. Which statement

would the nurse include in this patient’s teaching? a. “Add peppermint oil to the humidifier to relax the airway.” b. “Make sure you clean the humidifier to prevent infection.” c. “Keep the humidifier filled with water at all times.” d. “Use the humidifier when you sleep, even during daytime naps.”

ANS: B

Priority teaching related to the use of a room humidifier focuses on infection control. Clients would be taught to meticulously clean the humidifier to prevent the spread of mold or other sources of infection. Peppermint oil would not be added to a humidifier. The humidifier would be refilled with water as needed and would be used while awake and asleep.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Laryngectomy, Health teaching MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

12. A nurse is caring for a client who had a modified uvulopalatopharyngoplasty (modUPPP)

earlier in the day for obstructive sleep apnea. Which assessment finding indicates that a priority goal has been met? a. Client reports pain is controlled satisfactorily with analgesic regime. b. Client does not have foul odor to the breath or beefy red mucus membranes. c. Client is able to swallow own secretions without drooling. d. Client’s vital signs are within normal parameters.

ANS: C

The priority after a modUPPP is maintaining a patent airway. The client who has a patent airway can swallow his or her own secretions without drooling. Controlled pain is important, but not the priority. Foul breath odor and beefy red mucus membranes indicate possible infection, which probably would not occur this soon after surgery, but preventing infection does not take priority over airway. Vital signs “within normal parameters” are vague.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Obstructive sleep apnea, Airway MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential MULTIPLE RESPONSE 1. A nurse assesses a client who is 6 hours postsurgery for a nasal fracture and has nasal packing

in place. What actions would the nurse take? (Select all that apply.) a. Observe for clear drainage. b. Assess for signs of bleeding. c. Watch the client for frequent swallowing. d. Ask the client to open his or her mouth. e. Administer a nasal steroid to decrease edema. f. Change the nasal packing.

ANS: A, B, C, D

The nurse would observe for clear drainage because of the risk for cerebrospinal fluid leakage.

The nurse would assess for signs of bleeding by asking the client to open his or her mouth and observing the back of the throat for bleeding. The nurse would also note whether the client is swallowing frequently because this could indicate postnasal bleeding. A nasal steroid would increase the risk for infection. It is too soon to change the packing, which would be changed by the surgeon the first time.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Surgical care, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 2. The nurse is teaching a client with obstructive sleep apnea (OSA) about the prescribed CPAP.

What information does the nurse include? (Select all that apply.) a. Insurance will cover the cost if you wear it at least 4 hours a day. b. Once the delivery mask is adjusted, do not loosen the straps. c. The CPAP provides pressure that holds your upper airways open. d. You need to clean the mask at least once a week to prevent infection. e. The humidification increases the risk of fungal infections. f. Be patient when first using the system, it can be frustrating at first.

ANS: B, C, E, F

A CPAP for OSA provides pressure that keeps the upper airway open. A properly fitting mask or nasal pillows is necessary to provide the pressure. Humidification in the system leads to an increased risk for fungal infections. Patients may have anxiety about using the equipment and worry about it being disruptive; most clients have a period of adjustment when first starting to use a CPAP. Medicare will usually cover the cost if the client wears the CPAP at least 6 hours a day. The mask or pillows should be cleaned daily.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Obstructive sleep apnea, Health teaching MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 3. A nurse assesses a client who has facial trauma. Which assessment findings require

immediate intervention? (Select all that apply.) a. Stridor b. Nasal stuffiness c. Edema of the cheek d. Ecchymosis behind the ear e. Eye pain f. Swollen chin ANS: A, D

Stridor is a sign of airway obstruction and requires immediate intervention. Ecchymosis, or bruising, behind the ear is called “battle sign” and indicates basilar skull fracture.

Nasal stuffiness, edema of the cheek or chin, and eye pain do not interfere with respirations or neurologic function, and therefore are not priorities for immediate intervention.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Trauma, Medical emergencies MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 4. A nurse teaches a client who is being discharged after a jaw wiring for a mandibular fracture.

Which statements would the nurse include in this patient’s teaching? (Select all that apply.) a. “You will need to cut the wires if you start vomiting.” b. “Eat six soft or liquid meals each day while recovering.” c. “Use a Waterpik for dental hygiene until you can brush again. d. “Sleep in a semi-Fowler position after the surgery.” e. “Gargle with mouthwash that contains hydrogen peroxide once a day.”

ANS: A, B, C, D

The client needs to know how to cut the wires in case of emergency. If the client vomits, he or she may aspirate. The client would also be taught to eat soft or liquid meals multiple times a day, irrigate the mouth with a Waterpik to prevent infection, and sleep in a semi-Fowler position to assist in avoiding aspiration. Mouthwash with hydrogen peroxide is not a recommendation.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Surgical care, Health teaching MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

5. A nurse is assessing clients on a rehabilitation unit. Which clients are at greatest risk for

airway loss related to aspirated oral and nasopharyngeal secretions? (Select all that apply.) a. A 24 year old with a traumatic brain injury b. A 36 year old who fractured his left femur c. A 58 year old getting radiation therapy d. A 66 year old who is a quadriplegic e. An 80-year-old who is aphasic ANS: A, C, D, E

Thickly crusted, dry secretions that potentially can cause asphyxiation and airway obstruction (inspissated secretions or mucoid impaction) are seen most often in clients who have an altered mental status and level of consciousness (brain injury), are dehydrated, are unable to communicate (aphasic), are unable to cough effectively (quadriplegic), or are at risk for aspiration. The clients with the femur fracture and receiving radiation therapy are not as high of a risk. The location of the radiation is not known.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Medical emergencies MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. A nurse assesses a client who is at risk for neck cancer. Which symptoms would the nurse

assess for? (Select all that apply.) a. Oral mucosa is gray or dark brown b. Pain when drinking grapefruit juice c. Persistent weight gain over the past 2 months d. Oral lesions that are over 2 weeks old e. Changes in the patient’s voice quality ANS: A, B, D, E

Symptoms of head and neck cancer include color changes in the mouth or tongue to gray or dark brown; pain in the mouth, neck, and throat; burning sensation when drinking citrus juices; weight loss; oral lesions or soars that do not heal in 2 weeks; and hoarseness or changes in voice quality.

DIF: Knowing TOP: Integrated Process: Nursing Process: Assessment KEY: Cancer, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 7. A nurse teaches a client who has epistaxis and recently had his nasal packing removed. Which

statements indicate that the client correctly understood the teaching? (Select all that apply.) a. “I will vigorously blow my nose multiple times each day.” b. “Nasal saline sprays will help to prevent rebleeding.” c. “I will wait at least 1 month before resuming weight lifting.” d. “Ibuprofen will decrease nasal swelling and pain.” e. “I will apply a small amount of petroleum jelly to my nares.”

ANS: B, C, E

A nurse would teach a client to avoid vigorous nose blowing, the use of aspirin or other NSAIDs, and strenuous activities such as heavy lifting for at least 1 month. The nurse would also teach the client to apply petroleum jelly sparingly to the nares for lubrication and comfort, and to use nasal saline sprays and humidification to prevent rebleeding.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Epistaxis, Home care MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 8. A nurse is teaching a community group about the long-term effects of untreated sleep apnea.

What information does the nurse include? (Select all that apply.) a. Hypertension b. Stroke c. Weight gain d. Diabetes e. Cognitive deficits f. Pulmonary disease ANS: A, B, C, D, E, F

The long-term effects of untreated sleep apnea include increased risk for hypertension, stroke, cognitive deficits, weight gain, diabetes, and pulmonary and cardiovascular disease.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Obstructive sleep apnea, Health teaching MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

Chapter 27: Concepts of Care for Patients With Noninfectious Lower Respiratory Problems Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse assesses several clients who have a history of respiratory disorders. Which client

would the nurse assess first? a. A 66-year-old client with a barrel chest and clubbed fingernails b. A 48-year-old client with an oxygen saturation level of 92% at rest c. A 35-year-old client who reports orthopnea in bed d. A 27-year-old client with a heart rate of 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. Orthopnea at night in bed is breathlessness when lying down but is not an acute finding at this moment.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Respiratory distress, Nursing assessment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 2. A nurse cares for a client with arthritis who reports frequent asthma attacks. What action

would the nurse take first? a. Review the client’s pulmonary function test results. b. Ask about medications the client is currently taking. c. Assess how frequently the client uses a bronchodilator. d. Consult the primary health care provider and request arterial blood gases.

ANS: B

Aspirin and other nonsteroidal anti-inflammatory drugs (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 likely culprit given the client’s history.

Reviewing pulmonary function test results will not address the immediate problem of frequent asthma attacks. This is a good time to review response to bronchodilators, but assessing triggers is more important. 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: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Respiratory distress, Adverse medication effects MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 3. After teaching a client who is prescribed a long-acting beta2 agonist medication, a nurse

assesses the client’s understanding. Which statement indicates that the client comprehends the teaching? a. “I will carry this medication with me at all times in case I need it.” b. “I will take this medication when I start to experience an asthma attack.”

c. “I will take this medication every morning to help prevent an acute attack.” d. “I will be weaned off this medication when I no longer need it.”

ANS: C

Long-acting beta2 agonist medications will help prevent an acute asthma attack because they are long acting. The client will take this medication every day for best effect. The client does not have to always keep this medication with him or her because it is not used as a rescue medication. 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: Applying TOP: Integrated Process: Teaching/Learning KEY: Respiratory disorders, Medications, Health teaching MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. After teaching a client how to perform diaphragmatic breathing, the nurse assesses the client’s

understanding. Which action demonstrates that the client correctly understands the teaching? a. The client lies on his or her side with knees bent. b. The client places his or her hands on the abdomen. c. The client lies in a prone position with straight. d. The client places his or her hands above the head.

ANS: B

To perform diaphragmatic breathing correctly, the client would place his or her hands on the 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: Applying TOP: Integrated Process: Teaching/Learning KEY: Respiratory disorders, Health teaching MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. A nurse cares for a client who has developed esophagitis after undergoing radiation therapy

for lung cancer. Which diet selection would the nurse provide for this client? a. Spaghetti with meat sauce, ice cream b. Chicken soup, grilled cheese sandwich c. Omelet, soft whole-wheat bread d. Pasta salad, custard, orange juice ANS: C

Side effects of radiation therapy may include inflammation of the esophagus. Clients would 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. A grilled cheese sandwich is too difficult to swallow with this condition, and orange juice and other foods with citric acid are too caustic.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Cancer, Nutrition MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 6. After teaching a client who is prescribed salmeterol, the nurse assesses the client’s

understanding. Which statement by the client indicates a need for additional teaching?

a. b. c. d.

“I will be certain to shake the inhaler well before I use it.”

“It may take a while before I notice a change in my asthma.”

“I will use the drug when I have an asthma attack.”

“I will be careful not to let the drug escape out of my nose and mouth.”

ANS: C

Salmeterol is a long-acting beta2 agonist designed to prevent an asthma attack; it does not relieve or reverse symptoms. Salmeterol has a slow onset of action; therefore, it would 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: Applying TOP: Integrated Process: Teaching/Learning KEY: Medication, Client education MSC: Client Needs Category: Health Promotion and Maintenance 7. A nurse cares for a client with chronic obstructive pulmonary disease (COPD). The client

states that going out with friends is no longer enjoyable. How would the nurse respond? a. “There are a variety of support groups for people who have COPD.” b. “I will ask your primary health care provider to prescribe an antianxiety agent.” c. “I’d like to hear about thoughts and feelings causing you to limit social activities.” d. “Friends can be a good support system for clients with chronic disorders.”

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. While friends can be good sources of support, the client specifically is discussing going out of the home.

DIF: Applying TOP: Integrated Process: Caring KEY: Respiratory disorders, Psychosocial response MSC: Client Needs Category: Psychosocial Integrity 8. A nurse is teaching a client who has cystic fibrosis (CF). Which statement would the nurse

include in this client’s teaching? a. “Take an antibiotic each day.” b. “You should get genetic screening.” c. “Eat a well-balanced, nutritious diet.” d. “Plan to exercise for 30 minutes every day.”

ANS: C

Clients with CF often are malnourished due to vitamin deficiency and pancreatic malfunction.

Maintaining nutrition is essential. Daily antibiotics and daily exercise are not essential actions.

Genetic screening might be an option; however, the nurse would not just tell the client to do something like that.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Respiratory disorders, Nutrition, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance

9. While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a

nurse notices that the chest tube is dislodged. Which action by the nurse is best? a. Assess for drainage from the site. b. Cover the insertion site with sterile gauze. c. Contact the primary health care provider. d. Reinsert the tube using sterile technique.

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 would not leave the client to obtain a suture kit. An occlusive dressing may cause a tension pneumothorax. The nurse does not need to assess the site at this moment.

The primary health care provider would be called to reinsert the chest tube or prescribe other treatment options.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Respiratory disorders, Chest tubes MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 10. A nurse assesses a client who is prescribed fluticasone and notes oral lesions. What action

would the nurse take? a. Encourage oral rinsing after fluticasone administration. b. Obtain an oral specimen for culture and sensitivity. 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 would document the finding, but the best action to take is to have the client start rinsing his or her mouth after using fluticasone. An oral specimen for culture and sensitivity is not necessary to care for this client.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Respiratory disorders, Medication side effects MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 11. A nurse cares for a client who is infected with Burkholderia cepacia. What action would the

nurse take first when admitting this client to a pulmonary care unit? a. Instruct the client to wash his or her hands after contact with other people. b. Implement Droplet Precautions and don a surgical mask. c. Keep the client separated from other clients with cystic fibrosis. d. Obtain blood, sputum, and urine culture specimens.

ANS: C

B. cepacia infection is spread through casual contact between cystic fibrosis clients, thus the need for infected clients to be separated from noninfected clients. Strict isolation measures will not be necessary. Although the client would wash his or her hands frequently, the most important measure that can be implemented on the unit is isolation of the client from other clients with cystic fibrosis. There is no need to implement Droplet Precautions or don a surgical mask when caring for this client. Obtaining blood, sputum, and urine culture specimens will not provide information necessary to care for a client with B. cepacia infection.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Respiratory disorders, Infection control MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 12. A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep

breaths because of the pain. What action would the nurse take? a. Ambulate the client in the hallway to promote deep breathing. b. Auscultate the client’s anterior and posterior lung fields. c. Encourage the client to take shallow breaths to help with the pain. d. Administer pain medication and encourage the client to take deep breaths.

ANS: D

A chest tube is placed in the pleural space and may be uncomfortable for a client. The nurse would provide pain medication to minimize discomfort and encourage the client to take deep breaths. The other responses do not address the client’s discomfort and need to take deep breaths to prevent complications.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Respiratory disorders, Pharmacologic pain management MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 13. The nurse is caring for a client who has cystic fibrosis (CF). The client asks for information

about gene therapy. What response by the nurse is best? a. “Unfortunately, gene therapy is only provided to children upon diagnosis.” b. “Do you know that you will have to have genetic testing?” c. “There is a good treatment for the most common genetic defect in CF.” d. “Gene therapy will only help improve your pulmonary symptoms.”

ANS: C

The drug ivacaftor/lumacaftor is effective as therapy for patients whose CF is caused by the F508del (also known as the Phe508del) mutation, the most common mutation involved in CF, even in patients who are homozygous for the mutation with both alleles being affected. The nurse would provide that information as the best response. Asking if the client understands he or she will have to undergo genetic testing is a correct statement, but is a yes/no question which is not therapeutic and might sound paternalistic. It also does not provide any information on the therapy itself. The drug is not limited to children and helps move chloride closer to the membrane surfaces so it would have an effect on any organ compromised by CF. DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Respiratory disorders, Gene therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

14. A nurse cares for a client with a 40-year smoking history who is experiencing distended neck

veins and dependent edema. Which physiologic process would the nurse correlate with this client’s history and clinical signs and symptoms? a. Increased pulmonary pressure creating a higher workload on the right side of the heart b. Exposure to irritants resulting in increased inflammation of the bronchi and bronchioles c. Increased number and size of mucous glands producing large amounts of thick mucus d. Left ventricular hypertrophy creating a decrease in cardiac output ANS: A

Smoking increases pulmonary hypertension, resulting in cor pulmonale, or right-sided heart failure. Increased pressures in the lungs make it more difficult for blood to flow through the lungs. Blood backs up into the right side of the heart and then into the peripheral venous system, creating distended neck veins and dependent edema. Inflammation in bronchi and bronchioles creates an airway obstruction which manifests as wheezes. Thick mucus in the lungs has no impact on distended neck veins and edema. Left ventricular hypertrophy is associated with left-heart failure and is not directly caused by a 40-year smoking history.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Respiratory disorders, Cor pulmonale MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 15. A nurse cares for a client with chronic obstructive pulmonary disease (COPD) who appears

thin and disheveled. Which question would the nurse ask first? a. “Do you have a strong support system?” b. “What do you understand about your disease?” c. “Do you experience shortness of breath with basic activities?” d. “What medications are you prescribed to take each day?”

ANS: C

Clients with severe COPD may not be able to perform daily activities, including bathing and eating, because of excessive shortness of breath. The nurse would ask the client if shortness of breath is interfering with basic activities. Although the nurse would need to know about the client’s support systems, current knowledge, and medications, these questions do not address the client’s appearance.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Respiratory disorders, Functional ability MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 16. A clinic nurse is reviewing care measures with a client who has asthma, Step 3. What

statement by the client indicates the need to review the information? a. “I still will use my rapid-acting inhaler for an asthma attack.” b. “I will always use the spacer with my dry powder inhaler.” c. “If I am stable for 3 months, I might be able to reduce my drugs.” d. “My inhaled corticosteroid must be taken regularly to work well.”

ANS: B

Dry powder inhalers are not used with a spacer. The other statements are accurate.

DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Respiratory disorders, Medications, Health teaching MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 17. A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease

(COPD). Which client would the nurse assess first? a. A 46 year old with a 30–pack-year history of smoking b. A 52 year old in a tripod position using accessory muscles to breathe c. A 68 year old who has dependent edema and clubbed fingers d. A 74 year old with a chronic cough and thick, tenacious secretions ANS: B

The client who is in a tripod position and using accessory muscles is working to breathe. This client must be assessed first to establish how effectively the client is breathing and provide interventions to minimize respiratory distress. The other clients are not in acute distress.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Respiratory disorders, Nursing assessment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 18. A nurse cares for a client who has a pleural chest tube. What action would the nurse take to

ensure safe use of this equipment? a. Strip the tubing to minimize clot formation and ensure patency. b. Secure tubing junctions with clamps to prevent accidental disconnections. c. Connect the chest tube to wall suction as prescribed by the primary health care provider. d. Keep padded clamps at the bedside for use if the drainage system is interrupted.

ANS: D

Padded clamps would be kept at the bedside for use if the drainage system becomes dislodged or is interrupted. The nurse would never strip the tubing. Tubing junctions would be taped, not clamped. Wall suction would be set at the level indicated by the device’s manufacturer, not the primary health care provider.

DIF: Remembering TOP: Integrated Process: Nursing Process: Implementation KEY: Respiratory disorders, Chest tubes MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 19. A nurse cares for a client who tests positive for alpha1-antitrypsin (AAT) deficiency. The

client asks, “What does this mean?” How would the nurse respond? a. “Your children will be at high risk for chronic obstructive pulmonary disease.” b. “I will contact a genetic counselor to discuss your condition.” c. “Your risk for chronic obstructive pulmonary disease is higher, especially if you smoke.” d. “This is a recessive gene and would have no impact on your health.”

ANS: C

Alpha1-antitrypsin deficiency is an important risk factor for COPD. The gene for AAT is a recessive gene. Clients with only one allele produce enough AAT to prevent COPD unless the client smokes or there is sufficient exposure to other inhalants. A client with two alleles is at high risk for COPD even if not exposed to smoke or other irritants. The client is a carrier, and children may or may not be at high risk depending on the partner’s AAT levels. Contacting a genetic counselor may be helpful but does not address the client’s current question.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Respiratory disorders, Genetic disorders MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 20. A nurse cares for a client who has a family history of cystic fibrosis. The client asks, “Will my

children have cystic fibrosis?” How would the nurse respond? a. “Since many of your family members are carriers, your children will also be carriers of the gene.” b. “Cystic fibrosis is an autosomal recessive disorder. If you are a carrier, your children will have the disorder.” c. “Since you have a family history of cystic fibrosis, I would encourage you and your partner to be tested.” d. “Cystic fibrosis is caused by a protein that controls the movement of chloride.

Adjusting your diet will decrease the spread of this disorder.”

ANS: C

Cystic fibrosis is an autosomal recessive disorder in which both gene alleles must be mutated for the disorder to be expressed. The nurse would encourage both the client and partner to be tested for the abnormal gene. The other statements are not true.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Respiratory disorders, Genetic disorders MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 21. A nurse administers medications to a client who has asthma. Which medication classification

is paired correctly with its physiologic action? a. Bronchodilator—stabilizes the membranes of mast cells and prevents the release of inflammatory mediators. b. Cholinergic antagonist—causes bronchodilation by inhibiting the parasympathetic nervous system. c. Corticosteroid—relaxes bronchiolar smooth muscles by binding to and activating pulmonary beta2 receptors. d. Cromone—disrupts the production of pathways of inflammatory mediators.

ANS: B

Cholinergic antagonist drugs cause bronchodilation by inhibiting the parasympathetic nervous system. This allows the sympathetic nervous system to dominate and release norepinephrine that activates beta2 receptors. Bronchodilators relax bronchiolar smooth muscles by binding to and activating pulmonary beta2 receptors. Corticosteroids disrupt the production of pathways of inflammatory mediators. Cromones stabilize the membranes of mast cells and prevent the release of inflammatory mediators.

DIF: Remembering KEY: Respiratory disorders, Medications

TOP: Integrated Process: Nursing Process: Analysis

MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 22. A nurse evaluates the following arterial blood gas and vital sign results for a client with

chronic obstructive pulmonary disease (COPD): Arterial Blood Gas Results Vital Signs Heart rate = 110 beats/min pH = 7.32 PaCO2 = 62 mm Hg Respiratory rate = 12 breaths/min PaO2 = 46 mm Hg Blood pressure = 145/65 mm Hg Oxygen saturation = 76% HCO3 = 28 mEq/L (28 mmol/L) What action would the nurse take first? a. Administer a short-acting beta2 agonist inhaler. b. Document the findings as normal for a client with COPD. c. Teach the client diaphragmatic breathing techniques. d. Initiate oxygenation therapy to increase saturation to 88% to 92%.

ANS: D

Oxygen would be administered to a client who is hypoxic even if the client has COPD and is a carbon dioxide retainer. The other interventions do not address the client’s hypoxia, which is the major issue. There is no indication the client needs an inhaler. Diaphragmatic breathing techniques would not be taught to a client in distress. These findings are not normal for all clients with COPD. DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Respiratory disorders, Respiratory distress MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. A nurse assesses a client with asthma and notes bilateral wheezing, decreased pulse oxygen

saturation, and suprasternal retraction on inhalation. What actions by the nurse are best?

(Select all that apply.) a. Administer prescribed salmeterol inhaler. b. Assess the client for a tracheal deviation. c. Administer oxygen and place client on an oximeter. d. Perform peak expiratory flow readings. e. Administer prescribed albuterol inhaler. f. Assess the client’s lung sounds after administering the inhaler.

ANS: C, E, F

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 becoming unstable, and intervention is needed.

Administration of a rescue inhaler is indicated, probably along with administration of oxygen.

The nurse would reassess the lung sounds after the rescue inhaler. The nurse would not do a peak flow reading at this time, nor would a code be called. The nurse could assess for tracheal deviation after administering oxygen and albuterol.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Respiratory disorders, Respiratory distress

MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A nurse assesses a client who 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. Pain at insertion site d. Sudden onset of shortness of breath e. Drainage greater than 70 mL/hr f. Disconnection at Y site ANS: B, D, E, F

Immediate intervention is warranted if the client has tracheal deviation because this could indicate a tension pneumothorax. Sudden shortness of breath could indicate dislodgment of the tube, occlusion of the tube, or pneumothorax. Drainage greater than 70 mL/hr could indicate hemorrhage. Disconnection at the Y site could result in air entering the tubing.

Production of pink sputum and pain at the insertion site are not signs/symptoms that would require immediate intervention.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Drain, Respiratory distress, Failure MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. A nurse teaches a client who has chronic obstructive pulmonary disease. Which statements

related to nutrition would the nurse include in this client’s teaching? (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. “Eat high-fiber foods to promote gastric emptying.” e. “Use pursed-lip breathing during meals.” f. “Choose soft, high-calorie, high-protein foods.”

ANS: A, B, C, E, F

Clients with COPD often are malnourished for several reasons. The nurse would teach the client not to drink fluids before and with meals to avoid early satiety. The client needs to rest before eating, and eat smaller frequent meals: 4 to 6 a day. Pursed-lip breathing will help control dyspnea. Food that is easy to eat will be less tiring and the client should choose high-calorie, high-protein foods.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Respiratory disorders, Nutrition, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 4. A nurse assesses a client with chronic obstructive pulmonary disease. Which questions would

the nurse ask to determine the client’s activity tolerance? (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?” f. “How does your activity compare to this time last year?”

ANS: B, C, E, F

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. The nurse would ask the client to compare his or her current level of activity with that of a month or even a year ago.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Respiratory disorders, Functional ability MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. A client, who has become increasingly dyspneic over a year, has been diagnosed with

pulmonary fibrosis. What information would the nurse plan to include in teaching this client?

(Select all that apply.) a. The need to avoid large crowds and people who are ill b. Safety measures to take if home oxygen is needed c. Information about appropriate use of the drug nintedanib d. Genetic therapy to stop the progression of the disease e. Measures to avoid fatigue during the day f. The possibility of receiving a lung transplant if infection-free for a year ANS: A, B, C, E

Pulmonary fibrosis is a progressive disorder with no cure. Therapy focuses on slowing progression and managing dyspnea. Clients need to avoid contracting infections so should be taught to stay away from large crowds and sick people. Home oxygen is needed and the nurse would teach safety measures related to oxygen. The drug nintedanib has shown to improve cellular regulation and slow progression of the disease. Gene therapy is not available. Energy conservation measures are also an important topic. Lung transplantation is an unlikely option due to selection criteria.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Respiratory disorders, Pulmonary fibrosis, Health teaching MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 6. A nurse plans care for a client who has chronic obstructive pulmonary disease and thick,

tenacious secretions. Which interventions would the nurse include in this client’s plan of care?

(Select all that apply.) a. Ask the client to drink 2 L of fluids daily. b. Add humidity to the prescribed oxygen. c. Suction the client every 2 to 3 hours. d. Use a vibrating chest physiotherapy device. e. Encourage diaphragmatic breathing. f. Administer the ordered mucolytic agent.

ANS: A, B, D, F

Interventions to decrease thick tenacious secretions include maintaining adequate hydration and providing humidified oxygen. These actions will help to thin secretions, making them easier to remove by coughing. The use of a vibrating chest physiotherapy device can also help clients remove thick secretions but is usually used in clients with cystic fibrosis. Mucolytic agents help thin secretions, making them easier to bring up. Although suctioning may assist with the removal of secretions, frequent suctioning can cause airway trauma and does not support the client’s ability to successfully remove secretions through normal coughing.

Diaphragmatic breathing is not used to improve the removal of thick secretions.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Respiratory disorders, COPD MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 7. A nurse cares for a client who is prescribed an intravenous prostacyclin agent for pulmonary

artery hypertension. What actions would the nurse take to ensure the client’s safety while on this medication? (Select all that apply.) a. Keep an intravenous line dedicated strictly to the infusion. b. Teach the client that this medication increases pulmonary pressures. c. Ensure that there is always a backup drug cassette available. d. Start a large-bore peripheral intravenous line. e. Use strict aseptic technique when using the drug delivery system.

ANS: A, C, E

Intravenous prostacyclin agents would be administered to a client with pulmonary artery hypertension through a central venous catheter with a dedicated intravenous line for this medication. Death has been reported when the drug delivery system is interrupted even briefly; therefore, a backup drug cassette would also be available. The nurse would use strict aseptic technique when using the drug delivery system. The nurse would teach the client that this medication decreases pulmonary pressures and increases lung blood flow.

DIF: Understanding TOP: Integrated Process: Nursing Process: Implementation KEY: Respiratory disorders, Medication administration MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 8. A home health nurse evaluates a client who has chronic obstructive pulmonary disease. Which

assessments would the nurse include in this client’s evaluation? (Select all that apply.) a. Examination of mucous membranes and nail beds b. Measurement of rate, depth, and rhythm of respirations c. Auscultation of bowel sounds for abnormal sounds d. Check peripheral veins for distention while at rest e. Determine the client’s need and use of oxygen f. Ability to perform activities of daily living ANS: A, B, E, F

A home health nurse would assess the client’s respiratory status and adequacy of ventilation including an examination of mucous membranes and nail beds for evidence of hypoxia, measurement of rate, depth and rhythm of respirations, auscultation of lung fields for abnormal breath sounds, checking neck veins for distention with the client in a sitting position, and determining the client’s needs and use of supplemental oxygen. The home health nurse would also determine the client’s ability to perform his or her own ADLs. Auscultation of bowel sounds and assessment of peripheral veins are not part of a focused assessment for a client with COPD. DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Respiratory disorders, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 9. A nurse is teaching a client how to perform pursed-lip breathing. Which instructions would

the nurse include in this teaching? (Select all that apply.) a. “Open your mouth and breathe deeply.” b. “Use your abdominal muscles to squeeze air out of your lungs.” c. “Breath out slowly without puffing your cheeks.” d. “Focus on inhaling and holding your breath as long as you can.” e. “Exhale at least twice the amount of time it took to breathe in.” f. “Lie on your back with your knees bent.”

ANS: B, C, E

A nurse would teach a client to close his or her mouth and breathe in through his or her nose, purse his or her lips and breathe out slowly without puffing his or her cheeks, and use his or her abdominal muscles to squeeze out every bit of air. The nurse would also remind the client to use pursed-lip breathing during any physical activity, to focus on exhaling, and to never hold his or her breath. Lying on the back with bent knees is the preferred position for diaphragmatic breathing.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Respiratory disorders, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 10. A nurse is assessing a client with lung cancer. What nonpulmonary signs and symptoms

would the nurse be aware of? (Select all that apply.) a. Gynecomastia in male patients b. Frequent shaking and sweating relieved by eating c. Positive Chvostek and Trousseau signs d. “Moon” face and “buffalo” hump e. Expectorating purulent sputum f. General edema ANS: A, B, D, F

Lung cancer often is associated with paraneoplastic syndromes. Symptoms of these include gynecomastia from ectopic follicle-stimulating hormone release, hypoglycemia from ectopic insulin production (shaking and sweating relieved by eating), and Cushing syndrome (moon facies and buffalo hump) from ectopic adrenocorticotropic hormone. General edema can be caused by antidiuretic hormone.

DIF: Applying

TOP: Integrated Process: Nursing Process: Assessment

KEY: Respiratory disorders, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 11. The nurse is preparing to teach a community group about warning signs of lung cancer. What

information does the nurse include? (Select all that apply.) a. Over 10–pack-year history of smoking b. Persistent coughing c. Rusty or blood-tinged sputum d. Dyspnea e. Hoarseness f. Fatigue ANS: B, C, D, E

Some common signs of lung cancer include persistent cough, rusty or blood-tinged sputum, dyspnea, and hoarseness. Fatigue is common to many conditions. Smoking history is a risk factor for lung cancer.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Respiratory disorders, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance

Chapter 28: Concepts of Care for Patients With Infectious Respiratory Problems Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse working in a geriatric clinic sees clients with “cold” symptoms and rhinitis. The

primary health care provider (PHCP) often leaves a prescription for diphenhydramine. What action by the nurse is best? a. Teach the client about possible drowsiness. b. Instruct the client to drink plenty of water. c. Consult with the PHCP about the medication. d. Encourage the client to take the medication with food.

ANS: C

First-generation antihistamines are not appropriate for use in the older population. These drugs include chlorpheniramine, diphenhydramine, and hydroxyzine. The nurse would consult with the PHCP and request a different medication. Diphenhydramine does cause drowsiness, but the nurse would request a different medication. Drinking plenty of fluids is appropriate for the condition and is not related to the medication. Antihistamines can be taken without regard to food.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Antihistamines, Older adults MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 2. A nurse in a family practice clinic is preparing discharge instructions for a client reporting

facial pain that is worse when bending over, tenderness across the cheeks, and postnasal discharge. What instruction will be most helpful? a. “Ice packs may help with the facial pain.” b. “Limit fluids to dry out your sinuses.” c. “Try warm, moist heat packs on your face.” d. “We will schedule a computed tomography scan this week.”

ANS: C

This client has rhinosinusitis. Comfort measures for this condition include humidification, hot packs, nasal saline irrigations, sleeping with the head elevated, increased fluids, and avoiding cigarette smoke. The client does not need a CT scan.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Infectious respiratory problems, Nonpharmacologic comfort interventions MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 3. Which teaching point is most important for the client with a peritonsillar abscess? a. Gargle with warm salt water. b. Take all antibiotics as directed. c. Let us know if you want liquid medications. d. Wash hands frequently.

ANS: B

Any client on antibiotics must be instructed to complete the entire course of antibiotics. Not completing them can lead to complications or drug-resistant strains of bacteria. The other instructions are appropriate, just not the most important.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Antibiotics, Health teaching MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. A client is in the family practice clinic reporting a severe “cold” that started 4 days ago. On

examination, the nurse notes that the client also has a severe headache and muscle aches.

What action by the nurse is best? a. Educate the client on oseltamivir. b. Facilitate admission to the hospital. c. Instruct the client to have a flu vaccine. d. Teach the client to sneeze in the upper sleeve.

ANS: D

Sneezing and coughing into one’s sleeve helps prevent the spread of upper respiratory infections. The client does have symptoms of the flu (influenza), but it is too late to start antiviral medications; to be effective, they must be started within 24 to 48 hours of symptom onset. The client does not need hospital admission. The client would be instructed to have a flu vaccination, but now that he or she has the flu, vaccination will have to wait until next year.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Influenza, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 5. The charge nurse on a medical unit is preparing to admit several “clients” who have possible

pandemic flu during a preparedness drill. What action by the nurse is best? a. Admit the “clients” on Contact Precautions. b. Inquire as to recent travel outside the United States. c. Do not allow pregnant caregivers to care for these “clients.” d. Place the “clients” on enhanced Droplet Precautions.

ANS: B

Preventing the spread of pandemic flu is equally important as caring for the clients who have it. Preventing the spread of disease is vital. The nurse would ask the “clients” about recent overseas travel to assess the risk of a pandemic flu. Clients with possible pandemic flu need to be in Contact and Airborne Precautions the infectious organism is identified and routes of transmission known. There is no specific danger to pregnant caregivers. Droplet Precautions are not appropriate.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Infection control, Transmission-based precautions MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 6. A client admitted for pneumonia has been tachypneic for several days. When the nurse starts

an IV to give fluids, the client questions this action, saying “I have been drinking tons of water. How am I dehydrated?” What response by the nurse is best? a. “Breathing so quickly can be dehydrating.”

b. “Everyone with pneumonia is dehydrated.” c. “This is really just to administer your antibiotics.” d. “Why do you think you are so dehydrated?”

ANS: A

Tachypnea and mouth breathing (from increased work of breathing), both seen in pneumonia, increase insensible water loss and can lead to a degree of dehydration. The other options do not give the client useful information that addresses this specific concern.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Pneumonia, Fluid and electrolyte imbalances MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 7. An older adult is brought to the emergency department by a family member, who reports a

moderate change in mental status and mild cough. The client is afebrile. The primary health care provider orders a chest x-ray. The family member questions why this is needed since the symptoms seem so vague. What response by the nurse is best? a. “Chest x-rays are always ordered when we suspect pneumonia.” b. “Older people often have vague symptoms, so an x-ray is essential.” c. “The x-ray can be done and read before laboratory work is reported.” d. “We are testing for any possible source of infection in the client.”

ANS: B

It is essential to obtain an early chest x-ray in older adults suspected of having pneumonia because symptoms are often vague. Waiting until definitive signs and symptoms are present to obtain the x-ray leads to a costly delay in treatment. Stating that chest x-rays are always ordered does not give the family definitive information. The x-ray can be done while laboratory values are still pending, but this also does not provide specific information about the importance of a chest x-ray in this client. The client has symptoms of pneumonia, so the staff is not testing for any possible source of infection but rather is testing for a suspected disorder.

DIF: Understanding TOP: Integrated Process: Communication and Documentation KEY: Older adult, Pneumonia MSC: Client Needs Category: Health Promotion and Maintenance 8. A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest

priority? a. Educating the client on adherence to the treatment regimen b. Encouraging the client to eat a well-balanced diet c. Informing the client about follow-up sputum cultures d. Teaching the client ways to balance rest with activity ANS: A

The treatment regimen for TB often ranges from 26 weeks, but can be up to 2 years, making adherence problematic for many people. The nurse would stress the absolute importance of following the treatment plan for the entire duration of prescribed therapy. The other options are appropriate topics to educate this client on but do not take priority.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Tuberculosis, Health teaching MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

9. A client has been admitted for suspected inhalation anthrax infection. What question by the

nurse is most important? a. “Are any family members also ill?” b. “Have you traveled recently?” c. “How long have you been ill?” d. “What is your occupation?”

ANS: D

Inhalation anthrax is rare and is an occupational hazard among people who work with animal wool, bone meal, hides, and skin, such as taxidermists and veterinarians. Inhalation anthrax seen in someone without an occupational risk is considered a bioterrorism event and must be reported to authorities immediately. The other questions are appropriate for anyone with an infection.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Infection, Anthrax MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 10. A charge nurse is rounding on several older clients on ventilators in the Intensive Care Unit

whom the nurse identifies as being at high risk for ventilator-associated pneumonia. To reduce this risk, what activity would the nurse delegate to the assistive personnel (AP)? a. Encourage between-meal snacks. b. Monitor temperature every 4 hours. c. Provide oral care every 4 hours. d. Report any new onset of cough.

ANS: C

Oral colonization by gram-negative bacteria is a risk factor for health care–associated pneumonia. Good, frequent oral care can help prevent this from developing and is a task that can be delegated to the AP. Encouraging good nutrition is important, but this will not prevent pneumonia. Monitoring temperature and reporting new cough in clients are important to detect the onset of possible pneumonia but do not prevent it.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Pneumonia, Oral care MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 11. The emergency department (ED) manager is reviewing client charts to determine how well the

staff perform when treating clients with community-acquired pneumonia. What outcome demonstrates that goals for this client type have been met? a. Antibiotics started before admission. b. Blood cultures obtained within 20 minutes. c. Chest x-ray obtained within 30 minutes. d. Pulse oximetry obtained on all clients.

ANS: A

Goals for treatment of community-acquired pneumonia include initiating antibiotics prior to inclient admission or within 6 hours of presentation to the ED. Timely collection of blood cultures, chest x-ray, and pulse oximetry are important as well but do not coincide with established goals.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Infection, Pneumonia MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 12. A nurse has educated a client on isoniazid. What statement by the client indicates that

teaching has been effective? a. “I need to take extra vitamin C while on isoniazid.” b. “I should take this medicine with milk or juice.” c. “I will take this medication on an empty stomach.” d. “My contact lenses will be permanently stained.”

ANS: C

Isoniazid needs to be taken on an empty stomach, either 1 hour before or 2 hours after meals.

Extra vitamin B needs to be taken while on the drug. Staining of contact lenses commonly occurs while taking rifampin.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Tuberculosis, Medications, Health teaching MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 13. A client has been taking isoniazid for tuberculosis for 3 weeks. What laboratory results need

to be reported to the primary health care provider immediately? a. Albumin: 5.1 g/dL (7.4 mcmol/L) b. Alanine aminotransferase (ALT): 180 U/L c. Red blood cell (RBC) count: 5.2/million/µL (5.2  1012/L) d. White blood cell (WBC) count: 12,500/mm3 (12.5  109/L) ANS: B

INH can cause liver damage, especially if the client drinks alcohol. The ALT (one of the liver enzymes) is extremely high and needs to be reported immediately. The albumin and RBCs are normal. The WBCs are slightly high, but that would be an expected finding in a client with an infection.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Analysis KEY: Tuberculosis, Medication side effects MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 14. A client seen in the emergency department reports fever, fatigue, and dry cough but no other

upper respiratory symptoms. A chest x-ray reveals mediastinal widening. What action by the nurse is best? a. Collect a sputum sample for culture by deep suctioning. b. Inform the client that oral antibiotics will be needed for 60 days. c. Place the client on Airborne Precautions immediately. d. Tell the client that directly observed therapy is needed.

ANS: B

This client has signs and symptoms of early inhalation anthrax. For treatment, after IV antibiotics are finished, oral antibiotics are continued for at least 60 days. Sputum cultures are not needed. Anthrax is not transmissible from person to person, so Standard Precautions are adequate. Directly observed therapy is often used for tuberculosis.

DIF: Applying

TOP: Integrated Process: Teaching/Learning

KEY: Anthrax, Antibiotics MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 15. A client has been hospitalized with tuberculosis (TB). The client’s spouse is fearful of

entering the room where the client is in isolation and refuses to visit. What action by the nurse is best? a. Ask the spouse to explain the fear of visiting in further detail. b. Inform the spouse that the precautions are meant to keep other clients safe. c. Show the spouse how to follow the Isolation Precautions to avoid illness. d. Tell the spouse that he or she has already been exposed, so it’s safe to visit.

ANS: A

The nurse needs to obtain further information about the spouse’s specific fears so they can be addressed. This will decrease stress and permit visitation, which will be beneficial for both client and spouse. Precautions for TB prevent transmission to all who come into contact with the client. Explaining Isolation Precautions and what to do when entering the room will be helpful, but this is too narrow in scope to be the best answer. Telling the spouse that it’s safe to visit is demeaning of the spouse’s feelings.

DIF: Applying TOP: Integrated Process: Caring KEY: Tuberculosis, Therapeutic communication MSC: Client Needs Category: Psychosocial Integrity 16. A client is being discharged on long-term therapy for tuberculosis (TB). What referral by the

nurse is most appropriate? a. Community social worker for Meals on Wheels b. Occupational therapy for job retraining c. Physical therapy for homebound therapy services d. Visiting nurses for directly observed therapy ANS: D

Directly observed therapy is often utilized for managing clients with TB in the community.

Meals on Wheels, job retraining, and home therapy may or may not be appropriate.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Tuberculosis, Referrals MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 17. A client is admitted with suspected pneumonia from the emergency department. The client

went to the primary health care provider a “few days ago” and shows the nurse the results of what the client calls “an allergy test,” as shown below:

The reddened area is firm. What action by the nurse is best?

a. b. c. d.

Assess the client for possible items to which he or she is allergic.

Call the primary health care provider’s office to request records.

Immediately place the client on Airborne Precautions.

Prepare to begin administration of intravenous antibiotics.

ANS: C

This “allergy test” is actually a positive tuberculosis test. The client would be placed on Airborne Precautions immediately. The other options do not take priority over preventing the spread of the disease.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Implementation KEY: Tuberculosis, Transmission-based precautions MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 18. A nurse admits a client from the emergency department. Client data are listed below:

History Physical Assessment Laboratory Values ° 70 years of age ° Crackles and rhonchi heard ° WBC 5,200/mm3 (5.2  ° History of diabetes throughout the lungs 109/L) ° PaO2 on room air 85 mm ° On insulin twice a day ° Dullness to percussion ° Reports new onset dyspnea LLL Hg and productive cough ° Afebrile ° Oriented to person only What action by the nurse is the priority? a. Administer oxygen at 4 L per nasal cannula. b. Begin broad-spectrum antibiotics. c. Collect a sputum sample for culture. d. Start an IV of normal saline at 50 mL/hr.

ANS: A

All actions are appropriate for this client who has signs and symptoms of pneumonia.

However, airway and breathing come first, so begin oxygen administration and titrate it to maintain saturations greater than 95%. Start the IV and collect a sputum culture, and then begin antibiotics.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Analysis KEY: Pneumonia, Oxygen therapy MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. A nurse is providing pneumonia vaccinations in a community setting. Due to limited finances,

the event organizers must limit giving the vaccination to priority groups. What clients would be considered a priority when administering the pneumonia vaccination? (Select all that apply.) a. A 22-year-old client with asthma b. Client who had a cholecystectomy last year c. Client with well-controlled diabetes d. Healthy 72-year-old client

e. Client who is taking medication for hypertension ANS: A, C, D, E

Clients over 65 years of age and any client (no matter what age) with a chronic health condition would be considered a priority for a pneumonia vaccination. Having a cholecystectomy a year ago does not qualify as a chronic health condition.

DIF: Understanding TOP: Integrated Process: Nursing Process: Implementation KEY: Vaccinations, Health promotion MSC: Client Needs Category: Health Promotion and Maintenance 2. A hospital nurse is participating in a drill during which many “clients” with inhalation anthrax

are being admitted. What drugs would the nurse anticipate administering? (Select all that apply.) a. Vancomycin b. Ciprofloxacin c. Doxycycline d. Ethambutol e. Sulfamethoxazole-trimethoprim (SMX-TMP) ANS: A, B, C

Vancomycin, ciprofloxacin, and doxycycline are all possible treatments for inhalation anthrax.

Ethambutol is used for tuberculosis. SMX-TMP is commonly used for urinary tract infections and other common infections.

DIF: Remembering TOP: Integrated Process: Nursing Process: Implementation KEY: Anthrax, Emergency preparedness plan MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 3. A client in the emergency department is taking rifampin for tuberculosis. The client reports

yellowing of the sclera and skin and bleeding after minor trauma. What laboratory results correlate to this condition? (Select all that apply.) a. Blood urea nitrogen (BUN): 19 mg/dL (6.7 mmol/L) b. International normalized ratio (INR): 6.3 c. Prothrombin time: 35 seconds d. Serum sodium: 130 mEq/L (130 mmol/L) e. White blood cell (WBC) count: 72,000/mm3 (72  109/L) ANS: B, C

Rifampin can cause liver damage, evidenced by the client’s high INR and prothrombin time.

The BUN and WBC count are normal. The sodium level is low, but that is not related to this client’s problem.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Analysis KEY: Tuberculosis, Adverse medication effects MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 4. A client has been diagnosed with an empyema. What interventions would the nurse anticipate

providing to this client? (Select all that apply.) a. Assisting with chest tube insertion

b. c. d. e.

Facilitating pleural fluid sampling Performing frequent respiratory assessment Providing antipyretics as needed Suctioning deeply every 4 hours

ANS: A, B, C, D

The client with an empyema is often treated with chest tube insertion, which facilitates obtaining samples of the pleural fluid for analysis and re-expands the lungs. The nurse would perform frequent respiratory system assessments. Antipyretic medications are also used.

Suction is only used when needed and is not done deeply to prevent tissue injury.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Respiratory system, Chest tubes, Infection, Respiratory assessment MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 5. The emergency department nurse is participating in a bioterrorism drill in which several

“clients” are suspected to have inhalation anthrax. Which “clients” would the nurse see as the priorities? (Select all that apply.) a. Widened mediastinum on chest x-ray b. Dry cough c. Stridor d. Oxygen saturation of 91% e. Diaphoresis f. Oral temperature of 99.9° F (37.7° C) ANS: C, D, E

Clients with fulminant anthrax may exhibit stridor, hypoxia, and diaphoresis. Although an oxygen saturation of 91% is not critical, it is abnormally low. These clients would be seen as the priority. A widened mediastinum and dry cough are usually seen in the prodromal phase when the temperature elevation is not as severe.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Anthrax, Nursing assessment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 6. A client is taking ethambutol for tuberculosis. What instructions does the nurse provide the

client regarding this drug? (Select all that apply.) a. Contact the primary health care provider if preexisting gout becomes worse. b. Report any changes in vision immediately to the health care provider. c. Avoid drinking alcoholic beverages due to the chance of liver damage. d. Do not take antacids or eat within 2 hours after taking this medication. e. You will take this medication along with some others for 8 weeks. f. Take this medicine with a full glass of water.

ANS: A, B, E, F

The nurse would teach the client that preexisting gout may get worse and the client should report this as medications for gout may need to be adjusted. The nurse would also inform the client about the multi-drug routine used for TB. Optic neuritis can occur with this drug so the client needs to report visual changes right away. The medication should be taken with a full glass of water. Drinking while taking ethambutol causes severe nausea and vomiting.

Avoiding antacids and food (within 2 hours) is a precaution with isoniazid.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Tuberculosis, Health teaching MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 7. The nurse is learning about endemic pulmonary diseases. Which diseases are matched with

correct information? (Select all that apply.) a. Hanta virus: found in urine, droppings, and saliva of infected rodents. b. Aspergillosis: requires a prolonged course of antibiotics. c. Histoplasmosis: sources include soil containing bird and bat droppings. d. Blastomycosis: requires strict adherence to multi-antibiotic regimen. e. Cryptococcosis: has been eradicated due to strategic deforestation. f. Coccidioidomycosis: found in the southwest and far west of the United States.

ANS: A, C, F

Hanta virus is often seen in the southwest United States and is found in the urine, droppings, and saliva of infected rodents. Histoplasmosis is found in soil containing bird and bat droppings and on surfaces covered with bird droppings. Apergillosis is a common mold found both indoors and outdoors and is treated with a long course of antifungal drugs. Blastomycosis is a fungal disease requiring a prolonged course of antifungal medications. Cryptococcosis is a fungus found on trees and in the soil beneath trees, but has not been eradicated with strategic deforestation. Coccidioidomycosis is found in the southwest and far west of the United States, plus Mexico, and Central and South America.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Respiratory system, Infection, Respiratory assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

Chapter 29: Critical Care of Patients With Respiratory Emergencies Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain,

and has a blood pressure of 88/52 mm Hg. What action by the nurse takes priority? a. Assess the client’s lung sounds. b. Notify the Rapid Response Team. c. Provide reassurance to the client. d. Take a full set of vital signs.

ANS: B

This client has signs and symptoms of a pulmonary embolism, and the most critical action is to notify the Rapid Response Team for speedy diagnosis and treatment. The other actions are appropriate also but are not the priority.

DIF: Remembering TOP: Integrated Process: Communication and Documentation KEY: Pulmonary embolism, Critical rescue MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active

and has no known risk factors for PE. What action by the nurse is most appropriate? a. Encourage the client to walk 5 minutes each hour. b. Refer the client to smoking cessation classes. c. Teach the client about factor V Leiden testing. d. Tell the client that sometimes no cause for disease is found.

ANS: C

Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events, including PE. A client with no known risk factors for this disorder would be asked about family history and referred for testing. Encouraging the client to walk is healthy, but is not related to the development of a PE in this case, nor is smoking. Although there are cases of disease where no cause is ever found, this assumption is premature.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Pulmonary embolism, Genetic testing MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 3. A client has a large pulmonary embolism and is started on oxygen. The nurse asks the charge

nurse why the client’s oxygen saturation has not significantly improved. What response by the nurse is best? a. “Breathing so rapidly interferes with oxygenation.” b. “Maybe the client has respiratory distress syndrome.” c. “The blood clot interferes with perfusion in the lungs.” d. “The client needs immediate intubation and mechanical ventilation.”

ANS: C

A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless the clot is dissolved, this process will continue unabated. Hyperventilation can interfere with oxygenation by shallow breathing, but there is no evidence that the client is hyperventilating, and this is also not the most precise physiologic answer. Acute respiratory distress syndrome can occur, but this is not as likely soon after the client starts on oxygen plus there is no indication of how much oxygen the client is on. The client may need to be mechanically ventilated, but without concrete data on FiO2 and SaO2, the nurse cannot make that judgment.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Pulmonary embolism, Respiratory system MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. A client is on intravenous heparin to treat a pulmonary embolism. The client’s most recent

partial thromboplastin time (PTT) was 25 seconds. What order would the nurse anticipate? a. Decrease the heparin rate. b. Increase the heparin rate. c. No change to the heparin rate. d. Stop heparin; start warfarin.

ANS: B

For clients on heparin, a PTT of 1.5 to 2.5 times the normal value is needed to demonstrate that the heparin is working. A normal PTT is 25 to 35 seconds, so this client’s PTT value is too low. The heparin rate needs to be increased. Warfarin is not indicated in this situation.

DIF: Applying TOP: Integrated Process: Nursing Process: Analysis KEY: Pulmonary embolism, Anticoagulants, Laboratory values MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 5. A client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic

testing reveals that the client has an alteration in the gene CYP2C19. What action by the nurse is best? a. Instruct the client to eliminate all vitamin K from the diet. b. Prepare preoperative teaching for an inferior vena cava (IVC) filter. c. Refer the client to a chronic illness support group. d. Teach the client to use a soft-bristled toothbrush.

ANS: B

Often clients are discharged from the hospital on warfarin after a PE. However, clients with a variation in the CYP2C19 gene do not metabolize warfarin well and have much higher blood levels and more side effects. This client is a poor candidate for warfarin therapy, and the prescriber will most likely order an IVC filter device to be implanted. The other option is to lower the dose of warfarin. The nurse would prepare to do preoperative teaching on this procedure. It would be impossible to eliminate all vitamin K from the diet. A chronic illness support group may be needed, but this is not the best intervention as it is not as specific to the client as the IVC filter. A soft-bristled toothbrush is a safety measure for clients on anticoagulation therapy.

DIF: Applying TOP: Integrated Process: Nursing Process: Analysis KEY: Pulmonary embolism, Genetic alterations MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

6. A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value

possibly indicates that a serious side effect has occurred? a. Hemoglobin: 14.2 g/dL (142 g/L) b. Platelet count: 82,000/L (82  109/L) c. Red blood cell count: 4.8/mm3 (4.8  1012/L) d. White blood cell count: 8700/mm3 (8.7  109/L) ANS: B

This platelet count is low and could indicate heparin-induced thrombocytopenia. The other values are normal for either gender.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Anticoagulants, Laboratory values MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 7. A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best? a. Assess for other signs of hypoxia. b. Change the sensor on the pulse oximeter. c. Obtain a new oximeter from central supply. d. Tell the client to take slow, deep breaths.

ANS: A

Pulse oximetry is not always the most accurate assessment tool for hypoxia as many factors can interfere, producing normal or near-normal readings in the setting of hypoxia. The nurse would conduct a more thorough assessment. The other actions are not appropriate for a hypoxic client.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Respiratory assessment, Hypoxia MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 8. A nurse is assisting the primary health care provider (PHCP) who is intubating a client. The

PHCP has been attempting to intubate for 40 seconds. What action by the nurse is best? a. Ensure that the client has adequate sedation. b. Find another qualified provider to intubate. c. Interrupt the procedure to give oxygen. d. Monitor the client’s oxygen saturation.

ANS: C

Each intubation attempt should not exceed 30 seconds (15 is preferable) as it causes hypoxia.

The nurse would interrupt the intubation attempt and give the client oxygen. The nurse would also have adequate sedation during the procedure and monitor the client’s oxygen saturation, but these do not take priority. Finding another qualified provider to intubate the client is not appropriate at this time.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Respiratory system, Intubation MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 9. An intubated client’s oxygen saturation has dropped to 88%. What action by the nurse takes

priority? a. Determine if the tube is kinked.

b. Ensure that all connections are patent. c. Listen to the client’s lung sounds. d. Suction the endotracheal tube.

ANS: C

When an intubated client shows signs of hypoxia, check for DOPE: displaced tube (most common cause), obstruction (often by secretions), pneumothorax, and equipment problems.

The nurse listens for equal, bilateral breath sounds first to determine if the endotracheal tube is still correctly placed. If this assessment is normal, the nurse would follow the mnemonic and perform suction if needed, assess for pneumothorax, and finally check the equipment.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Mechanical ventilation, Respiratory assessment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 10. A client with acute respiratory failure is on a ventilator and is sedated. What care may the

nurse delegate to the assistive personnel AP)? a. Assess the client for sedation needs. b. Get family permission for restraints. c. Provide frequent oral care per protocol. d. Use nonverbal pain assessment tools.

ANS: C

The client on mechanical ventilation needs frequent oral care, which can be delegated to the AP. The other actions fall within the scope of practice of the nurse.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Mechanical ventilation, Oral care, Delegation MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 11. A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator

settings with the respiratory therapist, what would the nurse ensure? a. The client is able to initiate spontaneous breaths. b. The inspired oxygen has adequate humidification. c. The upper peak airway pressure limit alarm is off. d. The upper peak airway pressure limit alarm is on.

ANS: D

The upper peak airway pressure limit alarm will sound when the airway pressure reaches a preset maximum. This is critical to prevent barotrauma to the lungs. Alarms are never be turned off. Initiating spontaneous breathing is important for some modes of ventilation but not others. Adequate humidification is important but does not take priority over preventing injury.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Mechanical ventilation, Equipment safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 12. A nurse is caring for a client on mechanical ventilation and finds the client agitated and

thrashing about. What action by the nurse is most appropriate? a. Assess the cause of the agitation. b. Reassure the client that he or she is safe. c. Restrain the client’s hands.

d. Sedate the client immediately.

ANS: A

The nurse needs to determine the cause of the agitation. The inability to communicate often makes clients anxious, even to the point of panic. Pain, confusion, and hypoxia can also cause agitation. Once the nurse determines the cause of the agitation, he or she can implement measures to relieve the underlying cause. Reassurance is also important but may not address the etiology of the agitation. Restraints and more sedation may be necessary but not as a first step. Ensuring the client is adequately oxygenated is the priority.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Mechanical ventilation, Anxiety MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 13. A nurse is preparing to admit a client on mechanical ventilation for acute respiratory failure

from the emergency department. What action does the nurse take first? a. Assessing that the ventilator settings are correct b. Ensuring that there is a bag-valve-mask in the room c. Obtaining personal protective equipment d. Planning to suction the client upon arrival to the room ANS: B

Having a bag-valve-mask device is critical in case the client needs manual breathing. The respiratory therapist is usually primarily responsible for setting up the ventilator, although the nurse would know and check the settings. Personal protective equipment is important, but ensuring client safety is the most important action. The client may or may not need suctioning on arrival.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Mechanical ventilation, Client safety MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 14. A client is on mechanical ventilation and the client’s spouse wonders why ranitidine is needed

since the client “only has lung problems.” What response by the nurse is best? a. “It will increase the motility of the gastrointestinal tract.” b. “It will keep the gastrointestinal tract functioning normally.” c. “It will prepare the gastrointestinal tract for enteral feedings.” d. “It will prevent ulcers from the stress of mechanical ventilation.”

ANS: D

Stress ulcers can occur in many clients who are receiving mechanical ventilation, and often prophylactic medications are used to prevent them and possible subsequent aspiration.

Frequently used medications include antacids, histamine blockers, and proton pump inhibitors. Ranitidine is a histamine-blocking agent.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Mechanical ventilation, Histamine blocker MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 15. A client has been brought to the emergency department with a life-threatening chest injury.

What action by the nurse takes priority? a. Apply oxygen at 100%.

b. Assess the respiratory rate. c. Ensure a patent airway. d. Start two large-bore IV lines.

ANS: C

The priority for any chest trauma client is airway, breathing, and circulation. The nurse first ensures that the client has a patent airway. Assessing respiratory rate and applying oxygen are next, followed by inserting IVs. DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Emergency nursing, Primary survey, Trauma MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 16. A client with ARDS is receiving minimal amounts of IV fluids. The new nurse notes the client

is scheduled to receive a diuretic at this time. The nurse consults the Staff Development Nurse to determine the best course of action. What will the new nurse do? a. Contact the primary health care provider. b. Give the ordered diuretic as scheduled. c. Request an increase in the IV rate. d. Calculate the client’s 24-hour fluid balance.

ANS: B

Research has shown that clients with ARDS may benefit from conservative fluid therapy along with diuretics to maintain fluid balance. The nurse will give the ordered diuretic as scheduled. There is no reason to contact the provider or request an increased IV rate. The nurse can calculate the 24-hour fluid balance, but this will not influence the administration of the medication.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: ARDS, Medication MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 17. A nurse is assessing a client who is suspected of having ARDS. The nurse is confused that

although the client appears dyspneic and the oxygen saturation is 88% on 6 L/min of oxygen, the client’s lungs are clear. What explanation does the more senior nurse provide? a. “The client is too dehydrated for moist-sounding lungs.” b. “The client hasn’t started having any bronchospasm yet.” c. “Lung edema is in the interstitial tissues, not the airways.” d. “Clients with ARDS usually have clear lung sounds.”

ANS: C

The clear lung sounds are due to the fact that the edema is found in the lung interstitial tissues, where it can’t be auscultated, instead of in the airways. It is not related to the client being dehydrated or having bronchospasm. The statement about all clients with ARDS having clear lung sounds does not provide any information.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: ARDS, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 18. A client in the emergency department has several broken ribs and reports severe pain. What

care measure will best promote comfort?

a. b. c. d.

Prepare to assist with intercostal nerve block.

Humidify the supplemental oxygen.

Splint the chest with a large ACE wrap.

Provide warmed blankets and warmed IV fluids.

ANS: A

Uncomplicated rib fractures generally are simple to manage; however, opioids may be needed for pain. For severe pain, an intercostal nerve block is beneficial. The client needs to be able to breathe deeply and cough so as not to get atelectasis and/or pneumonia. Humidifying the oxygen will not help with the pain. Rib fractures are not wrapped or splinted in any way because this inhibits chest movement. Warmed blankets and warm IV fluids are nice comfort measures, but do not help with severe pain.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Respiratory system, Pharmacological pain management MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 19. A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping

blood pressure. What medication would the nurse being most beneficial? a. Alteplase b. Enoxaparin c. Unfractionated heparin d. Warfarin sodium ANS: A

Alteplase is a “clot-busting” agent indicated in large PEs in the setting of hemodynamic instability. The nurse knows that this drug is the priority, although heparin may be started initially. Enoxaparin and warfarin are not indicated in this setting.

DIF: Remembering TOP: Integrated Process: Nursing Process: Analysis KEY: Pulmonary embolism, Anticoagulants MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 20. A client is brought to the emergency department after sustaining injuries in a severe car crash.

The client’s chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic. What action does the nurse take first? a. Administer oxygen and reassess. b. Auscultate the client’s lung sounds. c. Facilitate a portable chest x-ray. d. Prepare to assist with intubation.

ANS: D

This client has signs and symptoms of flail chest and, with the other signs, needs to be intubated and mechanically ventilated immediately. The nurse does not have time to administer oxygen and wait to reassess, or to listen to lung sounds. A chest x-ray will be taken after the client is intubated.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Trauma, Respiratory system MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

21. A new nurse asks for an explanation of “refractory hypoxemia.” What answer by the staff

development nurse is best? a. “It is chronic hypoxemia that accompanies restrictive airway disease.” b. “It is hypoxemia from lung damage due to mechanical ventilation.” c. “It is hypoxemia that continues even after the client is weaned from oxygen.” d. “It is hypoxemia that persists even with 100% oxygen administration.”

ANS: D

Refractory hypoxemia is hypoxemia that persists even with the administration of 100% oxygen. It is a cardinal sign of acute respiratory distress syndrome. It does not accompany restrictive airway disease and is not caused by the use of mechanical ventilation or by being weaned from oxygen.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Respiratory disorders, Pathophysiology MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 22. A nurse is caring for a client on the medical stepdown unit. The following data are related to

this client: Subjective Information Shortness of breath for 20 minutes Reports feeling frightened “Can’t catch my breath”

Laboratory Analysis pH: 7.32 PaCO2: 28 mm Hg PaO2: 78 mm Hg SaO2: 88%

Physical Assessment Pulse: 120 beats/min Respiratory rate: 34 breaths/min Blood pressure 158/92 mm Hg Lungs have crackles

What action by the nurse is most appropriate? a. Call respiratory therapy for a breathing treatment. b. Facilitate a STAT pulmonary angiography. c. Prepare for immediate endotracheal intubation. d. Prepare to administer intravenous anticoagulants.

ANS: B

This client has signs and symptoms of pulmonary embolism (PE); however, many conditions can cause the client’s presentation. The gold standard for diagnosing a PE is pulmonary angiography. The nurse would facilitate this test as soon as possible. The client does not have wheezing, so a respiratory treatment is not needed. The client is not unstable enough to need intubation and mechanical ventilation. IV anticoagulants are not given without a diagnosis of PE. DIF: Analyzing TOP: Integrated Process: Nursing Process: Implementation KEY: Pulmonary embolism MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential MULTIPLE RESPONSE 1. A nurse is caring for five clients. For which clients would the nurse assess a high risk for

developing a pulmonary embolism (PE)? (Select all that apply.) a. Client who had a reaction to contrast dye yesterday b. Client with a new spinal cord injury on a rotating bed

c. d. e. f.

Middle-age client with an exacerbation of asthma Older client who is 1 day post-hip replacement surgery Young obese client with a fractured femur Middle-age adult with a history of deep vein thrombosis

ANS: B, D, E

Conditions that place clients at higher risk of developing PE include prolonged immobility, central venous catheters, surgery, obesity, advancing age, conditions that increase blood clotting, history of thromboembolism, smoking, pregnancy, estrogen therapy, heart failure, stroke, cancer (particularly lung or prostate), and trauma. A contrast dye reaction and asthma pose no risk for PE. DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Pulmonary embolism, Risk factors MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. When working with women who are taking hormonal birth control, what health promotion

measures does the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.) a. Avoid drinking alcohol. b. Eat more omega-3 fatty acids. c. Exercise on a regular basis. d. Maintain a healthy weight. e. Stop smoking cigarettes.

ANS: C, D, E

Health promotion measures for clients to prevent thromboembolic events such as PE include maintaining a healthy weight, exercising on a regular basis, and not smoking. Avoiding alcohol and eating more foods containing omega-3 fatty acids are heart-healthy actions but do not relate to the prevention of PE. DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Pulmonary embolism, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 3. A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most

appropriate? (Select all that apply.) a. Acknowledge the frightening nature of the illness. b. Delegate a back rub to the assistive personnel (AP). c. Give simple explanations of what is happening. d. Request a prescription for antianxiety medication. e. Stay with the client and speak in a quiet, calm voice.

ANS: A, B, C, E

Clients with PEs are often anxious. The nurse can acknowledge the client’s fears, delegate comfort measures, give simple explanations the client will understand, and stay with the client. Using a calm, quiet voice is also reassuring. Sedatives and antianxiety medications are not used routinely because they can contribute to hypoxia. If the client’s anxiety is interfering with diagnostic testing or treatment, they can be used, but there is no evidence that this is the case.

DIF: Applying

TOP: Integrated Process: Nursing Process: Implementation

KEY: Pulmonary embolism, Psychosocial response MSC: Client Needs Category: Psychosocial Integrity 4. The nurse caring for mechanically ventilated clients uses best practices to prevent

ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.) a. Adherence to proper hand hygiene b. Administering antiulcer medication c. Elevating the head of the bed d. Providing oral care per protocol e. Suctioning the client on a regular schedule f. Turning and positioning the client at least every 2 hours ANS: A, B, C, D, F

The “ventilator bundle” is a group of care measures to prevent ventilator-associated pneumonia. Actions in the bundle include using proper hand hygiene, giving antiulcer medications, elevating the head of the bed, providing frequent oral care per policy, preventing aspiration, turning and positioning, and providing pulmonary hygiene measures. Suctioning is done as needed.

DIF: Remembering TOP: Integrated Process: Nursing Process: Implementation KEY: Mechanical ventilation, Infection control MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 5. A nurse is caring for a client in acute respiratory failure who is on mechanical ventilation.

What actions will promote comfort in this client? (Select all that apply.) a. Allow visitors at the client’s bedside. b. Ensure that the client can communicate if awake. c. Keep the television tuned to a favorite channel. d. Provide back and hand massages when turning. e. Turn the client every 2 hours or more.

ANS: A, B, D, E

There are many basic care measures that can be employed for the client who is on a ventilator.

Allowing visitation, providing a means of communication, massaging the client’s skin, and routinely turning and repositioning the client are some of them. Keeping the TV on will interfere with sleep and rest.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Mechanical ventilation, Comfort measures MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 6. The nurse caring for mechanically ventilated clients knows that older adults are at higher risk

for weaning failure. What age-related changes contribute to this? (Select all that apply.) a. Chest wall stiffness b. Decreased muscle strength c. Inability to cooperate d. Less lung elasticity e. Poor vision and hearing f. Chronic anemia

ANS: A, B, D

Age-related changes that increase the difficulty of weaning older adults from mechanical ventilation include increased stiffness of the chest wall, decreased muscle strength, and less elasticity of lung tissue. Not all older adults have an inability to cooperate or poor sensory acuity. Anemia can make it difficult to wean a client, but this is not a normal age-related change.

DIF: Remembering TOP: Integrated Process: Nursing Process: Analysis KEY: Mechanical ventilation, Older adult MSC: Client Needs Category: Health Promotion and Maintenance 7. A 100-kg client has developed ARDS and needs mechanical ventilation. Which of the

following are potentially correct ventilator management choices? (Select all that apply.) a. Tidal volume: 600 mL b. Volume-controlled ventilation c. PEEP based on oxygen saturation d. Suctioning every hour e. High-frequency oscillatory ventilation f. Limited turning for ventilator pressures ANS: A, C, E

The client with ARDS who needs mechanical ventilation benefits from “open lung” and lung protective strategies, such as using low tidal volumes (6 mL/kg body weight).

Pressure-controlled ventilation is preferred due to the high pressures often required in these clients. PEEP usually starts at 5 cm H2O and adjusted to keep oxygen saturations in an acceptable range. Suctioning may need to be frequent due to secretions, but is not scheduled hourly. High-frequency oscillatory ventilation is an alternative to traditional modes of ventilation. Early mobility is encouraged as is turning and positioning the client.

DIF: Understanding TOP: Integrated Process: Nursing Process: Implementation KEY: Mechanical ventilation, ARDS MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

Chapter 30: Assessment of the Cardiovascular System Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse assesses a client who had a myocardial infarction and has a blood pressure of 88/58

mm Hg. Which additional assessment finding would the nurse expect? a. Heart rate of 120 beats/min b. Cool, clammy skin c. Oxygen saturation of 90% d. Respiratory rate of 8 breaths/min ANS: A

When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the sinoatrial node. This results in an increase in heart rate and respiratory rate. This tachycardia is an early response and is seen even when blood pressure is not critically low. An increased heart rate and respiratory rate will compensate for the low blood pressure and maintain oxygen saturation and perfusion. The client may not be able to compensate for long and decreased oxygenation and cool, clammy skin will occur later.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Coronary perfusion, Hemodynamics MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A nurse assesses a client after administering a prescribed beta blocker. Which assessment

would the nurse expect to find? a. Blood pressure increased from 98/42 to 132/60 mm Hg. b. Respiratory rate decreased from 25 to 14 breaths/min. c. Oxygen saturation increased from 88% to 96%. d. Pulse decreased from 100 to 80 beats/min.

ANS: D

Beta blockers block the stimulation of beta1-adrenergic receptors. They block the sympathetic (fight-or-flight) response and decrease the heart rate (HR). The beta blocker will decrease HR and blood pressure, increasing ventricular filling time. It usually does not have effects on beta2-adrenergic receptor sites. Cardiac output may drop because of decreased HR, but slowing the rate may allow for better filling and better cardiac output.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Beta blocker, Medication MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 3. A nurse assesses clients on a medical-surgical unit. Which client would the nurse identify as

having the greatest risk for cardiovascular disease? a. An 86-year-old man with a history of asthma. b. A 32-year-old man with colorectal cancer. c. A 65-year-old woman with diabetes mellitus. d. A 53-year-old postmenopausal woman who takes bisphosphonates.

ANS: C

Of the options, the client with diabetes has a two- to four-fold increase in risk for death due to cardiovascular disease. Advancing age also increases risk, but not as much. Asthma, colorectal cancer, and bisphosphonate therapy do not increase the risk for cardiovascular disease.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Health screening MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 4. A nurse assesses an older adult client who has multiple chronic diseases. The client’s heart

rate is 48 beats/min. What action would the nurse take first? a. Document the finding in the chart. b. Initiate external pacing. c. Assess the client’s medications. d. Administer 1 mg of atropine.

ANS: C

Pacemaker cells in the conduction system decrease in number as a person ages, potentially resulting in bradycardia. However, the nurse would first check the medication reconciliation for medications that might cause such a drop in heart rate, and then would inform the primary health care provider. Documentation is important, but it is not the first action. The heart rate is not low enough for atropine or an external pacemaker to be needed unless the client is symptomatic, which is not apparent.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Medication, Assessment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 5. An emergency department nurse obtains the health history of a client. Which statement by the

client would alert the nurse to the occurrence of heart failure? a. “I get short of breath when I climb stairs.” b. “I see halos floating around my head.” c. “I have trouble remembering things.” d. “I have lost weight over the past month.”

ANS: A

Dyspnea on exertion is an early manifestation of heart failure and is associated with an activity such as stair climbing. The other findings are not specific to early occurrence of heart failure.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Cardiovascular assessment, Heart failure MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. A nurse obtains the health history of a client who is newly admitted to the medical unit.

Which statement by the client would alert the nurse to the presence of edema? a. “I wake up to go to the bathroom at night.” b. “My shoes fit tighter by the end of the day.” c. “I seem to be feeling more anxious lately.” d. “I drink at least eight glasses of water a day.”

ANS: B

Weight gain can result from fluid accumulation in the interstitial spaces. This is known as edema. The nurse would note whether the client feels that his or her shoes or rings are tight, and would observe, when present, an indentation around the leg where the socks end. The other answers do not describe edema.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Heart failure, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 7. A nurse assesses female client who is experiencing a myocardial infarction. Which clinical

manifestation would the nurse expect? a. Excruciating pain on inspiration b. Left lateral chest wall pain c. Fatigue and shortness of breath d. Numbness and tingling of the arm ANS: C

In women, fatigue, shortness of breath, and indigestion may be the major symptoms of myocardial infarction caused by poor cardiac output. Chest pain is the classic symptom of myocardial infarction and can be present in women. Pain on inspiration may be related to a pleuropulmonary cause. Numbness and tingling of the arm could also be related to the myocardial infarction, but are not known to be specific symptoms for women having and MI. DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Coronary perfusion, Gender differences MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 8. A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The

nurse notes that the left pedal pulse is weak. What action would the nurse take next? a. Elevate the leg and apply a sandbag to the entrance site. b. Increase the flow rate of intravenous fluids. c. Assess the color and temperature of the left leg. d. Document the finding as “left pedal pulse of +1/4.”

ANS: C

Loss of a pulse distal to an angiography entry site is serious, indicating a possible arterial obstruction. The left pulse would be compared with the right, and pulses would be compared with previous assessments, especially before the procedure. Assessing color (pale, cyanosis) and temperature (cool, cold) will identify a decrease in circulation. Once all peripheral and vascular assessment data are acquired, the primary health care provider would be notified.

Simply documenting the findings is inappropriate. The leg would be positioned below the level of the heart to increase blood flow to the distal portion of the leg. Increasing intravenous fluids will not address the client’s problem.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Cardiovascular assessment, Complications MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 9. A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which

assessment finding requires immediate intervention?

a. b. c. d.

Urinary output less than intake Bruising at the insertion site Slurred speech and confusion Discomfort in the left leg

ANS: C

A left-sided cardiac catheterization specifically increases the risk for a cerebral vascular accident. A change in neurologic status needs to be acted on immediately. Discomfort and bruising are not unexpected at the site. Urinary output less than intake may or may not be significant.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Cardiovascular assessment, Diagnostic examination, Critical rescue MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 10. A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment

would the nurse complete as the priority prior to this procedure? a. Client’s level of anxiety b. Ability to turn self in bed c. Cardiac rhythm and heart rate d. Allergies to iodine-based agents ANS: D

Before the procedure, the nurse would ascertain whether the client has an allergy to iodine-containing preparations, such as seafood or local anesthetics. The contrast medium used during the procedure is iodine based. This allergy can cause a life-threatening reaction, so it is a high priority. It is important for the nurse to assess anxiety, mobility, and baseline cardiac status, but allergies take priority for client safety.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Diagnostic examination, Client safety MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 11. A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart.

The client’s health history includes a previous myocardial infarction and pacemaker implantation. What action would the nurse take? a. Schedule an electrocardiogram just before the MRI. b. Notify the primary health care provider before scheduling the MRI. c. Request lab for cardiac enzymes from the primary health care provider. d. Instruct the client to increase fluid intake the day before the MRI. ANS: B

The magnetic fields of the MRI can deactivate the pacemaker. The nurse would call the primary health care provider and report that the client has a pacemaker so that he or she can order other diagnostic tests. The client does not need an electrocardiogram, cardiac enzymes, or increased fluids. Some newer MRI scanners have eliminated the possibility of complications due to implants, but the nurse needs to notify the primary health care provider.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning KEY: Diagnostic examination, Client safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

12. A nurse assesses a client who is recovering from a myocardial infarction. The client’s blood

pressure is 140/88 mm Hg. What action would the nurse take first? a. Compare the results with previous blood pressure readings. b. Increase the intravenous fluid rate because these readings are low. c. Immediately notify the primary health care provider of the elevated blood pressure. d. Document the finding in the client’s chart as the only action.

ANS: A

The most recent range for normal blood pressure is less than 140 mm Hg systolic and less than 90mm Hg diastolic. This client’s blood pressure is at the upper range of acceptable, so the nurse would compare the client’s current reading with those previously recorded before doing anything else. The reading is not low, so the nurse would not increase IV fluids, nor would the nurse necessarily notify the primary health care provider. Documentation is important, but the nurse first checks previous readings.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Blood pressure, Assessment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 13. A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is

scheduled for bypass surgery. Which intervention would the nurse be prepared to implement while this client waits for surgery? a. Administration of IV furosemide b. Initiation of an external pacemaker c. Assistance with endotracheal intubation d. Placement of central venous access ANS: B

The RCA supplies the right atrium, right ventricle, inferior portion of the left ventricle, and atrioventricular (AV) node. It also supplies the sinoatrial node in 50% of people. If the client totally occludes the RCA, the AV node would not function and the client would go into heart block, so emergency pacing would be available for the client. Furosemide, intubation, and central venous access will not address the primary complication of RCA occlusion, which is AV node (and possibly SA node) malfunction.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Planning KEY: Coronary perfusion MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 14. A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk

for coronary artery disease. Which statement related to nutrition would the nurse include in this client’s teaching? a. “The best way to lose weight is a high-protein, low-carbohydrate diet.” b. “You should balance weight loss with consuming necessary nutrients.” c. “A nutritionist will provide you with information about your new diet.” d. “If you exercise more frequently, you won’t need to change your diet.”

ANS: B

Clients at risk for cardiovascular diseases should follow the American Heart Association guidelines to combat obesity and improve cardiac health. The nurse would encourage the client to eat vegetables, fruits, unrefined whole-grain products, and fat-free dairy products while losing weight. High-protein food items are often high in fat and calories. Although the nutritionist can assist with client education, the nurse would include nutrition education and assist the client to make healthy decisions. Exercising and eating nutrient-rich foods are both important components in reducing cardiovascular risk.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Nutrition, Health teaching MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 15. A nurse cares for a client who has advanced cardiac disease and states, “I am having trouble

breathing while I’m sleeping at night.” What is the nurse’s best response? a. “I will consult your primary health care provider to prescribe a sleep study.” b. “You become hypoxic while sleeping; oxygen therapy via nasal cannula will help.” c. “A continuous positive airway pressure, or CPAP, breathing mask will help you breathe at night.” d. “Use pillows to elevate your head and chest while you are sleeping.”

ANS: D

The client is experiencing orthopnea (shortness of breath while lying flat). The nurse would teach the client to elevate the head and chest with pillows or sleep in a recliner. A sleep study is not necessary to diagnose this client. Oxygen and CPAP will not help a client with orthopnea.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Heart failure, Orthopnea, Health teaching MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 16. A nurse cares for a client who is recovering from a myocardial infarction. The client states, “I

will need to stop eating so much chili to keep that indigestion pain from returning.” What is the nurse’s best response? a. “Chili is high in fat and calories; it would be a good idea to stop eating it.” b. “The primary health care provider has prescribed an antacid every morning.” c. “What do you understand about what happened to you?” d. “When did you start experiencing this indigestion?”

ANS: C

Clients who experience myocardial infarction often respond with denial, which is a defense mechanism. The nurse would ask the client what he or she thinks happened, or what the illness means to him or her. The other responses do not address the client’s misconception about recent pain and the cause of that pain.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Coronary perfusion, Coping MSC: Client Needs Category: Psychosocial Integrity 17. A nurse prepares a client for cardiac catheterization. The client states, “I am afraid I might

die.” What is the nurse’s best response? a. “This is a routine test and the risk of death is very low.”

b. “Would you like to speak with a chaplain prior to test?” c. “Tell me more about your concerns about the test.” d. “What support systems do you have to assist you?”

ANS: C

The nurse would discuss the client’s feelings and concerns related to the cardiac catheterization. The nurse would not provide false hope or push the client’s concerns off on the chaplain. The nurse would address support systems after addressing the client’s current issue.

DIF: Applying TOP: Integrated Process: Caring KEY: Diagnostic examination, Anxiety MSC: Client Needs Category: Psychosocial Integrity 18. An emergency department nurse triages clients who present with chest discomfort. Which

client would the nurse plan to assess first? a. Client who describes pain as a dull ache. b. Client who reports moderate pain that is worse on inspiration. c. Client who reports cramping substernal pain. d. Client who describes intense squeezing pressure across the chest.

ANS: D

All clients who have chest pain would be assessed more thoroughly. To determine which client would be seen first, the nurse must understand common differences in pain descriptions.

Intense stabbing and viselike (squeezing) substernal pain or pressure that spreads through the client ’s chest, arms, jaw, back, or neck are indicatives of a myocardial infarction. The nurse would plan to see this client first to prevent cardiac cell death. A dull ache, pain that gets worse with inspiration, and cramping pain are not usually associated with myocardial infarction.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning KEY: Cardiovascular disease, Assessment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 19. A nurse assesses a client who has aortic regurgitation. In which location in the illustration

shown below would the nurse auscultate to best hear a cardiac murmur related to aortic regurgitation?

a. b. c. d.

Location A Location B Location C Location D

ANS: A

The aortic valve is auscultated in the second intercostal space just to the right of the sternum.

The pulmonic valve would be heard in location B located in the second intercostal space just left of the sternum. The mitral valve would be heard in location D located in the fifth intercostal space at the apex of the heart. The tricuspid valve would be heard in location C located in the fifth intercostal space at the lower left of the sternal border.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Cardiovascular assessment, Physical assessment MSC: Client Needs Category: Health Promotion and Maintenance MULTIPLE RESPONSE 1. A nurse is caring for a client with a history of renal insufficiency who is scheduled for a

cardiac catheterization. What actions would the nurse take prior to the catheterization? (Select all that apply.) a. Assess for allergies to iodine. b. Administer intravenous fluids. c. Assess blood urea nitrogen (BUN) and creatinine results. d. Insert a Foley catheter. e. Administer a prophylactic antibiotic. f. Insert a central venous catheter.

ANS: A, B, C

If the client has kidney disease, fluids may be given 12 to 24 hours before the procedure for renal protection. Hydration would continue after the procedure. The client would be assessed for allergies to iodine, including shellfish; the contrast medium used during the catheterization contains iodine. Baseline renal labs would be assessed. A Foley catheter and central venous catheter are not required for the procedure and would only increase the client’s risk for infection. Prophylactic antibiotics are not administered prior to a cardiac catheterization.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Cardiovascular assessment, Diagnostic testing MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 2. An emergency department nurse assesses a female client. Which assessment findings would

alert the nurse to request a prescription for an electrocardiogram? (Select all that apply.) a. Hypertension b. Fatigue despite adequate rest c. Indigestion d. Abdominal pain e. Shortness of breath ANS: B, C, E

Women may not have chest pain with myocardial infarction, but may feel discomfort or indigestion. They often present with a triad of symptoms—indigestion or feeling of abdominal fullness, feeling of chronic fatigue despite adequate rest, and feeling unable to catch their breath. Frequently, women are not diagnosed and therefore are not treated adequately.

Hypertension and abdominal pain are not associated with acute coronary syndrome.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Cardiac electrical conduction, Diagnostic testing MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. A nurse assesses a client who is recovering after a coronary catheterization. Which assessment

findings in the first few hours after the procedure require immediate action by the nurse?

(Select all that apply.) a. Blood pressure of 140/88 mm Hg b. Serum potassium of 2.9 mEq/L (2.9 mmol/L) c. Warmth and redness at the site d. Expanding groin hematoma e. Rhythm changes on the cardiac monitor f. Oxygen saturation 93% on room air ANS: B, D, E

After a cardiac catheterization, the nurse monitors vital signs, entry site, cardiac function, and distal circulation. The potassium is very low which can lead to dysrhythmias. An expanding hematoma signifies bleeding. Rhythm changes on the monitor are a known complication.

These findings would require prompt action. The client’s blood pressure is slightly elevated but does not need immediate action. Warmth and redness at the site would indicate an infection, but this would not be present in the first few hours. The oxygen saturation is slightly low but not critical and there is no baseline to compare it to.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Cardiovascular assessment, Diagnostic testing MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 4. A nurse reviews a client’s laboratory results. Which findings would alert the nurse to the

possibility of atherosclerosis? (Select all that apply.) a. Total cholesterol: 280 mg/dL (7.3 mmol/L) b. High-density lipoprotein cholesterol: 50 mg/dL (1.3 mmol/L) c. Triglycerides: 200 mg/dL (2.3 mmol/L) d. Serum albumin: 4 g/dL (5.8 mcmol/L) e. Low-density lipoprotein cholesterol: 160 mg/dL (4.1 mmol/L) ANS: A, C, E

A lipid panel is often used to screen for cardiovascular risk. Total cholesterol, triglycerides, and low-density lipoprotein cholesterol levels are all high, indicating higher risk for cardiovascular disease. High-density lipoprotein cholesterol is within the normal range for both males and females. Serum albumin is not assessed for atherosclerosis.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Cardiovascular assessment, Laboratory values MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

5. A nurse prepares a client for a pharmacologic stress echocardiogram. What actions would the

nurse take when preparing this client for the procedure? (Select all that apply.) a. Assist the primary health care provider to place a central venous access device. b. Prepare for continuous blood pressure and pulse monitoring. c. Administer the client’s prescribed beta blocker. d. Give the client nothing by mouth 3 to 6 hours before the procedure. e. Explain to the client that dobutamine will simulate exercise for this examination.

ANS: B, D, E

Clients receiving a pharmacologic stress echocardiogram will need peripheral venous access and continuous blood pressure and pulse monitoring. The client must be NPO 3 to 6 hours prior to the procedure. Education about dobutamine, which will be administered during the procedure, would be performed. Beta blockers are often held prior to the procedure as they lower the heart rate and may result in inaccurate results.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning KEY: Cardiovascular assessment, Diagnostic testing MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 6. A nurse cares for a client who is recovering from a right-sided heart catheterization. For which

complications of this procedure would the nurse assess? (Select all that apply.) a. Thrombophlebitis b. Stroke c. Pulmonary embolism d. Myocardial infarction e. Cardiac tamponade f. Dysrhythmias ANS: A, C, E

Complications from a right-sided heart catheterization include thrombophlebitis, pulmonary embolism, and vagal response. Cardiac tamponade is a risk of both right- and left-sided heart catheterizations. Stroke, myocardial infarction, and dysrhythmias are complications of left-sided heart catheterizations.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Assessment, Diagnostic examination MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

Chapter 31: Concepts of Care for Patients With Dysrhythmias Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse assesses a client’s electrocardiograph tracing and observes that not all QRS

complexes are preceded by a P wave. How would the nurse interpret this observation? a. The client has hyperkalemia causing irregular QRS complexes. b. Ventricular tachycardia is overriding the normal atrial rhythm. c. The client’s chest leads are not making sufficient contact with the skin. d. Ventricular and atrial depolarizations are initiated from different sites.

ANS: D

Normal rhythm shows one P wave preceding each QRS complex, indicating that all depolarization is initiated at the sinoatrial node. QRS complexes without a P wave indicate a different source of initiation of depolarization. This finding on an electrocardiograph tracing is not an indication of hyperkalemia, ventricular tachycardia, or disconnection of leads.

DIF: Understanding TOP: Integrated Process: Nursing Process: Analysis KEY: Cardiac electrical conduction MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse

symptoms. Which activity modification would the nurse suggest to avoid further slowing of the heart rate? a. “Make certain that your bath water is warm.” b. “Avoid straining while having a bowel movement.” c. “Limit your intake of caffeinated drinks to one a day.” d. “Avoid strenuous exercise such as running.”

ANS: B

Bearing down strenuously during a bowel movement is one type of Valsalva maneuver, which stimulates the vagus nerve and results in slowing of the heart rate. Such a response is not desirable in a person who has bradycardia. The other instructions are not appropriate for this condition.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Cardiac electrical conduction, Health education MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 3. A nurse is assessing clients on a medical-surgical unit. Which client would the nurse identify

as being at greatest risk for atrial fibrillation? a. A 45-year-old who takes an aspirin daily. b. A 50-year-old who is post coronary artery bypass graft surgery. c. A 78-year-old who had a carotid endarterectomy. d. An 80-year-old with chronic obstructive pulmonary disease.

ANS: B

Atrial fibrillation occurs commonly in clients with cardiac disease. Other risk factors include hypertension (HTN), previous ischemic stroke, transient ischemic attack (TIA) or other thromboembolic event, diabetes mellitus, heart failure, obesity, hyperthyroidism, chronic kidney disease, excessive alcohol use, and mitral valve disease. The other conditions do not place these clients at higher risk for atrial fibrillation.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Cardiac electrical conduction, Risk factors MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 4. A nurse assesses a client with atrial fibrillation. Which manifestation would alert the nurse to

the possibility of a serious complication from this condition? a. Sinus tachycardia b. Speech alterations c. Fatigue d. Dyspnea with activity ANS: B

Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events includes changes in mentation, speech, sensory function, and motor function. Clients with atrial fibrillation often have a rapid ventricular response as a result. Fatigue is a nonspecific complaint. Clients with atrial fibrillation often have dyspnea as a result of the decreased cardiac output caused by the rhythm disturbance.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Cardiac electrical conduction, Vascular perfusion MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 5. A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication

would the nurse expect to find on this client’s medication administration record to prevent a common complication of this condition? a. Sotalol b. Warfarin c. Atropine d. Lidocaine ANS: B

Atrial fibrillation puts clients at risk for developing emboli. Clients at risk for emboli are treated with anticoagulants, such as heparin, enoxaparin, or warfarin. Sotalol, atropine, and lidocaine are not appropriate for preventing this complication.

DIF: Remembering TOP: Integrated Process: Nursing Process: Analysis KEY: Cardiac electrical conduction, Medication MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 6. A nurse administers prescribed adenosine to a client. Which response would the nurse assess

for as the expected therapeutic response? a. Decreased intraocular pressure b. Increased heart rate c. Short period of asystole d. Hypertensive crisis

ANS: C

Clients usually respond to adenosine with a short period of asystole, bradycardia with long pauses, nausea, or vomiting. Adenosine has no impact on intraocular pressure nor does it cause increased heart rate or hypertensive crisis.

DIF: Remembering TOP: Integrated Process: Nursing Process: Analysis KEY: Cardiac electrical conduction, Medication MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 7. A telemetry nurse assesses a client who has a heart rate of 35 beats/min on the cardiac

monitor. Which assessment would the nurse complete next? a. Pulmonary auscultation b. Pulse strength and amplitude c. Level of consciousness d. Mobility and gait stability ANS: C

A heart rate of 40 beats/min or less could have hemodynamic consequences. The client is at risk for inadequate cerebral perfusion. The nurse would assess for level of consciousness, dizziness, confusion, syncope, chest pain, shortness of breath. Although the other assessments would be completed, the nurse would assess the client’s neurologic status next.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Cardiac electrical conduction, Vascular perfusion MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 8. A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The

nurse observes the presence of a pacing spike but no QRS complex on the client’s electrocardiogram. What action would the nurse take next? a. Administer intravenous diltiazem. b. Assess vital signs and level of consciousness. c. Administer sublingual nitroglycerin. d. Assess capillary refill and temperature.

ANS: B

In temporary pacing, the wires are threaded onto the epicardial surface of the heart and exit through the chest wall. The pacemaker spike would be followed immediately by a QRS complex. Pacing spikes seen without subsequent QRS complexes imply loss of capture. If there is no capture, then there is no ventricular depolarization and contraction. The nurse would assess for cardiac output via vital signs and level of consciousness. The other interventions would not determine if the client is tolerating the loss of capture.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Cardiac electrical conduction MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 9. A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which intervention is

appropriate for the nurse to perform prior to defibrillating this client? a. Make sure that the defibrillator is set to the synchronous mode. b. Administer 1 mg of intravenous epinephrine. c. Test the equipment by delivering a smaller shock at 100 J.

d. Ensure that everyone is clear of contact with the client and the bed.

ANS: D

To avoid injury, the rescuer commands that all personnel clear contact with the client or the bed and ensures their compliance before delivery of the shock. Defibrillation is done in asynchronous mode. Equipment would not be tested before a client is defibrillated because this is an emergency procedure; equipment would be checked on a routine basis.

Defibrillation takes priority over any medications.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Cardiac electrical conduction, Safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 10. After teaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse

assesses the client’s understanding. Which statement by the client indicates correct understanding of the teaching? a. “I would wear a snug-fitting shirt over the ICD.” b. “I will avoid sources of strong electromagnetic fields.” c. “I would participate in a strenuous exercise program.” d. “Now I can discontinue my antidysrhythmic medication.”

ANS: B

The client being discharged with an ICD is instructed to avoid strong sources of electromagnetic fields, such as devices emitting microwaves (not microwave ovens); transformers; radio, television, and radar transmitters; large electrical generators; metal detectors, including handheld security devices at airports; antitheft devices; arc welding equipment; and sources of 60-cycle (Hz) interference. Also avoid leaning directly over the alternator of a running motor of a car or boat. Clients would avoid tight clothing, which could cause irritation over the ICD generator. The client would be encouraged to exercise but would not engage in strenuous activities that cause the heart rate to meet or exceed the ICD cutoff point because the ICD can discharge inappropriately. The client would continue all prescribed medications.

DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Cardiac electrical conduction, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 11. A nurse cares for a client with atrial fibrillation who reports fatigue when completing

activities of daily living. What intervention would the nurse implement to address this client’s concerns? a. Administer oxygen therapy at 2 L per nasal cannula. b. Provide the client with a sleeping pill to stimulate rest. c. Schedule periods of exercise and rest during the day. d. Ask assistive personnel (AP) to help bathe the client.

ANS: C

Clients who have atrial fibrillation are at risk for decreased cardiac output and fatigue when completing activities of daily living. The nurse would schedule periods of exercise and rest during the day to decrease fatigue. The other interventions will not assist the client with performing self-care activities and there is no indication for oxygen.

DIF: Applying

TOP: Integrated Process: Teaching/Learning

KEY: Cardiac electrical conduction MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 12. A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. What

action would the nurse take prior to the cardioversion? a. Administer intravenous adenosine. b. Turn off oxygen therapy. c. Ensure that a tongue blade is available. d. Position the client on the left side.

ANS: B

For safety during cardioversion, the nurse would turn off any oxygen therapy to prevent fire.

The other interventions are not appropriate for a cardioversion. The client would be placed in a supine position.

DIF: Remembering TOP: Integrated Process: Nursing Process: Implementation KEY: Cardiac electrical conduction, Safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 13. A nurse prepares to discharge a client with a cardiac dysrhythmia who is prescribed home

health care services. Which priority information would be communicated to the home health nurse upon discharge? a. Medication orders for home b. Immunization history c. Religious beliefs d. Nutrition preferences ANS: A

The home health nurse needs to know current medications the client is taking to ensure assessment, evaluation, and further education related to these medications. The other information might be used to plan care, but not as the priority.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Hand-off communication, Safety MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 14. A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate

intervention by the nurse? a. Midsternal chest pain b. Increased urine output c. Mild orthostatic hypotension d. P wave touching the T wave ANS: A

Chest pain, possibly angina, indicates that tachycardia may be increasing the client’s myocardial workload and oxygen demand to such an extent that normal oxygen delivery cannot keep pace. This results in myocardial hypoxia and pain. Increased urinary output and mild orthostatic hypotension are not life-threatening conditions and therefore do not require immediate intervention. The P wave touching the T wave indicates significant tachycardia and would be assessed to determine the underlying rhythm and cause; this is an important assessment but is not as critical as chest pain, which indicates cardiac cell death.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Cardiac electrical conduction MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 15. A nurse teaches a client who experiences occasional premature atrial contractions (PACs)

accompanied by palpitations that resolve spontaneously without treatment. Which statement would the nurse include in this client’s teaching? a. “Minimize or abstain from caffeine.” b. “Lie on your side until the attack subsides.” c. “Use your oxygen when you experience PACs.” d. “Take amiodarone daily to prevent PACs.” ANS: A

PACs usually have no hemodynamic consequences. For a client experiencing infrequent PACs, the nurse would explore possible lifestyle causes, such as excessive caffeine intake and stress. Lying on the side will not prevent or resolve PACs. Oxygen is not necessary. Although medications may be needed to control symptomatic dysrhythmias, for infrequent PACs, the client first would try lifestyle changes to control them.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Cardiac electrical conduction, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 16. The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse.

The client asks, “Why do you want to know if I use cocaine?” What is the nurse’s best response? a. “Substance abuse puts clients at risk for many health issues.” b. “The hospital requires that I ask you about cocaine use.” c. “Clients who use cocaine are at risk for fatal dysrhythmias.” d. “We can provide services for cessation of substance abuse.”

ANS: C

Clients who use cocaine or illicit inhalants are particularly at risk for potentially fatal dysrhythmias. The other responses do not adequately address the client’s question.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Cardiac electrical conduction, Substance abuse MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 17. A nurse supervises an assistive personnel (AP) applying electrocardiographic monitoring.

Which statement would the nurse provide to the AP related to this procedure? a. “Clean the skin and clip hairs if needed.” b. “Add gel to the electrodes prior to applying them.” c. “Place the electrodes on the posterior chest.” d. “Turn off oxygen prior to monitoring the client.”

ANS: A

To ensure the best signal transmission, the skin would be clean and hairs clipped. Electrodes would be placed on the anterior chest, and no additional gel is needed. Oxygen has no impact on electrocardiographic monitoring.

DIF: Understanding TOP: Integrated Process: Communication and Documentation KEY: Cardiac electrical conduction, Delegation MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 18. A nurse assesses a client’s electrocardiogram (ECG) and observes the reading shown below:

How would the nurse document this client’s ECG strip? a. Ventricular tachycardia b. Ventricular fibrillation c. Sinus rhythm with premature atrial contractions (PACs) d. Sinus rhythm with premature ventricular contractions (PVCs) ANS: D

Sinus rhythm with PVCs has an underlying regular sinus rhythm with ventricular depolarization that sometimes precede atrial depolarization. The PVC would exhibit as a widened QRS without a preceding p wave. Ventricular tachycardia and ventricular fibrillation rhythms would not have sinus beats present. Premature atrial contractions are atrial contractions initiated from another region of the atria before the sinus node initiates atrial depolarization.

DIF: Analyzing TOP: Integrated Process: Communication and Documentation KEY: Cardiac electrical conduction, Documentation MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 19. A nurse cares for a client who is on a cardiac monitor. The monitor displayed the rhythm

shown below:

What action would the nurse take first? a. Assess airway, breathing, and circulation. b. Administer an amiodarone bolus followed by a drip. c. Cardiovert the client with a biphasic defibrillator. d. Begin cardiopulmonary resuscitation (CPR).

ANS: A

Ventricular tachycardia occurs with repetitive firing of an irritable ventricular ectopic focus, usually at a rate of 140 to 180 beats/min or more. Ventricular tachycardia is a potentially lethal dysrhythmia. The nurse would first assess if the client is alert, breathing, and has a pulse. If this client is pulseless, then the nurse would call a Code Blue and begin CPR. The treatment of choice for pulseless ventricular tachycardia is defibrillation. If the client has a pulse, then cardioversion would be indicated. Amiodarone is an appropriate antidysrhythmic, but it is not the first action.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Implementation KEY: Cardiac electrical conduction, Medical emergency MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 20. A nurse performs an admission assessment on a 75-year-old client with multiple chronic

diseases. The client’s blood pressure is 135/75 mm Hg and oxygen saturation is 94% on 2 L per nasal cannula. The nurse assesses the client’s rhythm on the cardiac monitor and observes the reading shown below:

What action would the nurse take first? a. Begin external temporary pacing. b. Assess peripheral pulse strength. c. Ask the client what medications he or she takes. d. Administer 1 mg of atropine.

ANS: C

This client is stable and therefore does not require any intervention except to determine the cause of the bradycardia. Bradycardia is often caused by medications. Clients who have multiple chronic diseases are often on multiple medications that can interact with each other.

The nurse would assess the client’s current medications first. Pacing is not necessary.

Peripheral pulses are assessed with a full assessment since this client is stable. Atropine is not needed.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Cardiac electrical conduction, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 21. The nurse is caring for a client on the medical-surgical unit who suddenly becomes

unresponsive and has no pulse. The cardiac monitor shows the rhythm below:

After calling for assistance and a defibrillator, what action would the nurse take next? a. Perform a pericardial thump. b. Initiate cardiopulmonary resuscitation (CPR). c. Start an 18-gauge intravenous line. d. Ask the client’s family about code status.

ANS: B

The client’s rhythm is ventricular fibrillation. This is a lethal rhythm that is best treated with immediate defibrillation. While the nurse is waiting for the defibrillator to arrive, the nurse would start CPR. A pericardial thump is not a treatment for ventricular fibrillation. If the client does not already have an IV, other members of the team can insert one after defibrillation. The client’s code status would already be known by the nurse prior to this event.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Cardiac electrical conduction, Medical emergency MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 22. After assessing a client who is receiving an amiodarone intravenous infusion for unstable

ventricular tachycardia, the nurse documents the findings and compares these with the previous assessment findings: Vital Signs Nursing Assessment Time: 08:00 Time: 08:00 Temperature: 98° F (36.7° C) Client alert and oriented.

Heart rate: 68 beats/min Cardiac rhythm: normal sinus rhythm.

Blood pressure: 135/60 mm Hg Skin: warm, dry, and appropriate for Respiratory rate: 14 breaths/min race.

Oxygen saturation: 96% Respirations equal and unlabored.

Oxygen therapy: 2 L nasal cannula Client denies shortness of breath and chest pain.

Time: 10:00 Temperature: 98.2° F (36.8° C) Heart rate: 50 beats/min Blood pressure: 132/57 mm Hg Respiratory rate: 16 breaths/min Oxygen saturation: 95% Oxygen therapy: 2 L nasal cannula

Time: 10:00 Client alert and oriented.

Cardiac rhythm: sinus bradycardia.

Skin: warm, dry, and appropriate for race.

Respirations equal and unlabored.

Client denies shortness of breath and chest pain.

Client voids 420 mL of clear yellow urine.

Based on the assessments, what action would the nurse take? a. Stop the infusion and flush the IV. b. Slow the amiodarone infusion rate. c. Administer IV normal saline. d. Ask the client to cough and deep breathe.

ANS: B

Amiodarone lengthens the absolute refractory period and prolongs repolarization and the action potential duration (and heart rate), so IV administration of amiodarone may cause bradycardia and atrioventricular (AV) block. The correct action for the nurse to take at this time is to slow the infusion, because the client is asymptomatic and no evidence reveals AV block that might require pacing. Abruptly ceasing the medication could allow fatal dysrhythmias to occur. The administration of IV fluids and encouragement of coughing and deep-breathing exercises are not indicated, and will not increase the client’s heart rate.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Implementation KEY: Cardiac electrical conduction, Medication MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies MULTIPLE RESPONSE 1. A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of

128 beats/min. For which physiologic alterations would the nurse assess? (Select all that apply.) a. Decrease in cardiac output b. Increase in cardiac output c. Decrease in blood pressure d. Increase in blood pressure e. Decrease in urine output f. Increase in urine output ANS: A, C, E

Elevated heart rates in a healthy client initially cause blood pressure and cardiac output to increase. However, in a client who has congestive heart failure or a client with long-term tachycardia, ventricular filling time, cardiac output, and blood pressure eventually decrease.

As cardiac output and blood pressure decrease, urine output will fall.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Cardiac electrical conduction, Heart failure MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A nurse teaches a client with a new permanent pacemaker. Which instructions would the

nurse include in this client’s teaching? (Select all that apply.) a. “Until your incision is healed, do not submerge your pacemaker. Only take showers.” b. “Report any pulse rates lower than your pacemaker settings.” c. “If you feel weak, apply pressure over your generator.” d. “Have your pacemaker turned off before having magnetic resonance imaging (MRI).” e. “Do not lift your left arm above the level of your shoulder for 8 weeks.”

ANS: A, B, E

The client would not submerge in water until the site has healed; after the incision is healed, the client may take showers or baths without concern for the pacemaker. The client would be instructed to report changes in heart rate or rhythm, such as rates lower than the pacemaker setting or greater than 100 beats/min. The client would be advised of restrictions on physical activity for 8 weeks to allow the pacemaker to settle in place. The client would never apply pressure over the generator and would avoid tight clothing. The client would never have MRI because, whether turned on or off, the pacemaker contains metal. The client would be advised to inform all health care providers that he or she has a pacemaker.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Cardiac electrical conduction, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 3. A nurse is teaching a client who has premature ectopic beats. Which education would the

nurse include in this client’s teaching? (Select all that apply.) a. Smoking cessation b. Stress reduction and management c. Avoiding vagal stimulation d. Adverse effects of medications e. Foods high in potassium f. Types of aerobic exercise ANS: A, B, D

A client who has premature beats or ectopic rhythms would be taught to stop smoking, manage stress, take medications as prescribed, and report adverse effects of medications.

Clients with premature beats are not at risk for vasovagal attacks or potassium imbalances.

While exercise is beneficial, aerobic exercise is not specifically linked to this client’s educational needs.

DIF: Remembering TOP: Integrated Process: Nursing Process: Implementation KEY: Health teaching MSC: Client Needs Category: Health Promotion and Maintenance

Chapter 32: Concepts of Care for Patients With Cardiac Problems Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse assesses clients on a cardiac unit. Which client would the nurse identify as being at

greatest risk for the development of left-sided heart failure? a. A 36-year-old woman with aortic stenosis b. A 42-year-old man with pulmonary hypertension c. A 59-year-old woman who smokes cigarettes daily d. A 70-year-old man who had a cerebral vascular accident ANS: A

Causes of left ventricular failure include mitral or aortic valve disease, coronary artery disease, and hypertension. Pulmonary hypertension and chronic cigarette smoking are risk factors for right ventricular failure. A cerebral vascular accident does not increase the risk of heart failure.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Heart failure, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the

possibility of left-sided heart failure? a. “I have been drinking more water than usual.” b. “I am awakened by the need to urinate at night.” c. “I must stop halfway up the stairs to catch my breath.” d. “I have experienced blurred vision on several occasions.”

ANS: C

Clients with left-sided heart failure report weakness or fatigue while performing normal activities of daily living, as well as difficulty breathing, or “catching their breath.” This occurs as fluid moves into the alveoli. Nocturia is often seen with right-sided heart failure. Thirst and blurred vision are not related to heart failure.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Heart failure, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the

nurse to the possibility of right-sided heart failure? a. “I sleep with four pillows at night.” b. “My shoes fit really tight lately.” c. “I wake up coughing every night.” d. “I have trouble catching my breath.”

ANS: B

Signs of systemic congestion occur with right-sided heart failure. Fluid is retained, pressure builds in the venous system, and peripheral edema develops. Left-sided heart failure symptoms include respiratory symptoms. Orthopnea, coughing, and difficulty breathing all could be results of left-sided heart failure.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Heart failure, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. What

action would the nurse take next? a. Assess for symptoms of left-sided heart failure. b. Document this as a normal finding. c. Call the primary health care provider immediately. d. Transfer the client to the intensive care unit.

ANS: A

The presence of an S3 gallop is an early diastolic filling sound indicative of increasing left ventricular pressure and left ventricular failure. The other actions are not warranted.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Heart failure, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. A nurse cares for a client with right-sided heart failure. The client asks, “Why do I need to

weigh myself every day?” How would the nurse respond? a. “Weight is the best indication that you are gaining or losing fluid.” b. “Daily weights will help us make sure that you’re eating properly.” c. “The hospital requires that all clients be weighed daily.” d. “You need to lose weight to decrease the incidence of heart failure.”

ANS: A

Daily weights are needed to document fluid retention or fluid loss. One liter of fluid equals 2.2 lb (1 kg). Weight changes are the most reliable indicator of fluid loss or gain. The other responses do not address the importance of monitoring fluid retention or loss.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Heart failure, Health teaching MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. A nurse is teaching a client with heart failure who has been prescribed enalapril. Which

statement would the nurse include in this client’s teaching? a. “Avoid using salt substitutes.” b. “Take your medication with food.” c. “Avoid using aspirin-containing products.” d. “Check your pulse daily.”

ANS: A

Angiotensin-converting enzyme (ACE) inhibitors such as enalapril inhibit the excretion of potassium. Hyperkalemia can be a life-threatening side effect, and clients should be taught to limit potassium intake. Salt substitutes are composed of potassium chloride. ACE inhibitors do not need to be taken with food and have no impact on the client’s pulse rate. Aspirin is often prescribed in conjunction with ACE inhibitors and is not contraindicated.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Angiotensin-converting enzyme (ACE) inhibitor, Health teaching MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 7. After administering the first dose of captopril to a client with heart failure, the nurse

implements interventions to decrease complications. Which intervention is most important for the nurse to implement? a. Provide food to decrease nausea and aid in absorption. b. Instruct the client to ask for assistance when rising from bed. c. Collaborate with assistive personnel to bathe the client. d. Monitor potassium levels and check for symptoms of hypokalemia.

ANS: B

Hypotension is a side effect of ACE inhibitors such as captopril. Clients with a fluid volume deficit should have their volume replaced or start at a lower dose of the drug to minimize this effect. The nurse would instruct the client to seek assistance before arising from bed to prevent injury from postural hypotension. ACE inhibitors do not need to be taken with food.

Collaboration with assistive personnel to provide hygiene is not a priority. The client would be encouraged to complete activities of daily living as independently as possible. The nurse would monitor for hyperkalemia, not hypokalemia, especially if the client has renal insufficiency secondary to heart failure.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Angiotensin-converting enzyme (ACE) inhibitor, Client safety MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 8. A nurse assesses a client after administering the first dose of a nitrate. The client reports a

headache. What action would the nurse take? a. Initiate oxygen therapy. b. Hold the next dose. c. Instruct the client to drink water. d. Administer PRN acetaminophen.

ANS: D

The vasodilating effects of nitrates frequently cause clients to have headaches during the initial period of therapy. The nurse would inform the client about this side effect and offer a mild analgesic, such as acetaminophen. The client’s headache is not related to hypoxia or dehydration; therefore, applying oxygen and drinking water would not help. The client needs to take the medication as prescribed to prevent angina; the medication would not be held.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Nitroglycerin, Nitrates, Side effects MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

9. A nurse teaches a client who is prescribed digoxin therapy. Which statement would the nurse

include in this client’s teaching? a. “Avoid taking aspirin or aspirin-containing products.” b. “Increase your intake of foods that are high in potassium.” c. “Hold this medication if your pulse rate is below 80 beats/min.” d. “Do not take this medication within 1 hour of taking an antacid.”

ANS: D

Gastrointestinal absorption of digoxin is erratic. Many medications, especially antacids, interfere with its absorption. Clients are taught to hold their digoxin for bradycardia; a heart rate of 80 beats/min is too high for this cutoff. Potassium and aspirin have no impact on digoxin absorption.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Digoxin, Health teaching MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 10. A nurse teaches a client who has a history of heart failure. Which statement would the nurse

include in this client’s discharge teaching? a. “Avoid drinking more than 3 quarts (3 L) of liquids each day.” b. “Eat six small meals daily instead of three larger meals.” c. “When you feel short of breath, take an additional diuretic.” d. “Weigh yourself daily while wearing the same amount of clothing.”

ANS: D

Clients with heart failure are instructed to weigh themselves daily to detect worsening heart failure early, and thus avoid complications. Other signs of worsening heart failure include increasing dyspnea, exercise intolerance, cold symptoms, and nocturia. Fluid overload increases symptoms of heart failure. The client would be taught to eat a heart-healthy diet, balance intake and output to prevent dehydration and overload, and take medications as prescribed. The most important discharge teaching is daily weights as this provides the best data related to fluid retention.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Heart failure, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 11. A nurse admits a client who is experiencing an exacerbation of heart failure. What action

would the nurse take first? a. Assess the client’s respiratory status. b. Draw blood to assess the client’s serum electrolytes. c. Administer intravenous furosemide. d. Ask the client about current medications.

ANS: A

Assessment of respiratory and oxygenation status is the most important nursing intervention for the prevention of complications. Monitoring electrolytes, administering diuretics, and asking about current medications are important but do not take precedence over assessing respiratory status.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Heart failure, Nursing assessment

MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 12. A nurse assesses a client with mitral valve stenosis. What clinical sign or symptom would

alert the nurse to the possibility that the client’s stenosis has progressed? a. Oxygen saturation of 92% b. Dyspnea on exertion c. Muted systolic murmur d. Upper extremity weakness ANS: B

Dyspnea on exertion develops as the mitral valvular orifice narrows and pressure in the lungs increases. The other signs and symptoms do not relate to the progression of mitral valve stenosis.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Valvular disorders, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 13. A nurse cares for a client recovering from prosthetic valve replacement surgery. The client

asks, “Why will I need to take anticoagulants for the rest of my life?” What is the best response by the nurse? a. “The prosthetic valve places you at greater risk for a heart attack.” b. “Blood clots form more easily in artificial replacement valves.” c. “The vein taken from your leg reduces circulation in the leg.” d. “The surgery left a lot of small clots in your heart and lungs.”

ANS: B

Synthetic valve prostheses and scar tissue provide surfaces on which platelets can aggregate easily and initiate the formation of blood clots. The other responses are inaccurate.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Valvular disorders, Anticoagulants MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 14. After teaching a client who is being discharged home after mitral valve replacement surgery,

the nurse assesses the client’s understanding. Which client statement indicates a need for additional teaching? a. “I’ll be able to carry heavy loads after 6 months of rest.” b. “I will have my teeth cleaned by my dentist in 2 weeks.” c. “I must avoid eating foods high in vitamin K, like spinach.” d. “I must use an electric razor instead of a straight razor to shave.”

ANS: B

Clients who have defective or repaired valves are at high risk for endocarditis. The client who has had valve surgery should avoid dental procedures for 6 months because of the risk for endocarditis. When undergoing a mitral valve replacement surgery, the client needs to be placed on anticoagulant therapy to prevent vegetation forming on the new valve. Clients on anticoagulant therapy would be instructed on bleeding precautions, including using an electric razor. If the client is prescribed warfarin, the client should avoid foods high in vitamin K. Clients recovering from open-heart valve replacements should not carry anything heavy for 6 months while the chest incision and muscle heal.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Valvular disorders, Health teaching MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 15. A nurse cares for a client with infective endocarditis. Which infection control precautions

would the nurse use? a. Standard Precautions b. Bleeding Precautions c. Reverse isolation d. Contact isolation ANS: A

The client with infective endocarditis does not pose any specific threat of transmitting the causative organism. Standard Precautions would be used. Bleeding Precautions, reverse isolation, or Contact Precautions are not necessary.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Infection, Standard precautions MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 16. A nurse assesses a client with pericarditis. Which assessment finding would the nurse expect

to find? a. Heart rate that speeds up and slows down. b. Friction rub at the left lower sternal border. c. Presence of a regular gallop rhythm. d. Coarse crackles in bilateral lung bases.

ANS: B

The client with pericarditis may present with a pericardial friction rub at the left lower sternal border. This sound is the result of friction from inflamed pericardial layers when they rub together. The other assessments are not related.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Inflammatory response, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 17. After teaching a client who is recovering from a heart transplant to change positions slowly,

the client asks, “Why is this important?” How would the nurse respond? a. “Rapid position changes can create shear and friction forces, which can tear out your internal vascular sutures.” b. “Your new vascular connections are more sensitive to position changes, leading to increased intravascular pressure and dizziness.” c. “Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes.” d. “While your heart is recovering, blood flow is diverted away from the brain, increasing the risk for stroke when you stand up.”

ANS: C

Because the new heart is denervated, the baroreceptor and other mechanisms that compensate for blood pressure drops caused by position changes do not function. This allows orthostatic hypotension to persist in the postoperative period. The other options are false statements and do not correctly address the client’s question.

DIF: Understanding TOP: Integrated Process: Nursing Process: Implementation KEY: Transplant, Health teaching MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 18. A nurse is providing discharge teaching to a client recovering from a heart transplant. Which

statement would the nurse include? a. “Use a soft-bristled toothbrush and avoid flossing.” b. “Avoid large crowds and people who are sick.” c. “Change positions slowly to avoid hypotension.” d. “Check your heart rate before taking the medication.”

ANS: B

Clients who have had heart transplants must take immunosuppressant therapy for the rest of their lives. The nurse would teach this client to avoid crowds and sick people to reduce the risk of becoming ill him- or herself. These medications do not place clients at risk for bleeding, orthostatic hypotension, or changes in heart rate. Orthostatic hypotension from the denervated heart is generally only a problem in the immediate postoperative period.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Transplant, Health teaching MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 19. A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client

appears depressed and states, “I know a transplant is my last chance, but I don’t want to become a vegetable.” How would the nurse respond? a. “Would you like to speak with a priest or chaplain?” b. “I will arrange for a psychiatrist to speak with you.” c. “Do you want to come off the transplant list?” d. “Would you like information about advance directives?”

ANS: D

The client is verbalizing a real concern or fear about negative outcomes of the surgery. This anxiety itself can have a negative effect on the outcome of the surgery because of sympathetic stimulation. The best action is to allow the client to verbalize the concern and work toward a positive outcome without making the client feel as though the concerns are not valid. The client needs to feel that he or she has some control over the future. The nurse personally provides care to address the client’s concerns instead of immediately calling for the chaplain or psychiatrist. The nurse would not jump to conclusions and suggest taking the client off the transplant list, which is the best treatment option.

DIF: Applying TOP: Integrated Process: Caring KEY: Transplant, Psychosocial response MSC: Client Needs Category: Psychosocial Integrity 20. A nurse assesses a client who has a history of heart failure. Which question would the nurse

ask to assess the extent of the client’s heart failure? a. “Do you have trouble breathing or chest pain?” b. “Are you still able to walk upstairs without fatigue?” c. “Do you awake with breathlessness during the night?” d. “Do you have new-onset heaviness in your legs?”

ANS: B

Clients with a history of heart failure generally have negative findings, such as shortness of breath and fatigue. The nurse needs to determine whether the client’s activity is the same or worse, or whether the client identifies a decrease in activity level. Trouble breathing, chest pain, breathlessness at night, and peripheral edema are symptoms of heart failure, but do not provide data that can determine the extent of the client’s heart failure.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Heart failure, Functional ability MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 21. A nurse cares for an older adult client with heart failure. The client states, “I don’t know what

to do. I don’t want to be a burden to my daughter, but I can’t do it alone. Maybe I should die.”

What is the best response by the nurse? a. “I can stay if you would you like to talk more about this.” b. “You are lucky to have such a devoted daughter.” c. “It is normal to feel as though you are a burden.” d. “Would you like to meet with the chaplain?”

ANS: A

Depression can occur in clients with heart failure, especially older adults. Having the client talk about his or her feelings will help the nurse focus on the actual problem. Open-ended statements allow the client to respond safely and honestly. The other options minimize the client’s concerns and do not allow the nurse to obtain more information to provide client-centered care.

DIF: Applying TOP: Integrated Process: Caring KEY: Heart failure, Psychosocial response MSC: Client Needs Category: Psychosocial Integrity 22. A nurse teaches a client with heart failure about energy conservation. Which statement would

the nurse include in this client’s teaching? a. “Walk until you become short of breath, and then walk back home.” b. “Begin walking 200 feet a day three times a week.” c. “Do not lift heavy weights for 6 months.” d. “Eat plenty of protein to build your strength.”

ANS: B

A client who has heart failure would be taught to conserve energy and given an exercise plan.

The client should begin walking 200-400 feet a day at home three times a week. The client should not walk until becoming short of breath because he or she may not make it back home.

The lifting restriction is specifically for clients after valve replacements. Protein does help build strength, but this direction is not specific to heart failure.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Heart failure, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 23. A nurse is caring for a client with acute pericarditis who reports substernal precordial pain that

radiates to the left side of the neck. Which nonpharmacologic comfort measure would the nurse implement? a. Apply an ice pack to the client’s chest.

b. Provide a neck rub, especially on the left side. c. Allow the client to lie in bed with the lights down. d. Sit the client up with a pillow to lean forward on.

ANS: D

Pain from acute pericarditis may worsen when the client lays supine. The nurse would position the client in a comfortable position, which usually is upright and leaning slightly forward. An ice pack and neck rub will not relieve this pain. Dimming the lights will also not help the pain.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Nonpharmacologic pain management MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 24. A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia

would the nurse assess? a. Preventricular contractions b. Atrial fibrillation c. Symptomatic bradycardia d. Sinus tachycardia ANS: B

Atrial fibrillation is a clinical manifestation of mitral valve regurgitation and stenosis.

Preventricular contractions and bradycardia are not associated with valvular problems. These are usually identified in clients with electrolyte imbalances, myocardial infarction, and sinus node problems. Sinus tachycardia is a manifestation of aortic regurgitation due to a decrease in cardiac output.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Valve disorder, Cardiac dysrhythmia MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential MULTIPLE RESPONSE 1. A nurse is assessing a client with left-sided heart failure. For which clinical manifestations

would the nurse assess? (Select all that apply.) a. Pulmonary crackles b. Confusion c. Pulmonary hypertension d. Dependent edema e. Cough that worsens at night f. Jugular venous distention ANS: A, B, E

Left-sided heart failure occurs with a decrease in contractility of the heart or an increase in afterload. Most of the signs will be noted in the respiratory system. These include crackles, confusion (due to decreased oxygenation), and cough. Right ventricular failure is associated with pulmonary hypertension, edema, and jugular venous distention.

DIF: Remembering KEY: Heart failure, Nursing assessment

TOP: Integrated Process: Nursing Process: Assessment

MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A nurse evaluates laboratory results for a client with heart failure. Which results would the

nurse expect? (Select all that apply.) a. Hematocrit: 32.8% b. Serum sodium: 130 mEq/L (130 mmol/L) c. Serum potassium: 4.0 mEq/L (4.0 mmol/L) d. Serum creatinine: 1.0 mg/dL (88.4 mcmol/L) e. Proteinuria f. Microalbuminuria ANS: A, B, E, F

A hematocrit of 32.8% is low (should be 42.6%), indicating a dilutional ratio of red blood cells to fluid. A serum sodium of 130 mEq/L (130 mmol/L) is low because of hemodilution.

Microalbuminuria and proteinuria are present, indicating a decrease in renal filtration. These are early warning signs of decreased compliance of the heart. The potassium level is normal and the serum creatinine level is normal.

DIF: Applying TOP: Integrated Process: Nursing Process: Evaluation KEY: Heart failure, Laboratory values MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 3. A nurse assesses clients on a cardiac unit. Which clients would the nurse identify as at

greatest risk for the development of acute pericarditis? (Select all that apply.) a. A 36-year-old woman with systemic lupus erythematosus (SLE) b. A 42-year-old man recovering from coronary artery bypass graft surgery c. A 59-year-old woman recovering from a hysterectomy d. An 80-year-old man with a bacterial infection of the respiratory tract e. An 88-year-old woman with a stage III sacral ulcer ANS: A, B, D

Acute pericarditis is most commonly associated with acute exacerbations of systemic connective tissue disease, including SLE; with Dressler syndrome, or inflammation of the cardiac sac after cardiac surgery or a myocardial infarction; and with infective organisms, including bacterial, viral, and fungal infections. Abdominal and reproductive surgeries and pressure injuries do not increase clients’ risk for acute pericarditis.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Inflammatory response, Pericarditis MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. After teaching a client with congestive heart failure (CHF), the nurse assesses the client’s

understanding. Which client statements indicate a correct understanding of the teaching related to nutritional intake? (Select all that apply.) a. “I’ll read the nutritional labels on food items for salt content.” b. “I will drink at least 3 L of water each day.” c. “Using salt in moderation will reduce the workload of my heart.” d. “I will eat oatmeal for breakfast instead of ham and eggs.” e. “Substituting fresh vegetables for canned ones will lower my salt intake.” f. “Salt substitutes are a good way to cut down on sodium in my diet.”

ANS: A, D, E

Nutritional therapy for a client with CHF is focused on decreasing sodium and water retention to decrease the workload of the heart. The client would be taught to read nutritional labels on all food items, omit table salt and foods high in sodium (e.g., ham and canned foods), and limit water intake to a normal 2 L/day. Salt substitutes typically contain potassium, so although they are not strictly banned, clients would have to have their renal function and serum potassium monitored while using them. It would be safer to avoid them.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Heart failure, Health teaching MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. A nurse collaborates with assistive personnel (AP) to provide care for a client with congestive

heart failure. Which instructions would the nurse provide to the AP when delegating care for this client? (Select all that apply.) a. “Reposition the client every 2 hours.” b. “Teach the client to perform deep-breathing exercises.” c. “Accurately record intake and output.” d. “Use the same scale to weigh the client each morning.” e. “Place the client on oxygen if the client becomes short of breath.”

ANS: A, C, D

The AP should reposition the client every 2 hours to improve oxygenation and prevent atelectasis. The AP can also accurately record intake and output, and use the same scale to weigh the client each morning before breakfast. APs are not qualified to teach clients or assess the need for and provide oxygen therapy.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Heart failure, Delegation, Interdisciplinary team MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 6. A nurse prepares to discharge a client who has heart failure. Based on national quality

measures, what actions would the nurse complete prior to discharging this client? (Select all that apply.) a. Teach the client about energy conservation techniques. b. Ensure that the client is prescribed a beta blocker. c. Document a discussion about advanced directives. d. Confirm that a postdischarge nurse visit has been scheduled. e. Consult a social worker for additional resources. f. Care transition record transmitted to next level of care within 7 days of discharge.

ANS: B, C, D, F

National quality measures aim to decrease heart failure readmission by proper preparation for discharge. These measures include :(1) beta blocker prescribed for left ventricular dysfunction at discharge, (2) postdischarge follow-up appointment scheduled within 7 days of discharge with documentation of location, date, and time. (3) care transition record transmitted to next level of care within 7 days of discharge. (4) documentation of discussion of advance directives/advance care planning with a health care provider, (5) documentation of execution of advance directives within the medical record, and (6) postdischarge evaluation of patient for symptom assessment and treatment adherence within 72 hours of discharge (this can occur by phone, scheduled office visit, or home visit)

DIF: Understanding TOP: Integrated Process: Nursing Process: Analysis KEY: Heart failure, Core measures MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 7. A nurse prepares to discharge a client who has heart failure. Which questions would the nurse

ask to ensure this client’s safety prior to discharging home? (Select all that apply.) a. “Are your bedroom and bathroom on the first floor?” b. “What social support do you have at home?” c. “Will you be able to afford your oxygen therapy?” d. “What spiritual beliefs may impact your recovery?” e. “Are you able to accurately weigh yourself at home?”

ANS: A, B, D

To ensure safety upon discharge, the nurse would assess for structural barriers to functional ability, such as stairs. The nurse would also assess the client’s available social support, which may include family, friends, and home health services. The client’s beliefs about and ability to adhere to medication and treatments, including daily weights, would also be reviewed. The other questions do not specifically address the client’s safety upon discharge.

DIF: Applying TOP: Integrated Process: Nursing Process: Analysis KEY: Heart failure, Discharge, Safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 8. A nurse assesses a client who is recovering from a heart transplant. Which assessment

findings would alert the nurse to the possibility of heart transplant rejection? (Select all that apply.) a. Shortness of breath b. Abdominal bloating c. New-onset bradycardia d. Increased ejection fraction e. Hypertension f. Fatigue ANS: A, B, C, F

Clinical findings of heart transplant rejection include shortness of breath, fatigue, fluid gain, abdominal bloating, new-onset bradycardia, hypotension, atrial fibrillation or flutter, decreased activity tolerance, and decreased ejection fraction.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Transplant, Rejection MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 9. A nurse is caring for a client who was admitted with hypertrophic cardiomyopathy (HCM).

What interprofessional care does the nurse anticipate providing? (Select all that apply.) a. Administering beta blockers b. Administering high-dose furosemide c. Preparing for a cardiac catheterization d. Loading the client on digitalis e. Instructing the client to avoid strenuous exercise f. Teaching the client how to use the CardioMEMS™ ANS: A, C, E

Management of obstructive HCM includes administering negative inotropic agents such as beta-adrenergic blocking agents (carvedilol) and calcium antagonists (verapamil).

Vasodilators, diuretics, nitrates, and cardiac glycosides are contraindicated in patients with obstructive HCM. Strenuous exercise is also prohibited. Echocardiography, radionuclide imaging, and angiocardiography during cardiac catheterization are performed to diagnose and differentiate cardiomyopathies. The CardioMEMS™ device is used with clients who have heart failure.

DIF: Understanding TOP: Integrated Process: Nursing Process: Implementation KEY: Cardiomyopathy, Intraprofessional care MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

Chapter 33: Concepts of Care for Patients With Vascular Problems Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse is assessing the peripheral vascular system of an older adult. What action by the nurse

would cause the supervising nurse to intervene? a. Assessing blood pressure in both upper extremities b. Auscultating the carotid arteries for any bruits c. Classifying capillary filling of 4 seconds as normal d. Palpating both carotid arteries at the same time ANS: D

The nurse would not compress both carotid arteries at the same time to avoid brain ischemia.

Blood pressure would be taken and compared in both arms. Prolonged capillary filling is considered to be greater than 5 seconds in an older adult, so classifying refill of 4 seconds as normal would not require intervention. Bruits would be auscultated.

DIF: Remembering TOP: Integrated Process: Communication and Documentation KEY: Vascular system, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 2. The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel.

What meal selection indicates that the client is managing this condition well with diet? a. A 4-ounce steak, French fries, iceberg lettuce b. Baked chicken breast, broccoli, tomatoes c. Fried catfish, cornbread, peas d. Spaghetti with meat sauce, garlic bread ANS: B

The diet recommended for this client would be low in saturated fats and red meat, high in vegetables and whole grains (fiber), low in salt, and low in trans fat. The best choice is the chicken with broccoli and tomatoes. The French fries have too much fat and the iceberg lettuce has little fiber. The catfish is fried. The spaghetti dinner has too much red meat and no vegetables.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Nutrition, Self-care MSC: Client Needs Category: Health Promotion and Maintenance 3. A nurse is working with a client who takes clopidogrel. The client’s recent laboratory results

include a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best? a. Ask if the client eats grapefruit. b. Assess the client for dehydration. c. Facilitate admission to the hospital. d. Obtain a random urinalysis.

ANS: A

There is a drug–food interaction between clopidogrel and grapefruit that can lead to acute kidney failure. This client has elevated renal laboratory results, indicating some degree of kidney involvement. The nurse would assess if the client eats grapefruit or drinks grapefruit juice. Dehydration can cause the BUN to be elevated, but the elevation in creatinine is more specific for a kidney injury. The client does not necessarily need to be admitted. A urinalysis may or may not be ordered.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Medication-food interactions, Laboratory values MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. A client has been diagnosed with hypertension but does not take the antihypertensive

medications because of a lack of symptoms. What response by the nurse is best? a. “Do you have trouble affording your medications?” b. “Most people with hypertension do not have symptoms.” c. “You are lucky; most people get severe morning headaches.” d. “You need to take your medicine or you will get kidney failure.”

ANS: B

Most people with hypertension are asymptomatic, although a small percentage do have symptoms such as headache. The nurse would explain this to the client. Asking about paying for medications utilizes closed-ended questioning and is not therapeutic. Threatening the client with possible complications will not increase compliance.

DIF: Understanding TOP: Integrated Process: Communication and Documentation KEY: Hypertension, Medication adherence MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. A client asks what “essential hypertension” is. What response by the registered nurse is best? a. “It means it is caused by another disease.” b. “It means it is ‘essential’ that it be treated.” c. “It is hypertension with no specific cause.” d. “It refers to severe and life-threatening hypertension.”

ANS: C

Essential hypertension is the most common type of hypertension and has no specific cause such as an underlying disease process. Hypertension that is due to another disease process is called secondary hypertension. A severe, life-threatening form of hypertension is malignant hypertension.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Hypertension, Pathophysiology MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. A nurse is interested in providing community education and screening on hypertension. In

order to reach a priority population, to what target audience would the nurse provide this service? a. African-American churches b. Asian-American groceries c. High school sports camps

d. Women’s health clinics ANS: A

African Americans in the United States have one of the highest rates of hypertension in the world. The nurse has the potential to reach this priority population by providing services at African-American churches. Although hypertension education and screening are important for all groups, African Americans are the priority population for this intervention.

DIF: Remembering TOP: Integrated Process: Nursing Process: Analysis KEY: Hypertension, Primary prevention MSC: Client Needs Category: Health Promotion and Maintenance 7. A client has hypertension and high risk factors for cardiovascular disease. The client is

overwhelmed with the recommended lifestyle changes. What action by the nurse is best? a. Assess the client’s support system. b. Assist in finding one change the client can control. c. Determine what stressors the client faces in daily life. d. Inquire about delegating some of the client’s obligations.

ANS: B

All options are appropriate when assessing stress and responses to stress. However, this client feels overwhelmed by the suggested lifestyle changes. Instead of looking at all the needed changes, the nurse would assist the client in choosing one the client feels optimistic about controlling. Once the client has mastered that change, he or she can move forward with another change. Determining support systems, daily stressors, and delegation opportunities does not directly impact the client’s feelings of control.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Hypertension, Psychosocial response MSC: Client Needs Category: Psychosocial Integrity 8. The nurse is caring for four hypertensive clients. Which drug–laboratory value combination

would the nurse report immediately to the health care provider? a. Furosemide/potassium: 2.1 mEq/L b. Hydrochlorothiazide/potassium: 4.2 mEq/L c. Spironolactone/potassium: 5.1 mEq/L d. Torsemide/sodium: 142 mEq/L ANS: A

Furosemide is a loop diuretic and can cause hypokalemia. A potassium level of 2.1 mEq/L is quite low and would be reported immediately. Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia. A potassium level of 5.1 mEq/L is on the high side, but it is not as critical as the low potassium with furosemide. The other two laboratory values are normal.

DIF: Applying TOP: Integrated Process: Nursing Process: Analysis MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 9. A nurse is assessing a client with peripheral artery disease (PAD). The client states that

walking five blocks is possible without pain. What question asked next by the nurse will give the best information? a. “Could you walk further than that a few months ago?” b. “Do you walk mostly uphill, downhill, or on flat surfaces?”

c. “Have you ever considered swimming instead of walking?” d. “How much pain medication do you take each day?”

ANS: A

As PAD progresses, it takes less oxygen demand to cause pain. Needing to cut down on activity to be pain free indicates that the client’s disease is worsening. The other questions are useful, but not as important.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Peripheral artery disease, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 10. An older client with peripheral vascular disease (PVD) is explaining the daily foot care

regimen to the family practice clinic nurse. What statement by the client may indicate a barrier to proper foot care? a. “I nearly always wear comfy sweatpants and house shoes.” b. “I’m glad I get energy assistance so my house isn’t so cold.” c. “My daughter makes sure I have plenty of lotion for my feet.” d. “My hands shake when I try to do things requiring coordination.”

ANS: D

Clients with PVD need to pay special attention to their feet. Toenails need to be kept short and cut straight across. The client whose hands shake may cause injury when trimming toenails.

The nurse would refer this client to a podiatrist. Comfy sweatpants and house shoes are generally loose and not restrictive, which is important for clients with PVD. Keeping the house at a comfortable temperature makes it less likely the client will use alternative heat sources, such as heating pads, to stay warm. The client should keep the feet moist and soft with lotion.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Analysis KEY: Peripheral vascular disease, Home safety MSC: Client Needs Category: Health Promotion and Maintenance 11. A client is taking warfarin and asks the nurse if taking St. John’s wort is acceptable. What

response by the nurse is best? a. “No, it may interfere with the warfarin.” b. “There isn’t any information about that.” c. “Why would you want to take that?” d. “Yes, it is a good supplement for you.”

ANS: A

Many foods and drugs interfere with warfarin, St. John’s wort being one of them. The nurse would advise the client against taking it. The other answers are not accurate.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Anticoagulants, Medication-food interactions MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 12. A nurse is teaching a female client about alcohol intake and how it affects hypertension. The

client asks if drinking two beers a night is an acceptable intake. What answer by the nurse is best? a. “No, women should only have one beer a day as a general rule.”

b. “No, you should not drink any alcohol with hypertension.” c. “Yes, since you are larger, you can have more alcohol.” d. “Yes, two beers per day is an acceptable amount of alcohol.”

ANS: A

Alcohol intake should be limited to two drinks a day for men and one drink a day for women.

A “drink” is classified as one beer, 1.5 ounces of hard liquor, or 5 ounces of wine. Limited alcohol intake is acceptable with hypertension. The woman’s size does not matter.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Hypertension, Lifestyle choices MSC: Client Needs Category: Health Promotion and Maintenance 13. A nurse is caring for four clients. Which one would the nurse see first? a. Client who needs a beta blocker, and has a blood pressure of 98/58 mm Hg. b. Client who had a first dose of captopril and needs to use the bathroom. c. Hypertensive client with a blood pressure of 188/92 mm Hg. d. Client who needs pain medication prior to a dressing change of a surgical wound.

ANS: B

Angiotensin-converting enzyme inhibitors such as captopril can cause hypotension, especially after the first dose. The nurse would see this client first to prevent falling if the client decides to get up without assistance. The two blood pressure readings are abnormal but not critical.

The nurse would check on the client with higher blood pressure next to assess for problems related to the reading. The nurse can administer the beta blocker as standards state to hold it if the systolic blood pressure is below 90 to 100 mm Hg. The client who needs pain medication prior to the dressing change is not a priority over client safety and assisting the other client to the bathroom.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Analysis KEY: Hypertension, Angiotensin-converting enzyme (ACE) inhibitors MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 14. A client had a percutaneous angioplasty for renovascular hypertension 3 months ago. What

assessment finding by the nurse indicates that an important outcome for this client has been met? a. Client is able to decrease blood pressure medications. b. Insertion site has healed without redness or tenderness. c. Most recent lab data show BUN: 19 mg/dL and creatinine 1.1 mg/dL. d. Verbalizes understanding of postprocedure lifestyle changes.

ANS: A

Hypertension can be caused by renovascular disease. Opening up a constricted renal artery can lead to decreased blood pressure, manifested by the need for less blood pressure medication. The other findings are normal and desired, but not specifically related to hypertension caused by renal disease.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Hypertension, Perfusion MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

15. A client is 4 hours postoperative after a femoral-popliteal bypass. The client reports throbbing

leg pain on the affected side, rated as 7/10. What action by the nurse is most important? a. Administer pain medication as ordered. b. Assess distal pulses and skin color. c. Document the findings in the client’s chart. d. Notify the surgeon immediately.

ANS: B

Once perfusion has been restored or improved to an extremity, clients can often feel a throbbing pain due to the increased blood flow. However, it is important to differentiate this pain from ischemia. The nurse would assess for other signs of perfusion, such as distal pulses and skin color/temperature. Administering pain medication is done once the nurse determines that the client’s perfusion status is normal. Documentation needs to be thorough. Notifying the surgeon is not necessary.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Peripheral vascular disease, Nursing process assessment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 16. A client had a femoral-popliteal bypass graft with a synthetic graft. What action by the nurse

is most important to prevent wound infection? a. Appropriate hand hygiene before giving care b. Assessing the client’s temperature every 4 hours c. Clean technique when changing dressings d. Monitoring the client’s daily white blood cell count ANS: A

Hand hygiene is the best way to prevent infections in hospitalized clients. Dressing changes would be done with sterile technique. Assessing vital signs and white blood cell count will not prevent infection.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Infection control, Hand hygiene MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 17. A client is receiving an infusion of alteplase for an intra-arterial clot. The client begins to

mumble and is disoriented. What action by the nurse is most important? a. Assess the client’s neurologic status. b. Notify the Rapid Response Team. c. Prepare to administer vitamin K. d. Turn down the infusion rate.

ANS: B

Clients on fibrinolytic therapy are at high risk of bleeding. The sudden onset of neurologic signs may indicate that the client is having a hemorrhagic stroke. The nurse does need to complete a thorough neurologic examination, but would first call the Rapid Response Team based on the client’s manifestations. Vitamin K is not the antidote for this drug. Turning down the infusion rate will not be helpful if the client is still receiving any of the drug.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Critical rescue, Fibrinolytic agents MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care

18. A new nurse is caring for a client with an abdominal aneurysm. What action by the new nurse

requires the nurse’s mentor to intervene? a. Assesses the client for back pain. b. Auscultates over abdominal bruit. c. Measures the abdominal girth. d. Palpates the abdomen in four quadrants.

ANS: D

Abdominal aneurysms should never be palpated as this increases the risk of rupture. The nurse mentoring the new nurse would intervene when the new nurse attempts to do this. The other actions are appropriate.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Aneurysms, Abdominal assessment MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 19. A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment

indicates that an important outcome has been met? a. Ambulates with assistance b. Oxygen saturation of 98% c. Pain of 2/10 after medication d. Verbalizing risk factors ANS: B

A critical complication of DVT is pulmonary embolism. A normal oxygen saturation indicates that this has not occurred. The other assessments are also positive, but not as important.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Pulmonary embolism, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 20. A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to

the assistive personnel (AP)? a. Ambulate the client. b. Apply a warm moist pack. c. Massage the client’s leg. d. Provide an ice pack.

ANS: B

Warm moist packs will help with the pain of a DVT. Ambulation is not a comfort measure.

Massaging the client’s legs is contraindicated to prevent complications such as pulmonary embolism. Ice packs are not recommended for DVT. DIF: Understanding TOP: Integrated Process: Communication and Documentation KEY: Thromboembolic event, Comfort measures MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 21. A nurse is assessing an obese client in the clinic for follow-up after an episode of deep vein

thrombosis. The client has lost 20 lb (9.09 Kg) since the last visit. What action by the nurse is best?

a. b. c. d.

Ask if the weight loss was intended.

Encourage a high-protein, high-fiber diet.

Measure for new compression stockings.

Review a 3-day food recall diary.

ANS: C

Compression stockings must fit correctly in order to work. After losing a significant amount of weight, the client would be remeasured and new stockings ordered if needed. The other options are appropriate, but not the most important.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Thromboembolic event, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 22. A nurse wants to provide community service that helps meet the goals of Healthy People 2020

(HP2020) related to cardiovascular disease and stroke. What activity would best meet this goal? a. Teach high school students heart-healthy living. b. Participate in blood pressure screenings at the mall. c. Provide pamphlets on heart disease at the grocery store. d. Set up an “Ask the nurse” booth at the pet store.

ANS: B

An important goal of HP2020 is to increase the proportion of adults who have had their blood pressure measured within the preceding 2 years and can state whether their blood pressure was normal or high. Participating in blood pressure screening in a public spot will best help meet that goal. The other options are all appropriate but do not specifically help meet a goal.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Hypertension, Primary prevention MSC: Client Needs Category: Health Promotion and Maintenance 23. A client has been diagnosed with a deep vein thrombosis and is to be discharged on warfarin.

The client is adamant about refusing the drug because “it’s dangerous.” What action by the nurse is best? a. Assess the reason behind the client’s fear. b. Remind the client about laboratory monitoring. c. Tell the client that drugs are safer today than before. d. Warn the client about consequences of noncompliance.

ANS: A

The first step is to assess the reason behind the client’s fear, which may be related to the experience of someone the client knows who took warfarin or misinformation. If the nurse cannot address the specific rationale, teaching will likely be unsuccessful. Laboratory monitoring once every few weeks may not make the client perceive the drug to be safe.

General statements like “drugs are safer today” do not address the root cause of the problem.

Warning the client about possible consequences of not taking the drug is not therapeutic and is likely to lead to an adversarial relationship.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Psychosocial response, Therapeutic communication MSC: Client Needs Category: Psychosocial Integrity

24. A client with a history of heart failure and hypertension is in the clinic for a follow-up visit.

The client is on lisinopril and warfarin. The client reports new-onset cough. What action by the nurse is most appropriate? a. Assess the client’s lung sounds and oxygenation. b. Instruct the client on another antihypertensive. c. Obtain a set of vital signs and document them. d. Remind the client that cough is a side effect of lisinopril.

ANS: A

This client could be having an exacerbation of heart failure or experiencing a side effect of lisinopril (and other angiotensin-converting enzyme inhibitors). The nurse would assess the client’s lung sounds and other signs of oxygenation first. The client may or may not need to switch antihypertensive medications. Vital signs and documentation are important, but the nurse would assess the respiratory system first. If the cough turns out to be a side effect, reminding the client is appropriate, but then more action needs to be taken.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Angiotensin-converting enzyme (ACE) inhibitors, Adverse effects MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 25. A nurse is caring for a client with a nonhealing arterial lower leg ulcer. What action by the

nurse is best? a. Consult with the wound care nurse. b. Give pain medication prior to dressing changes. c. Maintain sterile technique for dressing changes. d. Prepare the client for eventual amputation.

ANS: A

A nonhealing wound needs the expertise of the wound care nurse. Premedicating prior to painful procedures and maintaining sterile technique are helpful, but if the wound is not healing, more needs to be done. The client may need an amputation, but other options need to be tried first.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Peripheral arterial disease, Wound care MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 26. A client has peripheral arterial disease (PAD). What statement by the client indicates

misunderstanding about self-management activities? a. “I can use a heating pad on my legs if it’s set on low.” b. “I should not cross my legs when sitting or lying down.” c. “I will go out and buy some warm, heavy socks to wear.” d. “It’s going to be really hard but I will stop smoking.”

ANS: A

Clients with PAD should never use heating pads as skin sensitivity is diminished and burns can result. The other statements show good understanding of self-management.

DIF: Evaluating TOP: Integrated Process: Nursing Process: Evaluation KEY: Peripheral arterial disease, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance

27. The nurse is assessing a client on admission to the hospital. The client’s leg appears as shown

below:

What action by the nurse is best? a. Assess the client’s ankle-brachial index. b. Elevate the client’s leg above the heart. c. Obtain an ice pack to provide comfort. d. Prepare to teach about heparin sodium.

ANS: A

This client has dependent rubor, a classic finding in peripheral arterial disease. The nurse would measure the client’s ankle-brachial index. Elevating the leg above the heart will further impede arterial blood flow. Ice will cause vasoconstriction, also impeding circulation and perhaps causing tissue injury. Heparin sodium is not the drug of choice for this condition.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Peripheral vascular disease, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 1. What nonpharmacologic comfort measures would the nurse include in the plan of care for a

client with severe varicose veins? (Select all that apply.) a. Administering mild analgesics for pain b. Applying elastic compression stockings c. Elevating the legs when sitting or lying d. Reminding the client to do leg exercises e. Teaching the client about surgical options f. Encouraging participation in high impact aerobic activity ANS: B, C, D

The three Es of care for varicose veins include elastic compression hose, exercise, and elevation. Mild analgesics are not a nonpharmacologic measure. Teaching about surgical options is not a comfort measure. High impact aerobics is not encouraged and is not a comfort measure.

DIF: Understanding TOP: Integrated Process: Nursing Process: Implementation KEY: Peripheral vascular disease, Nonpharmacologic comfort measures MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 2. A nurse is preparing a client for a femoropopliteal bypass operation. What actions does the

nurse delegate to the assistive personnel (AP)? (Select all that apply.) a. Administering preoperative medication b. Ensuring that the consent is signed c. Marking pulses with a pen d. Raising the side rails on the bed e. Recording baseline vital signs ANS: D, E

The AP can raise the side rails of the bed for client safety and take and record the vital signs.

Administering medications, ensuring that a consent is on the chart, and marking the pulses for later comparison would be done by the registered nurse. This is also often done by the postanesthesia care nurse and is part of the hand-off report.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Delegation, Client safety MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 3. A client has been bedridden for several days after major abdominal surgery. What action does

the nurse delegate to the assistive personnel (AP) for deep vein thrombosis (DVT) prevention?

(Select all that apply.) a. Apply compression stockings. b. Assist with ambulation. c. Encourage coughing and deep breathing. d. Offer fluids frequently. e. Teach leg exercises.

ANS: A, B, D

The AP can apply compression stockings, assist with ambulation, and offer fluids frequently to help prevent DVT. The AP can also encourage the client to do pulmonary exercises, but these do not decrease the risk of DVT. Teaching is a nursing function.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Deep vein thrombosis, Delegation MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 4. A nurse is caring for a client on IV infusion of heparin. What actions does this nurse include

in the client’s plan of care? (Select all that apply.) a. Assess the client for bleeding. b. Monitor the daily activated partial thromboplastin time (aPTT) results. c. Stop the IV for aPTT above baseline.

d. Use an IV pump for the infusion. e. Weigh the client daily on the same scale.

ANS: A, B, D

Assessing for bleeding, monitoring aPTT, and using an IV pump for the infusion are all important safety measures for heparin to prevent injury from bleeding. The aPTT needs to be 1.5 to 2.5 times normal in order to demonstrate that the heparin is therapeutic. Weighing the client is not related.

DIF: Applying TOP: Integrated Process: Nursing Process: Intervention KEY: Anticoagulants, Client safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 5. A client is being discharged on warfarin therapy. What discharge instruction is the nurse

required to provide? (Select all that apply.) a. Dietary restrictions b. Driving restrictions c. Follow-up laboratory monitoring d. Possible drug–drug interactions e. Reason to take medication f. Wearing a Medic Alert bracelet ANS: A, C, D, E

Best practices state that clients being discharged on warfarin need instruction on follow-up monitoring, dietary restrictions, drug–drug interactions, using a Medic Alert bracelet or necklace, and reason for compliance. Driving is typically not restricted.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Anticoagulants, Health teaching MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 6. Which statements by the client indicate good understanding of foot care in peripheral vascular

disease? (Select all that apply.) a. “A good abrasive pumice stone will keep my feet soft.” b. “I’ll always wear shoes if I can buy cheap flip-flops.” c. “I will keep my feet dry, especially between the toes.” d. “Lotion is important to keep my feet smooth and soft.” e. “Washing my feet in room-temperature water is best.” f. “I will inspect my feet daily.”

ANS: C, D, E

Good foot care includes appropriate hygiene and injury prevention. Keeping the feet dry; wearing good, comfortable shoes; using lotion; washing the feet in room-temperature water; cutting the nails straight across; and inspecting the feet daily are all important measures.

Abrasive material such as pumice stones would not be used. Cheap flip-flops may not fit well and won’t offer much protection against injury.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Peripheral vascular disease, Health teaching MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

7. A nurse is caring for a client with a nonhealing arterial ulcer. The primary health care provider

has informed the client about possibly needing to amputate the client’s leg. The client is crying and upset. What actions by the nurse are best? (Select all that apply.) a. Ask the client to describe his or her current emotions. b. Assess the client for support systems and family. c. Offer to stay with the client if he or she desires. d. Relate how smoking contributed to this situation. e. Tell the client that many people have amputations. f. Arrange for an amputee to come visit the client.

ANS: A, B, C

When a client is upset, the nurse would offer self by remaining with the client if desired.

Other helpful measures include determining what and whom the client has for support systems and asking the client to describe what he or she is feeling. Telling the client how smoking has led to this situation will only upset the client further and will damage the therapeutic relationship. Telling the client that many people have amputations belittles the client’s feelings. It is too early to send an amputee to visit the client as the decision to amputate has not yet been made.

DIF: Applying TOP: Integrated Process: Caring KEY: Psychosocial response, Therapeutic communication MSC: Client Needs Category: Psychosocial Integrity 8. The nurse working in the emergency department knows that which factors are commonly

related to aneurysm formation? (Select all that apply.) a. Atherosclerosis b. Down syndrome c. Frequent heartburn d. History of hypertension e. History of smoking f. Hyperlipidemia ANS: A, D, E, F

Atherosclerosis, hypertension, hyperlipidemia, hyperlipidemia, and smoking are the most commonly related factors. Down syndrome and heartburn have no relation to aneurysm formation.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Peripheral vascular disorders, Pathophysiology MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 9. A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal

pain. The nurse assesses the client’s blood pressure at 82/40 mm Hg. What actions by the nurse are most important? (Select all that apply.) a. Administer pain medication. b. Assess distal pulses every 10 minutes. c. Have the client sign a surgical consent. d. Notify the Rapid Response Team. e. Take vital signs every 10 minutes.

ANS: B, D, E

This client may have a ruptured/rupturing aneurysm. The nurse would notify the Rapid Response team and perform frequent client assessments. Giving pain medication will lower the client’s blood pressure even further. The nurse cannot have the client sign a consent until the surgeon has explained the procedure.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Aneurysm, Critical rescue MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 10. A client presents to the emergency department with a thoracic aortic aneurysm. Which

findings are most consistent with this condition? (Select all that apply.) a. Abdominal tenderness b. Difficulty swallowing c. Changes in bowel habits d. Shortness of breath e. Hoarseness ANS: B, E

Signs of a thoracic aortic aneurysm include shortness of breath, hoarseness, and difficulty swallowing. Pain is often rated as a 10 on a 10-point scale. Bowel habits are not related.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Aortic aneurysm, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 11. The nurse is reviewing risk factors in a client who has atherosclerosis. Which findings are

most concerning? (Select all that apply.) a. Elevated low-density lipoprotein (LDL-C) b. Decreased levels of high-density lipoprotein cholesterol (HDL-C) c. Asian ethnicity d. History of smoking e. Blood pressure: 142/92 mm Hg on one occasion ANS: A, B, D

Elevated levels of lipids (fats) such as low-density lipoprotein cholesterol (LDL-C) and decreased levels of high-density lipoprotein cholesterol can cause chemical damage to blood vessel walls. Smoking can cause endothelial damage in addition to increasing a client’s carbon monoxide levels. African American and Hispanic ethnicities carry an increased risk for atherosclerosis. Hypertension does increase atherosclerosis risk, but an elevated reading on one occasion is not classified as hypertension.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Atherosclerosis, Laboratory values MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

Chapter 34: Critical Care of Patients With Shock Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse is caring for a client who suffered massive blood loss after trauma. How does the

nurse correlate the blood loss with the client’s mean arterial pressure (MAP)? a. It causes vasoconstriction and increased MAP. b. Lower blood volume lowers MAP. c. There is no direct correlation to MAP. d. It raises cardiac output and MAP. ANS: B

Lower blood volume will decrease MAP. The other answers are not accurate.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Mean arterial blood pressure, Shock MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A nurse is caring for a client after surgery. The client’s respiratory rate has increased from 12

to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since the client was last assessed 4 hours ago. What action by the nurse is best? a. Ask if the client needs pain medication. b. Assess using the MEWS score. c. Document the findings in the client’s chart. d. Increase the rate of the client’s IV infusion.

ANS: B

Signs of the earliest stage of shock are subtle and may manifest in slight increases in heart rate, respiratory rate, or blood pressure. Even though these readings are not out of the normal range, the nurse would conduct a thorough assessment of the patient, focusing on indicators of perfusion. The MEWS score (Modified Early Warning Score) was developed to identify clients at risk for deterioration. The client may need pain medication, but this is not the priority at this time. Documentation would be done thoroughly but would be done after the assessment. The nurse would not increase the rate of the IV infusion without an order.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Shock, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 3. The nurse gets the hand-off report on four clients. Which client would the nurse assess first? a. Client with a blood pressure change of 128/74 to 110/88 mm Hg b. Client with oxygen saturation unchanged at 94% c. Client with a pulse change of 100 to 88 beats/min d. Client with urine output of 40 mL/hr for the last 2 hours ANS: A

This client has a falling systolic blood pressure, rising diastolic blood pressure, and narrowing pulse pressure, all of which may be indications of worsening perfusion status and possible shock. The nurse would assess this client first. The client with the unchanged oxygen saturation is stable at this point. Although the client with a change in pulse has a slower rate, it is not an indicator of shock since the pulse is still within the normal range; it may indicate that the client’s pain or anxiety has been relieved, or he or she is sleeping or relaxing. A urine output of 40 mL/hr is above the normal range, which is 30 mL/hr.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Shock, Nursing assessment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 4. A nurse is caring for a client after surgery who is restless and apprehensive. The assistive

personnel (AP) reports the vital signs and the nurse sees that they are only slightly different from previous readings. What action does the nurse delegate next to the AP? a. Assess the client for pain or discomfort. b. Measure urine output from the catheter. c. Reposition the client to the side. d. Stay with the client and reassure him or her.

ANS: B

Urine output changes are a sensitive early indicator of shock. The nurse would delegate emptying the urinary catheter and measuring output to the AP as a baseline for hourly urine output measurements. The AP cannot assess for pain. Repositioning may or may not be effective for decreasing restlessness, but does not take priority over physical assessments.

Reassurance is a therapeutic nursing action, but the nurse needs to do more in this situation.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Shock, Delegation MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 5. A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of

208 mg/dL (11.6 mmol/L). The spouse asks why the client needs insulin as the client is not a diabetic. What response by the nurse is best? a. “High glucose is common in shock and needs to be treated.” b. “Some of the medications we are giving are to raise blood sugar.” c. “The IV solution has lots of glucose, which raises blood sugar.” d. “The stress of this illness has made your spouse a diabetic.”

ANS: A

High glucose readings are common in shock, and best outcomes are the result of treating them and maintaining glucose readings in the range of 140 to 180 mg/dL (7.7 to 10 mmol/L. Medications and IV solutions may raise blood glucose levels, but this is not the most accurate answer. The stress of the illness has not “made” the client diabetic.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Shock, Insulin MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

6. A nurse caring for a client notes the following assessments: white blood cell count 3800/mm3

(3.8  109/L), blood glucose level 198 mg/dL (11 mmol/L), and temperature 96.2° F (35.6° C). What action by the nurse takes priority? a. Document the findings in the client’s chart. b. Give the client warmed blankets for comfort. c. Notify the primary health care provider immediately. d. Prepare to administer insulin per sliding scale.

ANS: C

This client has several indicators of sepsis with systemic inflammatory response. The nurse would notify the primary health care provider immediately. Documentation needs to be thorough but does not take priority. The client may appreciate warm blankets, but comfort measures do not take priority. The client may need insulin if blood glucose is being regulated tightly.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Shock, Critical rescue MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 7. A nurse works at a community center for older adults. What self-management measure can the

nurse teach the clients to prevent shock? a. Do not get dehydrated in warm weather. b. Drink fluids on a regular schedule. c. Seek attention for any lacerations. d. Take medications as prescribed.

ANS: B

Preventing dehydration in older adults is important because the age-related decrease in the thirst mechanism makes them prone to dehydration. Having older adults drink fluids on a regular schedule will help keep them hydrated without the influence of thirst (or lack of thirst). Telling clients not to get dehydrated is important, but not the best answer because it doesn’t give them the tools to prevent it from occurring. Older adults should seek attention for lacerations, but this is not as important an issue as staying hydrated. Taking medications as prescribed may or may not be related to hydration.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Older adult, Fluid and electrolyte imbalance MSC: Client Needs Category: Health Promotion and Maintenance 8. A client arrives in the emergency department after being in a car crash with fatalities. The

client has a nearly amputated leg that is bleeding profusely. What action by the nurse takes priority? a. Apply direct pressure to the bleeding. b. Ensure the client has a patent airway. c. Obtain a pulse oximetry reading d. Start two large-bore IV catheters.

ANS: B

Airway is the priority, followed by breathing (pulse oximetry) and circulation (IVs and direct pressure).

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Critical rescue, Shock MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 9. A client is receiving norepinephrine for shock. What assessment finding best indicates a

therapeutic effect from this drug? a. Alert and oriented, answering questions b. Client denies chest pain or chest pressure c. IV site without redness or swelling d. Urine output of 30 mL/hr for 2 hours ANS: A

Normal cognitive function is a good indicator that the client is receiving the benefits of norepinephrine. The brain is very sensitive to changes in oxygenation and perfusion.

Norepinephrine can cause chest pain as an adverse reaction, so the absence of chest pain is good but does not indicate therapeutic effect. The IV site is normal. The urine output is normal, but only minimally so.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Shock, Vasoconstrictors MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 10. A nurse is caring for a client who has a diagnosis of multiple organ dysfunction syndrome

(MODS) who will be receiving sodium nitroprusside via IV infusion. What action by the nurse causes the charge nurse to intervene? a. Assessing the IV site before giving the drug b. Obtaining a programmable (“smart”) IV pump c. Removing the IV bag from the brown plastic cover d. Taking and recording a baseline set of vital signs ANS: C

Nitroprusside degrades in the presence of light, so it must be protected by leaving it in the original brown plastic bag when infusing. The other actions are correct DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Shock, Vasoconstrictors MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 11. A nurse on the general medical-surgical unit is caring for a client in shock and assesses the

following: Respiratory rate: 10 breaths/min Pulse: 136 beats/min Blood pressure: 92/78 mm Hg Level of consciousness: responds to voice Temperature: 101.5° F (38.5° C) Urine output for the last 2 hours: 40 mL/hr.

What action by the nurse is best? a. Transfer the client to the Intensive Care Unit. b. Continue monitoring every 30 minutes. c. Notify the unit charge nurse immediately. d. Call the Rapid Response Team.

ANS: D

This client has a MEWS score of 7 (RR: 0, P: 3, SBP: 1, LOC: 1, Temperature: 1, UO: 1).

Scores above 5 are associated with a high risk of death and ICU admission. The most important action for the nurse is to notify the Rapid Response Team so that timely interventions can be initiated. The client most likely will be transferred to the ICU, but an order is required. Monitoring the client every 30 minutes is appropriate, but the nurse needs to obtain care for the client. The charge nurse is a valuable resource, but the best action is to notify the Rapid Response Team.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Implementation KEY: Sepsis, Critical rescue MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 12. A nurse is caring for several clients at risk for shock. Which laboratory value requires the

nurse to communicate with the primary health care provider? a. Creatinine: 0.9 mg/dL (68.6 mcmol/L) b. Lactate: 5.4 mg/dL (6 mmol/L) c. Sodium: 150 mEq/L (150 mmol/L) d. White blood cell count: 11,000/mm3 (11  109/L) ANS: B

A lactate level of 5.4 mg/dL (6 mmol/L) is high and is indicative of possible shock. A creatinine level of 0.9 mg/dL (68.6 mcmol/L) is normal. A sodium level of 150 mEq/L (150 mmol/L) is slightly high but does not need to be communicated. A white blood cell count of 11,000/mm3 (11  109/L) is slightly high but is not as critical as the lactate level.

DIF: Analyzing TOP: Integrated Process: Communication and Documentation KEY: Shock, Laboratory values MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 13. A nurse receives hand-off report from the emergency department on a new admission

suspected of having septic shock. The client’s qSOFA score is 3. What action by the nurse is best? a. Plan to calculate a full SOFA score on arrival. b. Contact respiratory therapy about ventilator setup. c. Arrange protective precautions to be implemented. d. Call the hospital chaplain to support the family.

ANS: A

The qSOFA score is an abbreviated Sequential Organ Failure Assessment (or “quick”). A score of 3 is high and requires the nurse to assess the client further for organ impairment. The client may or may not need a ventilator, but that in not specified in the score. The client does not need protective precautions. The client’s family may well need support, but the nurse would assess their needs and wishes prior to calling the chaplain.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Shock, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

14. A client is being discharged home after a large myocardial infarction and subsequent coronary

artery bypass grafting surgery. The client’s sternal wound has not yet healed. What statement by the client most indicates a higher risk of developing sepsis after discharge? a. “All my friends and neighbors are planning a party for me.” b. “I hope I can get my water turned back on when I get home.” c. “I am going to have my daughter scoop the cat litter box.” d. “My grandkids are so excited to have me coming home!”

ANS: B

All these statements indicate a potential for leading to infection once the client gets back home. A large party might include individuals who are themselves ill and contagious. Having litter boxes in the home can expose the client to microbes that can lead to infection. Small children often have upper respiratory infections and poor hand hygiene that spread germs.

However, the most worrisome statement is the lack of running water for handwashing and general hygiene and cleaning purposes.

DIF: Analyzing TOP: Integrated Process: Communication and Documentation KEY: Shock, Infection control MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 15. A client with MODS has been started on dobutamine. What assessment finding requires the

nurse to communicate with the primary health care provider immediately? a. Blood pressure of 98/68 mm Hg b. Pedal pulses 1+/4+ bilaterally c. Report of chest heaviness d. Urine output of 32 mL/hr ANS: C

Chest heaviness or pain indicates myocardial ischemia, a possible adverse effect of dobutamine. While taking dobutamine, the oxygen requirements of the heart are increased due to increased myocardial workload, and may cause ischemia. Without knowing the client’s previous blood pressure or pedal pulses, there is not enough information to determine if these are an improvement or not. A urine output of 32 mL/hr is acceptable.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Shock, Vasoconstrictors MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies MULTIPLE RESPONSE 1. The nurse studying shock understands that the common signs and symptoms of this condition

are directly related to which problems? (Select all that apply.) a. Anaerobic metabolism b. Hyperglycemia c. Hypotension d. Impaired renal perfusion e. Increased systemic perfusion ANS: A, C

The common signs and symptoms of shock, no matter the cause, are directly related to the effects of anaerobic metabolism and hypotension. Hyperglycemia, impaired renal function, and increased perfusion are not the cause of common signs and symptoms of shock.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Shock, Pathophysiology MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. The nurse caring for hospitalized clients includes which actions on their care plans to reduce

the possibility of the clients developing shock? (Select all that apply.) a. Assessing and identifying clients at risk b. Monitoring the daily white blood cell count c. Performing proper hand hygiene d. Removing invasive lines as soon as possible e. Using aseptic technique during procedures f. Limiting the client’s visitors until more stable ANS: A, C, D, E

Assessing and identifying clients at risk for shock is probably the most critical action the nurse can take to prevent shock from occurring. Proper hand hygiene, using aseptic technique, and removing IV lines and catheters are also important actions to prevent shock. Monitoring laboratory values does not prevent shock but can indicate a change. Limiting the client’s visitors is not a caring action. The nurse would ensure they perform proper hand hygiene on entering and leaving the room and that visitors are not ill themselves.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Shock, Infection control MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 3. The nurse caring frequently for older adults in the hospital is aware of risk factors that place

them at a higher risk for shock. For what factors would the nurse assess? (Select all that apply.) a. Altered mobility/immobility b. Decreased thirst response c. Diminished immune response d. Malnutrition e. Overhydration f. Use of diuretics ANS: A, B, C, D, F

Immobility, decreased thirst response, diminished immune response, malnutrition, and use of diuretics can place the older adult at higher risk of developing shock. Overhydration is not a common risk factor for shock.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Shock, Older adult MSC: Client Needs Category: Health Promotion and Maintenance 4. A client is in the early stages of shock and is restless. What comfort measures does the nurse

delegate to the assistive personnel (AP)? (Select all that apply.) a. Bringing the client warm blankets

b. c. d. e.

Giving the client hot tea to drink Massaging the client’s painful legs Reorienting the client as needed Sitting with the client for reassurance

ANS: A, B, D, E

The AP can bring the client warm blankets, reorient the client as needed to decrease anxiety, and sit with the client for reassurance. If the nurse assesses the client is safely able to swallow, small amounts of fluids would be allowed. Massaging the legs is not recommended as this can dislodge any clots present, which may lead to pulmonary embolism.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Shock, Nonpharmacologic comfort interventions MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 5. The nurse is caring for a client with suspected septic shock. What does the nurse prepare to do

within 1 hour of the client being identified as possibly having sepsis? (Select all that apply.) a. Administer antibiotics. b. Draw serum lactate levels. c. Infuse vasopressors. d. Measure central venous pressure. e. Obtain blood cultures. f. Administer rapid bolus of IV crystalloids.

ANS: A, B, C, E, F

Within the first hour of suspecting severe sepsis, the nurse would draw (or facilitate) serum lactate levels, obtain blood cultures (or other cultures), administer antibiotics (after the cultures have been obtained), begin rapid administration of 30 mL/kg crystalloid for hypotension or lactate 4 mmol/L. and administer vasopressors if hypotensive during or after fluid resuscitation to maintain a mean arterial pressure 65 mm Hg. Initiating hemodynamic monitoring would be done after these “bundle” measures have been accomplished.

DIF: Remembering TOP: Integrated Process: Nursing Process: Implementation KEY: Shock, Critical rescue MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

Chapter 35: Critical Care of Patients With Acute Coronary Syndromes Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A client is receiving an infusion of tissue plasminogen activator (tPA). The nurse assesses the

client to be disoriented to person, place, and time. What action by the nurse is best? a. Assess the client’s pupillary responses. b. Request a neurologic consultation. c. Call the primary health care provider immediately. d. Take and document a full set of vital signs.

ANS: C

A change in neurologic status in a client receiving t-PA could indicate intracranial hemorrhage. The nurse would notify the primary health care provider immediately. A full assessment, including pupillary responses and vital signs, occurs next. The nurse may or may not need to call a neurologist.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Coronary artery disease, Thrombolytic agents, Critical rescue MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 2. A client received tissue plasminogen activator (tPA) after a myocardial infarction and now is

on an intravenous infusion of heparin. The client’s spouse asks why the client needs this medication. What response by the nurse is best? a. “The t-PA didn’t dissolve the entire coronary clot.” b. “The heparin keeps that artery from getting blocked again.” c. “Heparin keeps the blood as thin as possible for a longer time.” d. “The heparin prevents a stroke from occurring as the t-PA wears off.”

ANS: B

After the original intracoronary clot has dissolved, large amounts of thrombin are released into the bloodstream, increasing the chance of the vessel reoccluding. The other statements are not accurate. Heparin is not a “blood thinner,” although laypeople may refer to it as such.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Coronary artery disease, Anticoagulants MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 3. A client is in the hospital after suffering a myocardial infarction and has bathroom privileges.

The nurse assists the client to the bathroom and notes the client’s O2 saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best? a. Administer oxygen at 2 L/min. b. Allow continued bathroom privileges. c. Obtain a bedside commode. d. Suggest the client use a bedpan.

ANS: B

This client’s physiologic parameters did not exceed normal during and after activity, so it is safe for the client to continue using the bathroom. There is no indication that the client needs oxygen, a commode, or a bedpan.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Coronary artery disease, Activity tolerance MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 4. A nurse is caring for a client who had a myocardial infarction. The nurse is confused because

the client states that nothing is wrong and yet listens attentively while the nurse provides education on lifestyle changes and healthy menu choices. What response by the charge nurse is best? a. “Continue to educate the client on possible healthy changes.” b. “Emphasize complications that can occur with noncompliance.” c. “Tell the client that denial is normal and will soon go away.” d. “You need to make sure the client understands this illness.”

ANS: A

Clients are often in denial after a coronary event. The client who seems to be in denial but is compliant with treatment may be using a healthy form of coping that allows time to process the event and start to use problem-focused coping. The nurse would not discourage this type of denial and coping, but rather continue providing education in a positive manner.

Emphasizing complications may make the client defensive and more anxious. Telling the client that denial is normal is placing too much attention on the process. Forcing the client to verbalize understanding of the illness is also potentially threatening to the client.

DIF: Understanding TOP: Integrated Process: Communication and Documentation KEY: Coronary artery disease, Psychosocial response MSC: Client Needs Category: Psychosocial Integrity 5. A client undergoing hemodynamic monitoring after a myocardial infarction has a right atrial

pressure of 0.5 mm Hg. What action by the nurse is most appropriate? a. Level the transducer at the phlebostatic axis. b. Lay the client in the supine position. c. Prepare to administer diuretics. d. Prepare to administer a fluid bolus.

ANS: D

Normal right atrial pressures are from 0 to 8 mm Hg. This pressure is at the extreme lower end, which indicates hypovolemia, so the nurse would prepare to administer a fluid bolus. The transducer would remain leveled at the phlebostatic axis. Positioning may or may not influence readings but a reading this low is definitive for volume depletion. Diuretics would be contraindicated.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Hemodynamic monitoring, Fluid and electrolyte imbalance MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. A client has hemodynamic monitoring after a myocardial infarction. What safety precaution

does the nurse implement for this client?

a. Document pulmonary artery occlusion pressure (PAOP) readings and assess their

trends. b. Ensure that the balloon does not remain wedged. c. Keep the client on strict NPO status. d. Maintain the client in a semi-Fowler position.

ANS: B

If the balloon remains inflated, it can cause pulmonary infarction or rupture. The nurse would ensure that the balloon remains deflated between PAOP readings. Documenting PAOP readings and assessing trends are important nursing actions related to hemodynamic monitoring, but are not specifically related to safety. The client does not have to be NPO while undergoing hemodynamic monitoring. Positioning is not related to safety with hemodynamic monitoring.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Hemodynamic monitoring, Equipment safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 7. A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse

notes that the client’s heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate? a. Allow the client to rest quietly. b. Assess the client for bleeding. c. Document the findings in the chart. d. Medicate the client for pain.

ANS: B

A major complication related to intra-arterial blood pressure monitoring is hemorrhage from the insertion site. Since these vital signs are out of the normal range, are a change, and are consistent with blood loss, the nurse would assess the client for any bleeding associated with the arterial line. The nurse would document the findings after a full assessment. The client may or may not need pain medication and rest; the nurse first needs to rule out any emergent bleeding.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Intra-arterial blood pressure monitoring, Equipment safety MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 8. A client is in the preoperative holding area prior to an emergency coronary artery bypass graft

(CABG). The client is yelling at family members and tells the doctor to “just get this over with” when asked to sign the consent form. What action by the nurse is best? a. Ask the family members to wait in the waiting area. b. Inform the client that this behavior is unacceptable. c. Stay out of the room to decrease the client’s stress levels. d. Tell the client that anxiety is common and that you can help.

ANS: D

Preoperative fear and anxiety are common prior to cardiac surgery, especially in emergent situations. The client is exhibiting anxiety, and the nurse would reassure the client that fear is common and offer to help. The other actions will not reduce the client’s anxiety.

DIF: Applying TOP: Integrated Process: Caring KEY: Coronary artery disease, Psychosocial response MSC: Client Needs Category: Psychosocial Integrity 9. A client is in the clinic a month after having a myocardial infarction. The client reports

sleeping well since moving into the guest bedroom. What response by the nurse is best? a. “Do you have any concerns about sexuality?” b. “I’m glad to hear you are sleeping well now.” c. “Sleep near your spouse in case of emergency.” d. “Why would you move into the guest room?”

ANS: A

Concerns about resuming sexual activity are common after cardiac events. The nurse would gently inquire if this is the issue. While it is good that the client is sleeping well, the nurse would investigate the reason for the move. The other two responses are likely to cause the client to be defensive.

DIF: Applying TOP: Integrated Process: Caring KEY: Coronary artery disease, Sexuality MSC: Client Needs Category: Psychosocial Integrity 10. A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by

nausea and vomiting. What action by the nurse takes priority? a. Administer an aspirin. b. Call for an electrocardiogram (ECG). c. Maintain airway patency. d. Notify the provider.

ANS: C

Airway always is the priority. The other actions are important in this situation as well, but the nurse would stay with the client and ensure that the airway remains patent (especially if vomiting occurs) while another person calls the primary health care provider (or Rapid Response Team) and facilitates getting an ECG done. Aspirin will probably be administered, depending on the primary health care provider’s prescription and the client’s current medications.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Coronary artery disease, Critical rescue MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 11. An older adult is on cardiac monitoring after a myocardial infarction. The client shows

frequent dysrhythmias. What action by the nurse is most appropriate? a. Assess for any hemodynamic effects of the rhythm. b. Prepare to administer antidysrhythmic medication. c. Notify the primary health care provider or call the Rapid Response Team. d. Turn the alarms off on the cardiac monitor.

ANS: A

Older clients may have dysrhythmias due to age-related changes in the cardiac conduction system. Or this client’s dysrhythmias could be a consequence of the myocardial infarction.

They may or may not have significant hemodynamic effects. The nurse would first assess for the effects of the dysrhythmia before proceeding further. The alarms on a cardiac monitor would never be shut off. The other two actions may or may not be needed.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Coronary artery disease, Dysrhythmias MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 12. The nurse is preparing to change a client’s sternal dressing. What action by the nurse is most

important? a. Assess vital signs. b. Don a mask and gown. c. Gather needed supplies. d. Perform hand hygiene.

ANS: D

To prevent a sternal wound infection, the nurse washes hands or performs hand hygiene as a priority and uses sterile technique when changing the dressing. Vital signs do not necessarily need to be assessed beforehand. A mask and gown are not needed. The nurse would gather needed supplies, but this is not the priority.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Coronary artery disease, Infection control MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 13. A client has progressed to Killip class III heart failure after a myocardial infarction. What

does the nurse anticipate the client’s care to include? a. Diuretics b. Nitrates c. Clopidogrel d. Dobutamine ANS: D

The client in class III heart failure would benefit from a positive inotrope such as dobutamine.

Clients in class I typically respond well to diuretics and nitrates so this client would already be on these medications. Clopidogrel is a platelet inhibitor that will be prescribed for anyone having acute coronary syndrome for at least 12 months.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Heart failure, Inotropic medications MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 14. A nurse is in charge of the coronary intensive care unit. Which client would the nurse see

first? a. Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours b. Client who is 1-day post coronary artery bypass graft, with blood pressure 88/64 mm Hg c. Client who is 1-day post percutaneous coronary intervention, going home this morning

d. Client who is 2-day post coronary artery bypass graft, who became dizzy this

morning while walking ANS: B

Hypotension after coronary artery bypass graft surgery can be dangerous because it can lead to collapse of the graft. The charge nurse would see this client first. The client who became dizzy earlier would be seen next. The client on the nitroglycerin drip is stable. The client going home can wait until the other clients are cared for.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Coronary artery disease, Coronary artery bypass graft MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 15. A client with coronary artery disease (CAD) asks the nurse about taking fish oil supplements.

What response by the nurse is best? a. “Fish oil is contraindicated with most drugs for CAD.” b. “The best source is fish, but pills have benefits too.” c. “There is no evidence to support fish oil use with CAD.” d. “You can reverse CAD totally with diet and supplements.”

ANS: B

Omega-3 fatty acids have shown benefit in reducing lipid levels, in reducing the incidence of sudden cardiac death, and for stabilizing atherosclerotic plaque. The preferred source of omega-3 acids is from fish rich in long-chain n-3 polyunsaturated fatty acids two times a week or a daily fish oil nutritional supplement (1 to 2 g/day). The other options are not accurate.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Coronary artery disease, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 16. A client has presented to the emergency department with an acute myocardial infarction (MI).

What action by the nurse is best for optimal client outcomes? a. Obtain an electrocardiogram (ECG) within 20 minutes. b. Give the client a nonenteric coated aspirin. c. Notify the Rapid Response Team immediately. d. Prepare to administer thrombolytics within 30 minutes.

ANS: B

Best practice recommendations for acute MI require that aspirin is administered when a client with MI presents to the emergency department or when an MI occurs in the hospital. A rapid ECG (within 10 minutes) is vital for best outcomes. The Rapid Response Team is not needed if an emergency department provider is available. Thrombolytics may or may not be needed depending on the type of myocardial infarction the client has.

DIF: Remembering TOP: Integrated Process: Nursing Process: Implementation KEY: Coronary artery disease, Best practice MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 17. A nurse is caring for four client s. Which client would the nurse assess first? a. Client with an acute myocardial infarction, pulse 102 beats/min b. Client who is 1 hour post-angioplasty, and has tongue swelling and anxiety

c. Client who is post coronary artery bypass, with chest tube drained 100 mL/hr d. Client who is post coronary artery bypass, with potassium 4.2 mEq/L (4.2 mmol/L) ANS: B

The post-angioplasty client with tongue swelling and anxiety is exhibiting signs and symptoms of an allergic reaction (perhaps to the contrast medium) that could progress to anaphylaxis. The nurse would assess this client first. The client with a heart rate of 102 beats/min may have increased oxygen demands but is just over the normal limit for heart rate.

The two post coronary artery bypass clients are stable.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Analysis KEY: Coronary artery disease, Critical rescue MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 18. A nurse is caring for a client who is intubated and has an intra-aortic balloon pump. The client

is restless and agitated. What action would the nurse perform first for comfort? a. Allow family members to remain at the bedside. b. Ask the family if the client would like a fan in the room. c. Keep the television tuned to the client’s favorite channel. d. Speak loudly to the client in case of hearing problems.

ANS: A

Allowing the family to remain at the bedside can help calm the client with familiar voices (and faces if the client wakes up). A fan might be helpful but may also spread germs through air movement or may agitate the client further. The TV would not be kept on all the time to allow for rest. Speaking loudly may agitate the client more.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Intra-aortic balloon pump, Nonpharmacologic comfort measures MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 19. The nurse is caring for a client with a chest tube after a coronary artery bypass graft. The

drainage stops suddenly. What action by the nurse is most important? a. Increase the setting on the suction. b. Notify the primary health care provider immediately. c. Reposition the chest tube. d. Take the tubing apart to assess for clots.

ANS: B

If the drainage in the chest tube decreases significantly and dramatically, the tube may be blocked by a clot. This could lead to cardiac tamponade. The nurse would notify the primary health care provider immediately. The nurse would not independently increase the suction, reposition the chest tube, or take the tubing apart.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Coronary artery bypass graft, Chest tubes MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 20. A client is to receive a dopamine infusion. What does the nurse do to prepare for this

infusion? a. Gather central line supplies. b. Mark the client’s pedal pulses.

c. Monitor the client’s vital signs. d. Ensure an accurate weight is charted.

ANS: A

Dopamine should be infused through a central line to prevent extravasation and necrosis of tissue. The nurse would gather supplies for the primary health care provider to insert a central line. Monitoring vital signs is important for any client who has an acute cardiac problem, but this doesn’t give the frequency of evaluation. Marking the client’s pedal pulses and ensuring a weight is documented are not related to this infusion.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Inotropic agents, Medication safety MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 21. A client had an acute myocardial infarction. What assessment finding indicates to the nurse

that a significant complication has occurred? a. Blood pressure that is 20 mm Hg below baseline b. Oxygen saturation of 94% on room air c. Poor peripheral pulses and cool skin d. Urine output of 1.2 mL/kg/hr for 4 hours ANS: C

Poor peripheral pulses and cool skin may be signs of impending cardiogenic shock and would be reported immediately. A blood pressure drop of 20 mm Hg may not be worrisome. An oxygen saturation of 94% is just slightly below normal. A urine output of 1.2 mL/kg/hr for 4 hours is normal.

DIF: Remembering TOP: Integrated Process: Nursing Process: Analysis KEY: Coronary artery disease, Critical rescue MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 22. A client presents to the emergency department with an acute myocardial infarction (MI) at

15:00 (3:00 p.m.). The facility has 24-hour catheterization laboratory abilities. To improve client outcomes, by what time would the client have a percutaneous coronary intervention performed? a. 15:30 (3:30 p.m.) b. 16:00 (4:00 p.m.) c. 16:30 (4:30 p.m.) d. 17:00 (5:00 p.m.)

ANS: C

Percutaneous coronary intervention would be performed within 90 minutes of diagnosis of myocardial infarction. Therefore, the client would have a percutaneous coronary intervention performed no later than 16:30 (4:30 p.m.).

DIF: Remembering TOP: Integrated Process: Communication and Documentation KEY: Coronary artery disease, Percutaneous coronary intervention MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 23. The primary health care provider requests the nurse start an infusion of milrinone on a client.

How does the nurse explain the action of this drug to the client and spouse?

a. b. c. d.

“It constricts vessels, improving blood flow.”

“It dilates vessels, which lessens the work of the heart.”

“It increases the force of the heart’s contractions.”

“It slows the heart rate down for better filling.”

ANS: C

Milrinone, is a positive inotrope, is a medication that increases the strength of the heart’s contractions. It is not a vasoconstrictor, a vasodilator, nor does it slow the heart rate.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Coronary artery disease, Inotropic agents MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 24. A client had an inferior wall myocardial infarction (MI). The nurse notes the client’s cardiac

rhythm as shown below:

What action by the nurse is most important? a. Assess the client’s blood pressure and level of consciousness. b. Call the primary health care provider or the Rapid Response Team. c. Obtain a permit for an emergency temporary pacemaker insertion. d. Prepare to administer antidysrhythmic medication.

ANS: A

Clients with an inferior wall MI often have bradycardia and blocks that lead to decreased perfusion, as seen in this ECG strip. The nurse would first assess the client’s hemodynamic status, including vital signs and level of consciousness. The client may or may not need the Rapid Response Team, a temporary pacemaker, or medication; there is no indication of this in the question.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Implementation KEY: Coronary artery disease, Dysrhythmias MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 25. A nurse prepares a client for coronary artery bypass graft surgery. The client states, “I am

afraid I might die.” What is the nurse’s best response? a. “This is a routine surgery and the risk of death is very low.” b. “Would you like to speak with a chaplain prior to surgery?” c. “Tell me more about your concerns about the surgery.” d. “What support systems do you have to assist you?”

ANS: C

The nurse would discuss the client’s feelings and concerns related to the surgery. The nurse would not provide false hope or simply call the chaplain. The nurse would address support systems after addressing the client’s current issue.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Coping, Anxiety MSC: Client Needs Category: Psychosocial Integrity MULTIPLE RESPONSE 1. A nurse learns about modifiable risk factors for coronary artery disease. Which factors does

this include? (Select all that apply.) a. Age b. Hypertension c. Obesity d. Smoking e. Stress f. Gender ANS: B, C, D, E

Hypertension, obesity, smoking, and excessive stress are all modifiable risk factors for coronary artery disease. Age and gender are not nonmodifiable risk factors.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Coronary artery disease, Lifestyle factors MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A nurse is caring for a client who had coronary artery bypass grafting 2 days ago. What

actions does the nurse delegate to the assistive personnel (AP)? (Select all that apply.) a. Assist the client to the chair for meals and to the commode. b. Encourage the client to use the spirometer every 4 hours. c. Ensure that the client wears TED hose or sequential compression devices. d. Have the client rate pain on a 0-10 scale and report to the nurse. e. Take and record a full set of vital signs per hospital protocol.

ANS: A, C, E

The nurse can delegate assisting the client to get up in the chair or commode (if the nurse has evaluated the client as being stable), applying TEDs or sequential compression devices, and taking/recording vital signs. The spirometer would be used every hour the day after surgery.

Assessing pain using a 0-10 scale is a nursing assessment, although if the client reports pain, the AP would inform the nurse so a more detailed assessment is done.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Coronary artery disease, Delegation MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 3. A nurse studying acute coronary syndromes learns that the pain of a myocardial infarction

(MI) differs from stable angina in what ways? (Select all that apply.) a. Accompanied by shortness of breath b. Feelings of fear or anxiety c. Lasts less than 15 minutes d. No relief from taking nitroglycerin e. Pain occurs without known cause f. Can be precipitated by exertion or stress ANS: A, B, D, E

The pain from an MI is often accompanied by shortness of breath and fear or anxiety. It lasts longer than 15 minutes and is not relieved by nitroglycerin. It occurs without a known cause such as exertion or stress.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Coronary artery disease, Pathophysiology MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. A client is 1-day postoperative after a coronary artery bypass graft. What nonpharmacologic

comfort measures does the nurse include when caring for this client? (Select all that apply.) a. Administer pain medication before ambulating. b. Assist the client into a position of comfort in bed. c. Encourage high-protein diet selections. d. Provide complementary therapies such as music. e. Remind the client to splint the incision when coughing.

ANS: B, D, E

Nonpharmacologic comfort measures can include positioning, complementary therapies, and splinting the chest incision. Medications are not nonpharmacologic. Food choices are not comfort measures.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Coronary artery disease, Nonpharmacologic comfort measures MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 5. Prior to discharge, a client who had an acute myocardial infarction and coronary artery bypass

graft asks the nurse about sexual activity. What information does the nurse provide? (Select all that apply.) a. “You will need to wait at least 6 weeks before intercourse.’ b. “Your usual sexual activity is not likely to damage your heart.” c. “Start having sex when you are most rested, like in the morning.” d. “When you can climb four flights of stairs, you can tolerate sex.” e. “Don’t eat for three hours before engaging in sexual activity.” f. “Use a comfortable position that doesn’t stress your incision.”

ANS: B, C, F

Clients have many concerns about resuming sexual activity after an acute coronary event.

Generally, once the client can walk one block or climb two flights of stairs, he or she can tolerate sex. The client should start after a period of rest and at least 11/2 hours after a heavy meal or exercise. Clients should be taught to choose a position that is comfortable for both parties and does not place undue stress on their incisions or on their hearts.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Coronary artery disease, Health teaching MSC: Client Needs Category: Psychosocial Integrity 6. A nurse is studying hemodynamic monitoring. Which measurements are correctly matched

with the physiologic cause? (Select all that apply.) a. Right atrial pressure 12 mm Hg: right ventricular failure b. Right atrial pressure 4 mm Hg: hypovolemia c. Pulmonary artery pressure 20/10 mm Hg: normal finding

d. Pulmonary artery occlusion pressure 20 mm Hg: mitral regurgitation e. Pulmonary artery occlusion pressure 2 mm Hg: afterload reduction ANS: A, C, D, E

Normal right atrial pressure is 0 to 8 mm Hg; high readings can indicate right ventricular failure; low readings often signify hypovolemia. Normal pulmonary artery pressure ranges from 15 to 30 mm Hg systolic to 3 to 12 mm Hg diastolic. Pulmonary artery occlusion pressure ranges from 5 to 12 mm Hg; high values may indicate left ventricular failure, hypervolemia, mitral regurgitation, or intracardiac shunting. A decreased PAOP is seen with hypovolemia or afterload reduction.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Hemodynamic monitoring MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

Chapter 36: Assessment of the Hematologic System Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. The nurse is assessing an older client for any potential hematologic health problem. Which

assessment finding is the most significant and would be reported to the primary health care provider? a. Poor skin turgor on both forearms b. Multiple petechiae and large bruises c. Dry, flaky skin on arms and legs d. Decreased body hair distribution ANS: B

The presence of multiple petechiae and large bruises indicate a possible problem with blood clotting. Older adults typically have poor skin turgor and dry, flaky skin due to decreased body fluid as a result of aging. They also lose body hair or have thinning hair as a normal change of aging.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Hematologic system, Nursing assessment, Older adult MSC: Client Needs Category: Health Promotion and Maintenance 2. A nurse is assessing a dark-skinned client for pallor. What nursing assessment is best to

assess for pallor in this client? a. Assess the conjunctiva of the eye. b. Have the patient open the hand widely. c. Look at the roof of the patient’s mouth. d. Palpate for areas of mild swelling.

ANS: A

To assess pallor in dark-skinned people, assess the conjunctiva of the eye or the mucous membranes. Looking at the roof of the mouth can reveal jaundice. Opening the hand widely is not related to pallor, nor is palpating for mild swelling.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Hematologic system, Nursing assessment, Anemia MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 3. A hospitalized client has a platelet count of 58,000/mm3 (58  109/L). What action by the

nurse is most appropriate? a. Encourage high-protein foods. b. Institute neutropenic precautions. c. Limit visitors to healthy adults. d. Place the client on safety precautions.

ANS: D

With a platelet count between 40,000 and 80,000/mm3 (40 and 80  109/L), clients are at risk of prolonged bleeding even after minor trauma. The nurse would place the client on safety or bleeding precautions as the most appropriate action. High-protein foods, while healthy, are not the priority. Neutropenic precautions are not needed as the patient’s white blood cell count is not low. Limiting visitors would also be more likely related to a low white blood cell count.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Hematologic system, Patient safety, Laboratory values MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 4. A client is having a bone marrow aspiration and biopsy. What action by the nurse takes

priority? a. Administer pain medication first. b. Ensure that valid consent is in the medical record. c. Have the client shower in the morning. d. Premedicate the client with sedatives.

ANS: B

A bone marrow aspiration and biopsy is an invasive procedure that requires informed consent.

Pain medication and sedation are important components of care for this client but do not take priority. The client may or may not need or be able to shower.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Hematologic system, Informed consent MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 5. What is the nurse’s priority when caring for a client who just completed a bone marrow

aspiration and biopsy? a. Teach the client to avoid activity for 24 to 48 hours to prevent infection. b. Administer a nonsteroidal anti-inflammatory drug (NSAID) to promote comfort. c. Check the pressure dressing frequently for signs of excessive or active bleeding. d. Report the laboratory results to the primary health care provider.

ANS: C

The client having a bone marrow aspiration and biopsy has a puncture wound from the large needle used to extract the bone marrow. Therefore, the client is at risk for bleeding. A NSAID should not be given because it can cause bleeding. Avoiding activity helps to prevent bleeding, not infection, and reporting the results of the biopsy is not the responsibility of the nurse.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Hematologic system, Patient safety, Diagnostic testing MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 6. A nurse is caring for four clients. After reviewing today’s laboratory results, which client

would the nurse assess first? a. Client with an international normalized ratio of 2.8 b. Client with a platelet count of 128,000/mm3 (128  109/L). c. Client with a prothrombin time (PT) of 28 seconds d. Client with a red blood cell count of 5.1 million/mcL (5.1  1012/L) ANS: C

A normal PT is 11 to 12.5 seconds. This client is at high risk of bleeding with a PT of 28 seconds. The other values are within normal limits.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Analysis KEY: Hematologic system, Laboratory values MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 7. A client is having a bone marrow aspiration and biopsy and is extremely anxious. What action

by the nurse is the most appropriate? a. Assess the client’s fears and coping mechanisms. b. Reassure the client that this is a common test. c. Sedate the client prior to the procedure. d. Tell the client that he or she will be asleep.

ANS: A

Assessing the client’s specific fears and coping mechanisms helps guide the nurse in providing holistic care that best meets the client’s needs. Reassurance will be helpful but is not the best option. Sedation is usually used. The client may or may not be totally asleep during the procedure.

DIF: Applying TOP: Integrated Process: Caring KEY: Hematologic system, Psychosocial response, Anxiety, Support MSC: Client Needs Category: Psychosocial Integrity 8. A client is having a radioisotopic imaging scan. What action by the nurse is most important? a. Assess the client for shellfish allergies. b. Place the client on radiation precautions. c. Sedate the client before the scan. d. Teach the client about the procedure.

ANS: D

The nurse should ensure that teaching is done and the client understands the procedure.

Contrast dye is not used, so shellfish/iodine allergies are not related. The client will not be radioactive and does not need radiation precautions. Sedation is not used in this procedure.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Hematologic system, Patient education MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential MULTIPLE RESPONSE 1. While taking a client history, which factor(s) that place the client at risk for a hematologic

health problem will the nurse document? (Select all that apply.) a. Family history of bleeding problems b. Diet low in iron and protein c. Excessive alcohol consumption d. Family history of allergies e. Diet high in saturated fats f. Diet high in Vitamin K ANS: A, C, F

A family history of bleeding problems places the client at risk for having a similar problem.

Excessive alcohol can damage the liver where prothrombin is produced. A diet high in Vitamin K can cause excessive clotting because it is a major clotting factor.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Hematologic system, Nursing assessment MSC: Client Needs Category: Health Promotion and Maintenance 2. An older client asks the nurse why “people my age” have weaker immune systems than

younger people. What responses by the nurse are best? (Select all that apply.) a. “Bone marrow produces fewer blood cells as you age.” b. “You may have decreased levels of circulating platelets.” c. “You have lower levels of plasma proteins in the blood.” d. “Lymphocytes become more reactive to antigens.” e. “Spleen function declines after age 60.”

ANS: A, C

The aging adult has bone marrow that produces fewer cells and decreased blood volume with fewer plasma proteins. Platelet numbers remain unchanged, lymphocytes become less reactive, and spleen function stays the same.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Hematologic system MSC: Client Needs Category: Health Promotion and Maintenance 3. The nurse is assessing a client experiencing anemia. Which laboratory findings will the nurse

expect for this client? (Select all that apply.) a. Increased hematocrit b. Decreased red blood cell count c. Decreased serum iron d. Decreased hemoglobin e. Increased platelet count f. Decreased white blood cell count ANS: B, C, D

Clients experiencing anemia have a decreased red blood cell count which leads to a decreased hemoglobin and hematocrit. For some clients, serum iron levels are also decreased. Anemia is not a problem involving platelets or white blood cells.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Analysis KEY: Lab Profile Box MSC: Client Needs Category: Physiological Integrity 4. A nurse works in a gerontology clinic. What age-related change(s) related to the hematologic

system will the nurse expect during health assessment? (Select all that apply.) a. Dentition deteriorates with more cavities. b. Nail beds may be thickened or discolored. c. Progressive loss or thinning of hair occurs. d. Sclerae begin to turn yellow or pale. e. Skin becomes more oily.

ANS: B, C

Common findings in older adults include thickened or discolored nail beds, dry (not oily) skin, and thinning hair. The nurse adapts to these changes by altering assessment techniques.

Having more dental caries and changes in the sclerae are not normal age-related changes.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Hematologic system, Older adult, Nursing assessment MSC: Client Needs Category: Health Promotion and Maintenance

Chapter 37: Concepts of Care for Patients With Hematologic Problems Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse caring for a client with sickle cell disease (SCD) reviews the client’s laboratory test

results. Which finding would the nurse report to the primary health care provider? a. Creatinine: 2.9 mg/dL (256 mcmol/L) b. Hematocrit: 30% c. Sodium: 146 mEq/L (146 mmol/L) d. White blood cell count: 12,000/mm3 (12  109/L) ANS: A

An elevated creatinine indicates kidney damage, which occurs in SCD. A hematocrit level of 30% is an expected finding, as is a slightly elevated white blood cell count due to chronic inflammation. A sodium level of 146 mEq/L (146 mmol/L), although slightly high, is not concerning.

DIF: Analyzing TOP: Integrated Process: Communication and Documentation KEY: Hematologic system, Laboratory values, Anemias MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 2. The nurse is assessing a client in sickle cell disease (SCD) crisis. What priority client

problem will the nurse expect? a. Infection b. Pallor c. Pain d. Fatigue ANS: C

The priority expected client problem for clients experiencing sickle cell disease crisis is pain, often concentrated in the legs, arms, and joints. Clients may also be fatigued and pale but these symptoms are not a priority for care. Infection is not expected but can occur in clients who have SCD crisis.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Hematologic system, Physical assessment, Sickle cell disease MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 3. A client in sickle cell crisis is dehydrated and in the emergency department. The nurse plans

to start an IV. Which fluid choice is best? a. 0.45% normal saline b. 0.9% normal saline c. Dextrose 50% (D50) d. Lactated Ringer’s solution ANS: A

Because clients in sickle cell crisis are often dehydrated, the fluid of choice is a hypotonic solution such as 0.45% normal saline. 0.9% normal saline and lactated Ringer’s solution are isotonic. D50 is hypertonic and not used for hydration.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Analysis KEY: Hematologic system, Anemias, Fluid and electrolyte imbalance, IV fluids, Hydration MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. A client presents to the emergency department in sickle cell disease crisis. What intervention

by the nurse takes priority? a. Administer oxygen. b. Initiate pulse oximetry. c. Give pain medication. d. Start an IV line.

ANS: A

All actions are appropriate, but remembering the ABCs, oxygen would come first. The main problem in a sickle cell crisis is tissue and organ hypoxia, so providing oxygen helps halt the process.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Hematologic system, Anemias, Oxygen, Oxygen therapy MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 5. A client hospitalized with sickle cell disease crisis frequently asks for opioid pain

medications, often shortly after receiving a dose. The nurses on the unit believe that the client is drug seeking. When the client requests pain medication, what action by the nurse is best? a. Give the client pain medication if it is time for another dose. b. Instruct the client not to request pain medication too early. c. Request the primary health care provider leave a prescription for a placebo. d. Tell the client that it is too early to have more pain medication.

ANS: A

Clients with sickle cell crisis often have severe pain that is managed with up to 48 hours of IV opioid analgesics. Even if the client is addicted and drug seeking, he or she is still in extreme pain. If the client can receive another dose of medication, the nurse would provide it. The other options are judgmental and do not address the client’s pain. Giving a placebo is unethical.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Hematologic system, Anemias, Pain, Caring MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. The nurse is caring for a client experiencing sickle cell disease crisis. Which priority action

would help prevent infection? a. Administering prophylactic antibiotics b. Monitoring the client’s temperature c. Checking the client’s white blood cell count d. Performing frequent handwashing ANS: D

Frequent and thorough handwashing is the most important intervention that helps prevent infection. Antibiotics are not usually used to prevent infection. Monitoring the client’s temperature or white blood cell count helps to detect the presence of infection, but prevent it.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Hematologic system, Sickle cell disease MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 7. A nurse in a hematology clinic is working with four clients who have polycythemia vera.

Which client would the nurse assess first? a. Client with a blood pressure of 180/98 mm Hg b. Client who reports shortness of breath c. Client who reports calf tenderness and swelling d. Client with a swollen and painful left great toe ANS: B

Clients with polycythemia vera often have clotting abnormalities due to the hyperviscous blood with sluggish flow. The client reporting shortness of breath may have a pulmonary embolism and should be seen first. The client with a swollen calf may have a deep vein thrombosis and should be seen next. High blood pressure and gout symptoms are common findings with this disorder.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Hematologic system, Polycythemia vera, Nursing assessment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 8. The nurse is teaching a client who has pernicious anemia about necessary dietary changes.

Which statement by the client indicates understanding about those changes? a. “I’ll increase animal proteins like fish and meat.” b. “I’ll work on increasing my fats and carbohydrates.” c. “I’ll avoid eating green leafy vegetables. d. “I’ll limit my intake of citrus fruits.”

ANS: A

Clients who have pernicious anemia have a Vitamin B12 deficiency and need to consume foods high in Vitamin B12, such as animal and plant proteins, citrus fruits, green leafy vegetables, and dairy products. While carbohydrates and fats can provide sources of energy, they do not supply the necessary nutrient to improve anemia.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Hematologic system, Anemia MSC: Client Needs Category: Health Promotion and Maintenance 9. An assistive personnel is caring for a client with leukemia and asks why the client is still at

risk for infection when the white blood cell count (WBC) is high. What response by the nurse is correct? a. “If the WBCs are high, there already is an infection present.” b. “The client is in a blast crisis and has too many WBCs.” c. “There must be a mistake; the WBCs should be very low.” d. “Those WBCs are abnormal and don’t provide protection.”

ANS: D

In leukemia, the WBCs are abnormal and do not provide protection to the client against infection. The other statements are not accurate.

DIF: Understanding

TOP: Integrated Process: Teaching/Learning

KEY: Leukemia, Infection, Laboratory values MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 10. The family of a neutropenic client reports that the client “is not acting right.” What action by

the nurse is the priority? a. Ask the client about pain. b. Assess the client for infection. c. Take a set of vital signs. d. Review today’s laboratory results.

ANS: B

Neutropenic clients often do not have classic manifestations of infection, but infection is the most common cause of death in neutropenic clients. The nurse would definitely assess for infection. The nurse would assess for pain but this is not the priority.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Hematologic system, Neutropenia, Infection MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 11. A nurse is caring for a client who is about to receive a bone marrow transplant. To best help

the client cope with the long recovery period, what action by the nurse is best? a. Arrange a visitation schedule among friends and family. b. Explain that this process is difficult but must be endured. c. Help the client find things to hope for each day of recovery. d. Provide plenty of diversionary activities for this time.

ANS: C

Providing hope is an essential nursing function during treatment for any disease process, but especially during the recovery period after bone marrow transplantation, which can take up to 3 weeks. The nurse can help the client look ahead to the recovery period and identify things to hope for during this time. Visitors are important to clients, but may pose an infection risk.

Telling the client that the recovery period must be endured does not acknowledge his or her feelings. Diversionary activities are important, but not as important as instilling hope.

DIF: Applying TOP: Integrated Process: Caring KEY: Psychosocial response, Caring, Hematologic system, Bone marrow transplant MSC: Client Needs Category: Psychosocial Integrity 12. A client asks about the process of graft-versus-host disease. What explanation by the nurse is

correct? a. “Because of immunosuppression, the donor cells take over.” b. “It’s like a transfusion reaction because no perfect matches exist.” c. “The patient’s cells are fighting donor cells for dominance.” d. “The donor’s cells are actually attacking the patient’s cells.”

ANS: D

Graft-versus-host disease is an autoimmune-type process in which the donor cells recognize the client’s cells as foreign and begin attacking them. The other answers are not accurate.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Hematologic system, Bone marrow transplant MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

13. The nurse is caring for a patient with leukemia who has severe fatigue. What action by the

client best indicates that an important outcome to manage this problem has been met? a. Doing activities of daily living (ADLs) using rest periods b. Helping plan a daily activity schedule c. Requesting a sleeping pill at night d. Telling visitors to leave when fatigued ANS: A

Fatigue is a common problem for clients with leukemia. This client is managing his or her own ADLs using rest periods, which indicates an understanding of fatigue and how to control it. Helping to plan an activity schedule is a lesser indicator. Requesting a sleeping pill does not help control fatigue during the day. Asking visitors to leave when tired is another lesser indicator. Managing ADLs using rest periods demonstrates the most comprehensive management strategy.

DIF: Evaluating TOP: Integrated Process: Nursing Process: Evaluation KEY: Hematologic system, Leukemia, Sleep and rest, Activity MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 14. A nurse is caring for a young male client with lymphoma who is to begin treatment. What

teaching topic is a priority? a. Genetic testing b. Infection prevention c. Sperm banking d. Treatment options ANS: C

All teaching topics are important to the client with lymphoma, but for a young male, sperm banking is of particular concern if the client is going to have radiation to the lower abdomen or pelvis.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Lymphoma, Hematologic system, Caring, Reproductive problems MSC: Client Needs Category: Health Promotion and Maintenance 15. A client has been admitted after sustaining a humerus fracture that occurred when picking up

the family cat. What test result would the nurse correlate to this condition? a. Bence-Jones protein in urine b. Epstein-Barr virus: positive c. Hemoglobin: 18 mg/dL (180 mmol/L) d. Red blood cell count: 8.2 million/mcL (8.2  1012/L) ANS: A

This client has possible multiple myeloma. A positive Bence-Jones protein finding would correlate with this condition. The Epstein-Barr virus is a herpesvirus that causes infectious mononucleosis and some cancers. A hemoglobin of 18 mg/dL (180 mmol/L) is slightly high for a male and somewhat high for a female; this can be caused by several conditions, and further information would be needed to correlate this value with a specific medical condition.

A red blood cell count of 8.2 million/mcL (8.2  1012/L) is also high, but again, more information would be needed to correlate this finding with a specific medical condition.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Hematologic system, Laboratory values MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 16. A client with multiple myeloma demonstrates worsening bone density on diagnostic scans.

About what drug does the nurse plan to teach this client? a. Bortezomib b. Dexamethasone c. Thalidomide d. Zoledronic acid ANS: D

All the options are drugs used to treat multiple myeloma, but the drug used specifically for bone manifestations is zoledronic acid, which is a bisphosphonate. This drug class inhibits bone resorption and is used to treat osteoporosis as well.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Hematologic system, Bisphosphonates, Patient education MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 17. A client has a platelet count of 9000/mm3 (9  109/L). The nurse finds the client confused and

mumbling. What nursing action takes priority at this time? a. Call the Rapid Response Team. b. Take a set of vital signs. c. Institute bleeding precautions. d. Place the client on bedrest.

ANS: A

With a platelet count this low, the client is at high risk of spontaneous bleeding. The most disastrous complication would be intracranial bleeding. The nurse needs to call the Rapid Response Team as this client has manifestations of a sudden neurologic change. Bleeding precautions will not address the immediate situation. Placing the client on bedrest is important, but the critical action is to call for immediate medical attention.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Hematologic system, Laboratory values, Critical rescue, Neurologic system MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 18. A nurse is preparing to administer a blood transfusion. What action is most important? a. Correctly identify client using two identifiers. b. Ensure that informed consent is obtained. c. Hang the blood product with Ringer’s lactate. d. Stay with the client for the entire transfusion.

ANS: B

If the facility requires informed consent for transfusions, this action is most important because it precedes the other actions taken during the transfusion. Correctly identifying the client and blood product is a National Patient Safety Goal, and is the most important action after obtaining informed consent. Ringer’s lactate is not used to transfuse blood. The nurse does not need to stay with the client for the duration of the transfusion.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Informed consent, Blood transfusions, Hematologic system MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 19. A nurse is preparing to administer a blood transfusion. Which action is most important? a. Document the transfusion. b. Place the client on NPO status. c. Place the client in isolation. d. Put on a pair of gloves.

ANS: D

To prevent bloodborne illness, the nurse should don a pair of gloves prior to hanging the blood. Documentation is important but not the priority at this point. NPO status and isolation are not needed.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Blood transfusion, Standard Precautions, Infection control MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 20. A client receiving a blood transfusion develops anxiety and low back pain. After stopping the

transfusion, what action by the nurse is most important? a. Document the events in the client’s medical record. b. Double-check the client and blood product identification. c. Place the client on strict bedrest until the pain subsides. d. Review the client’s medical record for known allergies.

ANS: B

This client most likely had a hemolytic transfusion reaction, most commonly caused by blood type or Rh incompatibility. The nurse should double-check all identifying information for both the client and blood type. Documentation occurs after the client is stable. Bedrest may or may not be needed. Allergies to medications or environmental items are not related.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Implementation KEY: Blood transfusion, Core measures, Transfusion reaction MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 21. A client has thrombocytopenia. What statement indicates that the client understands

self-management of this condition? a. “I brush and use dental floss every day.” b. “I chew hard candy for my dry mouth.” c. “I usually put ice on bumps or bruises.” d. “Nonslip socks are best when I walk.”

ANS: C

The client should be taught to apply ice to areas of minor trauma. Flossing is not recommended. Hard foods should be avoided. The client should wear well-fitting shoes when ambulating.

DIF: Evaluating TOP: Integrated Process: Nursing Process: Evaluation KEY: Hematologic system, Patient safety, Patient education MSC: Client Needs Category: Health Promotion and Maintenance

22. A nurse is caring for four clients with leukemia. After hand-off report, which client would the

nurse assess first? a. Client who had two bloody diarrhea stools this morning. b. Client who has been premedicated for nausea prior to chemotherapy. c. Client with a respiratory rate change from 18 to 22 breaths/min. d. Client with an unchanged lesion to the lower right lateral malleolus.

ANS: A

The client who had two bloody diarrhea stools that morning may be hemorrhaging in the gastrointestinal (GI) tract and should be assessed first to monitor for or avoid the client from going into hypovolemic shock. The client with the slight change in respiratory rate may have an infection or worsening anemia and should be seen next. If the client’s respiratory rate was greater than 28 to 30 breaths/min, the client may need the initial assessment. Marked tachypnea is an early sign of a deteriorating client condition. The other two clients are not a priority at this time.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Hematologic system, Anemias, Nursing assessment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 23. Which statement by a client with leukemia indicates a need for further teaching by the nurse? a. “I will use a soft-bristled toothbrush and avoid flossing.” b. “I will not take aspirin or any aspirin product.” c. “I will use an electric shaver instead of my manual one.” d. “I will take a daily laxative to prevent constipation.”

ANS: D

The client experiencing leukemia needs to prevent injury to prevent bleeding, including avoiding hard-bristled toothbrushes, floss, aspirin, and straight or manual safety razors.

However, although constipation can cause hemorrhoids or rectal bleeding, laxatives can cause fluid and electrolyte imbalances and abdominal cramping. Stool softeners would be a better option to allow the passage of soft stool.

DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Leukemia, Risk for bleeding, Bleeding Precautions MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 24. The nurse is assessing a client who has probable lymphoma. What is the most common early

assessment finding for clients with this disorder? a. Weight gain b. Enlarged painless lymph node(s) c. Fever at night d. Nausea and vomiting ANS: B

The first change that is noted for clients with probable lymphoma is one or more enlarged lymph nodes. The other findings are either not common in clients with lymphoma or later findings.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Hematologic system, Lymphoma, Physical assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

25. The nurse assesses a client’s oral cavity as seen in the photo below:

What action by the nurse is most appropriate? a. Encourage the client to have genetic testing. b. Instruct the client on high-fiber foods. c. Place the client in protective precautions. d. Teach the client about cobalamin therapy.

ANS: D

This condition is known as glossitis, and is characteristic of B12 anemia. If the anemia is a pernicious anemia, it is treated with cobalamin. Genetic testing is not a priority for this condition. The client does not need high-fiber foods or protective precautions.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Hematologic system, Anemias, Patient education, Medications MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies MULTIPLE RESPONSE 1. A nurse working with clients diagnosed with sickle cell disease (SCD) teaches about

self-management to prevent exacerbations and sickle cell crises. What factor(s) should clients be taught to avoid? (Select all that apply.) a. Dehydration b. Exercise c. Extreme stress d. High altitudes e. Pregnancy ANS: A, C, D, E

Several factors cause red blood cells to sickle in SCD, including dehydration, extreme stress, high altitudes, and pregnancy. Strenuous exercise can also cause sickling, but not unless it is very vigorous.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Hematologic system, Patient education, Genetic alterations, Anemias MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. Which risk factor(s) places a client at risk for leukemia? (Select all that apply.) a. Chemical exposure

b. c. d. e.

Genetically modified foods Ionizing radiation exposure Vaccinations Viral infections

ANS: A, C, E

Chemical and ionizing radiation exposure and viral infections are known risk factors for developing leukemia. Eating genetically modified food and receiving vaccinations are not known risk factors.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Hematologic System, Leukemia, Pathophysiology MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. The nurse is assessing a client with chronic leukemia. Which laboratory test result(s) is (are)

expected for this client? (Select all that apply.) a. Decreased hematocrit b. Abnormal white blood cell count c. Low platelet count d. Decreased hemoglobin e. Increased albumin ANS: A, B, C, D

Chronic leukemia affects all types of blood cells causing a decrease is red blood cells (RBCs) and platelets. When the number of RBCs decreases, the client’s hemoglobin and hematocrit also decrease. White blood cell counts are also abnormal depending on disease progression and management.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Hematologic system, Chronic leukemia, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 4. The nurse is caring for a client being treated for Hodgkin lymphoma. For which side effect(s)

of treatment will the nurse assess? (Select all that apply.) a. Severe nausea and vomiting b. Low platelet count c. Skin irritation at radiation site d. Low red blood cell count e. High white blood cell count ANS: A, B, C, D

Drug and radiation therapy for Hodgkin lymphoma cause many side and adverse effects, including all of the choices except for a high white blood cell (WBC) count. Instead, most clients experience a low WBC count making them very susceptible to infections.

DIF: Understanding TOP: Integrated Process: Nursing Process: Evaluation KEY: Hematologic system, Hodgkin lymphoma, Collaborative management MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 5. The nurse is preparing to administer a blood transfusion. Which action(s) by the nurse is (are)

most appropriate? (Select all that apply.) a. Hang the blood product using normal saline and a filtered tubing set.

b. c. d. e.

Take a full set of vital signs prior to starting the blood transfusion.

Tell the client that someone will remain at the bedside for the first 5 minutes.

Use gloves to start the client’s IV if needed and to handle the blood product.

Verify the client’s identity, and checking blood compatibility and expiration time.

ANS: A, B, D

Correct actions prior to beginning a blood transfusion include hanging the product with saline and the correct filtered blood tubing, taking a full set of vital signs prior to starting, and using gloves. Someone stays with the client for the first 15 to 20 minutes of the transfusion. Two registered nurses must verify the client’s identity and blood compatibility.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Blood transfusions, Patient safety, Core measures MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 6. Which statement(s) about blood transfusion compatibilities is (are) correct? (Select all that

apply.) a. Donor blood type A can donate to recipient blood type AB. b. Donor blood type B can donate to recipient blood type O. c. Donor blood type AB can donate to anyone. d. Donor blood type O can donate to anyone. e. Donor blood type A can donate to recipient blood type B. ANS: A, D

Blood type A can be donated to people who have blood types A or AB. Blood type O can be given to anyone. Blood type B can be donated to people who have blood types B or AB. Blood type AB can only go to recipients with blood type AB. DIF: Remembering REF: Table 37-5 TOP: Integrated Process: Teaching/Learning KEY: Blood transfusions, Patient safety MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 7. The nurse is caring for a client receiving a unit of whole blood. Which nursing action(s) is

(are) appropriate regarding infusion administration. (Select all that apply.) a. Use a dedicated filtered blood administration set. b. Stay with the client for the first 15 to 20 minutes of the infusion. c. Infuse the blood over a 30-minute period of time. d. Monitor and document vital signs per agency policy. e. Use a 21-gauge or smaller catheter to administer the blood. f. Infuse the transfusion with intravenous normal saline.

ANS: A, B, D, F

Blood administration requires a dedicated and filtered intravenous set and a larger catheter or needle due to the viscosity of the infusion. Normal saline is the only IV fluid that is compatible with blood. Vital signs are frequently monitored and documented while the client is carefully assesses for signs and symptoms of a blood transfusion reaction, usually within the first 15 to 20 minutes. One unit of blood is administered in no less than 60 minutes.

DIF: Understanding TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Blood transfusion, Patient safety

MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 8. A nurse is preparing to administer a packed red blood cell transfusion to an older adult.

Understanding age-related changes, what alteration(s) in the usual protocol is (are) necessary for the nurse to implement? (Select all that apply.) a. Assess vital signs at least every 15 minutes. b. Avoid giving other IV fluids. c. Premedicate to prevent transfusion reaction. d. Transfuse smaller bags of blood. e. Transfuse each unit over 8 hours. f. Assess the client for fluid overload.

ANS: A, B, F

The older adult needs vital signs monitored as often as every 15 minutes for the duration of the transfusion because vital sign changes may be the only indication of a transfusion-related problem. To prevent fluid overload, the nurse obtains a prescription to hold other running IV fluids during the transfusion and assesses the client frequently for signs and symptoms of overload. The other options are not correct.

DIF: Understanding TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Anemias, Blood transfusions, Older adults MSC: Client Needs Category: Health Promotion and Maintenance 9. Which assessment finding(s) may indicate that a client may be experiencing a blood

transfusion reaction? (Select all that apply.) a. Tachycardia b. Fever c. Bronchospasm d. Tachypnea e. Urticaria f. Hypotension ANS: A, B, C, D, E, F

Several types of blood transfusion reactions can occur and cause all of the findings listed.

DIF: Remembering TOP: Integrated Process: Nursing Process: Evaluation KEY: Blood transfusions, Transfusion reactions MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 10. A client has received a bone marrow transplant and is waiting for engraftment. What action(s)

by the nurse are most appropriate? (Select all that apply.) a. Not allowing any visitors until engraftment b. Limiting the protein in the client’s diet c. Placing the client in protective precautions d. Teaching visitors appropriate hand hygiene e. Telling visitors not to bring live flowers or plants ANS: C, D, E

The client waiting for engraftment after bone marrow transplant has no white cells to protect him or her against infection. The client is on protective precautions and visitors are taught hand hygiene. No fresh flowers or plants are allowed due to the standing water in the vase or container that may harbor organisms; clients are also told not to work with houseplants in the home. Limiting protein is not a healthy option and will not promote engraftment.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Anemias, Protective precautions, Infection control MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 11. A nurse is caring for an older adult receiving multiple packed red blood cell transfusions.

Which assessment finding(s) indicate(s) possible transfusion circulatory overload? (Select all that apply.) a. Acute confusion b. Dyspnea c. Depression d. Hypertension e. Bradycardia f. Bounding pulse ANS: A, B, D, F

Circulatory overload is the result of excessive body fluid which can cause signs and symptoms of heart failure including dyspnea, increased blood pressure, tachycardia (not bradycardia), and a bounding pulse. Dyspnea is caused by hypoxia which in older adults can cause acute confusion. Depression is not a common finding resulting from fluid overload.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Blood transfusions, Transfusion reactions MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

Chapter 38: Assessment of the Nervous System Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. The nurse teaches an 80-year-old client with diminished peripheral sensation. Which

statement would the nurse include in this client’s teaching? a. “Place soft rugs in your bathroom to decrease pain in your feet.” b. “Bathe in warm water to increase your circulation.” c. “Look at the placement of your feet when walking.” d. “Walk barefoot to decrease pressure injuries from your shoes.”

ANS: C

Older clients with decreased sensation are at risk of injury from the inability to sense changes in terrain when walking. To compensate for this loss, the client is instructed to look at the placement of his or her feet when walking. Throw rugs can slip and increase fall risk. Bath water that is too warm places the client at risk for thermal injury.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Neurologic assessment, Changes associated with aging, Client safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 2. The nurse assesses a client’s recent memory. Which statement by the client confirms that

recent memory is intact? a. “A young girl wrapped in a shroud fell asleep on a bed of clouds.” b. “I was born on April 3, 1967, in Johnstown Community Hospital.” c. “Apple, chair, and pencil are the words you just stated.” d. “I ate oatmeal with wheat toast and orange juice for breakfast.”

ANS: D

Asking clients about recent events that can be verified, such as what the client ate for breakfast, assesses recent memory. Asking clients about certain facts from the past that can be verified assesses remote or long-term memory. Asking the client to repeat words assesses immediate memory.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Neurologic assessment, Memory MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. A client is admitted to the emergency department with a probable traumatic brain injury.

Which assessment finding would be the priority for the nurse to report to the primary health care provider? a. Mild temporal headache b. Pupils equal and react to light c. Alert and oriented  3 d. Decreasing level of consciousness ANS: D

A decreasing level of consciousness is the first sign of increasing intracranial pressure, a potentially severe and possibly fatal complication of a traumatic brain injury (TBI). A mild headache would be expected for a client having a TBI. Equal reactive pupils and being alert and oriented are normal assessment findings.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Neurologic assessment, Level of consciousness MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 4. A nurse asks a client to take deep breaths during an electroencephalography. The client asks,

“Why are you asking me to do this?” How would the nurse respond? a. “Hyperventilation causes vascular dilation of cerebral arteries, which decreases electoral activity in the brain.” b. “Deep breathing helps you to relax and allows the electroencephalograph to obtain a better waveform.” c. “Hyperventilation causes cerebral vasoconstriction and increases the likelihood of seizure activity.” d. “Deep breathing will help you to blow off carbon dioxide and decreases intracranial pressures.”

ANS: C

Hyperventilation produces cerebral vasoconstriction and alkalosis, which increase the likelihood of seizure activity. The client is asked to breathe deeply 20 times for 3 minutes.

The other responses are not accurate.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Assessment, Diagnostic testing MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 5. A nurse assesses a client recovering from a cerebral angiography via the right femoral artery.

Which assessment would the nurse complete? a. Palpate bilateral lower extremity pulses. b. Obtain orthostatic blood pressure readings. c. Perform a funduscopic examination. d. Assess the gag reflex prior to eating.

ANS: A

Cerebral angiography is performed by threading a catheter through the femoral or brachial artery. The extremity is kept immobilized after the procedure. The nurse checks the extremity for adequate circulation by noting skin color and temperature, presence and quality of pulses distal to the injection site, and capillary refill. Clients usually are on bedrest; therefore, orthostatic blood pressure readings cannot be performed. The funduscopic (eye) examination would not be affected by cerebral angiography. The client is not given general anesthesia; therefore, the client’s gag reflex would not be compromised.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Assessment, Diagnostic testing MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

6. When assessing a client who had a traumatic brain injury, the nurse notes that the client is

drowsy but easily aroused. What level of consciousness will the nurse document to describe this client’s current level of consciousness? a. Alert b. Lethargic c. Stuporous d. Comatose ANS: B

The client is categorized as being lethargic because he or she can be easily aroused even though drowsy. The nurse would carefully monitor the client to determine any decrease in the level of consciousness (LOC).

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Neurologic assessment, Level of consciousness MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 7. The nurse is assessing a client diagnosed with trigeminal neuralgia affecting cranial nerve V.

What assessment findings will the nurse expect for this client? a. Expressive aphasia b. Ptosis (eyelid drooping) c. Slurred speech d. Severe facial pain ANS: D

Cranial nerve (CN) V is the Trigeminal Nerve which has both a motor and sensory function in the face. When affected by a health problem, the client experiences severely facial pain.

Expressive aphasia results from damage to the Broca speech area in the frontal lobe of the brain. Ptosis can result from damage to CN III and slurred speech often occurs from either damage to several cranial nerves or from damage to the motor strip in the frontal lobe of the brain.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Neurologic assessment, Cranial nerve assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 8. The nurse is performing an assessment of cranial nerve III. Which testing is appropriate? a. Pupil constriction b. Deep tendon reflexes c. Upper muscle strength d. Speech and language ANS: A

CN III is the oculomotor nerve which controls eye movement, pupil constriction, and eyelid movement.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Neurologic assessment, Cranial nerve assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

9. A nurse cares for a client who is experiencing deteriorating neurologic functions. The client

states, “I am worried I will not be able to care for my young children.” How would the nurse respond? a. “Caring for your children is a priority. You may not want to ask for help, but you really have to.” b. “Our community has resources that may help you with some household tasks so you have energy to care for your children.” c. “You seem distressed. Would you like to talk to a psychologist about adjusting to your changing status?” d. “Can you tell me more about what worries you, so we can see if we can do something to make adjustments?”

ANS: D

Investigate specific concerns about situational or role changes before providing additional information. The nurse would not tell the client what is or is not a priority for him or her.

Although community resources may be available, they may not be appropriate for the patient.

Consulting a psychologist would not be appropriate without obtaining further information from the client related to current concerns.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Neurologic assessment, Therapeutic communication, Psychosocial assessment MSC: Client Needs Category: Psychosocial Integrity 10. A nurse plans care for a 77-year-old client who is experiencing age-related

peripheral sensory perception changes. Which intervention would the nurse include in this client’s plan of care? a. Provide a call button that requires only minimal pressure to activate. b. Write the date on the client’s white board to promote orientation. c. Ensure that the path to the bathroom is free from clutter. d. Encourage the client to season food to stimulate nutritional intake.

ANS: C

Dementia and confusion are not common phenomena in older adults. However, physical impairment related to illness can be expected. Providing opportunities for hazard-free ambulation will maintain strength and mobility (and ensure safety). Providing a call button, providing the date, and seasoning food do not address the client’s impaired sensory perception.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Neurologic assessment, Client safety, Changes associated with aging MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 11. After teaching a patient who is scheduled for magnetic resonance imaging (MRI), the nurse

assesses the client’s understanding. Which statement indicates client understanding of the teaching? a. “I must increase my fluids because of the dye used for the MRI.” b. “My urine will be radioactive so I should not share a bathroom.” c. “My gag reflex will be tested before I can eat or drink anything.” d. “I can return to my usual activities immediately after the MRI.” ANS: D

No postprocedure restrictions are imposed after MRI. The client can return to normal activities after the test is complete. There are no dyes or radioactive materials used for the MRI; therefore, increased fluids are not needed and the client’s urine would not be radioactive. The procedure does not impact the client’s gag reflex.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Neurologic assessment, Diagnostic testing, Client education MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 12. A nurse performs an assessment of pain discrimination on an older adult. The client correctly

identifies, with eyes closed, a sharp sensation on the right hand when touched with a pin.

Which action would the nurse take next? a. Touch the pin on the same area of the left hand. b. Contact the primary health care provider with the assessment results. c. Ask the client about current and past medications. d. Continue the assessment on the client’s feet and legs.

ANS: A

If testing is begun on the right hand and the client correctly identifies the pain stimulus, the nurse would continue the assessment on the left hand. This is a normal finding and does not need to be reported to the provider, but instead documented in the client’s medical record.

Medications do not need to be assessed in response to this finding. The nurse would assess the left hand prior to assessing the feet.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Neurologic assessment, Motor, Sensory impairment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 13. A nurse is teaching a client with cerebellar function impairment. Which statement would the

nurse include in this client’s discharge teaching? a. “Connect a light to flash when your door bell rings.” b. “Label your faucet knobs with hot and cold signs.” c. “Ask a friend to drive you to your follow-up appointments.” d. “Use a natural gas detector with an audible alarm.”

ANS: C

Cerebellar function enables the client to predict distance or gauge the speed with which one is approaching an object, control voluntary movement, maintain equilibrium, and shift from one skilled movement to another in an orderly sequence. A client who has cerebellar function impairment should not be driving. The client would not have difficulty hearing, distinguishing between hot and cold, or smelling.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Neurologic assessment, Client safety, Brain function MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 14. Which statement would the nurse include when teaching the assistive personnel (AP) about

how to care for a client with cranial nerve II impairment? a. “Tell the client where food items are on the breakfast tray.” b. “Place the client in a high-Fowler position for all meals.” c. “Make sure the client’s food is visually appetizing.”

d. “Assist the client by placing the fork in the left hand.”

ANS: A

Cranial nerve II, the optic nerve, provides central and peripheral vision. A patient who has cranial nerve II impairment will have decreased visual acuity, so the AP would tell the client where different food items are on the meal tray. The other options are not appropriate for client with cranial nerve II impairment.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Neurologic assessment, Cranial nerve assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 15. A nurse prepares a client for lumbar puncture (LP). Which assessment finding would alert the

nurse to contact the primary health care provider? a. Shingles infection on the client’s back b. Client is claustrophobic c. Absence of intravenous access d. Paroxysmal nocturnal dyspnea ANS: A

An LP would not be performed if the client has a skin infection at or near the puncture site because of the risk of cerebrospinal fluid infection. A nurse would want to notify the primary health care provider if shingles were identified on the client’s back. If a client has shortness of breath when lying flat, the LP can be adapted to meet the client’s needs. Claustrophobia, absence of IV access, and paroxysmal nocturnal dyspnea have no impact on whether an LP can be performed.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Neurologic assessment, Diagnostic testing MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 16. A nurse assesses a patient who is recovering from a lumbar puncture (LP). Which

complication of this procedure would alert the nurse to urgently contact the primary health care provider? a. Weak pedal pulses b. Nausea and vomiting c. Increased thirst d. Hives on the chest ANS: B

The nurse would immediately contact the provider if the client experiences a severe headache, nausea, vomiting, photophobia, or a change in level of consciousness after an LP, which are all signs of increased intracranial pressure. Weak pedal pulses, increased thirst, and hives are not complications of an LP. DIF: Remembering TOP: Integrated Process: Communication and Documentation KEY: Neurologic assessment, Diagnostic testing MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 17. A nurse assesses a client and notes the client’s position as indicated in the illustration below:

How would the nurse document this finding? a. Decorticate posturing b. Decerebrate posturing c. Atypical hyperreflexia d. Spinal cord degeneration ANS: A

The client is demonstrating decorticate posturing, which is seen with interruption in the corticospinal pathway. This finding is abnormal and is a sign that the client’s condition has deteriorated. The primary health care provider, the charge nurse/team leader, and other health care team members would be notified immediately of this change in status. Decerebrate posturing consists of external rotation and extension of the extremities. Hyperreflexes present as increased reflex responses. Spinal cord degeneration presents frequently with pain and discomfort.

DIF: Remembering TOP: Integrated Process: Communication and Documentation KEY: Neurologic assessment, Diagnostic testing, Documentation MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 18. A nurse assesses a client with a brain tumor. The client opens his eyes when the nurse calls his

name, mumbles in response to questions, and follows simple commands. How would the nurse document this client’s assessment using the Glasgow Coma Scale shown below?

a. b. c. d.

8 10 12 14

ANS: C

The client opens his eyes to speech (Eye Opening: To sound = 3), mumbles in response to questions (Verbal Response: Inappropriate words = 3), and follows simple commands (Motor Response: Obeys commands = 6). Therefore, the client’s Glasgow Coma Scale score is 3 + 3 + 6 = 12.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Neurologic assessment, Glasgow Coma scale MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential MULTIPLE RESPONSE 1. A nurse assesses a client with an injury to the medulla. Which clinical manifestations would

the nurse expect to find? (Select all that apply.) a. Decreased respiratory rate b. Impaired swallowing c. Visual changes d. Inability to shrug shoulders e. Loss of gag reflex ANS: A, B, D, E

Cranial nerves IX (glossopharyngeal), X (vagus), XI (accessory), and XII (hypoglossal) emerge from the medulla, as do portions of cranial nerves VII (facial) and VIII (acoustic).

Damage to these nerves causes decreased respirations, impaired swallowing, inability to shrug shoulders, and loss of the gag reflex. The other manifestations are not associated with damage to the medulla.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Neurologic assessment, Brain function MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. An 84-year-old client who is usually alert and oriented experiences an acute cognitive decline.

Which of the following factors would the nurse anticipate as contributing to this neurologic change? (Select all that apply.) a. Chronic hearing loss b. Infection c. Drug toxicity d. Dementia e. Hypoxia f. Aging ANS: B, C, E

Acute client conditions that occur in older adults often cause acute confusion and associated emotional behaviors. Infection, drug toxicity, and hypoxia are all acute health problems that can contribute to the client’s cognitive decline. Aging does not cause changes in cognition. If the client had dementia, he or she would not be alert and oriented. Having a chronic hearing loss is not a change in the client’s condition.

DIF: Applying TOP: Integrated Process: Culture and Spirituality KEY: Neurologic assessment, Changes associated with aging MSC: Client Needs Category: Health Promotion and Maintenance 3. A nurse assesses a client with a brain tumor. Which newly identified assessment findings

would alert the nurse to urgently communicate with the primary health care provider? (Select all that apply.) a. Glasgow Coma Scale score of 8 b. Decerebrate posturing c. Reactive pupils d. Uninhibited speech e. Decreasing level of consciousness ANS: A, B, E

The nurse would urgently communicate changes in a patient’s neurologic status, including a decrease in the Glasgow Coma Scale score; abnormal flexion or extension; changes in cognition or level of consciousness; and pinpointed, dilated, and nonreactive pupils.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Neurologic assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. A nurse assesses an older client. Which assessment findings would the nurse identify as

normal changes in the nervous system related to aging? (Select all that apply.)

a. b. c. d. e.

Long-term memory loss Slower processing time Increased sensory perception Decreased risk for infection Change in sleep patterns

ANS: B, E

Normal changes in the nervous system related to aging include recent memory loss, slower processing time, decreased sensory perception, an increased risk for infection, changes in sleep patterns, changes in perception of pain, and altered balance and/or decreased coordination.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Neurologic assessment, Changes associated with aging MSC: Client Needs Category: Health Promotion and Maintenance

Chapter 39: Concepts of Care for Patients With Problems of the Central Nervous System: The Brain Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. The nurse is teaching the daughter of a client who has middle-stage Alzheimer disease. The

daughter asks, “Will the sertraline my mother is taking improve her dementia?” How would the nurse respond about the purpose of the drug? a. “It will allow your mother to live independently for several more years.” b. “It is used to halt the advancement of Alzheimer disease but will not cure it.” c. “It will not improve her dementia but can help control emotional responses.” d. “It is used to improve short-term memory but will not improve problem solving.”

ANS: C

Drug therapy is not effective for treating dementia or halting the advancement of Alzheimer disease. However, certain psychoactive drugs may help suppress emotional disturbances and manage depression, psychoses, or anxiety. Drug therapy will not allow the client with middle-stage dementia to safely live independently.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Alzheimer disease, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 2. A client with early-stage Alzheimer disease is admitted to the hospital with chest pain. Which

nursing action is most appropriate to manage this client’s dementia? a. Provide animal-assisted therapy as needed. b. Ensure a structured and consistent environment. c. Assist the client with activities of daily living (ADLs). d. Use validation therapy when communicating with the client.

ANS: B

The client who has early Alzheimer disease (AD) does not require assistance with ADLs or validation therapy. While animal-assisted therapy may be helpful, some health care agencies do not allow this intervention. Therefore, the most appropriate action is to provide a structured and consistent environment while the client is hospitalized to prevent worsening of the client’s symptoms.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Alzheimer disease, Nursing Interventions MSC: Client Needs Category: Psychosocial Integrity 3. The nurse observes a client with late-stage Alzheimer disease eat breakfast. Afterward the

client states, “I am hungry and want breakfast.” What is the nurse’s best response? a. “I see you are still hungry. I will get you some toast.” b. “You ate your breakfast 30 minutes ago.” c. “It appears you are confused this morning.” d. “Your family will be here soon. Let’s get you dressed.”

ANS: A

Use of validation therapy with clients who have late-stage Alzheimer disease involves acknowledgment of the client’s feelings and concerns. This technique has proved more effective in later stages of the disease because reality orientation only increases agitation. The other statements do not validate the client’s concerns.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Alzheimer disease, Therapeutic communication MSC: Client Needs Category: Psychosocial Integrity 4. The nurse cares for a client with middle-stage (moderate) Alzheimer disease. The client’s

caregiver states, “She is always wandering off. What can I do to manage this restless behavior?” What is the nurse’s best response? a. “This is a sign of fatigue. The client would benefit from a daily nap.” b. “Engage the client in scheduled activities throughout the day.” c. “It sounds like this is difficult for you. I will consult the social worker.” d. “The provider can prescribe a mild sedative for restlessness.”

ANS: B

Several strategies may be used to cope with restlessness and wandering. One strategy is to engage the client in structured activities. Another is to take the client for frequent walks. Daily naps and a mild sedative will not be as effective in the management of restless behavior.

Consulting the social worker does not address the caregiver’s concern.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Alzheimer disease, Client safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 5. The nurse prepares to discharge a client with early to moderate Alzheimer disease. Which

statement to maintain client safety would the nurse include in the discharge teaching for the caregiver? a. “Provide periods of exercise and rest for the client.” b. “Place a padded throw rug at the bedside.” c. “Provide a highly stimulating environment.” d. “Install safety locks on all outside doors.”

ANS: D

Clients with early to moderate Alzheimer disease have a tendency to wander, especially at night. If possible, alarms would be installed on all outside doors to alert family members if the client leaves. At a minimum, all outside doors should have safety locks installed to prevent the client from going outdoors unsupervised. The client would be allowed to exercise within his or her limits, but this action does not ensure his or her safety. Throw rugs are a slip and fall hazard and would be removed. A highly stimulating environment would likely increase the client’s confusion.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Alzheimer disease, Safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 6. The nurse is teaching a family caregiver about how best to communicate with the client who

has been diagnosed with Alzheimer disease. Which statement by the caregiver indicates a need for further teaching?

a. b. c. d.

“I will avoid communicating with the client to prevent agitation.”

“I should use simple, short sentences and one-step instructions.”

“I can try to use gestures or pictures to communicate with the client.”

“I will limit the number of choices I provide for the client.”

ANS: A

Communication with the client is important to provide cognitive stimulation. Using short simple sentences, using gestures and pictures, and limiting choices provided for the client will help promote communication.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Alzheimer disease, Therapeutic communication MSC: Client Needs Category: Psychosocial Integrity 7. The nurse teaches assistive personnel (AP) about how to care for a client with early-stage

Alzheimer disease. Which statement would the nurse include? a. “If she is confused, play along and pretend that everything is okay.” b. “Remove the clock from her room so that she doesn’t get confused.” c. “Reorient the client to the day, time, and environment with each contact.” d. “Use validation therapy to recognize and acknowledge the client’s concerns.”

ANS: C

Clients who have early-stage Alzheimer disease would be reoriented frequently to person, place, and time. The AP would reorient the client and not encourage the client’s delusions.

The room would have a clock and white board with the current date written on it. Validation therapy is used with late-stage Alzheimer disease.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Alzheimer disease, Staff teaching MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 8. The primary health care provider prescribes donepezil for a client diagnosed with early-stage

Alzheimer disease. What teaching about this drug will the nurse provide for the client’s family caregiver? a. “Monitor the client’s temperature because the drug can cause a low grade fever.” b. “Observe the client for nausea and vomiting to determine drug tolerance.” c. “Donepezil will prevent the client’s dementia from progressing as usual.” d. “Report any client dizziness or falls because the drug can cause bradycardia.”

ANS: D

Donepezil is a cholinesterase inhibitor that may temporarily slow cognitive decline for some clients but does not alter the course of the disease. The family caregiver would want to monitor the client’s heart rate and report any incidence of dizziness or falls because the drug can cause bradycardia. It does not typically cause fever or nausea/vomiting.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Alzheimer disease, Drug therapy, Caregiver health teaching MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 9. After teaching the wife of a client who has Parkinson disease, the nurse assesses the wife’s

understanding. Which statement by the client’s wife indicates that she correctly understands changes associated with this disease?

a. b. c. d.

“His masklike face makes it difficult to communicate, so I will use a white board.”

“He should not socialize outside of the house due to uncontrollable drooling.”

“This disease is associated with anxiety causing increased perspiration.”

“He may have trouble chewing, so I will offer bite-sized portions.”

ANS: D

Because chewing and swallowing can be problematic, small frequent meals and a supplement are better for meeting the client’s nutritional needs. A masklike face and drooling are common in clients with Parkinson disease. The client would be encouraged to continue to socialize and communicate as normally as possible. The wife should understand that the client’s masklike face can be misinterpreted and additional time may be needed for the client to communicate with her or others. Excessive perspiration is also common in clients with Parkinson disease and is associated with the autonomic nervous system’s response.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Parkinson disease, Signs and symptoms MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 10. The nurse plans care for a client with Parkinson disease. Which intervention would the nurse

include in this client’s plan of care? a. Restrain the client to prevent falling. b. Ensure that the client uses incentive spirometry. c. Teach the client pursed-lip breathing techniques. d. Keep the head of the bed at 30 degrees or greater.

ANS: D

Elevation of the head of the bed will help prevent aspiration. The other options will not prevent aspiration, which is the greatest respiratory complication of Parkinson disease, nor do these interventions address any of the complications of Parkinson disease. Pursed-lip breathing increases exhalation of carbon dioxide; incentive spirometry expands the lungs. The client should not be restrained to prevent falls. Other less restrictive interventions should be used to maintain client safety.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Parkinson disease, Complication prevention MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 11. A nurse teaches assistive personnel (AP) about how to care for a client with Parkinson

disease. Which statement would the nurse include as part of this teaching? a. “Allow the client to be as independent as possible with activities.” b. “Assist the client with frequent and meticulous oral care.” c. “Assess the client’s ability to eat and swallow before each meal.” d. “Schedule appointments early in the morning to ensure rest in the afternoon.”

ANS: A

Clients with Parkinson disease do not move as quickly and can have functional problems. The client would be encouraged to be as independent as possible and provided time to perform activities without rushing. Although oral care is important for all clients, instructing the UAP to provide frequent and meticulous oral is not a priority for this client. This statement would be a priority if the client was immune-compromised or NPO. The nurse would assess the client’s ability to eat and swallow; this would not be delegated. Appointments and activities would not be scheduled early in the morning because this may cause the client to be rushed and discourage the client from wanting to participate in activities of daily living.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Parkinson disease, Staff teaching MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 12. A client diagnosed with Parkinson disease will be starting ropinirole for symptom control.

Which statement by the client indicates a need for further teaching? a. “This drug should help decrease my tremors and help me move better.” b. “I need to change positions slowly to prevent dizziness or falls.” c. “I should take the drug at the same time each day for the best effect.” d. “I know the drug will probably make help me prevent constipation.”

ANS: D

Although ropinirole is a dopamine agonist and mimics dopamine to promote movement, it does not work to prevent constipation. This class of drugs can cause orthostatic hypotension and should be taken at the same time every day.

DIF: Understanding TOP: Integrated Process: Nursing Process: Evaluation KEY: Parkinson disease, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 13. A nurse is teaching a client who experiences migraine headaches and is prescribed

propranolol. Which statement would the nurse include in this client’s teaching? a. “Take this drug only when you have symptoms indicating the onset of a migraine headache.” b. “Take this drug as prescribed, even when feeling well, to prevent vascular changes associated with migraine headaches.” c. “This drug will relieve the pain during the aura phase soon after a headache has started.” d. “This drug will have no effect on your heart rate or blood pressure because you are taking it for migraines.”

ANS: B

Propranolol is a beta-adrenergic blocker which is prescribed as prophylactic treatment to prevent the vascular changes that initiate migraine headaches. Heart rate and blood pressure will also be affected, and the client would monitor these side effects. The other responses do not discuss appropriate uses of this drug.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Migraine headache, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

14. The nurse assesses a client who has a history of migraines. Which symptom would the nurse

identify as an early sign of a migraine with aura? a. Vertigo b. Lethargy c. Visual disturbances d. Numbness of the tongue ANS: C

Early warning of impending migraine with aura usually consists of visual changes, flashing lights, or diplopia. The other symptoms are not associated with an impending migraine with aura.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Migraine headache, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 15. The nurse obtains a health history on a client prior to administering prescribed sumatriptan

succinate for migraine headaches. Which condition would alert the nurse to withhold the medication and contact the primary health care provider? a. Bronchial asthma b. Heart disease c. Diabetes mellitus d. Rheumatoid arthritis ANS: B

Sumatriptan succinate effectively reduces pain and other associated symptoms of migraine headache by binding to serotonin receptors and triggering cranial vasoconstriction.

Vasoconstrictive effects are not confined to the cranium and can cause coronary vasospasm in clients with heart disease, hypertension, or Prinzmetal angina. The other conditions would not affect the client’s treatment.

DIF: Applying TOP: Integrated Process: Nursing Process: Analysis KEY: Migraine headache, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 16. The nurse assesses a client with a history of epilepsy who experiences stiffening of the

muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How would the nurse document this type of seizure? a. Atonic b. Myoclonic c. Absence d. Tonic-clonic ANS: D

Seizure activity that begins with stiffening of the arms and legs, followed by loss of consciousness and jerking of all extremities, is characteristic of a tonic-clonic seizure. An atonic seizure presents as a sudden loss of muscle tone followed by postictal confusion. A myoclonic seizure presents with a brief jerking or stiffening of extremities that may occur singly or in groups. Absence seizures present with automatisms, and the client is unaware of his or her environment.

DIF: Remembering

TOP: Integrated Process: Communication and Documentation KEY: Epilepsy, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 17. The nurse witnesses a client begin to experience a tonic-clonic seizure and loss of

consciousness. What action would the nurse take first? a. Start fluids via a large-bore catheter. b. Administer IV push diazepam. c. Turn the client’s head to the side. d. Prepare to intubate the client.

ANS: C

The nurse would turn the client’s head to the side to prevent aspiration and allow drainage of secretions. Anticonvulsants are administered on a routine basis if a seizure is sustained. If the seizure is sustained (status epilepticus), the client must be intubated and would be administered oxygen, 0.9% sodium chloride, and IV push lorazepam or diazepam.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Seizure, Aspiration precautions MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 18. A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication

would the nurse anticipate to prepare for administration? a. Atenolol b. Lorazepam c. Phenytoin d. Lisinopril ANS: B

Initially, intravenous lorazepam or diazepam is administered to stop motor movements. This is followed by the administration of phenytoin. Atenolol, a beta blocker, and lisinopril, an angiotensin-converting enzyme inhibitor, are not administered for seizure activity. These drugs are typically administered for hypertension and heart failure.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Epilepsy, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 19. After teaching a client who is diagnosed with new-onset epilepsy and prescribed phenytoin,

the nurse assesses the client’s understanding. Which statement by the client indicates a correct understanding of the teaching? a. “To prevent complications, I will drink at least 2 L of water daily.” b. “This medication will stop me from getting an aura before a seizure.” c. “I will not drive a motor vehicle while taking this medication.” d. “Even when my seizures stop, I will continue to take this drug.”

ANS: D

Discontinuing antiepileptic drugs can lead to the recurrence of seizures or status epilepticus.

The client does not need to drink more water and can drive while taking this medication. The drug will not stop an aura before a seizure.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Epilepsy, Drug therapy

MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 20. After teaching a client newly diagnosed with epilepsy, the nurse assesses the client’s

understanding. Which statement by the client indicates a need for additional teaching? a. “I will wear my medical alert bracelet at all times.” b. “While taking my medications, I will not drink any alcoholic beverages.” c. “I will tell my doctor about my prescription and over-the-counter medications.” d. “If I am nauseated, I will not take my epilepsy medication.”

ANS: D

The nurse must emphasize that antiepileptic drugs must be taken even if the client is nauseated. Discontinuing the medication can predispose the client to seizure activity and status epilepticus. The client should not drink alcohol while taking seizure medications. The client should wear a medical alert bracelet and should make the primary health care provider aware of all drugs he or she is taking to prevent complications of polypharmacy.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Epilepsy, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 21. The nurse is teaching a group of college students about the importance of preventing

meningitis. Which health promotion activity is the most appropriate for preventing this disease? a. Eating a well-balanced diet that is high in protein b. Having an annual physical examination c. Obtaining the recommended meningitis vaccination and boosters d. Identifying signs and symptoms for early treatment ANS: C

CDC-recommended vaccinations and boosters are available for prevention of a number of diseases including meningococcal meningitis. While the other activities are appropriate for general health promotion, they are not specific to meningitis prevention.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Meningitis, Health promotion MSC: Client Needs Category: Health Promotion and Maintenance 22. A nurse obtains a focused health history for a client who is suspected of having bacterial

meningitis. Which question would the nurse ask? a. “Do you live in a crowded residence?” b. “When was your last tetanus vaccination?” c. “Have you had any viral infections recently?” d. “Have you traveled out of the country in the last month?”

ANS: A

Bacterial meningitis tends to occur in multiple outbreaks. It is most likely to occur in areas of high-density population, such as college dormitories, prisons, and military barracks. A tetanus vaccination would not place the client at increased risk for meningitis or protect the client from meningitis. A viral infection would not lead to bacterial meningitis but could lead to viral meningitis. Simply knowing if the client traveled out of the country does not provide enough information.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Meningitis, Infection control MSC: Client Needs Category: Health Promotion and Maintenance MULTIPLE RESPONSE 1. The nurse plans care for a client with epilepsy who is admitted to the hospital. Which

interventions would the nurse include in this client’s plan of care? (Select all that apply.) a. Have suction equipment with an airway at the bedside. b. Place a padded tongue blade at the bedside. c. Permit only clear oral fluids. d. Have oxygen administration set at the bedside. e. Maintain the client on strict bedrest. f. Ensure that the client has IV access.

ANS: A, D, F

Oxygen and suctioning equipment with an airway must be readily available. If the client does not have an IV access, insert a saline lock, especially for those clients who are at significant risk for generalized tonic-clonic seizures. The saline lock provides ready access if IV drug therapy must be given to stop the seizure. Padded tongue blades may pose a danger to the client or nurse during a seizure and would not be used. Dietary restrictions and strict bedrest are not interventions associated with epilepsy.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Epilepsy, Seizure precautions, Client safety MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 2. The nurse assesses a client who is experiencing a common migraine without an aura. Which

assessment finding(s) would the nurse expect? (Select all that apply.) a. Headache lasting up to 72 hours b. Unilateral and pulsating headache c. Abrupt loss of consciousness d. Acute confusion e. Pain worsens with physical activities f. Photophobia ANS: A, B, E, F

A common migraine with an aura is usually accompanied by photophobia, phonophobia, unilateral and pulsating pain, and nausea and/or vomiting. These migraines usually last 4 to 72 hours and are aggravated by physical activity. Loss of consciousness and acute confusion are not associated with a common migraine without an aura.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Migraine headache, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. A nurse prepares to provide perineal care to a client with meningococcal meningitis. Which

personal protective equipment would the nurse wear? (Select all that apply.) a. Particulate respirator b. Isolation gown c. Shoe covers

d. Surgical mask e. Gloves ANS: D, E

Meningococcal meningitis is spread via saliva and droplets, and Droplet Precautions are necessary. Caregivers would wear a surgical mask when within 6 feet (1.8 m) of the client and would continue to use Standard Precautions, including gloves. A particulate respirator, an isolation gown, and shoe covers are not necessary for Droplet Precautions.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Meningitis, Infection control, Transmission-Based Precautions MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 4. The nurse assesses clients on a medical-surgical unit. Which clients would the nurse identify

as at risk for secondary seizures? (Select all that apply.) a. A 26-year-old woman with a left temporal brain tumor b. A 38-year-old male client in an alcohol withdrawal program c. A 42-year-old football player with a traumatic brain injury d. A 66-year-old female client with multiple sclerosis e. A 72-year-old man with chronic obstructive pulmonary disease ANS: A, B, C

Clients at risk for secondary seizures include those with a brain lesion from a tumor or trauma, and those who are experiencing a metabolic disorder, acute alcohol withdrawal, electrolyte disturbances, and high fever. Clients with a history of stroke, heart disease, and substance abuse are also at risk. Clients with multiple sclerosis or chronic obstructive pulmonary disease are not at risk for secondary seizures.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Seizure, Assessment MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 5. A nurse assesses a client who is recovering from the implantation of a vagal nerve-stimulation

device. For which signs and symptoms would the nurse assess as common complications of this procedure? (Select all that apply.) a. Bleeding b. Infection c. Hoarseness d. Dysphagia e. Seizures ANS: C, D

Complications of surgery to implant a vagal nerve-stimulation device include hoarseness (most common), dyspnea, neck pain, and dysphagia. The device is tunneled under the skin with an electrode connected to the vagus nerve to control simple or complex partial seizures.

Bleeding is not a common complication of this procedure, and infection would not occur during the recovery period.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Epilepsy, Surgical Management MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

6. The nurse assesses a client who has meningitis. Which sign(s) and symptom(s) would the

nurse anticipate? (Select all that apply.) a. Photophobia b. Decreased level of consciousness c. Severe headache d. Fever and chills e. Bradycardia ANS: A, B, C, D

All of the choices except for bradycardia are key features of meningitis. Tachycardia is more likely than bradycardia due to the infectious process and fever.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Meningitis, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 7. The nurse assesses a client who has Parkinson disease. Which signs and symptoms would the

nurse recognize as a key feature of this disease? (Select all that apply.) a. Flexed trunk b. Long, extended steps c. Slow movements d. Uncontrolled drooling e. Tachycardia ANS: A, C, D

Key features of Parkinson disease include a flexed trunk, slow and hesitant steps, bradykinesia, and uncontrolled drooling. Tachycardia is not a key feature of this disease.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Parkinson disease, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 8. A nurse teaches the spouse of a client who has Alzheimer disease. Which statements should

the nurse include in this teaching related to caregiver stress reduction? (Select all that apply.) a. “Establish advanced directives early.” b. “Trust that family and friends will help.” c. “Set aside time each day to be away from the client.” d. “Use discipline to correct inappropriate behaviors.” e. “Seek respite care periodically for longer periods of time.”

ANS: A, C, D

To reduce caregiver stress, the spouse should be encouraged to establish advanced directives early, set aside time each day for rest or recreation away from the client, seek respite care periodically for longer periods of time, use humor with the client, and explore alternative care settings and resources. Family and friends may not be available to help. A structured environment will assist the client with AD, but discipline will not correct inappropriate behaviors and not reduce caregiver stress.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Alzheimer disease, Caregiver stress, Elder abuse MSC: Client Needs Category: Psychosocial Integrity

9. The nurse is caring for a client who has Alzheimer disease. The client’s wife states, “I am

having trouble managing his behaviors at home.” Which questions would the nurse ask to assess potential causes of the client’s behavior problems? (Select all that apply.) a. “Does your husband bathe and dress himself independently?” b. “Do you weigh your husband each morning around the same time?” c. “Does his behavior become worse around large crowds?” d. “Does your husband eat healthy foods including fruits and vegetables?” e. “Do you have a clock and calendar in the bedroom and kitchen?”

ANS: A, C, E

To minimize behavior problems, the nurse would encourage the patient to be as independent as possible with ADLs, minimize excessive simulation, and assist the patient to remain orientated. The nurse would assess these activities by asking if the patient is independent with bathing and dressing, if behavior worsens around crowds, and if a clock and single-date calendar are readily available. Diet and weight are not related to the management of behavior problems for a patient who has Alzheimer disease.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Alzheimer disease, Communication MSC: Client Needs Category: Psychosocial Integrity 10. The nurse is caring for a client in late-stage Alzheimer disease. Which assessment finding(s)

will the nurse anticipate? (Select all that apply.) a. Immobile b. Has difficulty driving c. Wandering d. ADL dependent e. Incontinent f. Possible seizures ANS: A, D, E, F

The client in late-stage Alzheimer disease is totally bedridden and immobile, and therefore, cannot ambulate to wander or drive. The client is incontinent and ADL dependent.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Parkinson disease, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

Chapter 40: Concepts of Care for Patients With Problems of the Central Nervous System: The Spinal Cord Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. The nurse is preparing to teach a client recently diagnosed with multiple sclerosis about taking

glatiramer acetate. Which statement by the client indicates a need for further teaching? a. “I will rotate injection sites to prevent skin irritation.” b. “I need to avoid large crowds and people with infection.” c. “I should report any flulike symptoms to my primary health care provider.” d. “I will report any signs of infection to my primary health care provider.”

ANS: C

Glatiramer is given by subcutaneous injection. The first dose is administered under medical supervision, but the nurse teaches the client how to self-administer the medication after the initial dose, reminding the client about the need to rotate injection sites. Like other immunomodulators, this drug can make the client susceptible to infection. However, flulike symptoms occur more commonly with interferons rather than glatiramer.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Multiple sclerosis, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 2. A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod.

For which common side effect would the nurse monitor? a. Peripheral edema b. Facial flushing c. Tachycardia d. Fever ANS: B

Fingolimod is an oral immunomodulator that has two common side effects—facial flushing and GI disturbance, such as diarrhea. Peripheral edema, tachycardia, and fever are not common side effects of this drug.

DIF: Remembering TOP: Integrated Process: Nursing Process: Evaluation KEY: Multiple sclerosis, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 3. A client who has multiple sclerosis reports increased severe muscle spasticity and tremors.

What nursing action is most appropriate to manage this client’s concern? a. Request a prescription for an antispasmodic drug such as baclofen. b. Prepare the client for deep brain stimulation surgery. c. Refer the client to a massage therapist to relax the muscles. d. Consult with the occupational therapist for self-care assistance.

ANS: A

Clients who have multiple sclerosis often have muscle spasticity which may be reduced by drug therapy, such as baclofen. While massage and assistance with self-care may be helpful, these interventions are not the most effective and therefore not the most appropriate in managing muscle spasticity. If drug therapy and other interventions do not help reduce muscle spasms, some client are candidates for deep brain stimulation as a last resort.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Analysis KEY: Multiple sclerosis, Drug therapy MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 4. A client with multiple sclerosis is being discharged from rehabilitation. Which statement

would the nurse include in the client’s discharge teaching? a. “Be sure that you use a wheelchair when you go out in public.” b. “Wear an undergarment brief at all times in case of incontinence.” c. “Avoid overexertion, stress, and extreme temperature if possible.” d. “Avoid having sexual intercourse to conserve energy.”

ANS: C

Clients who have multiple sclerosis have chronic fatigue and are prone to disease exacerbation (flare-up) is they overexert, are stressed, or are exposed to extreme temperature and humidity.

They should not wear briefs unless they have actual problems with continence and should not use a wheelchair if they are able to ambulate with a cane or walker. Maintaining independence and self-esteem is important, so participating in sexual activities is encouraged.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Multiple sclerosis, Self-management MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. A nurse assesses a client with a spinal cord injury at level T5. The client’s blood pressure is

184/95 mm Hg, and the client presents with a flushed face and blurred vision. After raising the head of the bed, what action would the nurse take next? a. Initiate oxygen via a nasal cannula. b. Recheck the client’s blood pressure. c. Palpate the bladder for distention. d. Administer a prescribed beta blocker.

ANS: C

The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic injury such as s stroke. The other actions are not appropriate for this complication.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Spinal cord injury, Complications MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 6. The nurse initiates care for a client with a cervical spinal cord injury who arrives via

emergency medical services. What action would the nurse take first? a. Assess level of consciousness. b. Obtain vital signs. c. Administer oxygen therapy.

d. Evaluate respiratory status.

ANS: D

The first priority for a client with a spinal cord injury is assessment of respiratory status and airway patency. Clients with cervical spine injuries are particularly prone to respiratory compromise due to interference with diaphragmatic innervation. The other actions would be performed after airway and breathing are assessed.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Spinal cord injury, Assessment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 7. A client who had a complete spinal cord injury at level L5-S1 is admitted with a sacral

pressure injury. What other assessment finding will the nurse anticipate for this client? a. Quadriplegia b. Flaccid bowel c. Spastic bladder d. Tetraparesis ANS: B

A low-level complete spinal cord injury (SCI) is a lower motor neuron injury because the reflect arc is damaged. Therefore, the client would be expected to have paraplegia and a flaccid bowel and bladder. Quadriplegia and tetraparesis are seen in clients with cervical or high thoracic SCIs. DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Spinal cord injury, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 8. The nurse is collaborating with the occupational therapist to assist a client with a complete

cervical spinal cord injury to transfer from the bed to the wheelchair. What ambulatory aid would be most appropriate for the client to meet this outcome? a. Rolling walker b. Quad cane c. Adjustable crutches d. Sliding board ANS: D

A client who has a complete cervical spinal cord injury is unable to use any extremity except for parts of the hands and possibly the lower arms. Therefore, the client would be unable to use any of these ambulatory aids except for a sliding board, also known as a slider, which provides a “bridge” between the bed and a chair. The client uses his or her arms in a locked position to support the body while moving slowly across the board.

DIF: Understanding TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Spinal cord injury, Rehabilitation MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 9. The nurse is caring for a 60-year-old female client who sustained a thoracic spinal cord injury

10 years ago. For which potential complication will the nurse assess during this client’s care? a. Fracture

b. Malabsorption c. Delirium d. Anemia ANS: A

Older adults who have impaired mobility due to a health problem or injury are at risk for complications of immobility, such as osteoporosis (bone loss) which leads to fracture. Being an older woman increases that risk due to loss of estrogen to protect bone loss. The other choices are not problems of immobility. Delirium is possible but is more common in clients over 70 years of age.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Spinal cord injury, Older adult care MSC: Client Needs Category: Health Promotion and Maintenance 10. A nurse is caring for a client with paraplegia who is scheduled to participate in a rehabilitation

program. The client states, “I don’t understand the need for rehabilitation; the paralysis will not go away and it will not get better.” How would the nurse respond? a. “If you don’t want to participate in the rehabilitation program, I’ll let your primary health care provider know.” b. “Rehabilitation programs have helped many patients with your injury. You should give it a chance.” c. “The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability.” d. “When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first.”

ANS: C

Participation in rehabilitation programs has many purposes, including prevention of disability, maintenance of functional ability, and restoration of function. The other responses do not meet this client’s needs.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Spinal cord injury, Rehabilitation MSC: Client Needs Category: Psychosocial Integrity 11. A nurse cares for a client with a spinal cord injury. With which interprofessional health team

member would the nurse collaborate to assist the client with activities of daily living? a. Social worker b. Physical therapist c. Occupational therapist d. Case manager ANS: C

The occupational therapist instructs the patient in the correct use of all adaptive equipment. In collaboration with the therapist, the nurse instructs family members or the caregiver about transfer skills, feeding, bathing, dressing, positioning, and skin care. The other team members are consulted to assist the client with other issues.

DIF: Understanding TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Spinal cord injury, Interprofessional collaboration MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care

12. After teaching a client with a high thoracic spinal cord injury, the nurse assesses the client’s

understanding. Which statement by the client indicates a correct understanding of how to prevent respiratory problems at home? a. “I’ll use my incentive spirometer every 2 hours while I’m awake.” b. “I’ll drink thinned fluids to prevent choking.” c. “I’ll take cough medicine to prevent excessive coughing.” d. “I’ll position myself on my right side so I don’t aspirate.”

ANS: A

The client with a cervical or high thoracic spinal cord injury typically has weak intercostal muscles and is at higher risk for developing atelectasis and stasis pneumonia. Using an incentive spirometer every 2 hours helps the client expand the lungs more fully and helps prevent atelectasis and other respiratory problems. Clients should drink fluids that they can tolerate; usually thick fluids are easier to tolerate. The client would be encouraged to cough and clear secretions, and placed in high-Fowler position to prevent aspiration.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Spinal cord injury, Prevention of Complications MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 13. A client continues to have persistent low back pain even after using a number of

nonpharmacologic pain management strategies. Which prescribed drug would the nurse anticipate that the client might need to manage the pain? a. Oxycontin b. Gabapentin c. Lorazepam d. Tramadol ANS: D

When nonpharmacologic strategies, including physical therapy, are not effective in managing pain, current standards recommend a mild opioid such as tramadol or serotonin-norepinephrine reuptake inhibitor. Strong opioids such as oxycontin and benzodiazepines such as lorazepam are not considered best practice.

DIF: Remembering TOP: Integrated Process: Caring KEY: Low back pain, Pain management MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 14. A client is scheduled for a percutaneous endoscopic lumbar discectomy. Which statement by

the client indicates a need for further teaching? a. “I should have a lot less pain after surgery.” b. “I’ll be in the hospital for 2 to 3 days.” c. “I should not have any major surgical complications.” d. “I could possibly get an infection after surgery.”

ANS: B

Percutaneous endoscopic discectomy is a minimally invasive surgical procedure that requires a shorter hospital stay (23 hours or less) when compared to open traditional surgery. The risk for surgical complications is very low and clients experience less far pain from this procedure.

However, due to interrupting skin integrity, infection may occur at the surgical site.

DIF: Understanding TOP: Integrated Process: Nursing Process: Evaluation KEY: Low back pain, Perioperative care MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 15. A nurse assesses clients at a community center. Which client is at greatest risk for low back

pain? a. A 24-year-old female who is 25 weeks pregnant. b. A 36-year-old male who uses ergonomic techniques. c. A 53-year-old female who uses a walker. d. A 65-year-old female with osteoarthritis.

ANS: D

Osteoarthritis causes changes to support structures, increasing the client’s risk for low back pain. The other clients are not at high risk.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Low back pain, Risk factors MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 16. A nurse teaches a client who is recovering from an open traditional cervical spinal fusion.

Which statement would the nurse include in this client’s postoperative instructions? a. “Only lift items that are 10 lb (4.5 kg) or less.” b. “Wear your neck brace whenever you are out of bed.” c. “You must remain in bed for 3 weeks after surgery.” d. “You will be prescribed medications to prevent graft rejection.”

ANS: B

Clients who undergo spinal fusion are fitted with a neck brace that they must wear throughout the healing process whenever they are out of bed. The client should not lift anything more than 10 lb (4.5 kg). The client does not need to remain in bed. Medications for rejection prevention are not necessary for this procedure.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Cervical neck pain, Perioperative care MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 17. A nurse assesses a client who is recovering from an open anterior cervical discectomy and

fusion. Which complication would alert the nurse to urgently communicate with the primary health care provider? a. Auscultated stridor b. Weak pedal pulses c. Difficulty swallowing d. Inability to shrug shoulders ANS: A

Postoperative swelling can narrow the trachea, cause a partial airway obstruction, and manifest as stridor. The client may also have trouble swallowing, but maintaining an airway takes priority. Weak pedal pulses and an inability to shrug the shoulders are not complications of this surgery.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Cervical neck pain, Perioperative care

MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 18. A nurse assesses the health history of a client who is prescribed ziconotide for chronic low

back pain. Which assessment question would the nurse ask? a. “Are you taking a nonsteroidal anti-inflammatory drug?” b. “Have you been diagnosed with a mental health problem?” c. “Are you able to swallow oral medications?” d. “Do you smoke cigarettes or any illegal drugs?”

ANS: B

Clients who have a severe mental health or behavioral health problem would not take ziconotide because the drug can cause psychotic symptoms such as hallucinations. The other questions do not identify a contraindication for this medication.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Low back pain, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies MULTIPLE RESPONSE 1. A nurse promotes the prevention of lower back pain by teaching clients at a community

center. Which statement(s) would the nurse include in this education? (Select all that apply.) a. “Participate in an exercise program to strengthen back muscles.” b. “Purchase a mattress that allows you to adjust the firmness.” c. “Wear flat instead of high-heeled shoes to work each day.” d. “Keep your weight within 20% of your ideal body weight.” e. “Avoid prolonged standing or sitting, including driving.”

ANS: A, C, E

Exercise can strengthen back muscles, reducing the incidence of low back pain. Women should avoid wearing high-heeled shoes because they cause misalignment of the back.

Prolonged standing and sitting should also be avoided. The other options will not prevent low back pain.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Low back pain, Injury prevention MSC: Client Needs Category: Health Promotion and Maintenance 2. A nurse assesses a client who recently experienced a traumatic spinal cord injury. Which

assessment data would the nurse obtain to assess the client’s coping strategies? (Select all that apply.) a. Spiritual beliefs b. Level of pain c. Family support d. Level of independence e. Annual income f. Previous coping strategies ANS: A, C, D, F

Information about the client’s preinjury psychosocial status, usual methods of coping with illness, difficult situations, and disappointments would be obtained. Determine the client’s level of independence or dependence and his or her comfort level in discussing feelings and emotions with family members or close friends. Clients who are emotionally secure and have a positive self-image, a supportive family, and financial and job security often adapt to their injury. Information about the client’s spiritual and religious beliefs or cultural background also assists the nurse in developing the plan of care. The other options do not supply as much information about coping.

DIF: Applying TOP: Integrated Process: Caring KEY: Spinal cord injury, Psychosocial assessment, Coping MSC: Client Needs Category: Psychosocial Integrity 3. After teaching a male client with a spinal cord injury at the T4 level, the nurse assesses the his

understanding. Which client statements indicate a correct understanding of the teaching related to sexual effects of his injury? (Select all that apply.) a. “I will explore other ways besides intercourse to please my partner.” b. “I will not be able to have an erection because of my injury.” c. “Ejaculation may not be as predictable as before.” d. “I may urinate with ejaculation but this will not cause infection.” e. “I should be able to have an erection with stimulation.”

ANS: C, D, E

Men with injuries above T6 often are able to have erections by stimulating reflex activity. For example, stroking the penis will cause an erection. Ejaculation is less predictable and may be mixed with urine. However, urine is sterile, so the client’s partner will not get an infection.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Spinal cord injury, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 4. A nurse assesses a client who is recovering from an open traditional lumbar laminectomy with

fusion. Which complications would the nurse report to the primary health care provider?

(Select all that apply.) a. Surgical discomfort b. Redness and itching at the incision site c. Incisional bulging d. Clear drainage on the dressing e. Sudden and severe headache ANS: C, D, E

Bulging at the incision site or clear fluid on the dressing after open back surgery strongly suggests a cerebrospinal fluid leak, which constitutes an emergency. Loss of cerebrospinal fluid may cause a sudden and severe headache. Pain, redness, and itching at the site are normal.

DIF: Applying TOP: Integrated Process: Nursing Process: Analysis KEY: Low back pain, Perioperative care MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

5. A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas

over the client’s hips and sacrum. What actions would the nurse take? (Select all that apply.) a. Apply a barrier cream to protect the skin from excoriation. b. Perform range-of-motion (ROM) exercises for the hip joint. c. Reposition the client off of the reddened areas. d. Get the client out of bed and into a chair several times a day. e. Apply a pressure-reducing mattress.

ANS: C, E

Appropriate interventions to relieve pressure on the reddened areas include frequent repositioning, using a pressure-reducing mattress, and having the client sit in a chair to remove pressure from the hips and sacrum. Correct sitting position would allow the pressure to be on both ischial tuberosities. ROM exercises are used to prevent contractures.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Spinal cord injury, Skin care MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 6. A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago.

Which assessment findings would the nurse correlate with neurogenic shock? (Select all that apply.) a. Heart rate of 34 beats/min b. Blood pressure of 185/65 mm Hg c. Urine output less than 30 mL/hr d. Decreased level of consciousness e. Increased oxygen saturation ANS: A, C, D

Neurogenic shock with acute spinal cord injury manifests with decreased oxygen saturation, symptomatic bradycardia, decreased level of consciousness, decreased urine output, and hypotension.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Spinal cord injury, Complications MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 7. A nurse plans care for a client with a halo fixator. Which interventions would the nurse

include in this client’s plan of care? (Select all that apply.) a. Remove the vest for client bathing. b. Assess the pin sites for signs of infection. c. Loosen the pins when sleeping. d. Decrease the patient’s oral fluid intake. e. Assess the chest and back for skin breakdown.

ANS: B, E

The nurse would assess the pin sites for signs of infection or loose pins. The nurse would also assess the client’s chest and back for skin breakdown from the halo vest. The vest is not removed for bathing and the pins are not intentionally loosened.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Spinal cord injury, Immobilization MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort

8. A nurse assesses a client who is recovering from an open traditional anterior cervical fusion.

Which assessment findings would alert the nursing to a complication from this procedure?

(Select all that apply.) a. Difficulty swallowing b. Hoarse voice c. Constipation d. Bradycardia e. Hypertension ANS: A, B

Complications of the open traditional anterior cervical discectomy and fusion include dysphagia and hoarseness. Constipation, bradycardia, and hypertension are not complications of this procedure.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Cervical pain, Perioperative care MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 9. A nurse assesses cerebrospinal fluid leaking onto a client’s surgical dressing. What actions

would the nurse take? (Select all that apply.) a. Place the client in a flat position. b. Monitor vital signs for hypotension. c. Utilize a bedside commode. d. Assess for abdominal distension. e. Report the leak to the surgeon.

ANS: A, E

If cerebrospinal fluid (CSF) is leaking from a surgical wound, the nurse would place the client in a flat position and contact the surgeon for repair of the leak. Hypotension and abdominal distension are not complications of CSF leakage.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Low back pain, Surgical complications MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 10. The nurse is taking a history on an older adult. Which factors would the nurse assess as

potential risks for low back pain? (Select all that apply.) a. Scoliosis b. Spinal stenosis c. Hypocalcemia d. Osteoporosis e. Osteoarthritis ANS: A, B, C, D, E

All of these factors place the client at risk for low back pain due to changes in spinal alignment, loss of bone, or joint degeneration. Bone loss worsens if serum calcium levels are below normal.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Low back pain, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

Chapter 41: Critical Care of Patients With Neurologic Emergencies Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A client is in the emergency department reporting a brief episode during which he was dizzy,

unable to speak, and felt numbness in his left leg. Currently the client’s neurologic examination is normal. About what drug would the nurse plan to teach the patient? a. Alteplase b. Clopidogrel c. Heparin sodium d. Mannitol ANS: B

This client’s signs and symptoms are consistent with a transient ischemic attack, and the client would likely be prescribed aspirin or clopidogrel to prevent platelet aggregation on discharge.

Alteplase is used for ischemic stroke. Heparin and mannitol are not used for this condition.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Transient ischemic attack, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 2. The nurse is preparing a client for discharge from the emergency department after

experiencing a transient ischemic attack (TIA). Before discharge, which factor would the nurse identify as placing the client at high risk for a stroke? a. Age greater than or equal to 75 b. Blood pressure greater than or equal to 160/95 c. Unilateral weakness during a TIA d. TIA symptoms lasting less than a minute ANS: C

The client who has a TIA is at risk for a stroke is he or she has one-sided (unilateral) weakness during a TIA. Risk factors also include an age greater than or equal to 60, blood pressure greater than or equal to 140/90 (either or both systolic and diastolic), and/or a long duration of TIA symptoms. One minute is not a very long time for symptoms to occur.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Transient ischemic attack, Risk factors MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. The nurse is taking a history from a daughter about her father’s onset of stroke signs and

symptoms. Which statement by the daughter indicates that the client likely had an embolic stroke? a. Client’s symptoms occurred slowly over several hours. b. Client because increasingly lethargic and drowsy. c. Client reported severe headache before other symptoms. d. Client has a long history of atrial fibrillation.

ANS: D

The major cause of embolic strokes is a history of heart disease, especially atrial fibrillation.

Most clients who have an embolic stroke have acute sudden neurologic symptoms but stay alert rather than lethargic. Decreasing level of consciousness and severe headache are more common in clients who have hemorrhagic strokes.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Stroke, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. A client is admitted with a sudden decline in level of consciousness. What is the nursing

action at this time? a. Assess the client for hypoglycemia and hypoxia. b. Place the client on his or her side. c. Prepare for administration of a fibrinolytic agent. d. Start a continuous IV heparin sodium infusion.

ANS: A

The cause of a sudden decline in level of consciousness may or may not be related to a neurologic health problem. Therefore, the client must be evaluated for other common causes, especially hypoglycemia and hypoxia. Placing the client on his or her side may be helpful to prevent aspiration in case the client experiences vomiting, but the clinical situation does not indicate that the client has nausea or vomiting. Administering either an anticoagulant like heparin or a fibrinolytic agent assumes that the client has an acute ischemic stroke, which has not been confirmed through imaging tests.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Neurologic assessment, Stroke MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. The nurse is teaching assistive personnel (AP) about care for a male client diagnosed with

acute ischemic stroke and left-sided weakness. Which statement by the AP indicates understanding of the nurse’s teaching? a. “I will use “yes” and “no” questions when communicating with the client.” b. “I will remind the client frequently to not get out of bed without help.” c. “I will offer a urinal every hour to the client due to incontinence.” d. “I will feed the client slowly using soft or pureed foods.”

ANS: B

The client who has left-sided weakness has likely had a right-sided stroke in the brain. Clients who have strokes on the right side of the brain tend to be very impulsive and exhibit poor judgment. Therefore, to keep the client safe, the staff will need to remind the client to stay in bed unless he has assistance to prevent falling. There is no evidence in the clinical situation that the client has aphasia (which is less common in those with right-sided strokes), difficulty swallowing, or urinary incontinence.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Stroke, Nursing interventions MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. A nurse receives a hand-off report on a female client who had a left-sided stroke with

homonymous hemianopsia. What action by the nurse is most appropriate for this client?

a. b. c. d.

Assess for bladder and bowel retention and/or incontinence.

Listen to the client’s lungs after eating or drinking for diminished breath sounds.

Support the client’s left side when sitting in a chair or in bed.

Remind the client to move her head from side to side to increase her visual field.

ANS: D

Homonymous hemianopsia is blindness on the same side of both eyes. The client must turn his or her head to see the entire visual field. This condition is not related to bladder function, difficulty swallowing, or lack of trunk control.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Stroke, Visual disorders MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 7. A client with a stroke is being evaluated for fibrinolytic therapy. What information from the

client or family is most important for the nurse to obtain? a. Loss of bladder control b. Other medical conditions c. Progression of symptoms d. Time of symptom onset ANS: D

The time limit for initiating fibrinolytic therapy for a stroke is 3 to 4.5 hours, so the exact time of symptom onset is the most important information for this client. The other information is not as critical.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Stroke, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 8. The nurse is preparing to administer IV alteplase for a client diagnosed with an acute ischemic

stroke. Which statement is correct about the administration of this drug? a. The recommended time for drug administration is within 90 minutes after admission to the emergency department. b. The drug is given in a bolus over the first 3 minutes followed by a continuous infusion. c. The maximum dosage of the drug, including the bolus, is 120 mg intravenously. d. The drug is not given to clients who are already on anticoagulant or antiplatelet therapy.

ANS: D

Alteplase is a thrombolytic which dissolves clots and can cause bleeding as an adverse effect.

Clients who are already taking an anticoagulant or antiplatelet agent are at risk for bleeding and therefore they are not candidates for alteplase therapy.

DIF: Remembering TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Stroke, Fibrinolytic therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 9. A client is receiving IV alteplase and reports a sudden severe headache. What is the nurse’s

first action?

a. b. c. d.

Perform a comprehensive pain assessment.

Discontinue the infusion of the drug.

Conduct a neurologic assessment.

Administer an antihypertensive drug.

ANS: B

A severe headache may indicate that the client’s blood pressure has markedly increased and, therefore, the drug should be stopped immediately as the first action. The nurse would then perform the appropriate assessments and possibly administer an antihypertensive medication.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Stroke, Fibrinolytic therapy MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 10. A client experiences impaired swallowing after a stroke and has worked with speech–

language pathology on eating. What nursing assessment best indicates that the expected outcome for this problem has been met? a. Chooses preferred items from the menu. b. Eats 75 to 100% of all meals and snacks. c. Has clear lung sounds on auscultation. d. Gains 2 lb (1 kg) after 1 week.

ANS: C

Impaired swallowing can lead to aspiration and then aspiration pneumonia, so the expected outcome for this problem is to experience no aspiration. Clear lung sounds is the best indicator that aspiration has not occurred. Choosing menu items is not related to this problem.

Eating meals does not indicate that the client is not still aspirating. A weight gain indicates improved nutrition but still does not show a lack of aspiration.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Stroke, Complications MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 11. A male client was admitted with a left-sided stroke this morning. The assistive personnel asks

about meeting the client’s nutritional needs. Which response by the nurse is appropriate? a. “He is NPO until the speech–language pathologist performs a swallowing evaluation.” b. “You may give him a full-liquid diet, but please avoid solid foods until he gets stronger.” c. “Just be sure to add some thickener in his liquids to prevent choking and aspiration.” d. “Be sure to sit him up when you are feeding him to make him feel more natural.”

ANS: A

Any client who has or is suspected of having a stroke should have nothing by mouth until he or she is evaluated for any swallowing problem by the speech–language pathologist (SLP). If dysphagia is present, the SLP makes specific recommendations for the client’s plan of care which all staff members must follow to prevent choking and aspiration/aspiration pneumonia.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Stroke, Complications MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort

12. A client is admitted with a diagnosis of cerebellar stroke. What intervention is most

appropriate to include on the client’s plan of care? a. Ambulate only with a gait belt. b. Encourage double swallowing. c. Monitor lung sounds after eating. d. Perform postvoid residuals.

ANS: A

The client who has a cerebellar stroke would be expected to have ataxia, an abnormal gait. For the client’s safety, he or she should have assistance and use a gait belt when ambulating.

Ataxia is not related to swallowing, aspiration, or voiding.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Stroke, Client safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 13. A nurse is providing community screening for risk factors associated with stroke. Which

person would the nurse identify as being at the highest risk for a stroke? a. A 27-year-old heavy-cocaine user. b. A 30-year-old who drinks a beer a day. c. A 40-year-old who uses seasonal antihistamines. d. A 65-year-old who is active and on no medications.

ANS: A

Heavy drug use, particularly cocaine, is a risk factor for stroke. Heavy alcohol use is also a risk factor, but one beer a day is not considered heavy drinking. Antihistamines may contain phenylpropanolamine, which also increases the risk for stroke, but this person uses them seasonally and there is no information that they are abused or used heavily. The 65 year old has only age as a risk factor.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Stroke, Health screening MSC: Client Needs Category: Health Promotion and Maintenance 14. The nurse is caring for a client who had a hemorrhagic stroke. Which assessment finding is

the earliest sign of increasing intracranial pressure (ICP) for this client? a. Projectile vomiting b. Dilated and nonreactive pupils c. Severe hypertension d. Decreased level of consciousness ANS: D

The earliest sign of increasing ICP is decreased level of consciousness. The other signs occur later.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Stroke, Complications MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 15. A client is admitted with a traumatic brain injury. What is the nurse’s priority assessment? a. Complete neurologic assessment

b. Comprehensive pain assessment c. Airway and breathing assessment d. Functional assessment ANS: C

Although the client has a brain injury, the most important assessment is to assess the client’s ABCs, which includes airway, breathing, and circulation. The other assessments are performed later after the client is stabilized.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Stroke, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 16. A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The

patient’s spouse is very frustrated, stating that the patient’s personality has changed and the situation is very difficult. What response by the nurse is most appropriate? a. Explain that personality changes are common following brain injuries. b. Ask the client why he or she is acting out and behaving differently. c. Refer the client and spouse to a head injury support group. d. Tell the spouse that this is expected and he or she will have to learn to cope.

ANS: A

Personality and behavior often change permanently after head injury. The nurse will explain this to the spouse. Asking the client about his or her behavior isn’t useful because the patient probably cannot help it. A referral might be a good idea, but the nurse needs to do something in addition to just referring the couple. Telling the spouse to learn to cope belittles his or her concerns and feelings.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Traumatic brain injury, Therapeutic communication, Coping MSC: Client Needs Category: Psychosocial Integrity 17. The nurse is caring for four clients with traumatic brain injuries. Which client would the nurse

assess first? a. Client with amnesia for the incident b. Client who has a Glasgow Coma Scale score of 12 c. Client with a PaCO2 of 36 mm Hg and on a ventilator d. Client who has a temperature of 102° F (38.9° C) ANS: D

A fever is a poor prognostic indicator in patients with brain injuries. The nurse should see this client first. A Glasgow Coma Scale score of 12, a PaCO2 of 36, and amnesia for the incident are all either expected or positive findings.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Traumatic brain injury, Assessment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 18. A client with a severe traumatic brain injury has an organ donor card in his wallet. Which

nursing action is appropriate? a. Request a directive form the client’s primary health care provider. b. Ask the family if they agree to organ donation for the client.

c. Wait until brain death is determined before acting on organ donation. d. Contact the local organ procurement organization as soon as possible.

ANS: D

The appropriate nursing action is to respect the client’s desire to be an organ donor and contact the local organ procurement organization even if family members do not agree. In most agencies, the primary health care provider does not have to write an order or directive to approve the organ donation. Family consent is not required.

DIF: Understanding TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Traumatic brain injury, Brain death MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 19. After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes,

acute confusion, and restlessness. The client has IV fluids running at 75 mL/hr. What action by the nurse would the nurse take first? a. Assess the client’s urinary output. b. Assess the client’s serum sodium level. c. Increase the rate of the IV infusion. d. Provide oral care every hour.

ANS: B

This client has signs and symptoms of hypernatremia, which is a possible complication after craniotomy. The nurse would assess the client’s serum sodium level first and then possibly increase the rate of the IV infusion. Providing oral care is also a good option but does not take priority over assessing laboratory results.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Craniotomy, Complications MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 20. A client who had therapeutic hypothermia after a traumatic brain injury is slowly rewarmed to

a normal core temperature. For which assessment finding would the nurse monitor during the rewarming process? a. Cardiac dysrhythmias b. Loss of consciousness c. Nausea and vomiting d. Fever ANS: A

Due to fluid and electrolyte changes that typically occur during the rewarming process, the nurse monitors for cardiac dysrhythmias. The other findings are not common during this process.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Traumatic brain injury, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 21. A client who is experiencing a traumatic brain injury has increasing intracranial pressure

(ICP). What drug will the nurse anticipate to be prescribed for this client? a. Phenytoin

b. Lorazepam c. Mannitol d. Morphine ANS: C

Increased intracranial pressure is often the result of cerebral edema as a result of traumatic brain injury. Therefore, as osmotic diuretic such as mannitol or a loop diuretic like furosemide is administered. The other drugs are not appropriate to manage increasing ICP. DIF: Remembering TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Traumatic brain injury, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 22. A client has a brain tumor and is receiving phenytoin (Dilantin). The spouse questions the use

of the drug, saying that the client does not have a seizure disorder. What response by the nurse is correct? a. “Increased pressure from the tumor can cause seizures.” b. “Preventing febrile seizures with a tumor is important.” c. “Seizures always occur in clients with brain tumors.” d. “This drug is used to sedate with a brain tumor.”

ANS: A

Brain tumors can lead to seizures as a complication. The nurse would explain this to the spouse. Preventing febrile seizures is not related to a tumor. Seizures are possible but do not always occur in clients with brain tumors. This drug is not used for sedation.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Brain tumor, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies MULTIPLE RESPONSE 1. The nurse is assessing a client who has symptoms of stroke. What are the leading causes of a

stroke for which the nurse would assess for this client? (Select all that apply.) a. Heavy alcohol intake b. Diabetes mellitus c. Elevated cholesterol d. Obesity e. Smoking f. Hypertension ANS: A, B, C, D, E, F

The leading causes of stroke include all of these factors.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Stroke, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. Based on the known risk factors for stroke, which health promotion practices would the nurse

teach a client to promote heart health and prevent strokes? (Select all that apply.)

a. b. c. d. e. f.

Blood pressure control Aspirin use Smoking cessation Low carbohydrate diet Cholesterol management Increased red wine consumption

ANS: A, B, C, E

The evidence-based health promotion practices include blood pressure control, aspirin use, smoking cessation, and cholesterol management. There is no consensus on which diet is best to promote heart health and red wine does not protect the heart or prevent strokes.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Stroke, Health promotion MSC: Client Needs Category: Health Promotion and Maintenance 3. A client is admitted with a confirmed left middle cerebral artery occlusion. Which assessment

findings will the nurse expect? (Select all that apply.) a. Ataxia b. Dysphagia c. Aphasia d. Apraxia e. Hemiparesis/hemiplegia f. Ptosis ANS: B, C, D, E, F

All of these assessment findings are common in clients who have a stroke caused by an occlusion of the left middle cerebral artery with the exception of ataxia (most often present in clients who have cerebellar strokes). This artery supplies the majority of the left side of the brain where motor, sensory, speech, and language centers are located.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Stroke, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. The nurse is preparing for discharge of a client who had a carotid artery angioplasty with

stenting to prevent a stroke. For which signs and symptoms with the nurse teach the family to report to the primary health care provider immediately? (Select all that apply.) a. Muscle weakness b. Hoarseness c. Acute confusion d. Mild neck discomfort e. Severe headache f. Dysphagia ANS: A, B, C, E, F

Muscle weakness, acute confusion, severe headache, and dysphagia are all signs and symptoms that could indicate that a stroke occurred. Hoarseness and severe neck pain and swelling may occur as a result of the interventional radiologic procedure.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Stroke, Interventional radiological procedures

MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. The nurse is caring for a client with increasing intracranial pressure (ICP) following a stroke.

Which evidence-based nursing actions are indicated for this client? (Select all that apply.) a. Hyperoxygenate the client before and after suctioning. b. Avoid sudden or extreme hip or neck flexion. c. Provide oxygen to maintain an SaO2 of 95% or greater. d. Maintain the client in a supine position at all times. e. Avoid clustering care nursing activities and procedures. f. Provide environmental stimulation to improve cognition.

ANS: A, B, C, E

These precautions help prevent further increases in ICP. Clustering nursing activities and procedures and providing stimulation can increase ICP and should be avoided.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Stroke, Complications MSC: Client Needs Category: Physiological Adaptation: Reduction of Risk Potential 6. A nurse cares for older clients who have traumatic brain injury. What does the nurse

understand about this population? (Select all that apply.) a. Admission can overwhelm the coping mechanisms for older clients. b. Alcohol is typically involved in most traumatic brain injuries for this age-group. c. These clients are more susceptible to systemic and wound infections. d. Other medical conditions can complicate treatment for these clients. e. Very few traumatic brain injuries occur in this age-group.

ANS: A, C, D

Older adults often tolerate stress poorly, which includes being admitted to a hospital that is unfamiliar and noisy. Because of decreased protective mechanisms, they are more susceptible to both local and systemic infections. Other medical conditions can complicate their treatment and recovery. Alcohol is typically not related to traumatic brain injury in this population; such injury is most often from falls and motor vehicle crashes.

DIF: Understanding TOP: Integrated Process: Culture and Spirituality KEY: Traumatic brain injury, Developmental stages MSC: Client Needs Category: Health Promotion and Maintenance 7. A nurse is caring for a group of stroke patients. Which clients would the nurse consider

referring to a mental health provider? (Select all that apply.) a. Female client who exhibits extreme emotional lability b. Male client with an initial National Institutes of Health (NIH) Stroke Scale score of 38 c. Female client with mild forgetfulness and a history of depression d. Male client who has a past hospitalization for a suicide attempt e. Male client who is unable to walk or eat 3 weeks poststroke ANS: A, B, C, D, E

Patients most at risk for poststroke depression are those with a previous history of depression, severe stroke (NIH Stroke Scale score of 38 is severe), and poststroke physical or cognitive impairment.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Stroke, Psychosocial assessment MSC: Client Needs Category: Psychosocial Integrity 8. A nurse is discharging a client from the emergency department who has a mild traumatic brain

injury. What information obtained from the client represents a possible barrier to self-management? (Select all that apply.) a. Does not want to purchase a thermometer. b. Is allergic to acetaminophen. c. Laughing, says “Strenuous? What’s that?” d. Lives alone and is new in town with no friends. e. Plans to have a beer and go to bed once home.

ANS: B, D, E

Clients who have mild traumatic brain injuries should take acetaminophen for headache. An allergy to this drug may mean that the patient takes aspirin or ibuprofen, which should be avoided. The patient needs neurologic checks every 1 to 2 hours, and this client does not seem to have anyone available who can do that. Alcohol needs to be avoided for at least 24 hours. A thermometer is not needed. The patient laughing at strenuous activity probably does not engage in any kind of strenuous activity, but the nurse should confirm this.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Traumatic brain injury, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 9. The nurse assesses a client who has a mild traumatic brain injury (TBI) for signs and

symptoms consistent with this injury. What signs and symptoms does the nurse expect?

(Select all that apply.) a. Sensitivity to light and sound b. Reports “feeling foggy” c. Unconscious for an hour after injury d. Elevated temperature e. Widened pulse pressure ANS: A, B

A mild TBI would possibly lead to sensitivity to light and sound and a feeling of mental fogginess. The patient would have been unconscious for less than 30 minutes. An elevated temperature is not related. A widened pulse pressure is indicative of increased intracranial pressure, not a mild TBI. DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Traumatic brain injury, Assessment, Brain injury MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 10. The nurse would recognize which signs and symptoms as consistent with brainstem tumors?

(Select all that apply.) a. Hearing loss b. Facial pain c. Nystagmus d. Vomiting e. Hemiparesis ANS: A, B, C

Hearing loss (CN VIII), facial pain (CN V), and nystagmus (CN III, IV, and VI) all are indicative of a brainstem tumor because these cranial nerves originate in the brainstem.

Vomiting and hemiparesis are more indicative of cerebral tumors.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Brain tumor, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

Chapter 42: Assessment and Care of Patients With Eye and Vision Problems Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. The nurse is teaching a group of older adults about basic eye examinations. What would the

nurse recommend about the frequency for eye examinations for most people over 65 years of age? a. Every 1 to 2 years b. Every 2 to 4 years c. Every 3 to 5 years d. When the primary health care provider recommends ANS: A

Older adults need more frequent basic eye examinations due to the increased risk of glaucoma and cataracts associated with aging. Therefore, every 1 to 2 years for eye examination in the current best practice recommendation.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Eye and vision health, Eye examinations MSC: Client Needs Category: Health Promotion and Maintenance 2. A client with a family history of glaucoma asks the nurse how to prevent glaucoma? What

statement by the nurse is appropriate? a. “You should check with your primary health care provider about eye examination.” b. “You should have genetic testing to determine your risk for glaucoma.” c. “You should have your intraocular pressure measured once or twice a year.” d. “You should check with your primary health care provider about preventive drug therapy.”

ANS: C

Glaucoma tends to occur more often in clients who have a family history but cannot be prevented. Genetic testing is not the best response because the client’s family history is already known. Therefore, early detection by having intraocular pressure measured frequently.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Glaucoma, Health promotion MSC: Client Needs Category: Health Promotion and Maintenance 3. A client presents to the emergency department reporting a foreign body in the eye. For what

diagnostic testing would the nurse prepare the client? a. Corneal staining b. Fluorescein angiography c. Ophthalmoscopy d. Tonometry ANS: A

Corneal staining is used when the possibility of eye trauma exists, including a foreign body.

Fluorescein angiography is used to assess problems of retinal circulation. Ophthalmoscopy looks at both internal and external eye structures. Tonometry tests the intraocular pressure.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Eye trauma, Diagnostic testing MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 4. The nurse enters an examination room to help with an eye assessment. The client is directed

toward the chart shown below:

What is the primary health care provider assessing? a. Color vision b. Depth perception c. Spatial perception d. Visual acuity ANS: A

This is an Ishihara chart, which is used for assessing color vision. Depth and spatial perception are not typically assessed in a routine vision assessment. Visual acuity is usually tested with a Snellen chart.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Eye and vision examination, Assessment MSC: Client Needs Category: Health Promotion and Maintenance 5. The nurse assesses a client for factors that place the client at risk for cataracts. Which factor

places the client at the highest risk for cataract development? a. Heart disease b. Glaucoma c. Diabetes mellitus d. Advanced age ANS: D

Advanced age is the major risk factor for developing cataracts because the lens loses water and lens fibers become more compact.

DIF: Remembering KEY: Cataracts, Assessment

TOP: Integrated Process: Nursing Process: Assessment

MSC: Client Needs Category: Health Promotion and Maintenance 6. The nurse is teaching about signs and symptoms of cataracts. Which change would the nurse

emphasize as possibly indicating beginning cataract formation? a. Diplopia b. Cloudy pupil c. Loss of peripheral vision d. Blurred vision ANS: D

A cloudy pupil is a sign of late cataracts and loss of peripheral vision is more common in clients who have glaucoma. Diplopia occurs with a number of neurologic diseases. Blurred vision is the earliest sign that the lens of the eye is undergoing changes.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Cataracts, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 7. The nurse is teaching a client about cataract surgery. Which statement would the nurse include

as part of preoperative preparation? a. “You will receive general anesthesia for the surgical procedure.” b. “You will be in the hospital for only 1 to 2 days if everything goes as expected.” c. “You will need to put several types of eyedrops in your eyes before and after surgery.” d. “You will be on bedrest for about a week after the surgical procedure.”

ANS: C

Cataract surgery is done as an ambulatory care procedure and the client is not hospitalized, does not receive general anesthesia, and does not need to be on bedrest postoperatively.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Cataract, Perioperative care MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 8. A client’s intraocular pressure (IOP) is 28 mm Hg. What action would the nurse anticipate? a. Educate the client on corneal transplantation. b. Facilitate scheduling the eye surgery. c. Teach about drugs for glaucoma. d. Refer the patient to local Braille classes.

ANS: C

This increased IOP indicates glaucoma. The nurse’s main responsibility is teaching the client about drug therapy. Corneal transplantation is not used in glaucoma. Eye surgery is not indicated at this time. Braille classes are also not indicated at this time.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Glaucoma, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 9. A client had a retinal detachment and has undergone surgical correction. What discharge

health teaching is most important for the nurse to include? a. “Avoid reading, writing, or close work such as sewing.”

b. “Report immediate loss of vision of pain in the affected eye.” c. “Keep the follow-up appointment with the ophthalmologist.” d. “Remove your eye patch every hour for eyedrops.”

ANS: B

After surgery for retinal detachment, the client is advised to avoid reading, writing, and close work because these activities cause rapid eye movements. However, more importantly is the need for the client or family to report loss of vision or pain in the surgical eye. Keeping a postoperative appointment is important for any surgical patient. The eye patch is not removed for eyedrops after retinal detachment repair.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Retinal detachment, Perioperative care MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 10. A client has a foreign body in one eye. What action by the nurse is appropriate for the

client’s care? a. Administering ordered antibiotics b. Assessing the patient’s visual acuity c. Obtaining consent for enucleation d. Removing the object immediately ANS: A

To prevent infection, antibiotics are provided. Visual acuity in the affected eye cannot be assessed. The client may or may not need enucleation. The object is only removed by the ophthalmologist.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Eye trauma, Drug therapy MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 11. A client who is nearly blind is admitted to the hospital. What action by the nurse is most

important? a. Allow the client to feel his or her way around. b. Let the client arrange objects on the bedside table. c. Orient the client to the room using a focal point. d. Speak loudly and slowing when talking to the client.

ANS: C

Using a focal point, orient the client to the room by giving descriptions of items as they relate to the focal point. Letting the client arrange the bedside table is appropriate, but not as important as orienting the client to the room for safety. Allowing the client to just feel around may cause injury. Unless the client is also hearing impaired, use a normal tone of voice.

DIF: Understanding TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Decreased visual acuity, Client safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 12. A client is taking timolol eyedrops. The nurse assesses the client’s pulse at 48 beats/min.

What action by the nurse is the priority? a. Ask the client about excessive salivation.

b. Take the client’s blood pressure and temperature. c. Give the drops using punctal occlusion. d. Hold the eyedrops and notify the primary health care provider.

ANS: D

The nurse would hold the eyedrops and notify the primary health care provider because beta blockers can slow the heart rate. Excessive salivation can occur with cholinergic agonists.

Taking the blood pressure and temperature are not necessary. If the drops are given, the nurse uses punctal occlusion to avoid systemic absorption.

DIF: Applying TOP: Integrated Process: Nursing Process: Evaluation KEY: Glaucoma, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 13. A client has been prescribed brinzolamide for glaucoma. What assessment by the nurse

requires communication with the primary health care provider? a. Allergy to eggs b. Allergy to sulfonamides c. Use of contact lenses d. Use of beta blockers ANS: B

Brinzolamide is similar to sulfonamides, so an allergic reaction could occur. The other assessment findings are not related to brinzolamide.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Glaucoma, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 14. A client is brought to the emergency department after a car crash. The client has a large piece

of glass in the left eye. What action by the nurse takes priority? a. Administer a tetanus booster shot. b. Ensure that the client has a patent airway. c. Prepare to irrigate the client’s eye. d. Turn the client on the unaffected side.

ANS: B

Airway always comes first. After ensuring a patent airway and providing cervical spine precautions (do not turn the client to the side), the nurse provides other care that may include administering a tetanus shot. The client’s eye may or may not be irrigated.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Eye trauma, Primary survey MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 15. A nurse is seeing clients in the ophthalmology clinic. Which client would the nurse see first? a. Client with intraocular pressure reading of 24 mm Hg b. Client with a tearing, reddened eye with exudate c. Client whose red reflex is absent on ophthalmologic examination d. Client who has had cataract surgery and has worsening vision ANS: D

After cataract surgery, worsening vision indicates a postoperative infection or other complication. The nurse would see this client first. The intraocular pressure is slightly elevated. An absent red reflex may indicate cataracts. The client who has the tearing eye may have an infection.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Eye and visual disorders, Prioritization MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. The nurse teaches assistive personnel about age-related changes that affect the eyes and

vision. Which changes would the nurse include? (Select all that apply.) a. Decreased eye muscle tone b. Development of arcus senilis c. Increase in far point of near vision d. Decrease in general color perception e. Increase in point of near vision ANS: A, B, D, E

Normal age-related changes include decreased eye muscle tone, development of arcus senilis, decreased color perception, and increased point of near vision. The far point of near vision typically decreases.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Eye and vision health, Developmental stage MSC: Client Needs Category: Health Promotion and Maintenance 2. The nurse is teaching a group of adults about ways to prevent early cataract formation. What

health teaching would the nurse include? (Select all that apply.) a. “Wear eye and head protection when playing sports.” b. “Be sure to get 7 to 8 hours of sleep each night.” c. “Drink less carbonated beverages, especially those with caffeine.” d. “Wear sunglasses when going outdoors or in ultraviolet light.” e. “Increase consumption of high-protein, low-carbohydrate foods.” f. “Avoid smoking or participate in a smoking cessation program.”

ANS: A, D, F

Although all of these choices are strategies for overall health promotion. Wearing eye and head protection and sunglasses, and avoiding or quitting smoking are specific strategies to promote eye health. Cataracts may occur earlier in a client’s life if these recommendations are not followed.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Eye and vision health, Health promotion MSC: Client Needs Category: Health Promotion and Maintenance 3. The nurse is teaching a client about preventing intraocular pressure increase after cataract

surgery. Which health teaching would the nurse include? (Select all that apply.) a. “Don’t lift objects weighing more than 20 lb (9.1 kg).” b. “Avoid blowing your nose or sneezing.”

c. d. e. f.

“Don’t bend down from the waist.”

“Don’t strain to have a bowel movement.”

“Avoid having sexual intercourse.”

“Don’t wear tight shirt or blouse collars.”

ANS: B, C, D, E, F

All of these precautions can help prevent an increase in intraocular pressure except that the client should not lift anything weighing more than 10 lb (4.5 kg).

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Cataract, Perioperative care MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. The nurse is teaching a client and family regarding symptoms to report to the primary health

care provider after cataract surgery. Which symptoms would the nurse include in the teaching? (Select all that apply.) a. Sharp sudden pain in the surgical eye b. Green or yellow discharge from the surgical eye c. Eyelid swelling of the surgical eye d. Decreased vision in the surgical eye e. Blindness in the surgical eye f. Flashes or floaters seen in the surgical eye ANS: A, B, C, D, E, F

All of these symptoms are not normal and should be reported immediately to the surgeon or other appropriate primary health care provider.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Cataract, Perioperative care MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. The nurse is assessing a client admitted to the emergency department with possible retinal

detachment. What assessment findings would the nurse expect? (Select all that apply.) a. Presence of bright light flashes b. Decreased visual field in affected eye c. Feeling like a curtain is over one eye d. Gradual changes in visual acuity e. Painful throbbing in the affected eye ANS: A, B, C

Changes that occur in clients experiencing retinal detachment are usually sudden and painless.

Typical changes that occur include bright light flashes, sudden decrease in visual filed, and a feeling like a curtain is over all or part of the affected eye.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Retinal detachment, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. The nurse is teaching a client about care after surgery to repair a retinal detachment. What

health teaching would the nurse include? (Select all that apply.) a. “Report sudden pain in the surgical eye.” b. “Report if the surgical eye remains dilated.”

c. “Avoid close vision activities in the first week.” d. “Avoid activities that increase intraocular pressure.” e. “Report sudden reduced visual acuity.”

ANS: A, B, C, D, E

All of these instructions are important for the client who has a retinal detachment repair.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Retinal detachment, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 7. The nurse is teaching a client about postoperative care after a LASIK procedure. Which

common complications/adverse effects could occur either immediately or later after this type of surgery? (Select all that apply.) a. Halos around lights b. Blurred vision c. Blindness d. Infection e. Dry eyes ANS: A, B, D, E

All of these common problems can occur after LASIK surgery except for blindness. Some decrease in visual acuity can occur, however.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Refraction errors, Perioperative care MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

Chapter 43: Assessment and Care of Patients With Ear and Hearing Problems Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse is teaching a client about ear hygiene and health. Which statement by the client

indicates a need for further teaching? a. “A soft cotton swab is alright to clean my ears with.” b. “I make sure my ears are dry after I go swimming.” c. “I use good earplugs when I practice with the band.” d. “Keeping my diabetes under control helps my hearing.”

ANS: A

Clients should be taught not to put anything larger than their fingertip into their ears. Using a cotton swab, although soft, can cause damage to the ears and cerumen buildup. The other statements are accurate.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Ear and hearing health, Assessment MSC: Client Needs Category: Health Promotion and Maintenance 2. The nurse is teaching new assistive personnel (AP) about caring for older adults. Which

statement would the nurse include about hearing ability of this client group? a. “You need to talk very loudly when communicating with these clients.” b. “You always need to check each client’s ears for excess ear wax.” c. “Remember to face the client when talking with him or her.” d. “Assess each client’s hearing ability using the voice or whisper test.”

ANS: C

Losing one’s hearing is not a normal change of aging although high frequency sounds may be more difficult to hear. AP does not perform assessments and it is not necessary to talk loudly or shout unless a hearing impairment exists. Therefore, facing the client is the best strategy when communicating with most older adults.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Hearing assessment, Developmental stage MSC: Client Needs Category: Health Promotion and Maintenance 3. The client’s electronic health record indicates a sensorineural hearing loss. What assessment

question does the nurse ask to determine the possible cause? a. “Do you feel like something is in your ear?” b. “Do you have frequent ear infections?” c. “Have you been exposed to loud noises?” d. “Have you been told your ear bones don’t move?”

ANS: C

Sensorineural hearing loss can occur from damage to the cochlea, the eighth cranial nerve, or the brain. Exposure to loud music is one etiology. The other questions are related to conductive hearing loss.

DIF: Understanding

TOP: Integrated Process: Nursing Process: Assessment

KEY: Ear and hearing problems, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. A client has external otitis. About what comfort measure would the nurse instruct the client? a. Applying ice four times a day b. Instilling vinegar-and-water drops c. Use of a heating pad to the ear d. Using a home humidifier ANS: C

A heating pad on low or a warm moist pack can provide comfort to the client with otitis externa. The other options are not appropriate.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Otitis media, Comfort measures MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 5. An older adult in the family practice clinic reports a decrease in hearing in one ear for over a

week. What action by the nurse is most appropriate? a. Assess for cerumen buildup. b. Facilitate audiological testing. c. Perform tuning fork tests. d. Review the medication list.

ANS: A

All options are possible actions for the client with hearing loss. The first action the nurse would take is to look for cerumen buildup, which can decrease hearing in the older adult. If this is normal, medications would be assessed for ototoxicity. Further auditory testing may be needed for this patient.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Ear and hearing problems, Assessment MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 6. A client had a myringotomy. What would the nurse include as part of discharge teaching? a. Buy dry shampoo to use for a week. b. Drink liquids through a straw. c. Flying is not allowed for 1 month. d. Hot water showers will help the pain.

ANS: A

The client cannot shower or get the head wet for 1 week after surgery, so using dry shampoo is a good suggestion. The other instructions are incorrect: straws are not allowed for 2 to 3 weeks, flying is not allowed for 2 to 3 weeks, and the client should not shower.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Ear and hearing problems, Perioperative care MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 7. A nurse is teaching a community group about noise-induced hearing loss. Which client who

does not use ear protection would the nurse refer to an audiologist as the priority? a. Client with an hour car commutes on the freeway each day.

b. Client who rides a motorcycle to work 20 minutes each way. c. Client who sat in the back row at a rock concert recently. d. Client who is a tree-trimmer and uses a chainsaw 6 to 7 hours a day.

ANS: D

A chainsaw becomes dangerous to hearing after several hours of exposure without hearing protection. This client needs to be referred as the priority. Normal car traffic and motorcycle noise is safe unless for a very long time. Although a client was at a rock concert, he or she was in the back row and had less exposure. In addition, a one-time exposure is less damaging than chronic exposure.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Ear and hearing problems, Referral MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 8. A client who has had cold symptoms for a week visits the local urgent care center with report

of left ear discomfort, dizziness, and decreased hearing. What additional assessment findings would the nurse expect? a. High fever b. Nausea and vomiting c. Elevated blood pressure d. Purulent ear drainage ANS: D

The client presents with symptoms that indicate possible serous otitis or otitis media. In either case, the client would not have a high fever or blood pressure. Nausea and vomiting are not common with either diagnosis, but purulent ear drainage is likely to occur if the tympanic eardrum perforates. The client’s decreased hearing could indicate that perforation already occurred.

DIF: Analyzing TOP: Integrated Process: Assessment KEY: Otitis media, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 9. The nurse is teaching a client about factors that can cause external otitis. Which of these

factors would the nurse emphasize as the highest risk? a. Excess cerumen b. Swimming c. Sinus congestion d. Meniere disease ANS: B

External otitis is often called “swimmer’s ear” because it is most often caused by swimming in lakes, ponds, and untreated pools.

DIF: Remembering TOP: Integrated Process: Assessment KEY: Ear and hearing problems, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 10. A nurse is teaching a community group about preventing hearing loss. What instruction is

appropriate? a. “Always wear a bicycle helmet.” b. “Avoid swimming in ponds or lakes.”

c. “Don’t attend fireworks shows.” d. “Use a cerumen spoon to clean ears.”

ANS: A

Avoiding head trauma is a practical way to help prevent hearing loss. Swimming can lead to hearing loss only if the client has repeated infections. Fireworks displays/shows are loud, but usually brief and only occasional. A cerumen spoon is only used by primary health care providers to remove ear wax from in the ear canal.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Ear and hearing problems, Health promotion MSC: Client Needs Category: Health Promotion and Maintenance 11. A client has severe tinnitus that has not responded to treatment. What action by the nurse is

appropriate? a. Advise the client to take antianxiety medication. b. Educate the client on nerve-cutting procedures. c. Refer the client to online or local support groups. d. Refer the client to a mental health professional.

ANS: C

If the client’s tinnitus cannot be treated, he or she will need to learn how to cope with it.

Referring the client to tinnitus support groups can be helpful. The other options are not warranted.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Tinnitus, Referral MSC: Client Needs Category: Psychosocial Integrity 12. A client has mastoiditis and is prescribed antibiotics. What health teaching by the nurse is

most important for this client? a. “Immediately report headache or stiff neck.” b. “Keep all follow-up appointments.” c. “Take the antibiotics with a full glass of water.” d. “Take the antibiotic on an empty stomach.”

ANS: A

Meningitis is a complication of mastoiditis. The client should be taught to take all antibiotics as prescribed and to report manifestations of meningitis such as fever, headache, or stiff neck.

Keeping follow-up appointments is important for all clients. Without knowing what antibiotic was prescribed, the nurse cannot instruct the client on how to take it.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Mastoiditis, Infection control MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 13. A client with Ménière disease is in the hospital when the client has an episode of this disorder.

What action by the nurse is appropriate? a. Assess vital signs every 15 minutes. b. Dim or turn off lights in the client’s room. c. Place the client in bed with the upper side rails up. d. Provide a cool, wet cloth for the client’s face.

ANS: C

Clients with Ménière disease can have vertigo so severe that they can fall. The nurse would assist the client into bed and put the side rails up to keep the client from falling out of bed due to the intense whirling feeling. The other actions are not warranted for clients with Ménière disease.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Meniere disease, Client safety MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 14. A client is scheduled to have a tumor of the middle ear removed. Which perioperative health

teaching is most important for the nurse to include? a. Expecting hearing loss in the affected ear b. Managing postoperative pain c. Maintaining NPO status prior to surgery d. Understanding which medications are allowed the day of surgery ANS: A

Removal of an inner ear tumor will likely destroy hearing in the affected ear. The other teaching topics are appropriate for any surgical client.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Ear and hearing problems, Perioperative care MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 15. The nurse is teaching an older adult how to prevent buildup of ear wax. Which statement by

the nurse is most appropriate? a. “Visit your primary health care provider each month for wax removal.” b. “Drink plenty of water and other liquids to prevent hardening of the ear wax.” c. “Irrigate each ear once a month to remove wax and prevent was buildup.” d. “Put one drop of mineral oil in each ear once a week at bedtime.”

ANS: D

Mineral oil provides lubrication to soften cerumen so that it flows out of the ears to prevent buildup. It is a safer method than irrigating the ears. If needed, the client would need to go to a primary health care provider for removal of impaction. Drinking water helps prevent hardening of wax but does not necessarily prevent wax buildup.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Ear and hearing problems, Developmental stage MSC: Client Needs Category: Health Promotion and Maintenance 16. The nurse is assessing a client’s medication profile to determine risk for tinnitus. Which drug

classification is most likely to cause this health problem? a. Cephalosporins b. NSAIDs c. Beta-adrenergic blockers d. Osmotic diuretics ANS: B

None of these drug classifications except for NSAIDs pose a risk to clients for tinnitus as a side effect.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Tinnitus, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies MULTIPLE RESPONSE 1. A client is scheduled for a tympanoplasty. What action(s) by the nurse are (is) most

appropriate? (Select all that apply.) a. Administer preoperative opioids. b. Assess for allergies to local anesthetics. c. Ensure that informed consent is on the health record. d. Give prescribed antivertigo medications. e. Teach that hearing improves immediately.

ANS: C

Preoperatively, the nurse ensures that informed consent is in the health record. Local anesthetics can be used, but general anesthesia is used more often. Antivertigo medications are not used. Hearing will be decreased immediately after the operation until the ear packing is removed.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Ear and hearing problems, Perioperative care MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 2. A client has a hearing aid. What care instructions does the nurse provide the assistive

personnel (AP) in the care of this client? (Select all that apply.) a. “Be careful not to drop the hearing aid when handling.” b. “Soak the hearing aid in hot water for 20 minutes.” c. “Turn the hearing aid off when the client goes to bed.” d. “Use a toothpick to clean debris from the device.” e. “Wash the device with soap and a small amount of warm water.” f. “Avoid using hair or cosmetic products near the hearing aid.”

ANS: A, C, D, F

All these actions except using water are proper instructions for the nurse to give to the AP. DIF: Understanding TOP: Integrated Process: Communication and Documentation KEY: Ear and hearing problems, Assistive devices MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 3. A hospitalized client has a new diagnosis of Ménière disease. What would the nurse include in

health teaching to reduce symptoms for this disorder? (Select all that apply.) a. “Apply heat to the ear for 20 minutes three times a day.” b. “Move the head slowly to prevent worsening of the vertigo.” c. “Avoid food additives such as monosodium glutamate (MSG).” d. “Quit smoking to increase blood flow to the inner ear.” e. “Avoid caffeinated beverages.” f. “Avoid standing on chairs, step stools, or ladders.”

ANS: B, C, D, E, F

Ménière disease is an excess of endolymphatic fluid that distorts the entire inner-canal system causing vertigo, tinnitus, and unilateral hearing loss. Applying heat or irrigating the ear canal will not alleviate symptoms. Moving the head slowly will prevent worsening of the vertigo.

The diet recommendations for Ménière disease include avoiding caffeine and certain food additives. Smoking causes constriction of blood vessels and decreased blood flow to the inner ear. Clients should also avoid standing on high surfaces to prevent vertigo and falls.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Meniere disease, Health teaching MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. The nurse is caring for a client after ear surgery. What health teaching instruction(s) would the

nurse provide for this client to promote healing? (Select all that apply.) a. “Avoid straining when having a bowel movement.” b. “Avoid drinking through a straw for 2 to 3 weeks.” c. “Avoid air travel for 2 to 3 weeks after surgery.” d. “Avoid crowds and people with infection, especially respiratory infection.” e. “Avoid moving your head quickly, jumping, or bending over for 2 to 3 weeks.” f. “Blow your nose very gently without blocking either nostril and keep your mouth open.”

ANS: A, B, C, D, E, F

It is imperative that the patient having ear surgery is free from ear infection. The other precautions help to prevent increased intra-ear pressure which can affect the surgical procedure.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Ear and hearing problems, Perioperative care MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. The nurse is teaching a family member who is caring for a client who is hearing impaired.

What health teaching would the nurse include about communicating with the client? (Select all that apply.) a. “Make sure that the room is well lighted.” b. “Speak slowly and clearly.” c. “Do not shout but you may need to speak loudly.” d. “Have conversations in a quiet room with minimal noise.” e. “Get the client’s attention before you begin to speak.” f. “Move closer to the better hearing ear if possible.”

ANS: A, B, C, D, E, F

All of these recommendations are useful when communicating with clients who are hearing impaired.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Hearing Loss, Impairment, Communication Physiological Integrity: Physiological Adaptation MSC: Client Needs Category: Health Promotion and Maintenance

Chapter 44: Assessment of the Musculoskeletal System Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. The nurse is caring for an older client who has kyphosis and a widened gait. For which health

problems is the client at risk? a. Osteoporosis b. Contracture c. Osteopenia d. Falls ANS: D

Kyphosis is caused by bone loss and causes the client to bend forward which changes the center of gravity leading to problems with balance. Older adults who have balance issues are at risk for falls.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Musculoskeletal assessment, Spinal deformities MSC: Client Needs Category: Health Promotion and Maintenance 2. The nurse is teaching assistant personnel (AP) about care of an older ambulatory adult who

has osteopenia. Which statement by the AP indicates understanding of the teaching? a. “I will tell the client to change positions frequently to prevent pressure injury.” b. “I will remind the client to take frequent walks to strengthen bones.” c. “I will assist the client with activities of daily living as needed.” d. “I will apply warm compresses to the joints to relieve pain.”

ANS: B

The ambulatory client who has osteopenia has experienced bone loss. Therefore, taking walks as a weight-bearing exercise helps to prevent further bone loss. The client does not have joint pain and does not need assistance or position changes because the client is ambulatory and probably independent.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Musculoskeletal assessment, Health promotion MSC: Client Needs Category: Health Promotion and Maintenance 3. A client had an arthroscopy 1 hour ago on the left knee. The nurse finds the left lower leg to

be pale and cool, with a 1+ pedal pulse. What action would the nurse perform first? a. Assess the neurovascular status of the right leg. b. Document the findings in the patient’s chart. c. Elevate the left leg on at least two pillows. d. Notify the primary health care provider immediately.

ANS: A

The nurse would compare findings of the two legs as these findings may be normal for the client. If a difference is observed, the nurse would then notify the primary health care provider. Documentation would occur after the nurse has all the data. Elevating the left leg will not improve perfusion if there is a problem.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Musculoskeletal assessment, Diagnostic tests MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 4. A hospitalized client’s strength of the upper extremities is rated at a 4. What does the nurse

understand about this client’s ability to perform activities of daily living (ADLs)? a. The client is able to perform ADLs but not lift some items. b. The client is unable to perform ADLs alone. c. No difficulties are expected with ADLs. d. The client would need almost total assistance with ADLs. ANS: C

This rating indicates good muscle strength with full range of motion.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Musculoskeletal assessment, Muscle strength MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. An older client is distressed at body changes related to kyphosis. What response by the nurse

is appropriate? a. Ask the client to explain more about these feelings. b. Explain that these changes are irreversible. c. Offer to help select clothes to hide the deformity. d. Tell the client that safety is more important than looks.

ANS: A

Assessment is the first step of the nursing process, and the nurse would begin by getting as much information about the client’s feelings as possible. Explaining that the changes are irreversible discounts the client’s feelings. Depending on the extent of the deformity, clothing will not hide it. While safety is more objectively important than looks, the client is worried about looks and the nurse needs to address this issue.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Musculoskeletal assessment, Psychosocial assessment MSC: Client Needs Category: Psychosocial Integrity 6. The nurse is taking a history from an older client who reports having frequent falls. Which

dietary habit could be contributing to the client’s problem? a. Consumes high-protein foods. b. Eats few concentrated sweets. c. Limits fatty or greasy foods. d. Avoids dairy products.

ANS: D

Falls can occur when older adults have inadequate calcium and Vitamin D because they are at risk for osteopenia and osteoporosis. Dairy products have a high concentration of both calcium and Vitamin D and this client avoids those foods. High-protein foods are recommended to help prevent osteopenia and sweets and fatty/greasy foods have no impact on bone health.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Musculoskeletal assessment, Changes associated with aging

MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 7. The client’s electronic health record indicates genu varum. What does the nurse understand

this term to mean? a. Bow-legged b. Fluid accumulation c. Knock-kneed d. Spinal curvature ANS: A

Genu varum is a bow-legged deformity. A fluid accumulation is an effusion. Genu valgum is knock-kneed. A spinal curvature could be kyphosis or lordosis.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Musculoskeletal assessment, Musculoskeletal deformities MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 8. The nurse is teaching a client who had a left humeral biopsy about home care. Which

statement by the client indicates understanding of the nurse’s teaching? a. “I will take my opioids only when I have severe pain.” b. “I will keep my left arm elevated for 24 hours.” c. “I will watch for tenderness and warmth around the biopsy site.” d. “I will report any discomfort to my primary health care provider immediately.”

ANS: C

Bone biopsy is an ambulatory procedure which can cause some discomfort but not severe pain. The client can use the affected arm soon after the procedure but should watch for tenderness and warmth which could indicate infection.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Musculoskeletal assessment, Diagnostic tests MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 9. The nurse is teaching assistive personnel (AP) about the risk for osteoporosis associated with

race or ethnicity. Which population typically has a decreased incidence of osteoporosis when compared to Euro-Americans? a. Irish Americans b. African Americans c. American Indians d. Asian Americans ANS: B

African Americans usually have more bone mass when compared to Euro-Americans which makes them at a decreased risk for osteoporosis.

DIF: Remembering TOP: Integrated Process: Culture and Spirituality KEY: Musculoskeletal assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE

1. A female client is preparing to have open magnetic resonance imaging (MRI) of the spine.

What action(s) by the nurse is (are) most important to assess before the test? (Select all that apply.) a. Ask if the client has a history of kidney disease. b. Ask the client if she could possibly be pregnant. c. Ensure that the patient has no metal or electronic implants. d. Assess the client for the ability to communicate. e. Assess the client for a history of claustrophobia.

ANS: A, B, C, D

The contrast agent that is used for an MRI is gadolinium which can cause complications if the client is pregnant or has kidney disease. The client needs to be able to communicate and should not have any metal or electronic implants due to the magnetic nature of the machine.

For an open MRI, claustrophobia is not an issue because the client is not encased in the device.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Musculoskeletal assessment, Diagnostic tests MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 2. The nurse is reviewing the laboratory profile for a client who has muscular dystrophy. Which

laboratory value(s) would the nurse expect to be elevated? (Select all that apply.) a. Calcium (Ca) b. Phosphate (PO4) c. Creatine kinase (CK) d. Lactic dehydrogenase (LDH) e. Aspartate aminotransferase (AST) f. Aldolase (ALD) ANS: C, D, E, F

Muscular dystrophy causes elevations in muscle enzymes and does not affect minerals like calcium and phosphorus.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Musculoskeletal assessment, Diagnostic tests MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. An older client’s serum calcium level is 8.7 mg/dL (2.18 mmol/L). What possible

etiology(ies) does the nurse consider for this result? (Select all that apply.) a. Good dietary intake of calcium and vitamin D b. Normal age-related decrease in serum calcium c. Possible occurrence of osteoporosis or osteopenia d. Potential for metastatic cancer or Paget disease e. Recent bone fracture in a healing stage ANS: B, C

This slightly low calcium level could be an age-related decrease in serum calcium or could indicate a metabolic bone disease, such as osteoporosis or osteopenia. A good dietary intake would be expected to produce normal values. Metastatic cancer, Paget disease, or healing bone fractures will elevate calcium.

DIF: Applying

TOP: Integrated Process: Nursing Process: Analysis

KEY: Musculoskeletal assessment, Diagnostic tests MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 4. When assessing gait, what feature(s) would the nurse inspect? (Select all that apply.) a. Balance b. Ease of stride c. Goniometer readings d. Length of stride e. Steadiness ANS: A, B, D, E

To assess gait, look at balance, ease and length of stride, and steadiness. Goniometer readings assess flexion and extension or joint range of motion.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Musculoskeletal assessment, Gait MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. The nurse takes a history on a male client reporting chronic back pain. Which factor(s) in the

client’s history may have contributed to his pain? (Select all that apply.) a. Had a motor vehicle crash 10 years ago. b. Played football in college and high school. c. Has installed carpet and other flooring for 30 years. d. Typically takes walks 3 to 4 days each week. e. Eats two servings of dark, green leafy vegetables daily.

ANS: A, B, C

A history of trauma caused by an accident, occupation, or contact sports can result in chronic back pain. Regular exercise and diet helps to promote bone health.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Musculoskeletal assessment, History MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort

Chapter 45: Concepts of Care for Patients With Musculoskeletal Problems Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A client has a bone density score of –2.8. What intervention would the nurse anticipate based

on this assessment? a. Asking the client to complete a food diary b. Planning to teach about bisphosphonates c. Scheduling another scan in 2 years d. Scheduling another scan in 6 months ANS: B

A T-score from a bone density scan at or lower than –2.5 indicates osteoporosis. The nurse would plan to teach about medications used to treat this disease, such as the bisphosphonates.

A food diary is helpful to determine if the client gets adequate calcium and vitamin D, but at this point, dietary changes will not prevent the disease. Simply scheduling another scan will not help treat the disease either.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Musculoskeletal disorders, Health teaching MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. The nurse teaches assistive personnel (AP) about care of an older adult diagnosed with

osteoporosis. What teaching would the nurse include? a. “Teach the client to eat high-calcium foods in the diet.” b. “Assist the client with activities of daily living.” c. “Osteoporosis places the client is at risk for fractures.” d. “The client should stay in bed to prevent falling.”

ANS: C

Anyone who has osteoporosis is at risk for fragility fractures even if he or she does not experience trauma like a fall. The client needs to keep active rather than stay in bed where more bone could be lost. High-calcium foods may not be helpful because bone loss is already severe. There is no indication that the client needs assistance with ADLs. DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Musculoskeletal disorders, Osteoporosis MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 3. A client has been advised to perform weight-bearing exercises to help slow bone loss, but has

not followed this advice. What response by the nurse is appropriate at this time? a. Ask the client about fear of falling. b. Instruct the client to increase calcium. c. Suggest other exercises the client can do. d. Tell the client to try weight lifting.

ANS: A

Fear of falling can limit participation in activity. The nurse would first assess if the client has this fear and then offer suggestions for dealing with it. The client may or may not need extra calcium, other exercises, or weight lifting.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Musculoskeletal disorders, Osteoporosis MSC: Client Needs Category: Psychosocial Integrity 4. The nurse is caring for several clients with osteoporosis. For which client would

bisphosphonates not be a good option? a. Client with diabetes who has a serum creatinine of 0.8 mg/dL (61 mcmol/L). b. Client who recently fell and has vertebral compression fractures. c. Hypertensive client who takes calcium channel blockers. d. Client with a spinal cord injury who cannot tolerate sitting up.

ANS: D

Clients on bisphosphonates must be able to sit upright for 30 to 60 minutes after taking them.

The client who cannot tolerate sitting up is not a good candidate for this class of drug. Poor renal function also makes clients poor candidates for this drug, but the client with a creatinine of 0.8 mg/dL (61 mcmol/L) is within normal range. Diabetes and hypertension are not related unless the client also has renal disease. The client who recently fell and sustained fractures is a good candidate for this drug if the fractures are related to osteoporosis.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Analysis KEY: Musculoskeletal disorders, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 5. A client has been prescribed denosumab. What health teaching about this drug is most

appropriate for the nurse to include? a. “Drink at least 8 ounces (240 mL) of water with it.” b. “Make appointments to come get your injection.” c. “Sit upright for 30 to 60 minutes after taking it.” d. “Take the drug on an empty stomach.”

ANS: B

Denosumab is given by subcutaneous injection twice a year. The client does not need to drink 8 ounces (240 mL) of water with this medication as it is not taken orally. The client does not need to remain upright for 30 to 60 minutes after taking this medication, nor does the client need to take the drug on an empty stomach.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Musculoskeletal disorders, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 6. The nurse is performing an assessment of a client with possible plantar fasciitis in the right

foot. What assessment finding would the nurse expect in the right foot? a. Multiple toe deformities b. Numbness and paresthesias c. Severe pain in the arch of the foot d. Redness and severe swelling ANS: C

The most common assessment finding is the client’s report of severe pain in the arch of the foot, especially when walking. The other findings are not typical in clients with this health problem.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Musculoskeletal disorders, Plantar fasciitis MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 7. The nurse is caring for a young client who has been diagnosed with osteopenia. Which risk

factor in the client’s history most likely contributed to the bone loss? a. Osteoarthritis b. Hypothyroidism c. Addison disease d. Rheumatoid arthritis ANS: D

Rheumatoid arthritis often occurs in young female adults and can lead to osteoporosis as a common complication. Cushing disease (rather than Addison disease) and hyperthyroidism (rather than hypothyroidism) are also risk factors. Osteoarthritis is a joint disease.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Musculoskeletal disorders, Osteopenia MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 8. An older client with diabetes is admitted with a heavily draining leg wound. The client’s

white blood cell count is 38,000/mm3 (38  109/L) but the client is afebrile. Which nursing action is most appropriate at this time? a. Administer acetaminophen as needed. b. Educate the client on amputation. c. Place the client on Contact Precautions. d. Refer the client to the wound care nurse.

ANS: C

In the presence of a heavily draining wound, the nurse would place the client on Contact Precautions. If the client has discomfort, acetaminophen can be used, but this client has not reported pain and is afebrile. The client may or may not need an amputation in the future. The wound care nurse may be consulted but not as the most appropriate action.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Musculoskeletal disorders, Transmission-Based Precautions MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 9. A nurse is caring for four clients. After the hand-off report, which client would the nurse see

first? a. Client with osteoporosis and a white blood cell count of 27,000/mm3 (27  109/L) b. Client with osteoporosis and a bone fracture who requests pain medication c. Post-microvascular bone transfer client whose distal leg is cool and pale d. Client with suspected bone tumor who just returned from having a spinal CT ANS: C

This client is the priority because the assessment findings indicate a critical lack of perfusion.

A high white blood cell count is an expected finding for the client with osteoporosis. The client requesting pain medication should be seen second. The client who just returned from a CT scan is stable and needs no specific postprocedure care.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Analysis KEY: Musculoskeletal disorders, Nursing assessment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 10. A client has a metastatic bone tumor in the left leg. What action by the nurse is appropriate? a. Administer pain medication as prescribed. b. Elevate the extremity and apply moist heat. c. Teach the client about amputation care. d. Place the client on protective precautions.

ANS: A

Pain medication should be given to control metastatic bone pain. Elevation and heat may or may not be helpful. Protective precautions are not needed for this client.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Musculoskeletal disorders, Cancer MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 11. A client with bone cancer is hospitalized for a limb salvage procedure. How can the nurse best

address the client’s psychosocial needs? a. Assess the client’s coping skills and support systems. b. Explain that the surgery leads to a longer life expectancy. c. Refer the client to the social worker or hospital chaplain. d. Reinforce physical therapy to aid with ambulating normally.

ANS: A

The first step in the nursing process is assessment. The nurse would assess coping skills and possible support systems that will be helpful in this client’s treatment. Explaining that a limb salvage procedure will extend life does not address the client’s psychosocial needs. Referrals may be necessary, but the nurse should assess first. Reinforcing physical therapy is also helpful but again does not address the psychosocial needs of the client.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Musculoskeletal disorders, Psychosocial response MSC: Client Needs Category: Psychosocial Integrity 12. A client had a bunionectomy with osteotomy. The client asks why healing may take up to 3

months. What explanation by the nurse is best? a. “The bones in your feet are hard to operate on.” b. “The surrounding bones and tissue are damaged.” c. “Your feet have less blood flow, so healing is slower.” d. “Your feet bear weight so they never really heal.”

ANS: C

The feet are the most distal to the heart and receive less blood flow than other organs and tissues, prolonging the healing time after surgery. The other explanations are not correct.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Musculoskeletal disorders, Health teaching MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 13. A nurse assesses clients in an osteoporosis clinic. Which client would the nurse assess first? a. Client taking calcium with vitamin D who reports flank pain 2 weeks ago. b. Client taking ibandronate who cannot remember when the last dose was. c. Client taking raloxifene who reports unilateral calf swelling. d. Client taking risedronate who reports occasional dyspepsia.

ANS: C

The client on raloxifene needs to be assessed first because of the potential for deep vein thrombosis, which is an adverse effect of raloxifene. The client with flank pain may have had a kidney stone but is not acutely ill now. The client who cannot remember taking the last dose of ibandronate can be seen last. The client on risedronate may need to change medications.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Musculoskeletal disorders, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 14. What information does the nurse teach a women’s group about osteoporosis? a. “Primary osteoporosis occurs in postmenopausal women due to lack of estrogen.” b. “Men actually have higher rates of the disease but are underdiagnosed.” c. “There is no way to prevent or slow osteoporosis after menopause.” d. “Women and men have an equal chance of getting osteoporosis.”

ANS: A

Women are more at risk of developing primary osteoporosis after menopause due to the lack of estrogen. Men have a slower loss of bone after the age of 75. Many treatments are now available for women to slow osteoporosis after menopause.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Musculoskeletal disorders, Osteoporosis MSC: Client Needs Category: Health Promotion and Maintenance 15. A client with osteoporosis is going home where the client lives alone. What action by the

nurse is best? a. Refer the client to Meals on Wheels. b. Arrange a home safety evaluation. c. Ensure that the client has a walker at home. d. Help the client look into assisted living.

ANS: B

This client has several risk factors that place him or her at a high risk for falling. The nurse should consult social work or home health care to conduct a home safety evaluation. The other options may or may not be needed based upon the client’s condition at discharge.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Musculoskeletal disorders, Osteoporosis MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE

1. A nurse is assessing a community group for dietary factors that contribute to osteoporosis. In

addition to inquiring about calcium, the nurse also assesses for which other dietary components? (Select all that apply.) a. Alcohol b. Caffeine c. Fat d. Carbonated beverages e. Vitamin D ANS: A, B, D, E

Dietary components that affect the development of osteoporosis include alcohol, caffeine, high phosphorus intake, carbonated beverages, and vitamin D. Tobacco is also a contributing lifestyle factor. Fat intake does not contribute to osteoporosis.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Musculoskeletal disorders, Osteoporosis MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A nurse is providing education to a community women’s group about lifestyle changes helpful

in preventing osteoporosis. What topics does the nurse cover? (Select all that apply.) a. Cut down on tobacco product use. b. Limit alcohol to two drinks a day. c. Strengthening exercises are important. d. Take recommended calcium and vitamin D. e. Walk for 30 minutes at least three times a week.

ANS: C, D, E

Lifestyle changes can be made to decrease the occurrence of osteoporosis and include strengthening and weight-bearing exercises and getting the recommended amounts of both calcium and vitamin D. Tobacco should be totally avoided. Women should not have more than one drink per day.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Musculoskeletal disorders, Osteoporosis MSC: Client Needs Category: Health Promotion and Maintenance 3. A client with chronic osteomyelitis is being discharged from the hospital. What information is

important for the nurse to teach this client and family? (Select all that apply.) a. Adherence to the antibiotic regimen b. Correct intramuscular injection technique c. Eating high-protein and high-carbohydrate foods d. Keeping daily follow-up appointments e. Proper use of the intravenous equipment ANS: A, C, E

The client going home with chronic osteomyelitis will need long-term antibiotic therapy— first intravenous, and then oral. The client needs education on how to properly administer IV antibiotics, care for the IV line, adhere to the regimen, and eat a healthy diet to encourage wound healing. The antibiotics are not given by IM injection. The client does not need daily follow-up.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Musculoskeletal disorders, Osteomyelitis MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. The nurse is assessing a client for chronic osteomyelitis. Which features distinguish this from

the acute form of the disease? (Select all that apply.) a. Draining sinus tracts b. High fevers c. Presence of foot ulcers d. Swelling and redness e. Tenderness or pain ANS: A, C

Draining sinus tracts and foot ulcers are seen in chronic osteomyelitis. High fever, swelling, and redness are more often seen in acute osteomyelitis. Pain or tenderness can be in either case.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Musculoskeletal disorders, Osteomyelitis MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. The nurse reviews a list of drugs that can cause secondary osteoporosis.Which drugs are most

commonly associated with this health problem? (Select all that apply.) a. Antianxiety agents b. Antibiotics c. Barbiturates d. Corticosteroids e. Loop diuretics ANS: C, D, E

Several classes of drugs can cause secondary osteoporosis, including barbiturates, corticosteroids, and loop diuretics. Antianxiety agents and antibiotics are not associated with the formation of osteoporosis.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Musculoskeletal disorders, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

Chapter 46: Concepts of Care for Patients With Arthritis and Total Joint Arthroplasty Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. The nurse is caring for a client who has severe osteoarthritis. What primary joint problems

will the nurse expect the client to report? a. Crepitus b. Effusions c. Pain d. Deformities ANS: C

The primary assessment finding typically reported by clients who have osteoarthritis is joint pain, although crepitus, effusions (fluid), and mild deformities may occur.

DIF: Remembering TOP: Integrated Process: Assessment KEY: Osteoarthritis, Signs and symptoms MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 2. A nurse is teaching a client newly diagnosed with osteoarthritis (OA) about drugs used to treat

the disease. For which drug does the nurse plan health teaching? a. Acetaminophen b. Cyclobenzaprine hydrochloride c. Hyaluronate d. Ibuprofen ANS: A

All of these drugs may be appropriate to treat OA. However, the first-line drug is acetaminophen. Cyclobenzaprine is a muscle relaxant given to treat muscle spasms.

Hyaluronate is a synthetic joint fluid implant. Ibuprofen is a nonsteroidal anti-inflammatory drug.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Osteoarthritis, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 3. The nurse assesses a client with diabetes and osteoarthritis (OA) during a checkup. The nurse

notes the client’s blood glucose readings have been elevated. What question by the nurse is most appropriate? a. “Are you following the prescribed diabetic diet?” b. “Have you been taking glucosamine supplements?” c. “How much exercise do you really get each week?” d. “You’re still taking your diabetic medication, right?”

ANS: B

All of the topics are appropriate for a client whose blood glucose readings have been higher than usual. However, since this client also has OA, and glucosamine can increase blood glucose levels, the nurse would ask about its use. The other questions all have an element of nontherapeutic communication in them. Asking how much exercise the client “really” gets is or if the diet is being followed is accusatory. Asking if the client takes his or her medications “right?” is patronizing.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Osteoarthritis, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. The nurse interviews an older client with moderate osteoarthritis and her husband. What

psychosocial assessment question would the nurse include? a. “Do you feel like hurting yourself or others?” b. “Are you planning to retire due to your disease?” c. “Do you ask your husband for assistance?” d. “Do you experience discomfort during sex?”

ANS: D

Although some clients can become depressed and anxious as a result of having OA, suicidal ideation is not common. The nurse should not assume that an older adult will want to retire or that the client will need help from her husband. Many clients avoid sexual intercourse because of joint pain and stiffness.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Osteoarthritis, Psychosocial assessment MSC: Client Needs Category: Psychosocial Integrity 5. The nurse assesses a client after a total hip arthroplasty. The client’s surgical leg is visibly

shorter than the other one and the client reports extreme pain. While a co-worker calls the surgeon, what action by the nurse is appropriate? a. Assess neurovascular status in both legs. b. Elevate the surgical leg and apply ice. c. Prepare to administer pain medication. d. Try to place the surgical leg in abduction.

ANS: A

This client has signs and symptoms of hip dislocation, a potential complication of this surgery. Hip dislocation can cause neurovascular compromise. The nurse would assess neurovascular status while comparing both legs. The nurse would not try to move the extremity to elevate or abduct it. Pain medication may be administered if possible, but first the nurse would thoroughly assess the client.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Total joint arthroplasty, Perioperative care MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 6. The nurse is teaching a client who is prescribed acetaminophen for control of osteoarthritic

joint pain. What statement by the client indicates a need for further teaching? a. “I won’t take more than 5000 mg of this drug each day.” b. “I’ll follow up to get my lab tests done to check my liver.”

c. “I’ll check drugs that I take for acetaminophen in them.” d. “I can use topical patches and creams to help relieve pain.”

ANS: A

All of the choices are correct about acetaminophen except that the maximum daily dosage is 4000 mg. For older adults, 3000 mg are recommended due to slower drug metabolism by the liver.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Osteoarthritis, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapy 7. After a total knee arthroplasty, a client is on the postoperative nursing unit with a continuous

femoral nerve blockade. On assessment, the nurse notes the skin of both legs is pale pink, warm, and dry, but the client is unable to dorsiflex or plantarflex the surgical foot. What action would the nurse take next? a. Document the findings and monitor as prescribed. b. Increase the frequency of monitoring the client. c. Notify the surgeon or anesthesia provider immediately. d. Palpate the client’s bladder or perform a bladder scan.

ANS: C

With the femoral nerve block, the client would still be able to dorsiflex and plantarflex the affected surgical foot. Since this client has an abnormal finding, the nurse would notify either the surgeon or the anesthesia provider immediately. Documentation is the last priority.

Increasing the frequency of assessment may be appropriate, but first the nurse must notify the appropriate provider. Palpating the bladder is not related.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Total joint arthroplasty, Perioperative care MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 8. A client is prescribed celecoxib for joint pain. What statement by the client indicates a need

for further teaching? a. “I’ll report any signs of bleeding or bruising to my primary health care provider.” b. “I’ll take this drug only as prescribed by my primary health care provider.” c. “I’ll be sure to take this drug three times a day only on an empty stomach.” d. “I’ll monitor the amount of urine that I excrete every day and report any changes.”

ANS: C

All of the choices are correct for this NSAID except that celecoxib can cause GI distress unless taken with meals or food. The drug should not be taken on an empty stomach and is rarely taken more than twice a day.

DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Arthritis, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapy 9. The nurse is teaching a client who is planning to have a total hip arthroplasty. What statement

by the client indicates a need for further teaching? a. “I will get an IV antibiotic right before surgery to prevent infection.” b. “I may request a regional nerve block as part of the surgical anesthesia.”

c. “I will receive IV heparin before surgery to decrease the risk of clots.” d. “I will receive tranexamic acid to help reduce blood loss during surgery.”

ANS: C

All of the choices are correct except that IV heparin is not given before or after surgery. A different anticoagulant is given after surgery to prevent postoperative venous thromboembolism, such as deep vein thrombosis and pulmonary embolus.

DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Total hip arthroplasty, Perioperative care MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 10. A client asks the nurse about having a total knee arthroplasty to relieve joint pain. Which

factor would place the client at the highest risk for impaired postoperative healing? a. Controlled hypertension b. Obesity c. Osteoarthritis d. Mild osteopenia ANS: B

Obesity places a client at high risk for many postoperative complications including slower wound and bone healing. The other factors usually do not affect healing after surgery.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Total knee arthroplasty, Perioperative care MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 11. A nurse assesses a group of clients who have rheumatoid arthritis (RA). Which client would

the nurse see first? a. Client who reports jaw pain when eating b. Client with a red, hot, swollen right wrist c. Client who has a puffy-looking area behind the knee d. Client with a worse joint deformity since the last visit ANS: B

All of the options are possible manifestations of RA. However, the presence of one joint that is much redder, hotter, or more swollen that the other joints may indicate infection or an exacerbation of the RA disease process. The nurse needs to see this client first.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Rheumatoid arthritis, Signs and symptoms MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 12. The nurse assesses a client with rheumatoid arthritis (RA) and Sjögren syndrome. What

assessment would be most important for this client? a. Abdominal assessment b. Oxygen saturation c. Breath sounds d. Visual acuity ANS: D

Sjögren syndrome may be seen in clients with RA and manifests with dryness of the eyes, mouth, and vagina in females. Visual disturbances can occur. The other assessments are not related to Sjögren syndrome.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Rheumatoid arthritis, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 13. A client who has rheumatoid arthritis is prescribed etanercept. What health teaching by the

nurse about this drug is appropriate? a. Giving subcutaneous injections b. Having a chest x-ray once a year c. Taking the medication with food d. Using heat on the injection site ANS: A

Etanercept is given as a subcutaneous injection twice a week. The nurse would teach the client how to self-administer the medication. The other options are not appropriate for etanercept.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Rheumatoid arthritis, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapy 14. A client with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joint. What

nonpharmacologic intervention does the nurse recommend? a. Heating pad b. Ice packs c. Splint d. Paraffin dip ANS: B

Ice is best for acute inflammation. Heat often helps with joint stiffness. Splinting helps preserve joint function. A paraffin dip is used to provide warmth to the joint which is more appropriate for chronic pain and stiffness.

DIF: Understanding TOP: Integrated Process: Nursing Process: Implementation KEY: Rheumatoid arthritis, Pain management MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 15. A client is scheduled to have a total hip arthroplasty. What preoperative teaching by the nurse

is most important? a. Teach the need to discontinue all medications for 5 days before surgery. b. Teach the patient about foods high in protein, Vitamin C, and iron. c. Explain to the client the possible need for blood transfusions postoperatively. d. Remind the client to have all dental procedures completed at least 2 weeks prior to surgery.

ANS: D

The nurse would include teaching about dental procedures to avoid infection after new joint has been inserted. Planned procedures would be completed at least 2 weeks before surgery and the client will need to tell any future primary health care providers about having a total joint arthroplasty. Only home medications prescribed that increase the risk for bleeding or clotting need to be discontinued 5 to 10 days before surgery. Clients need to be aware that any postoperative anemia may need to be treated with a blood transfusion, but it is not the most important. Diets high in protein, Vitamin C, and iron help with tissue repair, but are not the most important.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Total joint arthroplasty, Perioperative care MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 16. A client is getting out of bed into the chair for the first time after an uncemented total hip

arthroplasty. What action by the nurse is appropriate? a. Have adequate help to transfer the patient. b. Provide socks so the patient can slide easier. c. Tell the patient full weight bearing is allowed. d. Use a footstool to elevate the patient’s leg.

ANS: A

The client with an uncemented hip will be on toe-touch only after surgery. The nurse would ensure there is adequate help to transfer the patient while preventing falls. Slippery socks may cause a fall. Elevating the leg is not going to assist with the client’s transfer.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Total joint arthroplasty, Safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 17. A client has long-term rheumatoid arthritis that especially affects the hands. The client wants

to finish quilting a baby blanket before the birth of her grandchild. What response by the nurse is appropriate? a. “Let’s ask your provider about increasing your pain pills.” b. “Hold ice bags against your hands before quilting.” c. “Try a paraffin wax dip 20 minutes before you quilt.” d. “You need to stop quilting before it destroys your fingers.”

ANS: C

Paraffin wax dips are beneficial for decreasing pain in arthritic hands and lead to increased mobility. Increasing pain pills may not help with movement. Ice has limited use unless the client has a “hot” or exacerbated joint. The client wants to finish the project, so the nurse would not negate its importance by telling the client it is destroying her joints.

DIF: Applying TOP: Integrated Process: Caring KEY: Rheumatoid arthritis, Pain management, Heat MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 18. A client has a left knee arthrocentesis to remove excess joint fluid. What postprocedure health

teaching will the nurse include? a. “Take your opioid medication as prescribed by the primary health care provider.” b. “Do not bear weight on your left leg for at least a week after you get home.”

c. “Monitor the site for bleeding or clear fluid leakage when you are home.” d. “Tell your employer that you can’t come back to work for 2 to 3 weeks.”

ANS: C

An arthrocentesis is performed as an ambulatory procedure and may require a mild analgesic such as acetaminophen for discomfort. Opioids are not used. The client may bear weight and return to work, but needs to monitor for bleeding or leakage of synovial fluid at the injection site.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Arthritis, Diagnostic tests MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 19. The primary health care provider prescribes methotrexate (MTX) for a client with a new

diagnosis of rheumatoid arthritis. The nurse provides health teaching about the drug. What statement by the nurse is appropriate to include about methotrexate? a. “It will take at least 1 to 2 weeks for the drug to help relieve your symptoms.” b. “The drug is very expensive but there are pharmacy plans to help pay for it.” c. “The drug can increase your risk for infection, so you should avoid crowds.” d. “It’s OK for you to drink about 2 to 3 glasses of wine each week while taking the drug.”

ANS: C

MTX takes up to 4 to 6 weeks to begin to help relieve RA symptoms and is very inexpensive.

Clients should avoid alcohol due to the potential for liver toxicity. MTX suppresses the immune system which makes clients susceptible to infection. The nurse teaches clients to avoid crowds and anyone with a known infection.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Rheumatoid arthritis, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies MULTIPLE RESPONSE 1. The nurse is assessing a client with long-term rheumatoid arthritis (RA) who has been taking

prednisone for 10 years. For which complications of chronic drug therapy would the nurse assess? (Select all that apply.) a. Osteoporosis b. Diabetes mellitus c. Glaucoma d. Hypertension e. Hypokalemia f. Decreased immunity ANS: A, B, C, D, E, F

Prednisone is a corticosteroid that is sometimes used for autoimmune disorders like RA when other drugs are not effective or cannot be tolerated. However, it can cause many complications when used long-term, including all of the health problems listed in the choices.

DIF: Remembering KEY: Rheumatoid arthritis, Drug therapy

TOP: Integrated Process: Assessment

MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapy 2. The nurse is teaching a client with mild rheumatoid arthritis (RA) about how to protect

synovial joints. Which health teaching will the nurse include? (Select all that apply.) a. “Use small joints rather than larger ones during tasks.” b. “Use both hands instead of one with holding objects.” c. “When getting out of bed or a chair, use the palms of your hands.” d. “Bend your knees instead of your waist and keep your back straight.” e. “Do not use multiple pillows under your head to prevent neck flexion.” f. “Use a device or rubber grip to open jars or bottle tops.” g. “Use long-handled devices such as a hairbrush with an extended handle.”

ANS: B, C, D, E, F, G

All of these options are part of health teaching for joint protection except that large joints should be used instead of smaller ones.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Arthritis, Joint protection MSC: Client Needs Category: Health Promotion and Maintenance 3. A client who had a recent total knee arthroplasty will be using a continuous passive motion

(CPM) machine after discharge at home. What health teaching about the CPM machine will the nurse include? (Select all that apply.) a. “Keep the machine padded well to prevent skin breakdown.” b. “Ensure that your leg is placed properly on the machine.” c. “Use the machine as prescribed but not at mealtime.” d. “When the machine is not being used, do not store it on the floor.” e. “Check that the cycle and range of motion is kept at the level prescribed.”

ANS: A, B, C, D, E

Although not used as often today, some clients are prescribed to use the CPM machine to increase range of motion in the surgical knee. All of these teaching points are important for any client who uses a CPM machine.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Total knee arthroplasty, Home care management MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. The nurse assesses a client with long-term rheumatoid arthritis (RA) for late signs and

symptoms. Which assessment findings will the nurse document as late signs and symptoms of RA? (Select all that apply.) a. Anorexia b. Felty syndrome c. Joint deformity d. Low-grade fever e. Weight loss ANS: B, C, E

Late signs and symptoms of RA include Felty syndrome, joint deformity, weight loss, organ involvement, osteoporosis, extreme fatigue, and anemia, among others. Anorexia and low-grade fever are both seen early in the course of the disease.

DIF: Remembering TOP: Integrated Process: Communication and Documentation KEY: Rheumatoid arthritis, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. The nurse is teaching assistive personnel about postoperative care for an older adult who had a

posterolateral total hip arthroplasty. What teaching will the nurse include? (Select all that apply.) a. “Move the client slowly to prevent dizziness and a possible fall.” b. “Encourage the client to deep breathe and cough at least every 2 hours.” c. “Help the client use the incentive spirometer at least every 2 hours.” d. “Keep the abduction pillow in place at all times while the client is in bed.” e. “Let me know if the client has an elevated temperature or pulse.” f. “Keep in mind that the client may be a little confused after surgery.” g. “Please let me know if you see any reddened or open skin areas during bathing.”

ANS: A, B, C, D, E, F

Older adults are at risk for complications of decreased mobility after surgery, including atelectasis, pneumonia, pressure injuries, and orthostatic hypotension. Therefore these precautions are to help keep the client safe and avoid complications that could be life threatening.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Total hip arthroplasty, Perioperative care MSC: Client Needs Category: Health Promotion and Maintenance 6. The nurse is caring for an older client who had a total knee arthroplasty. Prior to surgery, the

client lived alone independently. With which interprofessional health care team members will the nurse collaborate to ensure positive client outcomes? (Select all that apply.) a. Case manager b. Mental health counselor c. Physical therapist d. Occupational therapist e. Speech–language pathologist f. Clergy/Spiritual leader ANS: A, C

The client was independent and living alone prior to surgery but will likely need help for a short time at home. However, if the client was ADL independent, he or she will not need referral to an occupational therapist. Therefore, a case manager can assess the living situation and identify any special needs to be addressed. The physical therapist will help the client learn to ambulate independently with a walker. There is no indication that the client needs referral for mental, spiritual, or speech–language services.

DIF: Understanding TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Total knee arthroplasty, Home care management MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care

7. A client asks the nurse about what medications may be included for nonopioid multimodal

analgesia following a total knee arthroplasty. What medications may be given to the client?

(Select all that apply.) a. Gabapentin b. Ketorolac c. Hydrocodone d. Ketamine e. Morphine f. Bupivacaine ANS: A, B, D, F

All of the choices are appropriate to use for nonopioid multimodal analgesia except for the two opioid drugs—hydrocodone and morphine. The nonopioid medications are used to decrease inflammation and pain.

DIF: Remembering TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Total knee arthroplasty, Drug therapy MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 8. A client has rheumatoid arthritis (RA) and the nurse is conducting a home assessment. What

options can the nurse suggest for the client to maintain independence in activities of daily living (ADLs)? (Select all that apply.) a. Grab bars to reach high items b. Long-handled bath scrub brush c. Soft rocker-recliner chair d. Toothbrush with built-up handle e. Wheelchair cushion for comfort ANS: A, B, D

Grab bars, long-handled bath brushes, and toothbrushes with built-up handles all provide modifications for daily activities, making it easier for the client with RA to complete ADLs independently. The rocker-recliner and wheelchair cushion are comfort measures but do not help increase independence. Most clients who have RA are not wheelchair-bound.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Rheumatoid arthritis, Activities of daily living MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 9. A nurse is visiting a client discharged home after a total hip arthroplasty. What safety

precautions would the nurse recommend to the client and family? (Select all that apply.) a. Buy and install an elevated toilet seat. b. Install grab bars in the shower and by the toilet. c. Step into the bathtub with the affected leg first. d. Remove all throw rugs throughout the house. e. Use a shower chair while taking a shower.

ANS: A, B, D, E

Buying and installing an elevated toilet seat, installing grab bars, removing throw rugs, and using a shower chair will all promote safety for this client. The client is still on partial weight bearing, so he or she cannot step into the bathtub leading with the operative side.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Total joint arthroplasty, Home Management MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 10. A nurse is planning postoperative care for a client following a total hip arthroplasty. What

nursing interventions would help prevent venous thromboembolism for this client? (Select all that apply.) a. Early ambulation b. Fluid restriction c. Quadriceps-setting exercises d. Compression stockings/devices e. Anticoagulant drug therapy ANS: A, C, D, E

Early ambulation, leg exercises, and compression stockings/devices promote venous return and peripheral circulation which helps prevent deep vein thrombi. Anticoagulants such as subcutaneous low–molecular-weight heparin (LMWH) or factor Xa inhibitors are used for all clients who have a total lower extremity joint arthroplasty. The nurse would encourage fluids to expand blood volume and promote circulation; fluids would not be restricted.

DIF: Understanding TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Total hip arthroplasty, Perioperative care MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

Chapter 47: Concepts of Care for Patients With Musculoskeletal Trauma Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A client who had a surgical fractured femur repair reports new-onset shortness of breath and

increased respirations. What is the nurse’s first action? a. Place the client in a high-Fowler position. b. Document the client’s oxygen saturation level. c. Start oxygen therapy at 2 L/min via nasal cannula. d. Contact the primary health care provider.

ANS: A

The client is experiencing respiratory distress which could be due to pulmonary embolus, fat embolism syndrome, or anxiety. Regardless of the cause, the nurse would place the client in a sitting position first and then perform additional assessment. Oxygen would likely be needed, especially if the client’s oxygen saturation was under 95%.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Fracture, Complications MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 2. A client who had a fractured ankle open reduction internal fixation (ORIF) 4 weeks ago

reports burning pain and tingling in the affected foot. For which potential complication would the nurse anticipate? a. Delayed bone healing b. Complex regional pain syndrome c. Peripheral neuropathy d. Compartment syndrome ANS: B

Burning pain and tingling that occurs weeks or months after a fracture or other trauma may indicate complex regional pain syndrome. Compartment syndrome tends to occur within days of the initial injury.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Fracture, Complications MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. An older client who fell at home is admitted to the emergency department and reports pain in

her left groin and behind her left knee. What action would the nurse anticipate? a. Administer IV push morphine. b. Prepare for application of a leg cast. c. Begin oxygen at 6 L/min via mask. d. Obtain a left hip x-ray.

ANS: D

The location of the client’s pain indicates a possible fractured hip and therefore an x-ray of the hip is needed. A leg cast is not appropriate and oxygen may not be needed. Medication to make the client more comfortable would likely be needed after a diagnosis is determined.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Fracture, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. The nurse is performing a neurovascular assessment for an older client who has an extremity

fracture. How many seconds would the nurse expect for a capillary refill in it is within normal range? a. 20 seconds b. 15 seconds c. 10 seconds d. 5 seconds ANS: D

The normal capillary refill is usually 3 seconds, but for older adults, the refill usually takes up to 5 seconds due to vascular changes associated with aging.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Fracture, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. 5. A nurse assesses an older adult who was admitted 2 days ago with a fractured hip. The

nurse notes that the client is confused and restless with an oxygen saturation of 88%. Which action would the nurse take first? a. Administer oxygen via nasal cannula. b. Re-position to a semi-Fowler position. c. Increase the intravenous flow rate. d. Assess response to pain medication.

ANS: A

The client is at high risk for a fat embolism syndrome and pulmonary embolus. Although these complications are life-threatening emergencies, the nurse would administer oxygen first and then notify the primary health care provider. Oxygen administration can reduce the risk for cerebral damage from hypoxia. Pain medication most likely would not cause the client to be restless.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Fracture, Complications MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 6. A nurse is caring for several clients with fractures. Which client would the nurse identify as

being at the highest risk for developing deep vein thrombosis? a. An 18-year-old male athlete with a fractured clavicle b. A 36-year-old female with type 2 diabetes and fractured ribs c. A 55-year-old female prescribed ibuprofen for osteoarthritis d. A 74-year-old male who smokes and has a fractured pelvis ANS: D

Deep vein thrombosis (DVT) as a complication with bone fractures occurs more often when fractures are sustained in the lower extremities and the client has additional risk factors for thrombus formation. Other risk factors include obesity, smoking, oral contraceptives, previous thrombus events, advanced age, venous stasis, and heart disease. The other clients do not have additional risk factors for DVT.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Fracture, Complications MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 7. A nurse teaches assistive personnel (AP) about providing hygiene for a client in traction.

Which statement would the nurse include as part of the teaching about this client’s care? a. “Remove the traction when re-positioning the client.” b. “Assess the client’s skin when performing a bed bath.” c. “Provide pin care by using alcohol wipes to clean the sites.” d. “Ensure that the weights remain freely hanging at all times.”

ANS: D

Traction weights should be freely hanging at all times. They should not be lifted manually or allowed to rest on the floor. The client should remain in traction during hygiene activities. The nurse would assess the client’s skin and provide pin and wound care for a patient who is in traction; this would not be delegated to the AP. DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Fracture, Traction MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 8. A client is admitted to the emergency department with a fractured femur resulting from a

motor vehicle crash. What the nurse’s priority action? a. Keep the client warm and comfortable. b. Assess airway, breathing, and circulation. c. Maintain the client in a supine position. d. Immobilize the injured extremity with a splint.

ANS: B

As part of the primary survey, the nurse would ensure that the client does not have any life-threatening problem by assessing the ABCs first. If there are not major problems, then the nurse could attend to the injured extremity.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Fracture, Complications MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 9. The nurse is caring for a client who had a closed reduction of the left arm and notes a large

wet area of drainage on the cast. What action is the most important? a. Cut off the old cast. b. Document the assessment. c. Notify the primary health care provider. d. Wrap the cast with gauze.

ANS: C

The primary health care provider should be notified to examine the client and determine the source of the drainage. The nurse’s assessment should be documented, but that is not the most important action.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Fracture, Complications

MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 10. A nurse is caring for a client who is recovering from an above-the-knee amputation and

reports pain in the limb that was removed. How would the nurse respond? a. “The pain you are feeling does not actually exist.” b. “This type of pain is common and will eventually go away.” c. “Would you like to learn how to use imagery to minimize your pain?” d. “How would you describe the pain that you are feeling?”

ANS: D

The nurse would ask the client to rate the pain on a scale of 0-10 and describe how the pain feels. Although phantom limb pain is common, the nurse would not minimize the pain that the client is experiencing by stating that it does not exist or will eventually go away. Although imagery may help, the nurse must assess the client’s pain before determining the best action.

DIF: Applying TOP: Integrated Process: Caring MSC: Client Needs Category: Psychosocial Integrity

KEY: Amputation, Complications

11. A nurse cares for a client who had a wrist cast applied 3 days ago. The client states, “The cast

is loose enough to slide off.” How would the nurse respond? a. “Keep your arm above the level of your heart.” b. “As your muscles atrophy, the cast is expected to loosen.” c. “I will wrap a bandage around the cast to prevent it from slipping.” d. “You need a new cast now that the swelling is decreased.”

ANS: D

Often the surrounding soft tissues may be swollen considerably when the cast is initially applied. After the swelling has resolved, if the cast is loose enough to permit two or more fingers between the cast and the client’s skin, the cast needs to be replaced. Elevating the arm will not solve the problem, and the client’s muscles should not atrophy while in a cast for 6 weeks or less. An elastic bandage will not prevent slippage of the cast.

DIF: Understanding TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Fracture, Casts MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 12. A nurse assesses a client with a pelvic fracture. Which assessment finding would the nurse

identify as a complication of this injury? a. Hypertension b. Diarrhea c. Infection d. Hematuria ANS: D

The pelvis is very vascular and close to major organs. Injury to the pelvis can cause integral damage that may manifest as blood in the urine (hematuria) or stool. The nurse would also assess for signs of hemorrhage and hypovolemic shock, which include hypotension and tachycardia. Diarrhea and infection are not common complications of a pelvic fracture.

DIF: Understanding KEY: Fracture, Complications

TOP: Integrated Process: Nursing Process: Assessment

MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 13. A nurse cares for a client placed in skeletal traction. The client asks, “What is the primary

purpose of this type of traction?” How would the nurse respond? a. “Skeletal traction will assist in realigning your fractured bone.” b. “This treatment will prevent future complications and back pain.” c. “Traction decreases muscle spasms that occur with a fracture.” d. “This type of traction minimizes damage as a result of fracture treatment.”

ANS: A

Skeletal traction pins or screws are surgically inserted into the bone to aid in bone alignment.

As a last resort, traction can be used to relieve pain, decrease muscle spasm, and prevent or correct deformity and tissue damage. These are not primary purposes of skeletal traction.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Fracture, Traction MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 14. The nurse is caring for a postoperative client who have a regional nerve blockade for a

surgical tibial fracture repair this morning. What assessment finding would the nurse expect? a. Client reports nausea and vomiting. b. Client reports tingling in the surgical leg. c. Client responds well to imagery. d. Client reports little to no pain.

ANS: D

A regional nerve blockade can last for about 24 hours so the client has little to no pain until it wears off. The blockade is localized and therefore does not cause nausea or vomiting.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Fracture, Perioperative care MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 15. A nurse is caring for a client recovering from an above-the-knee amputation of the right leg.

The client reports pain in the right foot. Which prescribed medication would the nurse most likely administer? a. Intravenous morphine b. Oral acetaminophen c. Intravenous calcitonin d. Oral ibuprofen ANS: C

The client is experiencing phantom limb pain, which usually manifests as intense burning, crushing, or cramping. IV infusions of calcitonin during the week after amputation can reduce phantom limb pain. Opioid analgesics such as morphine are not as effective for phantom limb pain as they are for residual limb pain. Oral acetaminophen and ibuprofen are not used in treating phantom limb pain.

DIF: Understanding TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Amputation, Perioperative care MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

16. A nurse plans care for a client who is recovering from a below-the-knee amputation of the left

leg. Which intervention would the nurse include in this client’s plan of care? a. Place pillows between the client’s knees. b. Encourage range-of-motion exercises. c. Administer prophylactic antibiotics. d. Implement strict bedrest in a supine position.

ANS: B

Clients with a below-the-knee amputation should complete range-of-motion exercises to prevent flexion contractions and prepare for a prosthesis. A pillow may be used under the limb as support. Clients recovering from this type of amputation are at low risk for infection and should not be prescribed prophylactic antibiotics. The client should be encouraged to re-position, move, and exercise frequently, and therefore should not be restricted to bedrest.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Amputation, Perioperative care MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 17. The nurse is teaching a client how to use a cane after a right surgical fractured fibula repair.

What health teaching would the nurse include? a. “Place the cane on your left side.” b. “Move the cane and your left leg at the same time.” c. “Be sure the cane is parallel to your waist.” d. “Use the cane only when your right leg is painful.”

ANS: A

The cane should be placed on the unaffected side (left for this client) and moved forward with the injured leg (right for this client) to provide support. The cane should be parallel to the stylus of the wrist and used at all times when ambulating.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Fracture, Rehabilitation MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 18. A nurse is caring for a client with diabetes mellitus who has fractured her arm. Which action

would the nurse take first? a. Remove the medical alert bracelet from the fractured arm. b. Immobilize the arm by splinting the fractured site. c. Place the client in a supine position with a warm blanket. d. Cover any open areas with a sterile dressing.

ANS: A

A client’s medical alert bracelet or any other jewelry would be removed from the fractured arm before the affected extremity swells. Immobilization, positioning, and dressing should occur after the bracelet is removed.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Fracture, Management MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort

19. A nurse cares for a client with a recently fractured tibia. Which assessment would alert the

nurse to take immediate action? a. Pain of 4 on a scale of 0-10 b. Numbness in the extremity c. Swollen extremity at the injury site d. Feeling cold while lying in bed ANS: B

The client with numbness and/or tingling of the extremity may be displaying the first signs of acute compartment syndrome. This is an acute problem that requires immediate intervention because of possible decreased circulation. Moderate pain and swelling is an expected assessment after a fracture. These findings can be treated with comfort measures. Being cold can be treated with additional blankets or by increasing the temperature of the room.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Fracture, Complications MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 20. After teaching a client with a fractured humerus, the nurse assesses the client’s understanding.

Which dietary choice demonstrates that the client correctly understands the nutrition needed to assist in healing the fracture? a. Baked fish with orange juice and a vitamin D supplement b. Bacon, lettuce, and tomato sandwich with a vitamin B supplement c. Vegetable lasagna with a green salad and a vitamin A supplement d. Roast beef with low-fat milk and a vitamin C supplement ANS: D

The client with a healing fracture needs supplements of vitamins B and C and a high-protein, high-calorie diet. Milk for calcium supplementation and vitamin C supplementation is appropriate. Meat would increase protein in the diet that is necessary for bone healing. Fish, a sandwich, and vegetable lasagna would provide less protein.

DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Fracture, Health promotion MSC: Client Needs Category: Health Promotion and Maintenance 21. A client who had a traumatic above-the-knee amputation states that he fears he will never

have an intimate relationship again. What is the nurse’s best response? a. “You’ll be able to get a leg prosthesis soon.” b. “You think you won’t be able to have sex again?” c. “I will ask the social worker to talk with you.” d. “Are you married now or have a girl friend?”

ANS: B

The nurse’s response needs to allow further exploration of the client’s feelings. Referring the client to another health professional might be appropriate at a later time but discounts the client’s current feelings. Asking about marriage or a girlfriend assumes that the client is heterosexual.

DIF: Analyzing TOP: Integrated Process: Communication and Documentation KEY: Amputation, Psychosocial assessment MSC: Client Needs Category: Psychosocial Integrity

22. A nurse is caring for an older client who is recovering from a leg amputation surgery. The

client states, “I don’t want to live with only one leg. I should have died during the surgery.”

What is the nurse’s best response? a. “Your vital signs are good, and you are doing just fine right now.” b. “Your children are waiting outside. Do you want them to grow up without a father?” c. “This is a big change for you. What support system do you have to help you cope?” d. “You will be able to do some of the same things as before you became disabled.”

ANS: C

The client feels like less of a person following the amputation. The nurse would help the client to identify coping mechanisms that have worked in the past and current support systems to assist with coping. The nurse would not ignore the client’s feelings by focusing on vital signs.

The nurse would not try to make the client feel guilty by alluding to family members. The nurse would not refer to the patient as being “disabled” as this labels the client and may fuel poor body image.

DIF: Applying TOP: Integrated Process: Caring KEY: Amputation | Psychosocial assessment MSC: Client Needs Category: Psychosocial Integrity 23. After teaching a client who is recovering from a vertebroplasty, the nurse assesses the

patient’s understanding. Which statement by the client indicates a need for additional teaching? a. “I can drive myself home after the procedure.” b. “I will monitor the puncture site for signs of infection.” c. “I can start walking tomorrow and increase my activity slowly.” d. “I will remove the dressing the day after discharge.”

ANS: A

Before discharge, a client who has a vertebroplasty would be taught to avoid driving or operating machinery for the first 24 hours. The client should monitor the puncture site for signs of infection. Usual activities can resume slowly, including walking and slowly increasing activity over the next few days. The client should keep the dressing dry and remove it the next day.

DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Fracture, Perioperative care MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 24. A nurse plans care for a client who has an external fixator on the lower leg. Which

intervention would the nurse include in the plan of care to decrease the client’s risk for infection? a. Washing the frame of the fixator once a day b. Releasing fixator tension for 30 minutes twice a day c. Avoiding moving the extremity by holding the fixator d. Scheduling for pin care to be provided every shift ANS: D

To decrease the risk for infection in a client with skeletal traction or external fixation, the nurse would provide routine pin care and assess for signs and symptoms of infection at the pin sites every shift.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Fracture, External fixator MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control MULTIPLE RESPONSE 1. A nurse teaches a client with a fractured tibia about external fixation. Which advantages of

external fixation for the immobilization of fractures would the nurse share with the client?

(Select all that apply.) a. It leads to minimal blood loss. b. It allows for early ambulation. c. It decreases the risk of infection. d. It increases blood supply to tissues. e. It promotes healing.

ANS: A, B, E

External fixation is a system in which pins or wires are inserted through the skin and bone and then connected to a ridged external frame. With external fixation, blood loss is less than with internal fixation, but the risk for infection is much higher. The device allows early ambulation and exercise, maintains alignment, stabilizes the fracture site, and promotes healing. The device does not increase blood supply to the tissues. The nurse would assess for distal circulation, movement, and sensation, which can be disturbed by fracture injuries and treatments.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Fracture, External fixator MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 2. The nurse assesses a client who is admitted with a pelvic fracture. Which assessments would

the nurse monitor to prevent or detect a complication of this injury? (Select all that apply.) a. Temperature b. Urinary output c. Blood pressure d. Pupil reaction e. Skin color ANS: B, C, E

With a pelvic fracture, internal organ damage may result in bleeding and hypovolemic shock.

The nurse monitors the client’s heart rate, blood pressure, urine output, skin color, and level of consciousness frequently to detect assess for shock. It is important to monitor the urine for blood to assess whether the urinary system has been damaged with the pelvic fracture.

Changes in temperature and pupil reactions are not directly associated with hypovolemic shock. Temperature changes are usually associated with hypo- or hyperthermia or infectious processes. Pupillary changes occur with brain injuries, bleeds, or strokes.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Fracture, Complications

MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 3. The nurse is caring for a client who recently sustained a sports injury to his right leg. What

nursing interventions are appropriate for this client? (Select all that apply.) a. Immobilize the right leg. b. Apply heat immediately after the injury. c. Use compression to support the leg. d. Obtain an x-ray to detect possible fracture. e. Elevate the right leg to decrease swelling. f. Administer an opioid every 4 to 6 hours.

ANS: A, C, D, E

The client who experiences a sports injury should be managed using the RICE treatment plan.

Rest, ice, compression, and elevation are all appropriate. Heat would increase swelling and probably pain. An x-ray would be obtained to determine if one or more fractures are present.

Opioids may not be needed depending on the nature of the injury.

DIF: Understanding TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Sports injury, Management MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. A nurse plans care for a client who is recovering from open reduction and internal fixation

(ORIF) surgery for a right hip fracture. Which interventions would the nurse include in this client’s plan of care? (Select all that apply.) a. Elevate heels off the bed with a pillow. b. Ambulate the client on the first postoperative day. c. Push the client’s patient-controlled analgesia button. d. Re-position the client every 2 hours. e. Use pillows to encourage subluxation of the hip.

ANS: A, B, D

Postoperative care for a client who has ORIF of the hip includes elevating the client’s heels off the bed and re-positioning every 2 hours to prevent pressure and skin breakdown. It also includes ambulating the client on the first postoperative day, and using pillows or an abduction pillow to prevent subluxation of the hip. The nurse would teach the client to use the patient-controlled analgesia pump, but the nurse would never push the button for the client.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Fracture, Perioperative nursing MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 5. A nurse teaches a client who is at risk for carpal tunnel syndrome. Which health promotion

activities would the nurse include in the health teaching? (Select all that apply.) a. “Frequently assesses the ergonomics of the equipment being used.” b. “Take breaks to stretch fingers and wrists during working hours.” c. “Do not participate in activities that require repetitive actions.” d. “Take ibuprofen to decrease pain and swelling in wrists.” e. “Adjust chair height to allow for good posture.”

ANS: A, B, E

Health promotion activities to prevent carpal tunnel syndrome include assessing the ergonomics of the equipment being used, taking breaks to stretch fingers and wrists during working hours, and adjusting chair height to allow for good posture. The client should be allowed to participate in activities that require repetitive actions as long as precautions are taken to promote health. Pain medications are not part of health promotion activities.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Musculoskeletal injury, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 6. A nurse teaches a client about prosthesis care after amputation. Which statements would the

nurse include in the health teaching? (Select all that apply.) a. “The device has been custom made specifically for you.” b. “Your prosthetic is good for work but not for exercising.” c. “A prosthetist will clean your inserts for you each month.” d. “Make sure that you wear the correct liners with your prosthetic.” e. “I have scheduled a follow-up appointment for you.”

ANS: A, D, E

A client with a new prosthetic should be taught that the prosthetic device is custom made for the client, taking into account the level of amputation, lifestyle (including exercise preferences), and occupation. In collaboration with a prosthetist, the client should be taught proper techniques for cleansing the sockets and inserts, wearing the correct liners, and assessing shoe wear. Follow-up care and appointments are important for ongoing assessment.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Amputation, Health teaching MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 7. The nurse is caring for a client who just had a kyphoplasty. What nursing care is needed for

the client at this time? (Select all that apply.) a. Place the client in a prone position to prevent pressure on the surgical area. b. Apply an ice pack to the surgical area to help relieve pain. c. Assess the client’s pain level to compare it with pain before the procedure. d. Take vital signs, including oxygen saturation, frequently. e. Monitor for complications such as bleeding or shortness of breath. f. Perform frequent neurologic assessments and report major changes.

ANS: B, C, D, E, F

All of the choices are correct except that the client should stay in a flat supine position immediately after the procedure.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Fracture, Perioperative care MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort

Chapter 48: Assessment of the Gastrointestinal System Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. The nurse is interviewing a client who reports having abdominal cramping, bloating, and

diarrhea after drinking milk or ingesting other dairy products. What health problem does the client most likely have? a. Steatorrhea b. Ulcerative colitis c. Crohn disease d. Lactose intolerance ANS: D

The client is demonstrating signs and symptoms of lactose intolerance because they occur after the client eats or drinks dairy products which contain lactose.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: GI assessment, History MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. The primary health care provider documents that a client has a bruit over the abdominal aorta.

What teaching will the nurse provide for assistive personnel (AP) based on this assessment finding? a. “Use warm compresses on the client’s abdomen continuously.” b. “Avoid washing the client’s abdomen too aggressively.” c. “Apply ice to the client’s abdomen every 4 hours.” d. “Massage the client’s abdomen to help reduce pain.”

ANS: B

A bruit heard over the abdominal aorta possible indicates stenosis or an aneurysm which should not be palpated or percussed. Therefore, the AP should wash the client’s abdomen very gently.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: GI assessment, Abdominal assessment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 3. A client is having an esophagogastroduodenoscopy (EGD) and has been given midazolam

hydrochloride. The client’s respiratory rate is 8 breaths/min. What action by the nurse is appropriate? a. Administer naloxone. b. Call the Rapid Response Team. c. Provide physical stimulation. d. Ventilate with a bag-valve-mask.

ANS: C

For an EGD, clients are given mild sedation but would still be able to follow commands. For shallow or slow respirations after the sedation is given, the nurse’s most appropriate action is to provide a physical stimulation such as a sternal rub and directions to breathe deeply.

Naloxone is not the antidote for midazolam HCl. The Rapid Response Team is not needed at this point. The client does not need manual ventilation.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Gastrointestinal assessment, Diagnostic tests MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. A client is scheduled for a colonoscopy and the nurse has provided instructions on the bowel

cleansing regimen. What statement by the client indicates a need for further teaching? a. “It’s a good thing I love orange and cherry gelatin.” b. “My spouse will be here to drive me home.” c. “I’ll avoid ibuprofen for several days before the test.” d. “I’ll buy a case of clear Gatorade before the prep.”

ANS: A

The client would be advised to avoid beverages and gelatin that are red, orange, or purple in color as their residue can appear to be blood. The other statements show an understanding of the preparation for the procedure.

DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Gastrointestinal assessment, Diagnostic tests MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 5. A client had a colonoscopy and biopsy yesterday and calls the gastrointestinal clinic to report

a spot of bright red blood on the toilet paper today. What response by the nurse is appropriate? a. Ask the client to call back if this happens again today. b. Instruct the client to go to the emergency department. c. Remind the client that a small amount of bleeding is possible. d. Tell the client to come to the clinic this afternoon.

ANS: C

After a colonoscopy with biopsy, a small amount of bleeding is normal. The nurse would remind the client of this and instruct him or her to go to the emergency department for large amounts of bleeding, severe pain, or dizziness.

DIF: Understanding TOP: Integrated Process: Evaluation KEY: Gastrointestinal assessment, Diagnostic tests MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 6. An older adult has had an instance of drug toxicity and asks why this happens, since the client

has been on this medication for years at the same dose. What response by the nurse is best? a. “Changes in your liver cause drugs to be metabolized differently.” b. “Perhaps you don’t need as high a dose of the drug as before.” c. “Stomach muscles atrophy with age and you digest more slowly.” d. “Your body probably can’t tolerate as much medication anymore.”

ANS: A

Decreased liver enzyme activity depresses drug metabolism, which leads to accumulation of drugs—possibly to toxic levels. The other options do not accurately explain this age-related change.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Gastrointestinal assessment, Changes associated with aging MSC: Client Needs Category: Health Promotion and Maintenance 7. To promote comfort and the passage of flatus after a colonoscopy, in what position does the

nurse place the client? a. Left lateral b. Prone c. Right lateral d. Supine ANS: A

After colonoscopy, clients have less discomfort and quicker passage of flatus when placed in the left lateral position.

DIF: Remembering TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Gastrointestinal assessment, Diagnostic tests MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 8. A nurse is assessing a client reporting right upper quadrant (RUQ) abdominal pain. What

technique would the nurse use to assess this client’s abdomen? a. Auscultate after palpating. b. Avoid any type of palpation. c. Lightly palpate the RUQ first. d. Lightly palpate the RUQ last.

ANS: D

If pain is present in a certain area of the abdomen, that area would be palpated last to keep the client from tensing which could possibly affect the rest of the examination. Auscultation of the abdomen occurs prior to palpation.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Gastrointestinal assessment, Physical assessment MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 9. The nurse knows that a client with prolonged prothrombin time (PT) values (not related to

medication) probably has dysfunction in which organ? a. Kidneys b. Liver c. Spleen d. Stomach ANS: B

Severe acute or chronic liver damage leads to a prolonged PT secondary to impaired synthesis of clotting proteins. The other organs are not related to this issue.

DIF: Remembering

TOP: Integrated Process: Nursing Process: Assessment

KEY: Gastrointestinal assessment, Laboratory tests MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 10. A client is recovering from an esophagogastroduodenoscopy (EGD) and requests something

to drink. What action by the nurse is appropriate? a. Allow the client cool liquids only. b. Assess the client’s gag reflex. c. Remind the client to remain NPO. d. Tell the client to wait 4 hours.

ANS: B

The local anesthetic used during this procedure depresses the client’s gag reflex. After the procedure, the nurse would ensure that the gag reflex is intact before offering food or fluids.

The client does not need to be restricted to cool beverages only and is not required to wait 4 hours before oral intake is allowed. Telling the client to remain NPO does not inform the client of when he or she can have fluids, nor does it reflect the client’s readiness for them.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Gastrointestinal assessment, Diagnostic tests MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 11. The assistive personnel note that a client had a dark stool. What stool test would the nurse

obtain for this client? a. Culture and sensitivity b. Parasites and ova c. Occult blood test d. Total fat content ANS: C

Dark stools are typical in clients who have lower GI bleeding. Therefore, an fecal occult blood test would be the most appropriate test as a follow-up.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: GI Assessment: Laboratory tests MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 1. The nurse is aware of the most recent American Cancer Society Screening Guidelines for

colon cancer, which include which accepted testing modalities for people over the age of 50?

(Select all that apply.) a. Colonoscopy every 10 years b. Endoscopy every 5 years c. Computed tomography (CT) colonography every 5 years d. Double-contrast barium enema every 10 years e. Flexible sigmoidoscopy every 5 years ANS: A, C, E

The options for colon cancer screening for people over the age of 50 include colonoscopy every 10 years and CT colonography, double-contrast barium enema, or flexible sigmoidoscopy every 5 years.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Gastrointestinal assessment, Health promotion MSC: Client Needs Category: Health Promotion and Maintenance 2. A client had an endoscopic retrograde cholangiopancreatography (ERCP). The nurse teaches

the client and family about the signs of potential complications which include what problems?

(Select all that apply.) a. Cholangitis b. Pancreatitis c. Perforation d. Renal lithiasis e. Sepsis ANS: A, B, C, E

Possible complications after an ERCP include cholangitis, pancreatitis, perforation, sepsis, and bleeding. Kidney stones are not a complication of ERCP. DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Gastrointestinal assessment, Diagnostic tests, Patient education MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 3. The nurse working with older clients understands age-related changes in the gastrointestinal

system. Which changes does this include? (Select all that apply.) a. Decreased hydrochloric acid production b. Diminished sensation that can lead to constipation c. Fat not digested as well in older adults d. Increased peristalsis in the large intestine e. Pancreatic vessels become calcified ANS: A, B, C, E

Several age-related changes occur in the gastrointestinal system. These include decreased hydrochloric acid production, diminished nerve function that leads to decreased sensation of the need to pass stool, decreased fat digestion, decreased peristalsis in the large intestine, and calcification of pancreatic vessels.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Gastrointestinal assessment, Changes associated with aging MSC: Client Needs Category: Health Promotion and Maintenance 4. The nurse working with clients who have gastrointestinal problems knows that which

laboratory values are related to which organ functions or dysfunctions? (Select all that apply.) a. Alanine aminotransferase: biliary system b. Ammonia: liver c. Amylase: liver d. Lipase: pancreas e. Urine urobilinogen: stomach ANS: B, D

Alanine aminotransferase and ammonia are related to the liver. Amylase and lipase are related to the pancreas. Urobilinogen evaluates both hepatic and biliary function.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Gastrointestinal assessment, Laboratory tests MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. A nurse cares for a client who is recovering from a colonoscopy. Which actions would the

nurse take? (Select all that apply.) a. Obtain vital signs every 15 to 30 minutes until alert. b. Assess the client for rectal bleeding and severe pain. c. Administer prescribed pain medications as needed. d. Monitor the client’s serum and urine glucose levels. e. Confirm the client has a ride home and plans to rest.

ANS: A, B, E

During the recovery phase after a colonoscopy, the nurse would obtain vital signs every 15 to 30 minutes until the client is alert, assess for rectal bleeding or severe pain, and confirm the client has arranged for another person to drive home to get rest. Pain medications are not necessary after the procedure, and neither is glucose monitoring.

DIF: Remembering TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Gastrointestinal assessment, Diagnostic tests MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

Chapter 49: Concepts of Care for Patients With Oral Cavity and Esophageal Problems Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. The nurse is teaching a client diagnosed with stomatitis about special mouth care. Which

statement by the client indicates a need for further teaching? a. “I need to take out my dentures until my mouth heals.” b. “I’ll try to eat soft foods that aren’t spicy and acidic.” c. “I will use a more firm toothbrush to keep my mouth clean.” d. “I’ll be sure to rinse my mouth often with warm salt water.”

ANS: C

The client who has stomatitis has oral inflammation which causes discomfort. Therefore, all of these actions help to avoid irritation except for needing to use a soft toothbrush or gauze rather than a firm one.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Stomatitis, Oral care MSC: Client Needs Category: Health Promotion and Maintenance 2. A client is admitted with a large oral tumor. What assessment by the nurse takes priority? a. Airway b. Breathing c. Circulation d. Nutrition ANS: A

Airway always takes priority. Airway must be assessed first and any problems managed if present.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Oral cancer, Assessment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 3. The nurse is teaching a client about the use of viscous lidocaine for oral pain. What health

teaching would the nurse include? a. “Use the drug before every meal to prevent aspiration.” b. “Increase your intake of citrus foods to help with healing.” c. “Use the drug only at bedtime because you won’t be eating.” d. “Be sure to check food temperatures before eating.”

ANS: D

Viscous lidocaine has an anesthetic effect in the oral cavity. Therefore, to promote client safety, the nurse would want to teach the client to check food temperature before eating.

4. A nurse participates in a community screening event for oral cancer. What client is the

highest priority for referral to a primary health care provider? a. Client who has poor oral hygiene practices. b. Client who smokes and drinks daily. c. Client who tans for an upcoming vacation.

d. Client who occasionally uses illicit drugs.

ANS: B

Smoking and alcohol exposure create a high risk for this client. Poor oral hygiene is not related to the etiology of cancer but may cause a tumor to go unnoticed. Tanning is a risk factor, but short-term exposure does not have the same risk as daily exposure to tobacco and alcohol.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Oral cancer, Health screening MSC: Client Needs Category: Health Promotion and Maintenance 5. The nurse notes that the primary health care provider documented the presence of mucosal

erythroplasia in a client. What does the nurse understand that this most likely means for this client? a. Early sign of oral cancer b. Fungal mouth infection c. Inflammation of the gums d. Obvious oral tumor ANS: A

Mucosal erythroplasia is the earliest sign of oral cancer. It is not a fungal infection, inflammation of the gums, or an obvious tumor.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Oral cancer, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. The nurse is caring for a client diagnosed with oral cancer. What is the nurse’s priority for

client care? a. Encourage fluids to liquefy the client’s secretions. b. Place the client on Aspiration Precautions. c. Remind the client to use an incentive spirometer. d. Manage the client’s pain and inflammation.

ANS: B

The client who has oral cancer often has difficulty swallowing and is at risk for aspiration and possibly aspiration pneumonia. Therefore, the most important nursing action is to place the client on precautions to prevent aspiration. The nurse would implement the other actions but they are not as vital to promote client safety.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Oral cancer, Plan of care MSC: Client Needs Category: Safe and Effective Care Environment 7. A client has an open traditional hiatal hernia repair this morning. What is the nurse’s priority

for client care at this time? a. Managing surgical pain b. Ambulating the client early c. Preventing respiratory complications d. Managing the nasogastric tube

ANS: C

The client who has traditional surgery (rather than minimally invasive surgery) is at risk for respiratory complications such as atelectasis and pneumonia because he or she has an incision that may prevent the client from taking deep breaths or using an incentive spirometer.

Therefore, the nurse’s priority is to prevent these potentially life-threatening respiratory problems.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Hiatal hernia, Perioperative care MSC: Client Needs Category: Safe and Effective Care Environment 8. Which of these client assessment findings is typically associated with oral cancer? a. Dry sticky oral membranes b. Increased appetite c. Itchy rash in oral cavity d. Painless red or raised lesion ANS: D

A painless red or raised lesion often indicates a diagnosis of oral cancer. The client usually has a decreased appetite and thick secretions. Itchiness is not a common finding associated with oral cancer.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Oral cancer, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 1. The nurse is caring for a client with sialadenitis. What comfort measures are appropriate for

this client? (Select all that apply.) a. Applying warm compresses b. Applying ice to salivary glands c. Offering fluids every hour d. Providing lemon-glycerin swabs e. Reminding the patient to avoid speaking ANS: A, C

Warm compresses and fluids can help promote comfort for this client. Application of ice or lemon-glycerin swabs would not be used. Speaking has no effect on this condition.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Oral disorders, Comfort measures MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 2. A nurse knows that job-related risks for developing oral cancer include which occupations?

(Select all that apply.) a. Coal miner b. Electrician c. Metal worker d. Plumber e. Textile worker

ANS: A, C, D, E

The occupations of coal mining, metal working, plumbing, and textile work produce exposure to polycyclic aromatic hydrocarbons (PAHs), which are known carcinogens. Electricians do not have this risk.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Oral cancer, Risk factors MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. The nurse is caring for a client who had an open traditional esophagectomy. Which

assessment findings would the nurse report immediately to the primary health care provider?

(Select all that apply.) a. Nausea b. Wound dehiscence c. Fever d. Tachycardia e. Moderate pain f. Fatigue ANS: B, C, D

Wound dehiscence is a serious, potentially life-threatening problem that needs immediate attention of the primary health care provider, typically the surgeon. Fever and tachycardia may indicate that the client has a postoperative infection, another serious, potentially life-threatening complication. Indications of both of these problems need to be documented and reported by the nurse. Nausea, fatigue, and moderate pain are expected postoperative assessment findings.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Esophagectomy, Perioperative care MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. The nurse is caring for a client diagnosed with probable gastroesophageal reflux disease

(GERD). What assessment finding(s) would the nurse expect? (Select all that apply.) a. Dyspepsia b. Regurgitation c. Belching d. Coughing e. Chest discomfort f. Dysphagia ANS: A, B, C, D, E, F

All of these signs and symptoms are commonly seen in clients who have GERD. DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: GERD, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. The nursing is teaching a client diagnosed with gastroesophageal reflux disease (GERD) who

is planning to have an endoscopic radiofrequency (Stretta) procedure. What preprocedure health teaching would the nurse include? (Select all that apply.) a. “You will need to be on a liquid diet for the first week after the procedure.”

b. “Avoid taking any NSAIDs like ibuprofen for 10 days before the procedure.” c. “Contact the primary health care provider after the procedure if you have increased

pain.” d. “You will need a nasogastric tube for a few days after the procedure.” e. “You will have a small incision in your stomach area that will have a wound

closure.

ANS: B, C

The client having this procedure does not have an incision and will not require a nasogastric tube (NGT). The client should avoid an NGT placement for at least a month after the procedure. A liquid diet is required for only 24 hours after the procedure and then the client should progress to include soft floods like custard and applesauce.

DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: GERD, Management MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. The nurse is teaching a client about risk factors for esophageal cancer. Which risk factors

would the nurse include? (Select all that apply.) a. Alcohol intake b. Obesity c. Smoking d. Lack of fresh fruits and vegetables e. Untreated GERD f. Use of NSAIDs ANS: A, B, C, D, E

All of these factors increase the risk of esophageal cancer except for the use of NSAIDs. Untreated GERD causes damage to esophageal tissue which may develop into Barrett esophagus, or precancerous cells.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Esophageal cancer, Risk factors MSC: Client Needs Category: Health Promotion and Maintenance 7. The nurse is teaching a client about the risk of uncontrolled or untreated the client’s

gastroesophageal reflux disease (GERD). What complication(s) may occur if the GERD is not successfully managed? (Select all that apply.) a. Asthma b. Laryngitis c. Dental caries d. Cardiac disease e. Cancer ANS: A, B, C, D, E

Any of these complications may occur in clients who have uncontrolled or untreated GERD. DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: GERD, Complications MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

Chapter 50: Concepts of Care for of Patients With Stomach Disorders Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. The nurse is teaching a client who has been treated for acute gastritis. What statement by the

client indicates a need for further teaching? a. “I need to cut down on drinking martinis every might.” b. “I should decrease my intake of caffeinated drinks, especially coffee.” c. “I will only take ibuprofen once in a while when I really need it.” d. “I can continue smoking cigarettes which is better than chewing tobacco.”

ANS: D

To prevent another episode of acute gastritis, alcohol, caffeinated drinks, and NSAIDs should be avoided or kept at a minimum. Smoking and all forms of tobacco should also be avoided.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Acute gastritis, Health promotion MSC: Client Needs Category: Health Promotion and Maintenance 2. The nurse is caring for a client who has frequent gastric pain and dyspepsia. Which procedure

would the nurse expect for the client to make an accurate diagnosis? a. Esophagogastroduodenoscopy (EGD) b. Abdominal arteriogram c. Nuclear medicine scan d. Magnetic resonance imaging (MRI) ANS: A

The gold standard for diagnosing disorders of the stomach is an EGD which allows direct visualization by the endoscopist into the esophagus, stomach, and duodenum.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Gastric disorders, Diagnostic tests MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. The nurse is caring for a client who has been diagnosed with peptic ulcer disease. For which

complication would the nurse monitor? a. Large bowel obstruction b. Dyspepsia c. Upper gastrointestinal (GI) bleeding d. Gastric cancer ANS: C

Peptic ulcer disease (PUD) can cause gastric mucosal damage or perforation, which causes upper GI bleeding. Dyspepsia is a symptom of PUD, gastritis, and gastric cancer. PUD affects the stomach and/or duodenum, not the colon.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Peptic ulcer disease, Complications MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

4. A client who had a partial gastrectomy 3 days ago begins to experience vertigo, sweating, and

tachycardia about 30 minutes after eating breakfast. What postoperative complication would the nurse suspect? a. Pyloric obstruction b. Dumping syndrome c. Delayed gastric emptying d. Pernicious anemia ANS: B

Dumping syndrome causes autonomic symptoms as food quickly leaves the stomach due to its decreased size after surgery.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Gastric surgery, Complications MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. A client with peptic ulcer disease is in the emergency department and reports gastric pain that

has gotten much worse over the last 24 hours. The client’s blood pressure when lying down is 112/68 mm Hg and when standing is 98/52 mm Hg. What action by the nurse is most appropriate? a. Administer a proton pump inhibitor (PPI). b. Call the Rapid Response Team. c. Start a large-bore IV with normal saline. d. Tell the patient to remain lying down.

ANS: C

This client has orthostatic changes to the blood pressure, indicating fluid volume loss. The nurse would start a large-bore IV with isotonic solution. PPIs are not a treatment for an ulcer.

The Rapid Response Team is not needed at this point. The client should be put on safety precautions, which includes staying in bed, but this is not the most appropriate action at this time.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Peptic ulcer disease, Complications MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. During an interview, the client tells the nurse that the client has a duodenal ulcer. Which

assessment finding would the nurse expect? a. Hematemesis b. Pain when eating c. Melena d. Weight loss ANS: C

All of the other assessment findings are more commonly seen in clients who have gastric ulcers rather than duodenal ulcers.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Peptic ulcer disease, Assessment MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort

7. A client who has peptic ulcer disease is prescribed quadruple drug therapy for Helicobacter

pylori infection. What health teaching related to bismuth would the nurse include? a. “Report stool changes to your primary health care provider immediately.” b. “Do not take aspirin or aspirin products of any kind while on bismuth.” c. “Take bismuth about 30 minutes before each meal and at bedtime.” d. “Be aware that bismuth can cause frequent vomiting and diarrhea.”

ANS: B

Bismuth is a salicylate drug and causes stool discoloration but not vomiting and diarrhea. It does not have to be taken at a specific time relative to meals. Clients taking bismuth should not take other salicylates, such as aspirin or aspirin-containing products.

8. The nurse caring for clients with gastrointestinal disorders would recall that omeprazole is a

drug in which classification? a. Gastric acid inhibitor b. Histamine receptor blocker c. Mucosal barrier fortifier d. Proton pump inhibitor ANS: D

Omeprazole is a proton pump inhibitor.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Gastrointestinal disorders, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 9. The nurse is caring for a client experiencing upper gastrointestinal (GI) bleeding. What is the

priority action for the client’s care? a. Maintain airway, breathing, and circulation. b. Monitor vital signs, including orthostatic blood pressures. c. Draw blood for hemoglobin and hematocrit immediately. d. Insert a nasogastric (NG) tube and connect to intermittent suction.

ANS: A

The priority action for any client experiencing deterioration or an emergent situation is monitor and maintain airway, breathing, and circulation (ABCs). Taking orthostatic blood pressures would not be appropriate, but the nurse would monitor vital signs carefully and draw blood for hemoglobin and hematocrit. An NG tube would also need to be inserted and connected to gastric suction to rest the GI tract. However, none of these actions take priority over maintaining ABCs. 10. A client has a nasogastric (NG) tube as a result of an upper gastrointestinal (GI) hemorrhage.

What comfort measure would the nurse remind assistive personnel (AP) to provide? a. Lavaging the tube with ice water b. Performing frequent oral care c. Re-positioning the tube every 4 hours d. Taking and recording vital signs ANS: B

Clients with NG tubes need frequent oral care both for comfort and to prevent infection.

Lavaging the tube is done by the nurse. Repositioning the tube, if needed, is also done by the nurse. The can take vital signs, but this is not a comfort measure.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Gastrointestinal bleeding, Nasogastric tubes MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 11. A client has a recurrence of gastric cancer and is crying. What response by the nurse is most

appropriate? a. “Do you have family or friends for support?” b. “Would you tell me what you are feeling now.” c. “Well, we knew this would probably happen.” d. “Would you like me to refer you to hospice?”

ANS: B

The nurse assesses the client’s emotional state with open-ended questions and statements and shows a willingness to listen to the client’s concerns. Asking about support people is very limited in nature, and “yes-or-no” questions are not therapeutic. Stating that this was expected dismisses the client’s concerns. The client may or may not be ready to hear about hospice, and this is another limited, yes-or-no question.

DIF: Applying TOP: Integrated Process: Caring KEY: Gastric cancer, Psychosocial response MSC: Client Needs Category: Psychosocial Integrity 12. A client has dumping syndrome after a partial gastrectomy. Which action by the nurse would

be appropriate? a. Arrange a dietary consult. b. Increase fluid intake. c. Limit the client’s foods. d. Make the client NPO. ANS: A

The client with dumping syndrome after a gastrectomy has multiple dietary needs. A referral to the registered dietitian nutritionist will be extremely helpful. Food and fluid intake is complicated and needs planning. The client should not be NPO. DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Gastric surgery, Complications MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 1. The nurse recalls that the risk factors for acute gastritis include which of the following?

(Select all that apply.) a. Alcohol b. Caffeine c. Corticosteroids d. Fruit juice e. Nonsteroidal anti-inflammatory drugs (NSAIDs) ANS: A, B, C, E

Risk factors for acute gastritis include alcohol, caffeine, corticosteroids, and chronic NSAID use. Fruit juice is not a risk factor, although in some people it does cause distress.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Gastritis, Risk factors MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. The nurse is caring for a client with a long history of peptic ulcer disease. What assessment

findings would the nurse anticipate if the client experiences upper gastrointestinal (GI) bleeding? (Select all that apply.) a. Decreased heart rate b. Decreased blood pressure c. Bounding radial pulse d. Dizziness e. Hematemesis f. Decreased urinary output ANS: B, D, E, F

The client who has upper GI bleeding would likely have vomiting that contains blood (hematemesis), and would have signs and symptoms of dehydration such as a decreased blood pressure, dizziness, and/or decreased urinary output. The heart rate increases rather than decreases and the pulse is weak rather than bounding in clients who are dehydrated.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Peptic ulcer disease, Complications MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. Which of the following is (are) (a) risk factor(s) for gastric cancer? (Select all that apply.) a. Achlorhydria b. Chronic atrophic gastritis c. H. pylori infection d. Iron deficiency anemia e. Pernicious anemia ANS: A, B, C, E

Achlorhydria, chronic atrophic gastritis, H. pylori infection, and pernicious anemia are all risk factors for developing gastric cancer. Iron deficiency anemia is not a risk factor.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Gastric cancer, Risk factors MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. A client has dumping syndrome. What menu selections indicate the client understands the

correct diet to manage this condition? (Select all that apply.) a. Apricots b. Coffee cake c. Milk shake d. Potato soup e. Steamed broccoli ANS: A, D

Canned apricots and potato soup are appropriate selections as they are part of a high-protein, high-fat, and low- to moderate-carbohydrate diet. Coffee cake and other sweets must be avoided. Milk products and sweet drinks such as shakes must be avoided. Gas-forming foods such as broccoli must also be avoided.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Gastric surgery, Complications MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. The nurse assesses a client who has possible gastritis. Which assessment finding(s) indicate(s)

that the client has chronic gastritis? (Select all that apply.) a. Anorexia b. Dyspepsia c. Intolerance of fatty foods d. Pernicious anemia e. Nausea and vomiting ANS: C, D

Intolerance of fatty or spicy foods and pernicious anemia are signs of chronic gastritis.

Anorexia and nausea/vomiting can be seen in both conditions. Dyspepsia is seen in acute gastritis.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Gastritis, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. What action(s) by the nurse is (are) appropriate to promote nutrition in a client who had a

partial gastrectomy? (Select all that apply.) a. Administer vitamin B12 injections. b. Ask the primary health care provider about folic acid replacement. c. Educate the client on enteral feedings. d. Obtain consent for total parenteral nutrition. e. Provide iron supplements for the client.

ANS: A, B, E

After a partial or total gastrectomy, clients are at high risk for anemia due to vitamin B12 deficiency, folic acid deficiency, or iron deficiency. The nurse would provide supplements for all these nutrients. The client does not need enteral feeding or total parenteral nutrition.

DIF: Understanding TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Gastric surgery, Complications MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 7. A nurse is preparing to administer pantoprazole intravenously to prevent stress ulcers during

surgery. What action(s) by the nurse is (are) most appropriate? (Select all that apply.) a. Administer the drug through a separate IV line. b. Infuse pantoprazole using an IV pump. c. Keep the drug in its original brown container. d. Take vital signs frequently during infusion. e. Use an in-line IV filter when infusing.

ANS: A, B, E

When infusing pantoprazole, use a separate IV line, a pump, and an in-line filter. A brown wrapper and frequent vital signs are not needed.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Gastrointestinal disorders, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

Chapter 51: Concepts of Care for Patients With Noninflammatory Intestinal Disorders Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the client’s

understanding. Which menu selection indicates that the client correctly understands the dietary teaching? a. Ham sandwich on white bread, cup of applesauce, carbonated beverage b. Broiled chicken with brown rice, steamed broccoli, glass of apple juice c. Grilled cheese sandwich, small banana, cup of hot tea with lemon d. Baked tilapia, fresh green beans, cup of coffee with low-fat milk ANS: B

Patients with IBS are advised to eat a high-fiber diet. Chicken with brown rice, broccoli, and apple juice has the highest fiber content. Clients should avoid alcohol, caffeine, and other gastric irritants.

DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Irritable bowel syndrome, Health teaching MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 2. A nurse assesses a client who is prescribed alosetron. Which assessment question would the

nurse ask this client before starting the drug? a. “Have you been experiencing any constipation?” b. “Are you eating a diet high in fiber and fluids?” c. “Do you have a history of high blood pressure?” d. “What vitamins and supplements are you taking?”

ANS: A

Ischemic colitis is a life-threatening complication of alosetron. The nurse would assess the client for constipation because it places the client at risk for this complication. The other questions do not identify the risk for complications related to alosetron.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Irritable bowel syndrome, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 3. The nurse is caring for a client who is diagnosed with a complete small bowel obstruction. For

what priority problem is this client most likely at risk? a. Abdominal distention b. Nausea c. Electrolyte imbalance d. Obstipation ANS: C

The client who has a small bowel obstruction is at the highest risk for fluid and electrolyte imbalances, especially dehydration and hypokalemia due to profuse vomiting. Nausea, abdominal distention, and obstipation are also usually present, but these problems are not as life threatening as the imbalances in electrolytes.

DIF: Understanding TOP: Integrated Process: Nursing Process: Analysis KEY: Bowel obstruction, Complications MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 4. A nurse assesses clients at a community health center. Which client is at highest risk for

developing colorectal cancer? a. A 37-year-old who drinks eight cups of coffee daily. b. A 44-year-old with irritable bowel syndrome (IBS). c. A 60-year-old lawyer who works 65 hours per week. d. A 72-year-old who eats fast food frequently.

ANS: D

Colon cancer is rare before the age of 40, but its incidence increases rapidly with advancing age. Fast food tends to be high in fat and low in fiber, increasing the risk for colon cancer.

Coffee intake, IBS, and a heavy workload do not increase the risk for colon cancer.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Colorectal cancer, Risk factors MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. A nurse assessing a client with colorectal cancer auscultates high-pitched bowel sounds and

notes the presence of visible peristaltic waves. Which action would the nurse take? a. Ask if the client is experiencing pain in the right shoulder. b. Perform a rectal examination and assess for polyps. c. Recommend that the client have computed tomography. d. Administer a laxative to increase bowel movement activity.

ANS: C

The presence of visible peristaltic waves, accompanied by high-pitched or high-pitched bowel sounds, is indicative of bowel obstruction caused by the tumor. The nurse would contact the primary health care provider with these results and recommend a computed tomography scan for further diagnostic testing. This assessment finding is not associated with right shoulder pain; peritonitis and cholecystitis are associated with referred pain to the right shoulder. The nurse generalist is not qualified to complete a rectal examination for polyps, and laxatives would not help this client.

DIF: Applying TOP: Integrated Process: Nursing Process: Analysis KEY: Colorectal cancer, Complications MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 6. The nurse is caring for a client who has a postoperative paralytic ileus following abdominal

surgery. What drug is appropriate to manage this nonmechanical bowel obstruction? a. Alosetron b. Alvimopan c. Amitiptyline d. Amlodipine ANS: B

Alvimopan is the appropriate drug to promote peristalsis for clients who have a paralytic ileus.

The other drugs do not affect intestinal activity.

DIF: Remembering

TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Bowel obstruction, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapy 7. A nurse cares for a client with colorectal cancer who has a new colostomy. The client states,

“I think it would be helpful to talk with someone who has had a similar experience.” How would the nurse respond? a. “I have a good friend with a colostomy who would be willing to talk with you.” b. “The ostomy nurse will be able to answer all of your questions.” c. “I will make a referral to the United Ostomy Associations of America.” d. “You’ll find that most people with colostomies don’t want to talk about them.”

ANS: C

Nurses need to become familiar with community-based resources to better assist clients. The local chapter of the United Ostomy Associations of America has resources for clients and their families, including ostomates (specially trained visitors who also have ostomies). The nurse would not suggest that the client speak with a personal contact of the nurse. Although the ostomy nurse is an expert in ostomy care, talking with him or her is not the same as talking with someone who actually has had a colostomy. The nurse would not brush aside the client’s request by saying that most people with colostomies do not want to talk about them.

Many people are willing to share their ostomy experience in the hope of helping others.

DIF: Applying TOP: Integrated Process: Caring KEY: Colorectal cancer, Ostomy care MSC: Client Needs Category: Psychosocial Integrity 8. A nurse cares for a client who states, “My husband is repulsed by my colostomy and refuses

to be intimate with me.” How would the nurse respond? a. “Let’s talk to the ostomy nurse to help you and your husband work through this.” b. “You could try to wear longer lingerie that will better hide the ostomy appliance.” c. “You should empty the pouch first so it will be less noticeable for your husband.” d. “If you are not careful, you can hurt the stoma if you engage in sexual activity.”

ANS: A

The nurse would collaborate with the ostomy nurse to help the client and her husband work through intimacy issues. The nurse would not minimize the client’s concern about her husband with ways to hide the ostomy. The client will not hurt the stoma by engaging in sexual activity.

DIF: Applying TOP: Integrated Process: Caring MSC: Client Needs Category: Psychosocial Integrity

KEY: Ostomy care, Coping

9. The nurse is caring for a client with a large bowel obstruction due to fecal impaction. What

position would be appropriate for the client while in bed? a. Prone b. Supine c. Recumbent d. Semi-Fowler ANS: D

Having the client in a semi-sitting position helps to decrease the pressure caused by abdominal distention and promotes thoracic expansion to facilitate breathing.

DIF: Understanding TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Bowel obstruction, Nursing care MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 10. A nurse cares for a client who had a colostomy placed in the ascending colon 2 weeks ago.

The client states, “The stool in my pouch is still liquid.” How would the nurse respond? a. “The stool will always be liquid with this type of colostomy.” b. “Eating additional fiber will bulk up your stool and decrease diarrhea.” c. “Your stool will become firmer over the next couple of weeks.” d. “This is abnormal. I will contact your primary health care provider.”

ANS: A

The stool from an ascending colostomy can be expected to remain liquid because little large bowel is available to reabsorb the liquid from the stool. This finding is not abnormal. Liquid stool from an ascending colostomy will not become firmer with the addition of fiber to the client’s diet or with the passage of time.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Ostomy, Health Teaching MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 11. A nurse teaches a client who is at risk for colorectal cancer. Which dietary recommendation

would the nurse teach the client? a. “Eat low-fiber and low-residual foods.” b. “White rice and bread are easier to digest.” c. “Add vegetables such as broccoli and cauliflower to your diet.” d. “Foods high in animal fat help to protect the intestinal mucosa.”

ANS: C

The client would be taught to modify his or her diet to decrease animal fat and refined carbohydrates. The client should also increase high-fiber foods and Brassica vegetables, including broccoli and cauliflower, which help to protect the intestinal mucosa from colon cancer.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Colorectal cancer, Risk factors MSC: Client Needs Category: Health Promotion and Maintenance 12. A nurse cares for a client who has a new colostomy. Which action would the nurse take? a. Empty the pouch frequently to remove excess gas collection. b. Change the ostomy pouch and barrier every morning. c. Allow the pouch to completely fill with stool prior to emptying it. d. Use surgical tape to secure the pouch and prevent leakage.

ANS: A

The nurse would empty the new ostomy pouch frequently because of excess gas collection, and empty the pouch when it is one-third to one-half full of stool. The ostomy pouch does not need to be changed every morning. Ostomy barriers would be used to secure and seal the ostomy appliance; surgical tape would not be used.

DIF: Applying

TOP: Integrated Process: Nursing Process: Planning and Implementation

KEY: Ostomy, Nursing care MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 13. A nurse cares for a client who has a family history of colorectal cancer. The client states, “My

father and my brother had colon cancer. What is the chance that I will get cancer?” How would the nurse respond? a. “If you eat a low-fat and low-fiber diet, your chances decrease significantly.” b. “You are safe. This is an autosomal dominant disorder that skips generations.” c. “Preemptive surgery and chemotherapy will remove cancer cells and prevent cancer.” d. “You should have a colonoscopy more frequently to identify abnormal polyps early.”

ANS: D

The nurse would encourage the patient to have frequent colonoscopies to identify abnormal polyps and cancerous cells early. The abnormal gene associated with colon cancer is an autosomal dominant gene mutation that does not skip a generation and places the client at high risk for cancer. Changing the client’s diet to more high-fiber (not low-fiber) and preemptive chemotherapy may decrease the client’s risk of colon cancer but will not prevent it.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Colorectal cancer, Risk factors MSC: Client Needs Category: Health Promotion and Maintenance 14. A client is preparing to have a fecal occult blood test (FOBT). What health teaching would the

nurse include prior to the test? a. “This test will determine whether you have colorectal cancer.” b. “You need to avoid red meat and NSAIDs for 48 hours before the test.” c. “You don’t need to have this test because you can have a virtual colonoscopy.” d. “This test can determine your genetic risk for developing colorectal cancer.”

ANS: B

The FOBT is a screening test that is sometimes used to assess for microscopic lower GI bleeding. To help prevent false positive results, the client needs to avoid red meat, Vitamin C, and NSAIDs. The test is not diagnostic nor does it determine a client’s genetic risk for colorectal cancer.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Colorectal cancer, Diagnostic tests MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 15. The nurse is caring for a client who is planning to have a laparoscopic colon resection for

colorectal cancer tomorrow. Which statement by the client indicates a need for further teaching? a. “I should have less pain after this surgery compared to having a large incision.” b. “I will probably be in the hospital for 3 to 4 days after surgery.” c. “I will be able to walk around a little on the same day as the surgery.” d. “I will be able to return to work in a week or two depending on how I do.”

ANS: B

All of these statements are correct about having minimally invasive laparoscopic surgery except that the hospital stay will likely be only 1 or 2 days.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Colorectal cancer, Perioperative care MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 16. The nurse is caring for a client who has been prescribed lubiprostone for irritable bowel

syndrome (IBS-C). What health teaching will the nurse include about taking this drug? a. “This drug will make you very dry because it will decrease your diarrhea.” b. “Be sure to take this drug with food and water to help manage constipation.” c. “Avoid people who have infection as this drug will suppress your immune system.” d. “Include high-fiber foods in your diet to help produce more solid stools.”

ANS: B

Lubiprostone is an oral laxative approved for women who have IBS with constipation (IBS-C). Water and food will also help to improve constipation. The drug is not used for clients who have diarrhea and does not affect the immune system. Although high-fiber foods are important for clients who have IBS, this client does not need fiber to help make stool more solid. Instead the fiber will help prevent constipation.

DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Irritable bowel syndrome, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 17. A client is admitted with a diagnosis of possible strangulated inguinal hernia. For which

complication would the nurse monitor? a. Paralytic ileus b. Bowel volvulus c. Sepsis d. Colitis ANS: C

The client who has a strangulated inguinal hernia would likely develop bowel necrosis which can lead to sepsis. The nurse would observe for early signs and symptoms of sepsis such as fever, tachypnea, and tachycardia. If the client’s condition is not promptly managed, bowel perforation, septic shock, and death can result.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Inguinal hernia, Complications MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 18. The nurse is teaching a client how to avoid the formation of hemorrhoids. What lifestyle

change would the nurse include? a. Avoiding alcohol b. Quitting smoking c. Decreasing fluid intake d. Increasing dietary fiber ANS: C

The major cause of hemorrhoid formation is constipation. Therefore, the nurse teaches the client ways to prevent constipation, which include increasing dietary fiber, increasing exercise and fluid intake, and avoiding straining when have a stool.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Hemorrhoids, Risk factors MSC: Client Needs Category: Health Promotion and Maintenance MULTIPLE RESPONSE 1. The nurse is caring for a client with probable colorectal cancer (CRC). What assessment

findings would the nurse expect? (Select all that apply.) a. Weight gain b. Rectal bleeding c. Anemia d. Change in stool shape e. Electrolyte imbalances f. Abdominal discomfort ANS: B, C, D, F

The client who has CRC usually experiences unintentional weight loss and rectal bleeding, either gross or occult. As a result of bleeding, the client has anemia and fatigue. Electrolyte imbalances are not common, but the client may note that the shape or consistency of stool has changed.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Colorectal cancer, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. After teaching a client who is recovering from a colon resection to treat early-stage colorectal

cancer (CRC), the nurse assesses the client’s understanding. Which statements by the client indicate understanding of the teaching? (Select all that apply.) a. “I must change the ostomy appliance daily and as needed.” b. “I will use warm water and a soft washcloth to clean around the stoma.” c. “I might start bicycling and swimming again once my incision has healed.” d. “I will make sure that I make lifestyle changes to prevent constipation.” e. “I will be sure to have the recommended colonoscopies.”

ANS: C, D, E

The client has had a colon resection for early CRC and there is no indication that the client also had a colostomy. Follow up with recommended colonoscopies are essential to monitor for CRC recurrence. Avoiding constipation will help improve intestinal motility which helps to decrease the risk for CRC recurrence. Exercise and other activities do not need to be restricted after the client has healed.

DIF: Applying TOP: Integrated Process: Nursing Process: Evaluation KEY: Colorectal cancer, Perioperative care MSC: Client Needs Category: Health Promotion and Maintenance 3. A nurse assesses a client with irritable bowel syndrome (IBS). Which questions would the

nurse include in this client’s assessment? (Select all that apply.)

a. b. c. d. e.

“Which food types cause an exacerbation of symptoms?”

“Where is your pain or discomfort and what does it feel like?”

“Have you lost a significant amount of weight lately?”

“Are your stools soft, watery, and black?”

“Do you often experience nausea and vomiting”

ANS: A, B

The nurse would ask the client about factors that may cause exacerbations of symptoms, including food, stress, and anxiety. The nurse would also assess the location, intensity, and quality of the patient’s pain or discomfort. Clients who have IBS do not usually lose weight, have nausea and vomiting, or have stools that are black.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Irritable bowel syndrome, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. A nurse is caring for a client who has been diagnosed with a small bowel obstruction. Which

assessment findings would the nurse correlate with this diagnosis? (Select all that apply.) a. Serum potassium of 2.8 mEq/L (2.8 mmol/L) b. Loss of 15 lb (6.8 kg) without dieting c. Abdominal pain in upper quadrants d. Low-pitched bowel sounds e. Serum sodium of 121 mEq/L (121 mmol/L) ANS: A, C, E

Small bowel obstructions often lead to severe fluid and electrolyte imbalances. The client is hypokalemic (normal range is 3.5 to 5.0 mEq/L [3.5 to 5.0 mmol/L]) and hyponatremic (normal range is 136 to 145 mEq/L [136 to 145 mmol/L]). Abdominal pain across the upper quadrants is associated with small bowel obstruction. Dramatic weight loss without dieting followed by bowel obstruction leads to the probable development of colon cancer.

High-pitched sounds may be noted with small bowel obstructions.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Analysis KEY: Intestinal obstruction, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. The nurse is caring for a client who has a nasogastric tube (NGT). Which actions would the

nurse take for client care? (Select all that apply.) a. Assess for proper placement of the tube every 4 hours or per agency policy. b. Flush the tube with water every hour to ensure patency. c. Secure the NG tube to the client’s chin. d. Disconnect suction when auscultating bowel peristalsis. e. Monitor the client’s skin around the tube site for irritation.

ANS: A, D, E

The nurse would frequently assess for NGT placement, patency, and output (drainage) every 4 hours or per agency policy. The nurse would also monitor the skin around the tube for irritation and secure the tube to the client’s nose. When auscultating bowel sounds for peristalsis, the nurse would disconnect suction. NGT irrigation may or may not be prescribed.

If it is prescribed, hourly irrigation is not appropriate.

DIF: Applying

TOP: Integrated Process: Nursing Process: Planning and Implementation

KEY: Nasogastric tubes, Nursing care MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. The nurse is caring for a client who has perineal surgical wound. Which actions would the

nurse take to promote comfort and wound healing? (Select all that apply.) a. Assist the client into a side-lying position. b. Use a rubber donut device when sitting up. c. Apply warm compresses three to four times a day. d. Instruct the client to wear boxer shorts. e. Place an absorbent dressing over the wound.

ANS: A, C, E

The nurse would place an absorbent pad over the wound and apply warm compresses to the wound area. The nurse would also instruct the male client to wear jockey-type shorts for support rather than boxers, assume a side-lying position in bed, avoid sitting for long periods, and use foam pads or soft pillows whenever in a sitting position. The patient should avoid the use of air rings or rubber donut devices.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: AP Resection, Wound care MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 7. The nurse assists the wound care/ostomy nurse assess a client prior to ostomy surgery. Which

assessments would the nurse complete before marking the placement for the ostomy? (Select all that apply.) a. Contour of the abdomen when standing b. Location of the client’s belt line c. Contour of the abdomen when lying d. Location of abdominal muscles e. Contour of the abdomen when sitting ANS: A, B, C, E

Before marking the placement for the ostomy, the nurse would consider the contour of the abdomen in lying, sitting, and standing positions, the location of the belt line and possible location in the rectus muscle. The location of abdominal muscles is not considered.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Ostomy care, Perioperative care MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 8. The nurse is caring for a client who just had a minimally invasive inguinal hernia repair.

Which nursing actions would the nurse implement? (Select all that apply.) a. Apply ice to the surgical area for the first 24 hours after surgery. b. Encourage ambulation with assistance within the first few hours after surgery. c. Encourage deep breathing after surgery but teach the client to avoid coughing. d. Assess vital signs frequently for the first few hours after surgery. e. Teach the client to rest for several days after surgery when at home. f. Teach the client not to lift more than 10 lb (4.5 kg) until allowed by the surgeon.

ANS: A, B, C, D, E, F

All of these nursing actions are appropriate for the client having MIS for inguinal hernia repair.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Inguinal hernia, Perioperative care MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 9. The nurse is teaching a client who had a descending colostomy 2 days ago about the ostomy

stoma. Which changes in the stoma would the nurse teach the client to report to the primary health care provider? (Select all that apply.) a. Stool consistency is similar to paste. b. Stoma becomes dark and dull. c. Skin around the stoma becomes excoriated. d. Skin around stoma becomes protruded. e. Stoma becomes retracted into the abdomen.

ANS: B, C, D, E

A colostomy placed in the descending colon would be expect to have a paste-like stool consistency. However, if the stoma becomes retracted or discolored, the client should report those changes to the primary health care provider. Skin around the stoma that becomes protruded would suggest the formation of a peristomal hernia, and skin excoriation needs appropriate management. Therefore, both of those skin changes would need to be reported to the primary health care provider.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Colostomy, Health teaching MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

Chapter 52: Concepts of Care for Patients With Inflammatory Intestinal Disorders Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. The nurse assesses a client who has appendicitis. Which assessment finding would the nurse

expect? a. Severe, steady right lower quadrant pain b. Abdominal pain associated with nausea and vomiting c. Marked peristalsis and hyperactive bowel sounds d. Abdominal pain that increases with knee flexion ANS: A

Right lower quadrant pain, specifically at McBurney’s point, is characteristic of appendicitis.

Usually if nausea and vomiting begin first, the client has gastroenteritis. Marked peristalsis and hyperactive bowel sounds are not indicative of appendicitis. Abdominal pain due to appendicitis decreases with knee flexion.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Appendicitis, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. The nurse reviews the laboratory results for a client who has possible appendicitis. Which

laboratory test finding would the nurse expect? a. Decreased potassium level b. Increased sodium level c. Elevated leukocyte count d. Decreased thrombocyte count ANS: C

Appendicitis is an acute inflammatory disorder that frequently results in elevation of leukocytes (white blood cells). Serum electrolytes are not affected because the client does not usually have diarrhea. Thrombocyte (platelet) count is unrelated to this GI disorder.

DIF: Understanding KEY: Appendicitis, Diagnostic tests

TOP: Integrated Process: Nursing Process: Assessment MSC: Client Needs Category: Physiological Adaptation

3. The nurse teaches a client who has viral gastroenteritis. Which dietary instruction would the

nurse include in the health teaching? a. “Drink plenty of fluids to prevent dehydration.” b. “You should only drink 1 L of fluids daily.” c. “Increase your protein intake by drinking more milk.” d. “Sips of cola or tea may help to relieve your nausea.”

ANS: A

The client should drink plenty of fluids to prevent dehydration. Milk products may not be tolerated. Caffeinated beverages increase intestinal motility and should be avoided.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Gastroenteritis, Nutritional interventions MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort

4. The nurse assesses a client with gastroenteritis. What risk factor would the nurse consider as

the most likely cause of this disorder? a. Consuming too much fruit b. Consuming fried or pickled foods c. Consuming dairy products d. Consuming raw seafood ANS: D

Raw seafood is often contaminated and unless cooked can would most likely cause gastroenteritis. Any of the other food can also become contaminated if not stored properly or contaminated by workers/cooks who contaminate these foods.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Gastroenteritis, Risk factors MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. The nurse assesses a client who is hospitalized with an exacerbation of Crohn disease. Which

assessment finding would the nurse expect? a. Positive Murphy sign with rebound tenderness to palpitation b. Dull, hypoactive bowel sounds in the lower abdominal quadrants c. High-pitched, rushing bowel sounds in the right lower quadrant d. Reports of abdominal cramping that is worse at night ANS: C

The nurse expects high-pitched, rushing bowel sounds due to narrowing of the bowel lumen in Crohn disease. A positive Murphy sign is indicative of gallbladder disease, and rebound tenderness often indicates peritonitis. Dullness in the lower abdominal quadrants and hypoactive bowel sounds is not commonly found with Crohn disease. Nightly worsening of abdominal cramping is not consistent with Crohn disease.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Crohn disease, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. After teaching a patient with diverticular disease, a nurse assesses the client’s understanding.

Which menu selection indicates the client correctly understood the teaching? a. Roasted chicken with rice pilaf and a cup of coffee with cream b. Spaghetti with meat sauce, a fresh fruit cup, and hot tea c. Garden salad with a cup of bean soup and a glass of low-fat milk d. Baked fish with steamed carrots and a glass of apple juice ANS: D

Clients who have diverticular disease are prescribed a low-residue diet. Whole grains (rice pilaf), uncooked fruits and vegetables (salad, fresh fruit cup), and high-fiber foods (cup [240 mL] of bean soup) would be avoided with a low-residue diet. Canned or cooked vegetables are appropriate. Apple juice does not contain fiber and is acceptable for a low-residue diet.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Diverticular disease, Nutritional interventions MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort

7. A nurse cares for a young client with a new ileostomy. The client states, “I cannot go to prom

with an ostomy.” How would the nurse respond? a. “Sure you can. Purchase a prom dress one size larger to hide the ostomy appliance.” b. “The pouch won’t be as noticeable if you avoid broccoli and carbonated drinks prior to the prom.” c. “Let’s talk to the ostomy nurse about options for ostomy supplies and dress styles.” d. “You can remove the pouch from your ostomy appliance when you are at the prom so that it is less noticeable.”

ANS: C

The ostomy nurse is a valuable resource for patients, providing suggestions for supplies and methods to manage the ostomy. A larger dress size will not necessarily help hide the ostomy appliance. Avoiding broccoli and carbonated drinks does not offer reassurance for the client.

Ileostomies have an almost constant liquid effluent, so pouch removal during the prom is not feasible.

DIF: Applying TOP: Integrated Process: Caring MSC: Client Needs Category: Psychosocial Integrity

KEY: Ostomy care, Coping

8. The nurse teaches a client about how to prevent transmission of gastroenteritis. Which

statement by the nurse indicates a need for further teaching? a. “I won’t let anyone use my dishes or glasses.” b. “I’ll wash my hands with antibacterial soap.” c. “I’ll keep my bathroom extra clean.” d. “I’ll cook all the meals for my family.”

ANS: D

All of these statements are correct except for that the client should not prepare meals for others to help prevent transmission of gastroenteritis.

DIF: Applying TOP: Integrated Process: Nursing Process: Teaching/Learning KEY: Gastroenteritis, Infection control MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 9. After teaching a client who is prescribed adalimumab for severe ulcerative colitis (UC), the

nurse assesses the client’s understanding. Which statement made by the client indicates a need for further teaching? a. “I will avoid large crowds and people who are sick.” b. “I will take this medication with my breakfast each morning.” c. “Nausea and vomiting are common side effects of this drug.” d. “I should wash my hands after I play with my dog.”

ANS: B

Adalimumab is an immune modulator that is given via subcutaneous injection. It does not need to be given with food or milk. Nausea and vomiting are two common side effects.

Adalimumab can cause immune suppression, so clients receiving the medication should avoid large crowds and people who are sick, and should practice good handwashing.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Ulcerative colitis, Drug therapy

MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 10. The nurse is caring for a client who is prescribed sulfasalazine. Which question would the

nurse ask the client before starting this drug? a. “Are you taking Vitamin C or B? b. “Do you have any allergy to sulfa drugs?” c. “Can you swallow pills pretty easily?” d. “Do you have insurance to cover this drug?”

ANS: B

Sulfasalazine is a sulfa drug given for clients who have ulcerative colitis. However, it should not be given to those who have an allergy to sulfa and sulfa drugs to prevent a hypersensitivity reaction.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Ulcerative colitis, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 11. A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment

would the nurse complete first? a. Inspection of oral mucosa b. Recent dietary intake c. Heart rate and rhythm d. Percussion of abdomen ANS: C

Although the client with severe diarrhea may experience skin irritation and hypovolemia, the client is most at risk for cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client would have her or his electrolyte levels monitored, and electrolyte replacement may be necessary. Oral mucosa inspection, recent dietary intake, and abdominal percussion are important parts of physical assessment but are lower priority for this patient than heart rate and rhythm.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Ulcerative colitis, Assessment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 12. A nurse reviews the electronic health record of a client who has Crohn disease and a draining

fistula. Which documentation would alert the nurse to urgently contact the primary health care provider for additional prescriptions? a. Serum potassium of 2.6 mEq/L (2.6 mmol/L) b. Client ate 20% of breakfast meal c. White blood cell count of 8200/mm3 (8.2  109/L) d. Client’s weight decreased by 3 lb (1.4 kg) ANS: A

Fistulas place the patient with Crohn disease at risk for hypokalemia which can lead to serious dysrhythmias. This potassium level is low and would cause the nurse to intervene. The white blood cell count is normal. The other two findings are abnormal and also warrant intervention, but the potassium level takes priority.

DIF: Applying

TOP: Integrated Process: Nursing Process: Analysis

KEY: Crohn disease, Complications MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 13. A client is preparing to have a laparoscopic restorative proctocolectomy with ileo pouch-anal

anastomosis (RCA-IPAA). Which preoperative health teaching would the nurse include? a. “You will have to wear an appliance for your permanent ileostomy.” b. “You should be able to have better bowel continence after healing occurs.” c. “You will have a large abdominal incision that will require irrigation.” d. “This procedure can be performed under general or regional anesthesia.”

ANS: B

A RCA-IPAA can improve bowel continence although leakage may still occur for some clients. The procedure is a 2-step process performed under general anesthesia using a laparoscope which does not require an abdominal incision or permanent ileostomy.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Ulcerative colitis, Perioperative care MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 14. After teaching a client who has diverticulitis, a nurse assesses the client’s understanding.

Which statement made by the client indicates a need for further teaching? a. “I’ll ride my bike or take a long walk at least three times a week.” b. “I must try to include at least 25 g of fiber in my diet every day.” c. “I will take a laxative nightly at bedtime to avoid becoming constipated.” d. “I should use my legs rather than my back muscles when I lift heavy objects.”

ANS: C

Laxatives are not recommended for patients with diverticulitis because they can increase pressure in the bowel, causing additional outpouching of the lumen. Exercise and a high-fiber diet are recommended for clients with diverticulitis because they promote regular bowel function. Using the leg muscles rather than the back for lifting prevents abdominal straining.

DIF: Applying TOP: Integrated Process: Nursing Process: Evaluation KEY: Diverticulitis, Self-management MSC: Client Needs Category: Health Promotion and Maintenance 15. The nurse plans care for a client with Crohn disease who has a heavily draining fistula. Which

intervention would be the nurse’s priority action? a. Low-fiber diet b. Skin protection c. Antibiotic administration d. Intravenous glucocorticoids ANS: B

Protecting the client’s skin is the priority action for a patient who has a heavily draining fistula. Intestinal fluid enzymes are caustic and can cause skin breakdown or fungal infections if the skin is not protected. The plan of care for a client who has Crohn disease also includes adequate nutrition focused on high-calorie, high-protein, high-vitamin, and low-fiber meals, antibiotic administration, and glucocorticoids.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Crohn disease, Nursing interventions

MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 16. The nurse assesses a patient who is recovering from an ileostomy placement. Which

assessment finding would alert the nurse to immediately contact the primary health care provider? a. Pale and bluish stoma b. Liquid stool c. Ostomy pouch intact d. Blood-tinged output ANS: A

The nurse would assess the stoma for color and contact the primary health care provider if the stoma is pale, bluish, or dark because these changes indicate possible lack of perfusion. The nurse would expect the client to have an intact ostomy pouch with dark green liquid stool that may contain some blood.

DIF: Applying TOP: Integrated Process: Nursing Process: Analysis KEY: Ostomy care, Assessment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 17. A nurse cares for a client with a new ileostomy. The client states, “I don’t think my friends

will accept me with this ostomy.” How would the nurse respond? a. “Your friends will be happy that you are alive.” b. “Tell me more about your concerns.” c. “A therapist can help you resolve your concerns.” d. “With time you will accept your new body.”

ANS: B

Social anxiety and apprehension are common in clients with a new ileostomy. The nurse would encourage the client to discuss concerns by restating them in an open-ended manner.

The nurse would not minimize the client’s concerns or provide false reassurance.

DIF: Applying TOP: Integrated Process: Caring MSC: Client Needs Category: Psychosocial Integrity

KEY: Ostomy care, Coping

MULTIPLE RESPONSE 1. The nurse teaches a community group ways to prevent Escherichia coli infection. Which

statements would the nurse include in this group’s teaching? (Select all that apply.) a. “Wash your hands after any contact with animals.” b. “It is not necessary to buy a meat thermometer.” c. “Stay away from people who are ill with diarrhea.” d. “Use separate cutting boards for meat and vegetables.” e. “Avoid swimming in backyard pools and using hot tubs.”

ANS: A, D

Washing hands after contact with animals and using separate cutting boards for meat and other foods will help prevent E. coli infection. The other statements are not related to preventing E. coli infection.

DIF: Applying

TOP: Integrated Process: Teaching/Learning

KEY: Gastroenteritis, Infection control MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 2. The nurse assesses a client with ulcerative colitis. Which complications are paired correctly

with their physiologic processes? (Select all that apply.) a. Lower gastrointestinal bleeding—erosion of the bowel wall b. Abscess formation—localized pockets of infection develop in the ulcerated bowel lining c. Toxic megacolon—transmural inflammation resulting in pyuria and fecaluria d. Nonmechanical bowel obstruction—paralysis of colon resulting from colorectal cancer e. Fistula—dilation and colonic ileus caused by paralysis of the colon ANS: A, B, D

Lower GI bleeding can lead to erosion of the bowel wall. Abscesses are localized pockets of infection that develop in the ulcerated bowel lining. Nonmechanical bowel obstruction is paralysis of the colon that results from colorectal cancer. When the inflammation is transmural, fistulas can occur between the bowel and bladder resulting in pyuria and fecaluria.

Paralysis of the colon causing dilation and subsequent colonic ileus is known as a toxic megacolon.

DIF: Understanding TOP: Integrated Process: Nursing Process: Analysis KEY: Ulcerative colitis, Complications MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. A nurse assesses a patient who has celiac disease. Which signs and symptoms would the nurse

expect? (Select all that apply.) a. Weight gain b. Anorexia c. Constipation d. Anal fistula e. Abdominal pain ANS: B, C, E

Signs and symptoms of celiac disease include weight loss, anorexia, constipation, and abdominal pain. Anal fistulas are not associated with celiac disease.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Celiac disease, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. A nurse cares for an older adult who is admitted to the hospital with complications of

diverticulitis. Which actions would the nurse include in the client’s plan of care? (Select all that apply.) a. Administer pain medications as prescribed. b. Palpate the abdomen for distention. c. Assess for sudden changes in mental status. d. Provide the client with a high-fiber diet. e. Evaluate stools for occult blood.

ANS: A, B, C, E

When caring for an older adult who has diverticulitis, the nurse would administer analgesics as prescribed, palpate the abdomen for distention and tenderness, assess for confusion and sudden changes in mental status, and check stools for occult or frank bleeding. A low-fiber/residue diet would be provided when symptoms are present and a high-fiber diet when inflammation resolves.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Diverticulitis, Nursing interventions MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. A nurse prepares to discharge a client who is newly diagnosed with a chronic inflammatory

bowel disease. Which questions would the nurse ask in preparation for discharge? (Select all that apply.) a. Does your gym provide yoga classes? b. When should you contact your provider? c. What do you plan to eat for dinner? d. Do you have a scale for daily weights? e. How many bathrooms are in your home?

ANS: A, B, C, E

A home assessment for a client who has a chronic inflammatory bowel disease would include identifying adequacy and availability of bathroom facilities, opportunities for rest and relaxation, and the client’s knowledge of dietary therapy, and when to contact the primary health care provider. The client does not need to perform daily weights.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Chronic inflammatory bowel disorder, Transition management MSC: Client Needs Category: Health Promotion and Maintenance 6. After teaching a patient who has a permanent ileostomy, a nurse assesses the client’s

understanding. Which dietary items chosen for dinner indicate that the client needs further teaching? (Select all that apply.) a. Corn b. String beans c. Carrots d. Wheat rice e. Squash ANS: A, B, D

Clients with an ileostomy should be cautious of high-fiber and high-cellulose foods including corn, string beans, and rice. Carrots and squash are low-fiber items.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Ileostomy care, Nutritional interventions MSC: Client Needs Category: Health Promotion and Maintenance 7. A nurse cares for a patient who has a chronic inflammatory bowel disease. Which actions

would the nurse take to prevent skin excoriation? (Select all that apply.) a. Cleanse the perineum with an antibacterial soap. b. Use medicated wipes instead of toilet paper. c. Identify foods that decrease constipation.

d. Apply a thin coat of aloe cream to the perineum. e. Gently pat the perineum dry after cleansing.

ANS: B, D, E

To prevent skin excoriation from frequent bowel movements associated with inflammatory bowel disease, the nurse would encourage good skin care with a mild soap and water and gently patting the area dry after each bowel movement. Using medicated wipes instead of toilet paper and applying a thin coat of aloe cream are appropriate. The client should identify and avoid foods that increase diarrhea. Antibacterial soaps are harsh and should not be used.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Chronic inflammatory bowel disease, Nursing interventions MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 8. The nurse is caring for a client who is diagnosed with celiac disease and preparing to start

natalizumab. Which health teaching would the nurse include in the teaching? (Select all that apply.) a. Need to have drug administered by a primary health care provider. b. Need to avoid crowds and individuals who have infection. c. Need to report injection reactions such as redness and swelling. d. Awareness of a rare but potentially fatal drug complication. e. Need to report any signs and symptoms of infection immediately.

ANS: A, B, D, E

All of these choices are correct except that the drug is given intravenously. Therefore, there is no need to teach the client to report injection reactions because the client does not self-administer the medication subcutaneously. Natalizumab can cause progressive multifocal leukoencephalopathy (PML), but it is a very rare disorder causing cognitive, sensory, and/or motor changes.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Celiac disease, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 9. The nurse is caring for a client with peritonitis. What assessment findings would the nurse

expect? (Select all that apply.) a. Nausea and vomiting b. Distended rigid abdomen c. Abdominal pain d. Bradycardia e. Decreased urinary output f. Fever ANS: A, C, D, E, F

Peritonitis is an acute inflammatory disorder. Therefore, the client would likely have all of these signs and symptoms but would have tachycardia rather than bradycardia due to dehydration from fever.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Peritonitis, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

Chapter 53: Concepts of Care for Patients With Liver Problems Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. The nurse is caring for a client who has cirrhosis of the liver. Which risk factor is the leading

cause of cirrhosis? a. Metabolic syndrome b. Liver cancer c. Nonalcoholic fatty liver disease d. Hepatitis C ANS: D

Hepatitis C is the leading cause of cirrhosis and an also cause liver cancer. Clients with nonalcoholic fatty liver disease often have metabolic syndrome and can also develop cirrhosis.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Cirrhosis, Risk factors MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. The nurse is caring for a client who has cirrhosis of the liver. What nursing action is

appropriate to help control ascites? a. Monitor intake and output. b. Provide a low-sodium diet. c. Increase oral fluid intake. d. Weigh the patient daily.

ANS: B

A low-sodium diet is one means of controlling abdominal fluid collection. Monitoring intake and output does not control fluid accumulation, nor does weighing the client. These interventions merely assess or monitor the situation. Increasing fluid intake would not be helpful.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Cirrhosis, Diet therapy MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. The nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which

assessment finding would require immediate action by the nurse? a. Urine output via indwelling urinary catheter is 20 mL/hr b. Blood pressure increases from 110/58 to 120/62 mm Hg c. Respiratory rate decreases from 22 to 16 breaths/min d. A decrease in the client’s weight by 3 lb (1.4 kg) ANS: A

Rapid removal of ascitic fluid causes decreased abdominal pressure, which can contribute to hypovolemia. This can be manifested by a decrease in urine output to below 30 mL/hr. A slight increase in systolic blood pressure is insignificant. A decrease in respiratory rate indicates that breathing has been made easier by the procedure. The nurse would expect the client’s weight to drop as fluid is removed. To prevent hypovolemic shock, no more than 2000 mL are usually removed from the abdomen at one time. The patient’s weight typically only decreases by less than 2 kg or 4.4 lb.

DIF: Applying TOP: Integrated Process: Nursing Process: Analysis KEY: Cirrhosis, Management MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 4. The nurse is caring for a client who has a risk gene for developing cirrhosis. Which

racial/ethnic group has this gene most often? a. Blacks b. Asian/Pacific Islanders c. Latinos d. French ANS: C

The Patatin-like phospholipase domain containing 3 gene (PNPLA3) has been identified as a risk gene for cirrhosis, which occurs most often in Latinos when compared to other populations.

DIF: Remembering TOP: Integrated Process: Culture and Spirituality KEY: Cirrhosis, Risk factors MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. The nurse is caring for a client with hepatic portal-systemic encephalopathy (PSE). The client

is thin and cachectic, and the family expresses distress that the patient is receiving little dietary protein. How would the nurse respond? a. “A low-protein diet will help the liver rest and will restore liver function.” b. “Less protein in the diet will help prevent confusion associated with liver failure.” c. “Increasing dietary protein will help the patient gain weight and muscle mass.” d. “Low dietary protein is needed to prevent fluid from leaking into the abdomen.”

ANS: B

A low-protein diet is prescribed when serum ammonia levels increase and/or the client shows signs of PSE. A low-protein diet helps reduce excessive breakdown of protein into ammonia by intestinal bacteria. Encephalopathy is caused by excess ammonia. A low-protein diet has no impact on restoring liver function. Increasing the patient’s dietary protein will cause complications of liver failure and would not be suggested. Increased intravascular protein will help prevent ascites, but clients with liver failure are not able to effectively synthesize dietary protein.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Cirrhosis, Diet therapy MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 6. The nurse is caring for a client who is prescribed lactulose. The client states, “I do not want to

take this medication because it causes diarrhea.” How would the nurse respond?

a. b. c. d.

“Diarrhea is expected; that’s how your body gets rid of ammonia.”

“You may take antidiarrheal medication to prevent loose stools.”

“Do not take any more of the medication until your stools firm up.”

“We will need to send a stool specimen to the laboratory as soon as possible.”

ANS: A

The purpose of administering lactulose to this patient is to help ammonia leave the circulatory system through the colon. Lactulose draws water into the bowel with its high osmotic gradient, thereby producing a laxative effect and subsequently evacuating ammonia from the bowel. The patient must understand that this is an expected and therapeutic effect for him or her to remain compliant. The nurse would not suggest administering anything that would decrease the excretion of ammonia or holding the medication. There is no need to send a stool specimen to the laboratory because diarrhea is the therapeutic response to this medication.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Cirrhosis, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 7. After teaching a client who has been diagnosed with hepatitis A, the nurse assesses the

client’s understanding. Which statement by the client indicates correct understanding of the teaching? a. “Some medications have been known to cause hepatitis A.” b. “I may have been exposed when we ate shrimp last weekend.” c. “I was infected with hepatitis A through a recent blood transfusion.” d. “My infection with Epstein-Barr virus can co-infect me with hepatitis A.” ANS: B

The route of transmission for hepatitis A infection is through close personal contact or ingestion of contaminated water or shellfish. Hepatitis A is not transmitted through medications, blood transfusions, or Epstein-Barr virus. Toxic and drug-induced hepatitis is caused from exposure to hepatotoxins, but this is not a form of hepatitis A. Hepatitis B can be spread through blood transfusions. Epstein-Barr virus causes a secondary infection that is not associated with hepatitis A. DIF: Applying TOP: Integrated Process: Nursing Process: Evaluation KEY: Hepatitis, Infection control MSC: Client Needs Category: Health Promotion and Maintenance 8. The nurse is caring for a client scheduled to have a transjugular intrahepatic portal-systemic

shunt (TIPS) procedure. What client assessment would the nurse perform prior to this procedure? a. Musculoskeletal assessment b. Neurologic assessment c. Mental health assessment d. Cardiovascular assessment ANS: D

A postprocedure complication of a TIPS procedure is right-sided heart failure. Therefore, the nurse would perform a cardiovascular assessment before the procedure to determine if the client has signs and symptoms of heart failure.

DIF: Understanding

TOP: Integrated Process: Nursing Process: Assessment

KEY: TIPS, Complications MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 9. The nurse is preparing to teach a client with chronic hepatitis B about lamivudine therapy.

What health teaching would the nurse include? a. “Follow up on all appointments to monitor your lab values.” b. “Do not take amiodorone at any time while on this drug.” c. “Monitor for jaundice, rash, and itchy skin while on this drug.” d. “Report any changes in urinary elimination while on this drug.”

ANS: D

Lamivudine can cause renal impairment and the nurse would remind the client of changes that may indicate kidney damage.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Hepatitis, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 10. The nurse is teaching a client a client about taking elbasvir for hepatitis C. What information

in the client’s history would the nurse need prior to drug administration? a. History of hepatitis B b. History of kidney disease c. History of cardiac disease d. History of rectal bleeding ANS: A

Elbasvir can cause liver toxicity and therefore the nurse would assess for a history of or current hepatitis B. DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Hepatitis, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 11. A telehealth nurse speaks with a client who is recovering from a liver transplant 2 weeks ago.

The client states, “I’m having right belly pain and have a temperature of 101° F (38.3° C).”

How would the nurse respond? a. “The anti-rejection drugs you are taking make you susceptible to infection.” b. “You should go to the hospital immediately to get checked out.” c. “You should take an additional dose of cyclosporine today.” d. “Take acetaminophen every 4 hours until you feel better soon.”

ANS: B

Fever, right abdominal quadrant pain, and jaundice are signs of possible liver transplant rejection; the client would be admitted to the hospital as soon as possible for intervention.

Antirejection drugs do make a client more susceptible to infection, but this client has signs of rejection, not infection. The nurse would not advise the client to take an additional dose of cyclosporine or acetaminophen as these medications will not treat the acute rejection.

DIF: Applying TOP: Integrated Process: Caring KEY: Liver transplantation, Complications MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care

12. After teaching a client who has alcohol-induced cirrhosis, a nurse assesses the client’s

understanding. Which statement made by the client indicates a need for further teaching? a. “I cannot drink any alcohol at all anymore.” b. “I should not take over-the-counter medications.” c. “I need to avoid protein in my diet.” d. “I should eat small, frequent, balanced meals.”

ANS: C

Based on the degree of liver involvement and decreased function, protein intake may have to be decreased. However, some protein is necessary for the synthesis of albumin and normal healing. The other statements indicate accurate understanding of self-care measures for this client.

DIF: Applying TOP: Integrated Process: Nursing Process: Evaluation KEY: Cirrhosis, Self-management MSC: Client Needs Category: Health Promotion and Maintenance 13. The nurse is caring for a client who is scheduled for a paracentesis. Which action is

appropriate for the nurse to take? a. Have the client sign the informed consent form. b. Get the patient into a chair before the procedure. c. Help the client lie flat in bed on the right side. d. Assist the client to void before the procedure.

ANS: D

For safety, the patient would void just before a paracentesis to prevent bladder damage to the procedure. The primary health care provider would have the client sign the consent form. The proper position for a paracentesis is sitting upright in bed or, alternatively, sitting on the side of the bed and leaning over the bedside table.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Cirrhosis, Management MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 14. The nurse is caring for a client who has cirrhosis from substance abuse. The client states, “All

of my family hates me.” How would the nurse respond? a. “You should make peace with your family.” b. “This is not unusual. My family hates me too.” c. “I will help you identify a support system.” d. “You must attend Alcoholics Anonymous.”

ANS: C

Clients who have cirrhosis due to addiction may have alienated relatives over the years because of substance abuse. The nurse would assist the client to identify a friend, neighbor, clergy/spiritual leader, or group for support. The nurse would not minimize the patient’s concerns. Attending AA may be appropriate, but this response doesn’t address the client’s concern. “Making peace” with the client’s family may not be possible. This statement is not client-centered.

DIF: Applying TOP: Integrated Process: Caring KEY: Cirrhosis, Psychosocial support MSC: Client Needs Category: Psychosocial Integrity

15. The nurse is caring for a client with hepatitis C. The client’s brother states, “I do not want to

get this infection, so I’m not going into his hospital room.” How would the nurse respond? a. “Hepatitis C is not spread through casual contact.” b. “If you wear a gown and gloves, you will not get this virus.” c. “This virus is only transmitted through a fecal specimen.” d. “I can give you an update on your brother’s status from here.”

ANS: A

Although family members may be afraid that they will contract hepatitis C, the nurse would educate them about how the virus is spread. Hepatitis C is spread via blood-to-blood transmission and is associated with illicit IV drug needle sharing, blood and organ transplantation, accidental needlesticks, unsanitary tattoo equipment, and sharing of intranasal drug paraphernalia. Wearing a gown and gloves will not decrease the transmission of this virus. Hepatitis C is not spread through casual contact or a fecal specimen. The nurse would be violating privacy laws by sharing the client’s status with the brother.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Hepatitis, Infection control MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control MULTIPLE RESPONSE 1. The nurse is caring for a client with early encephalopathy due to cirrhosis of the liver. Which

factors may contribute to increased encephalopathy for which the nurse would assess? (Select all that apply.) a. Infection b. GI bleeding c. Irritable bowel syndrome d. Constipation e. Anemia f. Hypovolemia ANS: A, B, D, F

Anemia and irritable bowel syndrome are unrelated to developing or worsening encephalopathy, which is caused by increased protein which breaks down into ammonia.

Infection can cause hypovolemia which would increase serum protein concentration.

Constipation and GI bleeding causes a large protein load in the intestines.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Cirrhosis, Complications MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 2. A nurse assesses a client who has cirrhosis of the liver. Which laboratory findings would the

nurse expect in clients with this disorder? (Select all that apply.) a. Elevated aspartate transaminase b. Elevated international normalized ratio (INR) c. Decreased serum globulin levels d. Decreased serum alkaline phosphatase e. Elevated serum ammonia f. Elevated prothrombin time (PT)

ANS: B, E, F

Elevated INR and PT are indications of clotting disturbances and alert the nurse to the increased possibility of hemorrhage. Elevated ammonia levels increase the client’s confusion.

The other values are abnormal and associated with liver disease but do not necessarily place the client at increased risk for complications.

DIF: Applying TOP: Integrated Process: Nursing Process: Analysis KEY: Cirrhosis, Diagnostic tests MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. The nurse is teaching assistive personnel (AP) about care of a client who has advanced

cirrhosis. Which statements would the nurse include in the staff teaching? (Select all that apply.) a. “Apply lotion to the client’s dry skin areas.” b. “Use a basin with warm water to bathe the patient.” c. “For the patient’s oral care, use a soft toothbrush.” d. “Provide clippers so the patient can trim the fingernails.” e. “Bathe with antibacterial and water-based soaps.”

ANS: A, C, D

Clients with advanced cirrhosis often have pruritus. Lotion will help decrease itchiness from dry skin. A soft toothbrush would be used to prevent gum bleeding, and the client’s nails would need to be trimmed short to prevent the patient from scratching himself or herself.

These clients should use cool, not warm, water on their skin, and should not use excessive amounts of soap.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Cirrhosis, Comfort measures MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 4. The nurse is caring for a client who has late-stage (advanced) cirrhosis. What assessment

findings would the nurse expect? (Select all that apply.) a. Jaundice b. Clay-colored stools c. Icterus d. Ascites e. Petechiae f. Dark urine ANS: A, B, C, D, E, F

All of these assessment findings are very common for a client who has late-stage cirrhosis due to biliary obstruction and poor liver function. The client has vascular lesions and excess fluid from portal hypertension.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Cirrhosis, Signs and symptoms MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. The nurse plans care for a patient who has hepatopulmonary syndrome. Which interventions

would the nurse include in this client’s plan of care? (Select all that apply.) a. Oxygen therapy

b. c. d. e. f.

Prone position Feet elevated on pillows Daily weights Physical therapy Respiratory therapy

ANS: A, C, D, F

Care for a client who has hepatopulmonary syndrome would include oxygen therapy, the head of bed elevated at least 30 degrees or as high as the client wants to improve breathing, elevated feet to decrease dependent edema, and daily weights. There is no need to place the patient in a prone position, on the patient’s stomach. Although physical therapy may be helpful to a patient who has been hospitalized for several days, physical therapy is not an intervention specifically for hepatopulmonary syndrome. However, respiratory support from a specialized therapist may be needed.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Cirrhosis, Complications MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 6. The nurse is assessing a client with hepatitis C. The client asks the nurse how it was possible

to have this disease. What questions might the nurse ask to help the client determine how the disease was contracted? (Select all that apply.) a. “How old are you?” b. “Do you work in health care? c. “Are you receiving hemodialysis?” d. “Do you use IV drugs?” e. “Did you receive blood before 1992?” f. “Have you even been in prison or jail?”

ANS: A, B, C, D, E, F

The nurse would ask all of these questions because “baby boomers,” people who use illicit drugs, people on hemodialysis, health workers, and prisoners are at a very high risk for hepatitis C. Additionally, individuals who received blood, blood products, or an organ transplant prior to 1992 before bloodborne disease screening of these products was mandated are at risk for hepatitis C. DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Hepatitis, Risk factors MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 7. The nurse is assessing a client who has hepatitis C. What extrahepatic complications would

the nurse anticipate? (Select all that apply.) a. Pancreatitis b. Polyarthritis c. Heart disease d. Myalgia e. Peptic ulcer disease f. Ulcerative colitis ANS: B, C, D

The client who has hepatitis C has complications that do not relate to the liver, including polyarthritis, myalgia, heart disease and vasculitis, renal disease, and cognitive impairment.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Hepatitis, Complications MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

Chapter 54: Concepts of Care for Patients With Problems of the Biliary System and Pancreas Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A client is scheduled for a hepatobiliary iminodiacetic acid (HIDA) scan. What would the

nurse include in client teaching about this diagnostic test? a. “You’ll have to drink a contrast medium right before the test.” b. “You’ll need to do a bowel prep the nursing before the test.” c. “You’ll be able to drink liquids up until the test begins.” d. “You’ll have a large camera close to you during the test.”

ANS: D

Clients having a HIDA scan are NPO and receive an injectable nuclear medicine contrast. No bowel preparation is required. A large camera is close to the client for most of the test which can be a problem for clients who are claustrophobic.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Cholecystitis, Diagnostic tests MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A client has an external percutaneous transhepatic biliary catheter inserted for a biliary

obstruction. What health teaching about catheter care would the nurse provide for the client? a. “Cap the catheter drain at night to prevent leakage and skin damage.” b. “Position the drainage bag lower than the catheter insertion site.” c. “Irrigate the catheter with an ounce of saline every night.” d. “Pierce a hole in the top of the drainage bag to get rid of odors.”

ANS: B

An external temporary or permanent catheter drains bile by gravity into a bag that collects bile. Therefore, the drainage bag should be lower that the catheter insertion site. The catheter should not be capped or irrigated, and no holes should be made in the bag to prevent bile from having contact with the skin.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Biliary obstruction, Management MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. After teaching a client who has a history of cholelithiasis, the nurse assesses the client’s

understanding. Which menu selection indicates that the client understands the dietary teaching? a. Lasagna, tossed salad with Italian dressing, and low-fat milk b. Grilled cheese sandwich, tomato soup, and coffee with cream c. Cream of potato soup, Caesar salad with chicken, and a diet cola d. Roasted chicken breast, baked potato with chives, and orange juice ANS: D

Clients with cholelithiasis should avoid foods high in fat and cholesterol, such as whole milk, butter, and fried foods. Lasagna, low-fat milk, grilled cheese, cream, and cream of potato soup all have high levels of fat. The meal with the least amount of fat is the chicken breast dinner.

DIF: Applying TOP: Integrated Process: Nursing Process: Evaluation KEY: Cholecystitis, Diet therapy MSC: Client Needs Category: Health Promotion and Maintenance 4. A client is admitted with acute pancreatitis. What priority problem would the nurse expect

the client to report? a. Nausea and vomiting b. Severe boring abdominal pain c. Jaundice and itching d. Elevated temperature ANS: B

The client who has acute pancreatitis reports severe boring abdominal pain that is often rated by clients as a 10+ on a 0-10 pain scale. Nausea, vomiting, and fever may also occur, but that is not the client’s priority for care.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Pancreatitis, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. After teaching a client who is prescribed pancreatic enzyme replacement therapy, the nurse

assesses the client’s understanding. Which statement by the client indicates a need for further teaching? a. “The capsules can be opened and the powder sprinkled on applesauce if needed.” b. “I will wipe my lips carefully after I drink the enzyme preparation.” c. “The best time to take the enzymes is immediately after I have a meal or a snack.” d. “I will not mix the enzyme powder with food or liquids that contain protein.”

ANS: C

The enzymes must be taken immediately before eating meals or snacks. If the client cannot swallow the capsules whole, they can be opened up and the powder sprinkled on applesauce, mashed fruit, or rice cereal. The client should wipe his or her lips carefully after drinking the enzyme preparation because the liquid could damage the skin. Protein items will be dissolved by the enzymes if they are mixed together.

DIF: Understanding TOP: Integrated Process: Nursing Process: Evaluation KEY: Pancreatitis, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 6. The nurse documents the vital signs of a client diagnosed with acute pancreatitis:

Apical pulse = 116 beats/min Respirations = 28 breaths/min Blood pressure = 92/50 What complication of acute pancreatitis would the nurse suspect that the client might have? a. Electrolyte imbalance b. Pleural effusion c. Internal bleeding

d. Pancreatic pseudocyst ANS: C

The client is exhibiting signs of hypovolemia most likely due to internal bleeding or hemorrhage. Due to decreased blood volume, the blood pressure is low and the heart rate increases to compensate for hypovolemia to ensure organ perfusion. Respirations often increase to increase oxygen in the blood.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Analysis KEY: Pancreatitis, Complications MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 7. A nurse cares for a client with end-stage pancreatic cancer. The client asks, “Why is this

happening to me?” How would the nurse respond? a. “I don’t know. I wish I had an answer for you, but I don’t.” b. “It’s important to keep a positive attitude for your family right now.” c. “Scientists have not determined why cancer develops in certain people.” d. “I think that this is a trial so you can become a better person because of it.”

ANS: A

The client is not asking the nurse to actually explain why the cancer has occurred. The client may be expressing his or her feelings of confusion, frustration, distress, and grief related to this diagnosis. Reminding the client to keep a positive attitude for his or her family does not address the client’s emotions or current concerns. The nurse would validate that there is no easy or straightforward answer as to why the client has cancer. Telling a client that cancer is a trial is untrue and may negatively impact the client–nurse relationship.

DIF: Applying TOP: Integrated Process: Caring MSC: Client Needs Category: Psychosocial Integrity

KEY: Pancreatic cancer, Coping

8. A client had an open traditional Whipple procedure this morning. For what priority

complication would the nurse assess? a. Urinary tract infection b. Chronic kidney disease c. Heart failure d. Fluid and electrolyte imbalances ANS: D

Due to the length and complexity of this type of surgery, the client is at risk for fluid and electrolyte imbalances. The nurse would assess for signs and symptoms of these imbalances so they can be managed early to prevent potentially life-threatening complications.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 9. A nurse assesses a client who has cholecystitis. Which sign or symptom indicates that this

condition is chronic rather than acute? a. Temperature of 100.1° F (37.8° C) b. Positive Murphy sign c. Clay-colored stools d. Upper abdominal pain after eating

ANS: C

Jaundice, clay-colored stools, and dark urine are more commonly seen with chronic cholecystitis. The other symptoms are seen in clients with either chronic or acute cholecystitis.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Cholecystitis, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 10. A nurse assesses a client who is recovering from a Whipple procedure. Which assessment

finding alerts the nurse to immediately contact the primary health care provider? a. Drainage from a fistula b. Diminished bowel sounds c. Pain at the incision site d. Nasogastric (NG) tube drainage ANS: A

Complications of a Whipple procedure include secretions that drain from a fistula and peritonitis. Absent bowel sounds, pain at the incision site, and NG tube drainage are normal postoperative findings.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Whipple procedure, Perioperative care MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 11. The nurse is caring for a client who is recovering from an open traditional Whipple surgical

procedure. What action would the nurse take? a. Clamp the nasogastric tube. b. Place the patient in semi-Fowler position. c. Assess vital signs once every shift. d. Provide oral rehydration.

ANS: B

Postoperative care for a patient recovering from an open Whipple procedure would include placing the client in a semi-Fowler position to reduce tension on the suture line and anastomosis sites and promote breathing, setting the nasogastric tube to low continuous suction to remove free air buildup and pressure, assessing vital signs frequently to assess fluid and electrolyte complications, and providing intravenous fluids.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Whipple procedure, Perioperative care MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential MULTIPLE RESPONSE 1. A nurse assesses a client who is recovering from an open traditional Whipple surgical

procedure. Which assessment finding(s) alert(s) the nurse to a complication from this surgery?

(Select all that apply.) a. Clay-colored stools b. Substernal chest pain c. Shortness of breath d. Lack of bowel sounds or flatus

e. Urine output of 20 mL/6 hr ANS: B, C, D, E

Myocardial infarction (chest pain), pulmonary embolism (shortness of breath), adynamic ileus (lack of bowel sounds or flatus), and acute kidney injury (urine output of 20 mL/6 hr) are common complications for which the nurse must assess the client after the Whipple procedure. Clay-colored stools are associated with cholecystitis and are not a complication of a Whipple procedure.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Whipple procedure, Perioperative care MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 2. The nurse is caring for a client who has possible acute pancreatitis. What serum laboratory

findings would the nurse expect for this client? (Select all that apply.) a. Elevated amylase b. Elevated lipase c. Elevated glucose d. Decreased calcium e. Elevated bilirubin f. Elevated leukocyte count ANS: A, B, C, D, E, F

All of these choices are correct. Amylase and lipase are pancreatic enzymes that are released during pancreatic inflammation and injury. Leukocytes also increased due to his inflammatory response. Pancreatic injury affects the ability of insulin to be released causing increased glucose levels. Bilirubin is also typically increased due to hepatobiliary obstruction. Calcium and magnesium levels decrease because fatty acids bind free calcium and magnesium causing a lowered serum level; these changes occur in the presence of fat necrosis.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Acute pancreatitis, Diagnostic tests MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. The nurse plans care for a client who has acute pancreatitis and is prescribed nothing by

mouth (NPO). With which health care team members would the nurse collaborate to provide appropriate nutrition to this client? (Select all that apply.) a. Registered dietitian nutritionist b. Nursing assistant c. Clinical pharmacist d. Certified herbalist e. Primary health care provider ANS: A, C, E

Clients who are prescribed NPO while experiencing an acute pancreatitis episode may need enteral or parenteral nutrition. The nurse would collaborate with the registered dietitian nutritionist, clinical pharmacist, and primary health care provider to plan and implement the more appropriate nutritional interventions. The nursing assistant and certified herbalist would not assist with this clinical decision.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Pancreatitis, Collaboration

MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 4. The nurse is caring for a client who was recently diagnosed with pancreatic cancer. What

factors present risks for developing this type of cancer? (Select all that apply.) a. Diabetes mellitus b. Cirrhosis c. Smoking d. Female gender e. Family history f. Older age ANS: A, B, C, E, F

All of these choices are risk factors except that pancreatic cancer occurs most frequently in men.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Pancreatic cancer, Risk factors MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. The nurse assesses a client who has chronic pancreatitis. What assessment findings would the

nurse expect for this client? (Select all that apply.) a. Ascites b. Weight gain c. Steatorrhea d. Jaundice e. Polydipsia f. Polyuria ANS: A, C, D, E, F

The client who has chronic pancreatitis has all of these signs and symptoms except he or she loses weight. Ascites and jaundice result from biliary obstruction; ascites is associated with portal hypertension. Steatorrhea is fatty stool that occurs because lipase is not available in the duodenum; because it is released by the disease pancreas into the bloodstream. Polydipsia, polyuria, and polyphagia result from diabetes mellitus, a common problem seen in clients whose pancreas is unable to release adequate amounts of insulin.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Pancreatitis, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. After teaching a client who has chronic pancreatitis and will be discharged with enzyme

replacement therapy, a nurse assesses the client’s understanding. Which statement by the client indicates a need for further teaching? (Select all that apply.) a. “I will take the enzymes between meals.” b. “The enteric-coated preparations cannot be crushed.” c. “Swallowing the tables without chewing is best.” d. “I will wipe my lips after taking the enzymes.” e. “Enzymes should be taken with high-protein foods.”

ANS: A, E

Client teaching related to self-management of enzyme replacement therapy would include taking the enzymes with meals and snacks but not mixing enzyme preparations with protein-containing foods. Clients would not crush enteric-coated preparations and should swallow tablets without chewing to minimize oral irritation and allow the drug to be released slowly. Wiping lips after taking enzymes also minimizes skin irritation.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Pancreatitis, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 7. The nurse is preparing a client who has chronic pancreatitis about how to prevent

exacerbations of the disease. Which health teaching will the nurse include? (Select all that apply.) a. “Avoid alcohol ingestion.” b. “Be sure and balance rest with activity.” c. “Avoid caffeinated beverages.” d. “Avoid green, leafy vegetables.” e. “Eat small meals and high-calorie snacks.”

ANS: A, B, C, E

Clients who have chronic pancreatitis need to avoid GI stimulants, including alcohol, caffeine, and nicotine. Food and snacks need to be high-calorie to prevent additional weight loss. Green vegetables can be consumed if tolerated by the client.

Chapter 55: Concepts of Care for Patients With Malnutrition: Undernutrition and Obesity Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. The nurse is performing an initial assessment and notes that the client weighs 186.4 lb (84.7

kg). Six months ago, the client weighed 211.8 lb (96.2 kg). What action by the nurse is appropriate? a. Ask the client if the weight loss was intentional. b. Determine if there are food allergies or intolerances. c. Perform a comprehensive nutritional assessment. d. Perform a rapid bedside blood glucose test.

ANS: A

This client has had a 12% weight loss. The nurse first determines if the weight loss was intentional. If not, then the nurse proceeds to a comprehensive nutritional assessment. Food intolerances are part of this assessment. Depending on risk factors and other findings, a blood glucose test may be warranted.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Nutrition, Assessment MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 2. The nurse assesses a newly admitted client and documents a body mass index (BMI) of 31.2.

What does this value indicate to the nurse? a. The client has a healthy weight. b. The client is underweight. c. The client is obese. d. The client is overweight.

ANS: C

A BMI of over 30 indicates that the client is obese.

DIF: Understanding TOP: Integrated Process: Nursing Process: Analysis KEY: Nutrition, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. A nurse is reviewing laboratory values for several clients. Which value indicates a need for a

nutritional assessment? a. Client with an albumin of 3.5 g/dL b. Client with a cholesterol of 142 mg/dL (3.7 mmol/L) c. Client with a hemoglobin of 9.8 mg/dL (98 mmol/L) d. Client with a prealbumin of 28 mg/dL ANS: B

A cholesterol level below 160 mg/dL (4 mmol/L) is a possible indicator of undernutrition, so this client would be at highest priority for a nutritional assessment. The albumin and prealbumin levels are normal. The low hemoglobin could be from several problems, including dietary deficiencies, hemodilution, and bleeding.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Nutrition, Laboratory tests MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 4. A client is receiving bolus feedings through a small-bore nasoduodenal tube. What action by

the nurse is the priority? a. Auscultate lung sounds after each feeding. b. Weigh the client daily on the same scale. c. Check tube placement every 8 hours. d. Check tube placement before each feeding.

ANS: D

For bolus feedings, the nurse checks placement of the tube per institutional policy prior to each feeding, which is more often than every 8 hours during the day. Auscultating lung sounds is also important, but this may indicate a complication that has already occurred.

Weighing the client is important to determine if nutritional goals are being met, but it is not the priority.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Undernutrition, Total enteral nutrition MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 5. A client receiving continuous tube feeding to provide total enteral nutrition begins vomiting.

What action by the nurse is most appropriate? a. Administer an antiemetic. b. Check the patient’s gastric residual. c. Hold the feeding until the vomiting subsides. d. Reduce the rate of the tube feeding by half.

ANS: C

The nurse would stop the feeding until the vomiting subsides and consult with the registered dietitian nutritionist or primary health care provider about the rate at which to restart the feeding. Giving an antiemetic is not appropriate. After vomiting, a gastric residual will not be accurate. The nurse would not continue to feed the patient while he or she is vomiting.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Undernutrition, Total enteral nutrition MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. The nurse inserts a small-bore nasoduodenal tube for a client who is undernourished. What

priority nursing action is required prior to starting the continuous tube feeding to confirm correct tube placement? a. Assess for carbon dioxide using capnometry. b. Perform pH testing of gastric fluid. c. Auscultate over the epigastric area. d. Request an x-ray before starting the feeding.

ANS: D

The most reliable assessment to determine correct feeding tube placement in to have an x-ray to visualize where the tip of the tube is located.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Total enteral nutrition, Assessment MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 7. The nurse is caring for an older client receiving total enteral nutrition via a small-bore

nasoduodenal tube. For what priority complication would the nurse assess? a. Intermittent diarrhea b. Cholecystitis c. Aspiration pneumonia d. Peptic ulcer disease ANS: C

Aspiration pneumonia is one of the most common complications in older adults who have enteral nutrition via a nasoduodenal tube because their gag reflex is often decreased.

Intermittent diarrhea may also occur, but that is not potentially life threatening if the client does not become dehydrated.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Undernutrition, Total enteral nutrition MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 8. The nurse is managing care for a client receiving feeding through a gastrostomy tube

(G-tube). What assessment would the nurse perform? a. Check the skin around the tube insertion site. b. Weigh the client every shift with the same scale. c. Draw blood to assess albumin every shift. d. Irrigate the tube at least once a day.

ANS: A

The most important assessment would be to observe the skin around the tube for irritation, redness, and skin breakdown. The skin should be cleaned frequently to keep it free of drainage and moisture which can lead to excoriation or other type of skin breakdown. For a client who is undernourished, he or she is usually weighed every day and prealbumin is a more sensitive indicator of over nutritional health. The G-tube is not routinely irrigated.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Undernutrition, Total enteral nutrition MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 9. A client is receiving total parenteral nutrition (TPN). On assessment, the nurse notes that the

client’s pulse is 128 beats/min, blood pressure is 98/56 mm Hg, skin is dry, and skin turgor is poor. What action should the nurse perform next? a. Assess the 24-hour intake and output. b. Assess the client’s oral cavity. c. Prepare to hang a normal saline bolus. d. Increase the infusion rate of the TPN. ANS: A

This client has clinical indicators of dehydration, so the nurse calculates the patient’s 24-hour intake, output, and fluid balance. This information is then reported to the health care provider.

The client’s oral cavity assessment may or may not be consistent with dehydration. The nurse may need to give the client a fluid bolus, but not as an independent action. The client’s dehydration is most likely due to fluid shifts from the TPN, so increasing the infusion rate would make the problem worse, and is not done as an independent action for clients receiving TPN. DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Undernutrition, Parenteral nutrition MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 10. A client who had minimally invasive bypass gastric surgery 2 days ago reports new-onset of

severe abdominal pain. What is the nurse’s best action as this time? a. Listen to the client’s bowel sounds. b. Call the Rapid Response Team. c. Take the client’s vital signs. d. Contact the primary health care provider.

ANS: C

The client may be experiencing either bleeding or anastomosis leak(s). Clients having these complications have severe abdominal, back, or shoulder pain, tachycardia, and hypotension.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Analysis KEY: Obesity, Perioperative care MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 11. A client just returned to the surgical unit after an open traditional gastric bypass. What action

by the nurse is the priority? a. Assess the patient’s pain. b. Check the surgical incision. c. Ensure an adequate airway. d. Program the morphine pump.

ANS: C

All actions are appropriate care measures for this patient; however, airway is always the priority. Bariatric patients tend to have short, thick necks that complicate airway management.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Obesity, Perioperative care MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 12. A client is in the bariatric clinic 1 month after having gastric bypass surgery. The client is

crying and says “I didn’t know it would be this hard to live like this.” What approach by the nurse is best? a. Assess the client’s coping and support systems. b. Inform the client that things will get easier. c. Re-educate the client on needed dietary changes. d. Tell the client that lifestyle changes are always hard.

ANS: A

The nurse would assess this patient’s coping styles and support systems to best provide holistic care. The other options do not address the patient’s distress.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Obesity, Coping MSC: Client Needs Category: Psychosocial Integrity 13. A client has been prescribed lorcaserin. What health teaching about the drug is appropriate for

the nurse to provide? a. “Increase the fiber and water in your diet to prevent diarrhea.” b. “Report any suicidal thoughts to your primary health care provider” c. “Report dry mouth and decreased sweating.” d. “Do not take antibiotics or nay other anti-infective drugs.”

ANS: B

Lorcaserin can cause suicidal thoughts which needs to be reported to the client’s primary health care provider. This drug can also cause dry mouth but not decreased sweating. Loose stools are most common with orlistat. Increasing fiber and water would help to prevent constipation, not diarrhea.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Obesity, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 14. A client is awaiting bariatric surgery in the morning. What action by the nurse is most

important? a. Answering questions the client has about surgery b. Beginning venous thromboembolism prophylaxis c. Informing the client that he or she will be out of bed tomorrow d. Teaching the client about needed dietary changes ANS: B

Morbidly obese clients are at high risk of venous thromboembolism and should be started on a regimen to prevent this from occurring as a priority. Answering questions about the surgery is done by the surgeon. Teaching is important, but safety comes first.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Obesity, Perioperative care MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential MULTIPLE RESPONSE 1. The nurse understands that undernutrition can occur in hospitalized clients for several reasons.

Which of the following factors are possible reasons for this complication to occur? (Select all that apply.) a. Cultural food preferences b. Family bringing snacks c. Increased need for nutrition d. Need for NPO status e. Staff shortages ANS: A, C, D, E

Many factors increase the hospitalized client’s risk for nutritional deficits. Cultural food preferences may make hospital food unpalatable. Ill patients have increased nutritional needs but may be NPO for testing or treatment, or have a loss of appetite from their illness. Staff shortages impact clients who need to be fed or assisted with meals. The family may bring snacks that are either healthy or unhealthy, so without further information, the nurse cannot assume that the snacks are leading to undernutrition.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Undernutrition, Risk factors MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 2. A nurse has delegated feeding a client to assistive personnel (AP). What action(s) does the

nurse include in the directions to the AP? (Select all that apply.) a. Allow 30 minutes for eating so food doesn’t get spoiled. b. Assess the patient’s mouth while providing premeal oral care. c. Ensure that warm and cold items stay at appropriate temperatures. d. Remove bedpans, soiled linens, and other unpleasant items. e. Sit with the client, making the atmosphere more relaxed.

ANS: C, D, E

The AP should make sure that food items remain at the appropriate temperatures for maximum palatability. Removing items such as bedpans, urinals, or soiled linens helps make the atmosphere more conducive to eating. The AP should sit, not stand, next to the client to promote a relaxing experience. The client, especially older clients who tend to eat more slowly, should not be rushed. Assessment is done by the nurse.

DIF: Understanding TOP: Integrated Process: Communication and Documentation KEY: Nutritional disorders, Undernutrition MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 3. The nurse is assessing a client who has undernutrition. What signs and symptom(s) would the

nurse expect? (Select all that apply.) a. Alopecia b. Stomatitis c. Muscle wasting d. Peripheral edema e. Anemia f. Dry, scaly skin ANS: A, B, C, D, E, F

All of these body changes occur due to nutrient deficiencies associated with low protein, zinc, Vitamin A, and complex B vitamins.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Undernutrition, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. A client’s small-bore feeding tube has become occluded after the nurse administered

medications. What actions by the nurse are appropriate? (Select all that apply.) a. Attempt to dissolve the clog by instilling a cola product.

b. c. d. e.

Determine if any of the medications come in liquid form.

Flush the tube before and after administering medications.

Mix all medications in the formula and use a feeding pump.

Try to flush the tube with 30 mL of water and gentle pressure.

ANS: B, C, E

If the tube is obstructed, use a 50-mL syringe and gentle pressure to attempt to open the tube.

Cola products should not be used unless water is not effective. To prevent future problems, determine if any of the medications can be dispensed in liquid form and flush the tube with water before and after medication administration. Do not mix medications with the formula.

DIF: Understanding TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Undernutrition, Total enteral nutrition management MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 5. When working with older adults to promote good nutrition, what action(s) by the nurse is(are)

most appropriate? (Select all that apply.) a. Allow uninterrupted time for eating. b. Assess dentures (if worn) for appropriate fit. c. Ensure that the client has glasses on or contacts in when eating. d. Provide salty or highly spicy foods that the client can taste. e. Serve high-calorie, high-protein snacks one to two times a day.

ANS: A, B, C, E

Older adults need unhurried and uninterrupted time for eating. Dentures should fit appropriately and glasses or contacts, if used, should be on. High-calorie, high-protein snacks are a good choice. Salty or spicy snacks are not recommended because all adults should limit sodium in their diets and spicy foods may not be tolerated.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Nutrition, Older adult MSC: Client Needs Category: Health Promotion and Maintenance

Chapter 56: Assessment of the Endocrine System Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. The nurse assesses an older client. What age-related physiologic changes would the nurse

expect? a. Heat intolerance b. Rheumatoid arthritis c. Dehydration d. Increased appetite ANS: C

As people age, the many of the endocrine glands decrease hormone production, including a decrease in antidiuretic hormone production. This change, in addition to less body fluid being present as one ages, can cause dehydration. Older adults usually have cold intolerance and a decrease in appetite. Rheumatoid arthritis is not an age-related change; osteoarthritis causes primarily by aging.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Endocrine assessment, Human development MSC: Client Needs Category: Health Promotion and Maintenance 2. A client is scheduled to have a glycosylated hemoglobin (A1C) drawn and asks the nurse why

she has to have it. How would the nurse respond? a. “It measures your average blood glucose level for the past 3 months.” b. “It determines what type of anemia you may have.” c. “It measures the amount of liver glycogen you have.” d. “It determines you have some type of leukemia or other blood cancer.”

ANS: A

A1C measures the average blood glucose level to determine if the client is a diabetic or how controlled a diabetic client is.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Endocrine assessment, Diagnostic tests MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. The nurse assesses a client who is scheduled to have a laboratory test to determine if the

client’s adrenal glands are hypoactive. What type of testing would the client likely have? a. Catecholamine testing b. Suppression testing c. Bone marrow testing d. Provocative testing ANS: D

Provocative testing is done to determine if an endocrine gland is capable of producing its normal level of hormone(s), especially when a client is suspected of having a hypoactive endocrine gland.

DIF: Understanding

TOP: Integrated Process: Nursing Process: Assessment

KEY: Endocrine assessment, Diagnostic testing MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. A nurse assesses a client who is prescribed a medication that stimulates beta1 receptors.

Which assessment finding would indicate that the medication is effective? a. Heart rate of 92 beats/min b. Respiratory rate of 18 breaths/min c. Oxygenation saturation of 92% d. Blood pressure of 144/69 mm Hg 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 other vital signs are within normal limits and do not indicate any response to the medication.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Endocrine system, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 5. A nurse collaborates with assistive personnel (AP) to provide care for a client who is

prescribed a 24-hour urine specimen collection. Which statement would the nurse include when teaching the AP about this activity? a. “Note the time of the client’s first void and collect urine for 24 hours.” b. “Add the preservative to the container at the end of the test.” c. “Start the collection by saving the first urine of the morning.” d. “It is okay if one urine sample during the 24 hours is not collected.”

ANS: A

The collection of a 24-hour urine specimen is often delegated to AP. The nurse must ensure that the AP understands the proper process for collecting the urine. The 24-hour urine collection specimen is started after the client’s first urination. The first urine specimen is discarded because there is no way to know how long it has been in the bladder, but the time of the client’s first void 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. All urine samples need to be collected for the test results to be accurate.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Endocrine assessment, Diagnostic testing MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. A nurse assesses a female client who presents with hirsutism. Which question would the nurse

ask when assessing this client? a. “How do you plan to pay for your treatments?” b. “How do you feel about yourself?” c. “What medications are you prescribed?” d. “What are you doing to prevent this from happening?”

ANS: B

Hirsutism, or 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 would inquire into the client’s body image and self-perception. Asking about the client’s financial status or current medications does not address the client’s immediate problem. The client is not doing anything to herself to cause the problem, nor can the client prevent it from happening.

DIF: Applying TOP: Integrated Process: Caring MSC: Client Needs Category: Psychosocial Integrity

KEY: Endocrine system, Coping

7. A nurse is caring for a patient who has excessive catecholamine release. Which assessment

finding would the nurse correlate with this condition? a. Decreased blood pressure b. Increased pulse c. Decreased respiratory rate d. Increased urine output ANS: B

Catecholamines are responsible for the fight-or-flight stress response. Activation of the sympathetic nervous system can be correlated with tachycardia. Catecholamines do not decrease blood pressure or respiratory rate, nor do they increase urine output.

DIF: Remembering TOP: Integrated Process: Nursing Process: Analysis KEY: Endocrine system, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 8. The nurse is teaching assistive personnel (AP) about hormones that are produced by the

adrenal glands. Which hormone has the primary responsibility of maintaining fluid volume and electrolyte composition? a. Sodium b. Magnesium c. Aldosterone d. Renin ANS: C

Aldosterone is a hormone secreted by the adrenal cortex that causes water and sodium absorption to maintain body fluid volume. Renin is secreted by the kidney to trigger angiotensinogen converting angiotensin I to angiotensin II to help control blood pressure.

Magnesium and sodium are electrolytes and not hormones.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Endocrine system, Anatomy and physiology MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 9. The nurse reviews the function of thyroid gland hormones. What is the primary function of

calcitonin? a. Sodium and potassium balance b. Magnesium balance c. Norepinephrine balance d. Calcium and phosphorus balance ANS: D

Calcitonin is the primary body hormone that is secreted from the thyroid gland and is responsible for maintaining calcium and phosphorus balance.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Endocrine system, Anatomy and physiology MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 10. A nurse teaches an older woman who has a decreased production of estrogen. Which

statement would the nurse include in this client’s teaching to decrease injury? a. “Drink at least 2 quarts (2 L) of fluids each day.” b. “Walk around the neighborhood for daily exercise.” c. “Bathe your perineal area twice a day.” d. “You should check your blood glucose before meals.”

ANS: B

An older female with decreased production of estrogen is at risk for decreased bone density and fractures. The nurse would encourage the client to participate in weight-bearing exercises such as walking. Drinking fluids and performing perineal care will decrease vaginal drying but not injury. Older adults often have a decreased glucose tolerance, but this is not related to a decrease in estrogen.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Endocrine system, Safety MSC: Client Needs Category: Health Promotion and Maintenance MULTIPLE RESPONSE 1. A nurse cares for clients with hormone disorders. 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 tissues 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: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Endocrine system, Anatomy and physiology MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A nurse cares for a client with a hypofunctioning anterior pituitary gland. Which hormones

would the nurse expect to be decreased as a result? (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: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Endocrine system, Anatomy and physiology MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. A nurse assesses clients who have endocrine disorders. Which assessment findings are paired

correctly with the endocrine disorder? (Select all that apply.) a. Excessive thyroid-stimulating hormone—increased bone formation b. Excessive melanocyte-stimulating hormone—darkening of the skin c. Excessive parathyroid hormone—synthesis and release of corticosteroids d. Excessive antidiuretic hormone—increased urinary output e. Excessive adrenocorticotropic hormone—increased bone resorption ANS: A, B

Thyroid-stimulating hormone targets thyroid tissue and stimulates the formation of bone.

Melanocyte-stimulating hormone stimulates melanocytes and promotes pigmentation or the darkening of the skin. Parathyroid hormone stimulates bone resorption. Antidiuretic hormone targets the kidney and promotes water reabsorption, causing a decrease in urinary output.

Adrenocorticotropic hormone targets the adrenal cortex and stimulates the synthesis and release of corticosteroids.

DIF: Remembering TOP: Integrated Process: Nursing Process: Analysis KEY: Endocrine system, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. When caring for an older client who has hypothyroidism, what assessment findings will the

nurse expect? (Select all that apply.) a. Lethargy b. Diarrhea c. Low body temperature d. Tachycardia e. Slowed speech f. Weight gain ANS: A, C, E, F

A client who has an underactive thyroid gland has a decreased metabolic rate, resulting in lethargy and lack of energy, weight gain, slowed speech, and decreased vital signs like a lowered body temperature. The client also typically has constipation (instead of diarrhea) due to slower peristalsis and bradycardia (instead of tachycardia).

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Thyroid disorders, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

Chapter 57: Concepts of Care for Patients With Pituitary and Adrenal Gland Problems Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse assesses clients for potential endocrine dysfunction. Which client is at greatest risk

for a deficiency of gonadotropin and growth hormone? a. A 36-year-old female who has used oral contraceptives for 5 years b. A 42-year-old male who experienced head trauma 3 years ago c. A 55-year-old female with a severe allergy to shellfish and iodine d. A 64-year-old male with adult-onset diabetes mellitus ANS: B

Gonadotropin and growth hormone are anterior pituitary hormones. Head trauma is a common cause of anterior pituitary hypofunction. The other factors do not increase the risk of this condition.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Pituitary disorder, Risk factors MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A nurse plans care for a client with a growth hormone deficiency. Which action would the

nurse include in this client’s plan of care? a. Avoid intramuscular medications. b. Place the client in protective isolation. c. Use a lift sheet to reposition the patient. d. Assist the client to dangle before rising.

ANS: C

In adults, growth hormone is necessary to maintain bone density and strength. Adults with growth hormone deficiency have thin, fragile bones. Avoiding IM medications, using protective isolation, and assisting the client as he or she moves from sitting to standing will not serve as safety measures when the client is deficient in growth hormone.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Pituitary disorder, Safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 3. The nurse is caring for a client who has acromegaly. What physical change would the nurse

expect to observe? a. Large hands and face b. Thin, dry skin c. Short height d. Truncal obesity ANS: A

The client who has acromegaly has an excess of growth hormone as an adult and therefore has a large musculoskeletal structure that is readily observed.

DIF: Remembering KEY: Pituitary disorder, Assessment

TOP: Integrated Process: Nursing Process: Assessment

MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. After teaching a client with acromegaly who is scheduled for an open transsphenoidal

hypophysectomy, the nurse assesses the client’s understanding. Which statement made by the client indicates a need for further teaching? a. “I will no longer need to limit my fluid intake after surgery.” b. “I am glad no visible incision will result from this surgery.” c. “I hope I can go back to wearing size 8 shoes instead of size 12.” d. “I will wear slip-on shoes after surgery to limit bending over.”

ANS: C

Although removal of the tissue that is oversecreting hormones can relieve many symptoms of hyperpituitarism, skeletal changes and organ enlargement are not reversible. It will be appropriate for the client to drink as needed postoperatively and avoid bending over. The client can be reassured that the incision will not be visible.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Acromegaly, Perioperative care MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. The nurse is caring for a client with acromegaly who is starting bromocriptine. What health

teaching by the nurse about drug therapy will the nurse include? a. “Take this drug on an empty stomach first thing in the morning.” b. “You will be starting on a high dose of the drug to ensure it will work.” c. “You might experience an increase in blood pressure in about a week.” d. “Seek medical attention immediately if you have chest pain and dizziness.”

ANS: D

Bromocriptine should be started on a low dose and taken with food. The drug can cause decreased blood pressure, including orthostatic hypotension. Serious effects such as cardiac dysrhythmias, coronary artery spasms, and cerebrospinal leak can occur Therefore, the nurse teaches the client should seek medical attention if he or she experiences chest pain, dizziness, and watery nasal discharge.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Acromegaly, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 6. After teaching a client who is recovering from an endoscopic transsphenoidal

hypophysectomy, the nurse assesses the client’s understanding. Which statement made by the client indicates a correct understanding of the teaching? a. “I will wear dark glasses to prevent sun exposure.” b. “I’ll keep food on upper shelves so I do not have to bend over.” c. “I must wash the incision with saline and redress it daily.” d. “I should cough and deep breathe every 2 hours while I am awake.”

ANS: B

After this surgery, the client must take care to avoid activities that can increase intracranial pressure. The client should avoid bending from the waist and should not bear down, cough, or lie flat. With this approach, there is no incision to clean and dress. Protection from sun exposure is not necessary after this procedure.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Pituitary disorder, Perioperative nursing MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 7. A nurse cares for a client who possibly has syndrome of inappropriate antidiuretic hormone

(SIADH). The client’s serum sodium level is 114 mEq/L (114 mmol/L). What nursing action would be appropriate? a. Consult with the dietitian about increased dietary sodium. b. Restrict the client’s fluid intake to 600 mL/day. c. Handle the client gently by using turn sheets for repositioning. d. Instruct assistive personnel to measure intake and output.

ANS: B

With SIADH, clients often have dilutional hyponatremia. The client needs a fluid restriction, sometimes to as little as 500 to 600 mL/24 hr. Adding sodium to the client’s diet will not help if he or she is retaining fluid and diluting the sodium. The client is not at increased risk for fracture, so gentle handling is not an issue. The client would be on intake and output; however, this will monitor only the client’s intake, so it is not the best answer. Reducing fluid intake will help increase the client’s sodium.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: SIADH, Electrolyte imbalance MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 8. The nurse is caring for a client who is diagnosed with diabetes insipidus (DI). For what

common complication will the nurse monitor? a. Hypertension b. Bradycardia c. Dehydration d. Pulmonary embolus ANS: C

The client who has DI has fluid loss through excessive urination. Decreased fluid volume, or dehydration, is manifested by tachycardia, hypotension, and possibly elevated temperature.

Pulmonary embolism (PE) could possible as a clot in the lower extremity (caused by dehydration) could fragment and travel to the lungs.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: DI, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 9. A client is being treated for diabetes insipidus (DI) with synthetic vasopressin (desmopressin).

What is the priority health teaching that the nurse provides regarding drug therapy? a. The need to check the client’s urinary specific gravity. b. The need to take blood pressure at least twice a day. c. The need to monitor blood glucose every day. d. The need to weigh every day and report weight gain.

ANS: D

The client with DI who takes lifelong hormone replacement will need to report significant weight gain to monitor for water toxicity. Water toxicity causes headache, vomiting, and acute confusion.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: DI, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 10. A nurse cares for a client with adrenal hyperfunction. The client screams at her husband,

bursts into tears, and throws her water pitcher against the wall. She then tells the nurse, “I feel like I am going crazy.” How would the nurse respond? a. “I will ask your doctor to order a mental health consult for you.” b. “You feel this way because of your hormone levels.” c. “Can I bring you information about support groups?” d. “I will close the door to your room and restrict visitors.”

ANS: B

Hypercortisolism can cause the client to have neurotic or psychotic behaviors. The client needs to know that these behavior changes do not reflect a true mental or behavioral health disorder and will resolve when therapy results in lower and steadier blood cortisol levels. The client needs to understand this effect and does not need a psychiatrist, support groups, or restricted visitors at this time.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Hypercortisolism, Coping MSC: Client Needs Category: Psychosocial Integrity 11. A nurse is reviewing care for a client who has syndrome of inappropriate antidiuretic hormone

(SIADH) with assistive personnel. What statement by the AP indicates understanding of this client’s care? a. “I will weigh the client carefully before breakfast and compare with yesterday’s weight.” b. “I will encourage plenty of fluids to promote urination and prevent dehydration.” c. “I will teach the client not to select high-sodium or salty foods on the menu.” d. “I will assess the client’s mucous membranes and skin for signs of dehydration.”

ANS: A

The client with SIADH usually has a fluid restriction, not an increase in fluids. It is the role of the RN rather than AP to perform assessments and provide health teaching. The AP needs to weigh the client daily and report a significant weight changes.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: SIADH, Nursing care MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 12. The nurse is preparing to give tolvaptan for a client who has syndrome of inappropriate

antidiuretic hormone (SIADH). For which potentially life-threatening adverse effect would the nurse monitor? a. Increased intracranial pressure b. Myocardial infarction c. Rapid-onset hypernatremia d. Bowel perforation ANS: C

Tolvaptan has a black box warning that rapid increases in serum sodium levels have been associated with central nervous system demyelination that can lead to serious complications and death.

DIF: Remembering TOP: Integrated Process: Assessment KEY: SIADH, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 13. The nurse is caring for a client with adrenal insufficiency. What priority physical assessment

would the nurse perform? a. Respiratory assessment b. Skin assessment c. Neurologic assessment d. Cardiac assessment ANS: D

The client who has adrenal insufficiency has hyperkalemia that can cause cardiac dysrhythmias. Therefore, the nurse would monitor the client’s cardiovascular status through frequent assessments.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Adrenal insufficiency MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 1. A client is admitted with a possible diagnosis of diabetes insipidus (DI). What assessment

findings would the nurse expect? (Select all that apply.) a. Hypotension b. Increased urinary output c. Concentrated urine d. Decreased thirst e. Poor skin turgor f. Bradycardia ANS: A, B, E

The client who has DI has excessive urination and dehydration. Clients who are dehydrated have decreased blood pressure, increased pulse (tachycardia), and poor skin turgor. The urine is dilute with a low specific gravity.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: DI, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A nurse assesses a client who potentially has hyperaldosteronism. Which serum laboratory

values would the nurse associate with this disorder? (Select all that apply.) a. Sodium: 150 mEq/L (150 mmol/L) b. Sodium: 130 mEq/L (130 mmol/L) c. Potassium: 2.5 mEq/L (2.5 mmol/L) d. Potassium: 5.0 mEq/L (5.0 mmol/L) e. pH 7.28

f.

pH 7.50

ANS: A, C, E

Aldosterone increases reabsorption of sodium and excretion of potassium.

Hyperaldosteronism causes hypernatremia, hypokalemia, and metabolic alkalosis.

Hyponatremia, hyperkalemia, and acidosis are manifestations of adrenal insufficiency.

DIF: Applying TOP: Integrated Process: Nursing Process: Analysis KEY: Hyperaldosteronism, Diagnostic tests MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. A nurse teaches a client with Cushing disease. Which dietary requirements would the nurse

include in this client’s health teaching? (Select all that apply.) a. Low calcium b. Low carbohydrate c. Low protein d. Low calories e. Low sodium ANS: B, D, E

The client with Cushing disease has weight gain, muscle loss, hyperglycemia, and sodium retention. Dietary modifications need to include reduction of carbohydrates and total calories to prevent or reduce the degree of hyperglycemia. Sodium retention causes water retention and hypertension. Clients are encouraged to restrict their sodium intake moderately. Clients often have bone density loss and need more calcium. Increased protein intake will help decrease muscle loss.

DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Cushing disease, Diagnostic tests MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. A nurse assesses a client with Cushing disease. Which assessment findings would the nurse

expect? (Select all that apply.) a. Moon face b. Weight loss c. Hypotension d. Petechiae e. Muscle atrophy ANS: A, D, E

Clinical manifestations of Cushing disease include moon face, weight gain, hypertension, petechiae, and muscle atrophy.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Cushing disease, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

Chapter 58: Concepts of Care for Patients With Problems of the Thyroid and Parathyroid Glands Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. The nurse is planning health teaching for a client starting on levothyroxine. What health

teaching about this drug would the nurse include? a. The need to take the drug when the client feels fatigued and weak. b. The need to report chest pain and dyspnea when starting the drug. c. The need to check blood pressure and pulse every day. d. The need to rotate injection sites when giving self the drug.

ANS: B

Levothyroxine is a replacement hormone for clients who have hypothyroidism and is taken orally for life. Vital signs do not have to be checked every day, but the client should report any chest pain and dyspnea when first starting the drug.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Thyroid disorders, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 2. A nurse assesses a client who is recovering from a subtotal thyroidectomy and observes the

development of stridor. What is the priority action for the nurse to take? a. Apply oxygen via nasal cannula at 2 L/min. b. Document the finding and assess the client hourly. c. Place the client in high-Fowler position in the bed. d. Contact the Rapid Response Team and prepare for intubation.

ANS: D

Stridor on exhalation is a hallmark of respiratory distress, usually caused by obstruction resulting from edema. The nurse should prepare to assist with emergency intubation or tracheostomy while notifying the Rapid Response Team. Stridor is an emergency situation; therefore, reassuring the client, documenting, and reassessing in an hour do not address the urgency of the situation. Oxygen should be applied, but this action will not keep the airway open.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Thyroid disorder, Perioperative nursing MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 3. A nurse assesses a client who is recovering from a subtotal thyroidectomy. On the first

postoperative day before discharge, the client states, “I feel numbness and tingling around my mouth.” What action does the nurse take? a. Offer mouth care. b. Loosen the dressing. c. Assess for muscle twitching. d. Ask the client orientation questions.

ANS: C

Numbness and tingling around the mouth or in the fingers and toes are manifestations of hypocalcemia, which could progress to cause tetany and seizure activity. The nurse would assess for muscle twitching and, if present, notify the surgeon or Rapid Response Team to give calcium gluconate or other IV calcium replacement. Mouth care, loosening the dressing, and orientation questions do not provide important information to prevent complications of low calcium levels.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Thyroid disorder, Perioperative nursing MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 4. A nurse assesses a client on the medical-surgical unit. Which statement made by the client

alerts the nurse to assess the patient for hypothyroidism? a. “My sister has thyroid problems.” b. “I seem to feel the heat more than other people.” c. “Food just doesn’t taste good without a lot of salt.” d. “I am always tired, even with 12 hours of sleep.”

ANS: D

Clients with hypothyroidism usually feel tired or weak despite getting many hours of sleep.

Most thyroid problems are not inherited, although they may occur in families. Heat intolerance is indicative of hyperthyroidism. Loss of taste is not a manifestation of hypothyroidism. The nurse would assess the client further for hypothyroidism.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Thyroid disorder, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. A nurse cares for a client who presents with bradycardia secondary to hypothyroidism. Which

medication does the nurse prepare to administer? a. Atropine sulfate b. Levothyroxine c. Propranolol d. Epinephrine ANS: B

The treatment for bradycardia from hypothyroidism is to treat the hypothyroidism using levothyroxine. If the heart rate were so slow that it became an emergency, then atropine or epinephrine might be an option for short-term management. Propranolol is a beta blocker and would be contraindicated for a client with bradycardia.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Thyroid disorder, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 6. A nurse plans care for a client with hypothyroidism. Which priority problem does the nurse

address first for this client? a. Heat intolerance b. Body image problems c. Depression and withdrawal d. Obesity and water retention

ANS: C

Hypothyroidism causes many problems in psychosocial functioning. Depression is the most common reason for seeking medical attention. Memory and attention span may be impaired.

The client’s family may have great difficulty accepting and dealing with these changes. The client is often unmotivated to participate in self-care. Lapses in memory and attention require the nurse to ensure that the patient’s environment is safe. Heat intolerance is seen in hyperthyroidism. Body image problems and weight issues do not take priority over mental status and safety.

DIF: Applying TOP: Integrated Process: Nursing Process: Analysis KEY: Thyroid disorder, Assessment MSC: Client Needs Category: Psychological Integrity 7. A nurse assesses a client who is prescribed levothyroxine for hypothyroidism. Which

assessment finding alerts the nurse that drug therapy is effective? a. Thirst is recognized and fluid intake is appropriate. b. Weight has been the same for 3 weeks. c. Total white blood cell count is 6000 cells/mm3 (6  109/L). d. Heart rate is 76 beats/min and regular.

ANS: D

Hypothyroidism decreases body functioning and can result in effects such as bradycardia, confusion, and constipation. If a client’s heart rate is bradycardic while on thyroid hormone replacement, this is an indicator that the replacement may not be adequate. Conversely, a heart rate above 100 beats/min may indicate that the client is receiving too much of the thyroid hormone. Thirst, fluid intake, weight, and white blood cell count do not represent a therapeutic response to this medication.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Thyroid disorder, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 8. A nurse cares for a client who has hypothyroidism as a result of Hashimotothyroiditis. The

client asks, “How long will I need to take this thyroid medication?” How would the nurse respond? a. “You will need to take the thyroid medication until the goiter is completely gone.” b. “Thyroiditis is cured with antibiotics. Then you won’t need thyroid medication.” c. “You’ll need thyroid pills for life because your thyroid won’t start working again.” d. “When blood tests indicate normal thyroid function, you can stop the medication.”

ANS: C

Hashimoto thyroiditis results in a permanent loss of thyroid function. The client will need lifelong thyroid replacement therapy and will not be able to stop taking the medication.

DIF: Understanding TOP: Integrated Process: Communication and Documentation KEY: Thyroid disorder, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 9. The nurse is caring for a client who is starting on propylthiouracil for hyperthyroidism. What

statement by the client indicates a need for further teaching? a. “I will let my provider know if I have weight gain and cold intolerance.”

b. “I will let my provider know if I have a metallic taste or stomach upset.” c. “I will avoid crowds and other people who have infection.” d. “I am aware that if the drug changes the color of my urine, I should stop it.”

ANS: B

If the client’s urine turns dark and/or the skin has a yellow appearance, the client may have possible liver toxicity from the drug. This is a serious adverse effect and needs to be reported to the primary health care provider after stopping the drug. If weight gain and cold intolerance occurs, then the client may need a lower dose of the drug. The drug should not cause GI distress or a metallic taste in his or her mouth.

10. A nurse plans care for a client with hyperparathyroidism. Which intervention does the nurse

include in this client’s plan of care? a. Use a lift sheet to assist the client with position changes in bed. b. Ask the client to ambulate in the hallway twice a day. c. Provide the client with a soft-bristled toothbrush for oral care. d. Instruct the assistive personnel to strain the patient’s urine for stones.

ANS: A

Hyperparathyroidism causes increased resorption of calcium from the bones, increasing the risk for pathologic fractures. Using a lift sheet when moving or positioning the client, instead of pulling on the client, reduces the risk of bone injury. Hyperparathyroidism can cause kidney stones, but not every client will need to have urine strained. The priority is preventing injury. Ambulating in the hall and using a soft toothbrush are not specific interventions for this patient.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Parathyroid disorder, Safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 11. While assessing a client with Graves disease, the nurse notes that the client’s temperature has

risen 1° F (1° C). What does the nurse do first? a. Turn the lights down and shut the patient’s door. b. Call for an immediate electrocardiogram (ECG). c. Calculate the client’s apical-radial pulse deficit. d. Administer a dose of acetaminophen.

ANS: A

A temperature increase of 1° F (5/9° C) may indicate the development of thyroid storm, and the primary health care provider or RRT needs to be notified. But before notifying the provider, the nurse should first take measures to reduce environmental stimuli that increase the risk of cardiac complications. The nurse can then call for an ECG. The apical-radial pulse deficit would not be necessary, and acetaminophen is not needed because the temperature increase is due to thyroid activity.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Thyroid disorder, Emergency care MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential MULTIPLE RESPONSE

1. The nurse is caring for a client who has possible hypothyroidism. What possible risk factors

can cause this health problem? (Select all that apply.) a. Lithium drug therapy b. Thyroid cancer c. Autoimmune thyroid disease d. Iodine deficiency e. Laryngitis f. Pituitary tumors ANS: A, B, C, D, F

All of these factors place a client at risk for hypothyroidism except for laryngitis which is an inflammation of the larynx.

DIF: Understanding TOP: Integrated Process: Assessment KEY: Thyroid disorders, Risk factors MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A nurse is caring for a client with elevated triiodothyronine and thyroxine, and normal

thyroid-stimulating hormone levels. What actions does the nurse take? (Select all that apply.) a. Administer levothyroxine. b. Administer propranolol. c. Monitor the apical pulse. d. Assess for Trousseau sign. e. Initiate telemetry monitoring.

ANS: C, E

The client’s laboratory findings suggest that the client is experiencing hyperthyroidism. The increased metabolic rate can cause an increase in the client’s heart rate, and the client should be monitored for the development of dysrhythmias. Placing the client on a telemetry monitor might also be a precaution. Levothyroxine is given for hypothyroidism. Propranolol is a beta blocker often used to lower sympathetic nervous system activity in hyperthyroidism.

Trousseau sign is a test for hypocalcemia.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Thyroid disorder, Diagnostic tests MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. A nurse teaches a client with hyperthyroidism. Which dietary modifications should the nurse

include in this client’s health teaching? (Select all that apply.) a. Increased carbohydrates b. Decreased fats c. Increased calorie intake d. Supplemental vitamins e. Increased proteins ANS: A, C, E

The client is hypermetabolic and has an increased need for carbohydrates, calories, and proteins. Proteins are especially important because the client is at risk for a negative nitrogen balance. There is no need to decrease fat intake or take supplemental vitamins.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Thyroid disorder, Dietary therapy

MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

Chapter 59: Concepts of Care for Patients With Diabetes Mellitus Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse is teaching a client with diabetes mellitus who asks, “Why is it necessary to maintain

my blood glucose levels no lower than about 60 mg/dL (3.3 mmol/L)?” How would the nurse respond? a. “Glucose is the only fuel used by the body to produce the energy that it needs.” b. “Your brain needs a constant supply of glucose because it cannot store it.” c. “Without a minimum level of glucose, your body does not make red blood cells.” d. “Glucose in the blood prevents the formation of lactic acid and prevents acidosis.”

ANS: B

Because the brain cannot synthesize or store significant amounts of glucose, a continuous supply from the body’s circulation is needed to meet the fuel demands of the central nervous system. The nurse would want to educate the patient to prevent hypoglycemia. The body can use other sources of fuel, including fat and protein, and glucose is not involved in the production of red blood cells. Glucose in the blood will encourage glucose metabolism but is not directly responsible for lactic acid formation.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Diabetes mellitus, Hypoglycemia MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. The nurse is assessing a client for risk of developing metabolic syndrome. Which risk factor is

associated with this health condition? a. Hypotension b. Hyperthyroidism c. Abdominal obesity d. Hypoglycemia ANS: C

The client at risk for metabolic syndrome typically has hypertension, abdominal obesity, hyperlipidemia, and hyperglycemia.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Metabolic syndrome, Assessment MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 3. After teaching a young adult client who is newly diagnosed with type 1 diabetes mellitus, the

nurse assesses the client’s understanding. Which statement made by the client indicates a correct understanding of the need for eye examinations? a. “At my age, I should continue seeing the ophthalmologist as I usually do.” b. “I will see the eye doctor when I have a vision problem and yearly after age 40.” c. “My vision will change quickly. I should see the ophthalmologist twice a year.” d. “Diabetes can cause blindness, so I should see the ophthalmologist yearly.”

ANS: D

Diabetic retinopathy is a leading cause of blindness in North America. All clients with diabetes, regardless of age, should be examined by an ophthalmologist (rather than an optometrist or optician) at diagnosis and at least yearly thereafter.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Diabetes mellitus, Health screening MSC: Client Needs Category: Health Promotion and Maintenance 4. A nurse assesses a client who has a 15-year history of diabetes and notes decreased tactile

sensation in both feet. What action would the nurse take first? a. Document the finding in the client’s chart. b. Assess tactile sensation in the client’s hands. c. Examine the client’s feet for signs of injury. d. Notify the primary health care provider.

ANS: C

Diabetic neuropathy is common when the disease is of long duration. The client is at great risk for injury in any area with decreased sensation because he or she is less able to feel injurious events. Feet are common locations for neuropathy and injury, so the nurse would inspect them for any signs of injury. After assessment, the nurse would document findings in the client’s chart. Testing sensory perception in the hands may or may not be needed. The primary health care provider can be notified after assessment and documentation have been completed.

DIF: Applying TOP: Integrated Process: Nursing Process: Analysis KEY: Diabetes mellitus, Complications MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 5. A nurse cares for a client who has a family history of diabetes mellitus. The client states, “My

father has type 1 diabetes mellitus. Will I develop this disease as well?” How would the nurse respond? a. “Your risk of diabetes is higher than the general population, but it may not occur.” b. “No genetic risk is associated with the development of type 1 diabetes mellitus.” c. “The risk for becoming a diabetic is 50% because of how it is inherited.” d. “Female children do not inherit diabetes mellitus, but male children will.”

ANS: A

Risk for type 1 diabetes is determined by inheritance of genes coding for HLA-DR and HLA-DQ tissue types. Clients who have one parent with type 1 diabetes are at increased risk for its development. Diabetes (type 1) seems to require interaction between inherited risk and environmental factors, so not everyone with these genes develops diabetes. The other statements are not accurate.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Diabetes mellitus, Genetics MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. A nurse teaches a client who is diagnosed with diabetes mellitus. Which statement would the

nurse include in this client’s plan of care to delay the onset of microvascular and macrovascular complications? a. “Maintain tight glycemic control and prevent hyperglycemia.” b. “Restrict your fluid intake to no more than 2 L a day.”

c. “Prevent hypoglycemia by eating a bedtime snack.” d. “Limit your intake of protein to prevent ketoacidosis.”

ANS: A

Hyperglycemia is a critical factor in the pathogenesis of long-term diabetic complications.

Maintaining tight glycemic control will help delay the onset of complications. Restricting fluid intake is not part of the treatment plan for patients with diabetes. Preventing hypoglycemia and ketosis, although important, is not as important as maintaining daily glycemic control.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Diabetes mellitus, Hyperglycemia MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 7. A nurse assesses clients who are at risk for diabetes mellitus. Which client is at greatest risk? a. A 19-year-old Caucasian b. A 22-year-old African American c. A 44-year-old Asian American d. A 58-year-old American Indian ANS: D

Diabetes is a particular problem among African Americans, Hispanics, and American Indians.

The incidence of diabetes increases in all races and ethnic groups with age. Being both an American Indian and middle age places this patient at highest risk.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Diabetes mellitus, Risk factors MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 8. A nurse teaches a patient about self-monitoring of blood glucose levels. Which statement

would the nurse include in this client’s teaching to prevent bloodborne infections? a. “Wash your hands after completing each test.” b. “Do not share your monitoring equipment.” c. “Blot excess blood from the strip with a cotton ball.” d. “Use gloves when monitoring your blood glucose.”

ANS: B

Small particles of blood can adhere to the monitoring device, and infection can be transported from one user to another. Hepatitis B in particular can survive in a dried state for about a week. The client would be taught to avoid sharing any equipment, including the lancet holder.

The client would also be taught to wash his or her hands before testing. He or she would not need to blot excess blood away from the strip or wear gloves.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Diabetes mellitus, Infection control MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 9. A nurse teaches a client with type 2 diabetes mellitus who is prescribed glipizide (Glucotrol).

Which statement would the nurse include in this client’s teaching? a. “Change positions slowly when you get out of bed.” b. “Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs).” c. “If you miss a dose of this drug, you can double the next dose.”

d. “Discontinue the medication if you develop a urinary infection.”

ANS: B

NSAIDs potentiate the hypoglycemic effects of sulfonylurea agents. Glipizide is a sulfonylurea. The other statements are not applicable to glipizide.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Diabetes mellitus, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 10. After teaching a patient with type 2 diabetes mellitus who is prescribed nateglinide, the nurse

assesses the client’s understanding. Which statement made by the patient indicates a correct understanding of the prescribed therapy? a. “I’ll take this medicine during each of my meals.” b. “I must take this medicine in the morning when I wake.” c. “I will take this medicine before I go to bed.” d. “I will take this medicine immediately before I eat.”

ANS: D

Nateglinide is an insulin secretagogue that is designed to increase meal-related insulin secretion. It should be taken immediately before each meal. The medication should not be taken without eating as it will decrease the client’s blood glucose levels causing hypoglycemia. The medication should be taken before meals instead of during meals.

DIF: Applying TOP: Integrated Process: Nursing Process: Evaluation KEY: Diabetes mellitus, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 11. A nurse cares for a patient who is prescribed pioglitazone. After 6 months of therapy, the

client reports that he has a new onset of ankle edema. What assessment question would the nurse take? a. “Have you gained unexpected weight this week?” b. “Has your urinary output declined recently?” c. “Have you had fever and achiness this week?” d. “Have you had abdominal pain recently?”

ANS: A

Thiazolidinediones (including pioglitazone) can cause cardiovascular adverse effects including health failure which is manifested by peripheral edema and unintentional weight gain. The client should have been taught to weigh every week and report sudden increases in weight.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Diabetes mellitus, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 12. A nurse cares for a client with diabetes mellitus who asks, “Why do I need to administer more

than one injection of insulin each day?” How would the nurse respond? a. “You need to start with multiple injections until you become more proficient at self-injection.” b. “A single dose of insulin each day would not match your blood insulin levels and your food intake patterns.”

c. “A regimen of a single dose of insulin injected each day would require that you eat

fewer carbohydrates.” d. “A single dose of insulin would be too large to be absorbed, predictably putting

you at risk for insulin shock.”

ANS: B

Even when a single injection of insulin contains a combined dose of different-acting insulin types, the timing of the actions and the timing of food intake may not match well enough to prevent wide variations in blood glucose levels. One dose of insulin would not be appropriate even if the patient decreased carbohydrate intake. Additional injections are not required to allow the client practice with injections, nor will one dose increase the client’s risk of insulin shock.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Diabetes mellitus, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 13. After teaching a client with diabetes mellitus to inject insulin, the nurse assesses the client’s

understanding. Which statement made by the client indicates a need for further teaching? a. “The lower abdomen is the best location because it is closest to the pancreas.” b. “I can reach my thigh the best, so I will use the different areas of my thighs.” c. “By rotating the sites in one area, my chance of having a reaction is decreased.” d. “Changing injection sites from the thigh to the arm will change absorption rates.”

ANS: A

The abdominal site has the fastest rate of absorption because of blood vessels in the area, not because of its proximity to the pancreas. The other statements are accurate assessments of insulin administration.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Diabetes mellitus, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 14. A nurse reviews the laboratory test values for a client with a new diagnosis of diabetes

mellitus type 2. Which A1C value would the nurse expect? a. 5.0% b. 5.7% c. 6.2% d. 7.4% ANS: D

A client is diagnosed with diabetes if the client’s A1C is 6.5% or greater. All listed values are below that level except for 7.4%.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Diabetes mellitus, Diagnostic tests MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 15. The nurse is planning teaching for a client who is starting exenatide extended release (ER) for

diabetes mellitus type 2. Which statement will the nurse include in the teaching? a. “Be sure to take the drug once a day before breakfast.” b. “Take the drug every evening before bedtime.”

c. “Give your drug injection the same day every week.” d. “Take the drug with dinner at the same time each day.”

ANS: C

Exenatide ER is an incretin mimetic (GLP-1 agonist) that works with insulin to lower blood glucose levels by reducing pancreatic glucagon secretion, reducing liver glucose production, and delaying gastric emptying. As an extended-release drug, it is given only once a week by injection.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Diabetes mellitus, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 16. The nurse is planning teaching for a client who is starting acarbose for diabetes mellitus type

2. Which statement will the nurse include in the teaching? a. “Be sure to take the drug with each meal.” b. “Take the drug every evening before bedtime.” c. “Take the drug on an empty stomach in the morning.” d. “Decide on the best day of the week to take the drug.”

ANS: A

Acarbose is an alpha-glucosidase inhibitor that works in the intestinal tract to prevent enzymes from breaking down starches into glucose. However, it must be taken with food at each meal, usually 3 times a day, to allow the drug to work as intended.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Diabetes mellitus, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 17. After teaching a client who has diabetes mellitus with retinopathy, nephropathy, and

peripheral neuropathy, the nurse assesses the client’s understanding. Which statement made by the client indicates a correct understanding of the teaching? a. “I have so many complications; exercising is not recommended.” b. “I will exercise more frequently because I have so many complications.” c. “I used to run for exercise; I will start training for a marathon.” d. “I should look into swimming or water aerobics to get my exercise.”

ANS: D

Exercise is not contraindicated for this client, although modifications based on existing pathology are necessary to prevent further injury. Swimming or water aerobics will give the client exercise without the worry of having the correct shoes or developing a foot injury. The client should not exercise too vigorously.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Diabetes mellitus, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 18. The nurse assesses a client with diabetic ketoacidosis. Which assessment finding would the

nurse correlate with this condition? a. Increased rate and depth of respiration b. Extremity tremors followed by seizure activity c. Oral temperature of 102° F (38.9° C)

d. Severe orthostatic hypotension ANS: A

Ketoacidosis decreases the pH of the blood, stimulating the respiratory control areas of the brain to buffer the effects of increasing acidosis. The rate and depth of respiration are increased (Kussmaul respirations) in an attempt to excrete more acids by exhalation. Tremors, elevated temperature, and orthostatic hypotension are not associated with ketoacidosis.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Diabetes mellitus, Complications MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 19. A nurse assesses a client who has diabetes mellitus. Which arterial blood gas values would the

nurse identify as potential ketoacidosis in this client? a. pH 7.38, HCO3 22 mEq/L (22 mmol/L), PCO2 38 mm Hg, PO2 98 mm Hg b. pH 7.28, HCO3 18 mEq/L (18 mmol/L), PCO2 28 mm Hg, PO2 98 mm Hg c. pH 7.48, HCO3 28 mEq/L (28 mmol/L), PCO2 38 mm Hg, PO2 98 mm Hg d. pH 7.32, HCO3 22 mEq/L (22 mmol/L), PCO2 58 mm Hg, PO2 88 mm Hg ANS: B

When the lungs can no longer offset acidosis, the pH decreases to below normal. A client who has diabetic ketoacidosis would present with arterial blood gas values that show primary metabolic acidosis with decreased bicarbonate levels and a compensatory respiratory alkalosis with decreased carbon dioxide levels.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Analysis KEY: Diabetes mellitus, Complications MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 20. A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul

respirations. What action would the nurse take? a. Administration of oxygen via facemask b. Intravenous administration of 10% glucose c. Implementation of seizure precautions d. Administration of intravenous insulin ANS: D

The rapid, deep respiratory efforts of Kussmaul respirations are the body’s attempt to reduce the acids produced by using fat rather than glucose for fuel. Only the administration of insulin will reduce this type of respiration by assisting glucose to move into cells and to be used for fuel instead of fat. The patient who is in ketoacidosis may not experience any respiratory impairment and therefore does not need additional oxygen. Giving the patient glucose would be contraindicated. The patient does not require seizure precautions.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Diabetes mellitus, Complications MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 21. A nurse teaches a client with type 1 diabetes mellitus. Which statement would the nurse

include in this client’s teaching to decrease the client’s insulin needs? a. “Limit your fluid intake to 2 L a day.”

b. “Animal organ meat is high in insulin.” c. “Limit your carbohydrate intake to 80 g a day.” d. “Walk at a moderate pace for 1 mile daily.”

ANS: D

Moderate exercise such as walking helps regulate blood glucose levels on a daily basis and results in lowered insulin requirements for patients with type 1 diabetes mellitus. Restricting fluids and eating organ meats will not reduce insulin needs. People with diabetes need at least 130 g of carbohydrates each day.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Diabetes mellitus, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 22. After teaching a client who is recovering from pancreas transplantation, the nurse assesses the

client’s understanding. Which statement made by the client indicates a need for further teaching? a. “If I develop an infection, I should stop taking my corticosteroid.” b. “If I have pain over the transplant site, I will call the surgeon immediately.” c. “I should avoid people who are ill or who have an infection.” d. “I should take my cyclosporine exactly the way I was taught.”

ANS: A

Immunosuppressive agents should not be stopped without the consultation of the transplantation physician, even if an infection is present. Stopping immunosuppressive therapy endangers the transplanted organ. The other statements are correct. Pain over the graft site may indicate rejection. Antirejection drugs cause immunosuppression, and the patient should avoid crowds and people who are ill. Changing the routine of antirejection medications may cause them to not work optimally.

DIF: Applying TOP: Integrated Process: Nursing Process: Evaluation KEY: Diabetes mellitus, Pancreas transplantation MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 23. A nurse teaches a client with diabetes mellitus who is experiencing numbness and reduced

sensation. Which statement would the nurse include in this client’s teaching to prevent injury? a. “Examine your feet using a mirror every day.” b. “Rotate your insulin injection sites every week.” c. “Check your blood glucose level before each meal.” d. “Use a bath thermometer to test the water temperature.”

ANS: D

Clients with diminished sensory perception can easily experience a burn injury when bathwater is too hot. Instead of checking the temperature of the water by feeling it, they should use a thermometer. Examining the feet daily does not prevent injury, although daily foot examinations are important to find problems so they can be addressed. Rotating insulin and checking blood glucose levels will not prevent injury.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Diabetes mellitus, Health teaching MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

24. A nurse assesses a client with diabetes mellitus. Which assessment finding would alert the

nurse to decreased kidney function in this client? a. Urine specific gravity of 1.033 b. Presence of protein in the urine c. Elevated capillary blood glucose level d. Presence of ketone bodies in the urine ANS: B

Renal dysfunction often occurs in the client with diabetes. Proteinuria is a result of renal dysfunction. Specific gravity is elevated with dehydration. Elevated capillary blood glucose levels and ketones in the urine are consistent with diabetes mellitus but are not specific to renal function.

DIF: Applying TOP: Integrated Process: Nursing Process: Analysis KEY: Diabetes mellitus, Complications MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 25. A nurse develops a dietary plan for a client with diabetes mellitus and new-onset

microalbuminuria. Which component of the client’s diet would the nurse decrease? a. Carbohydrates b. Proteins c. Fats d. Total calories ANS: B

Restriction of dietary protein is recommended for clients with microalbuminuria to delay progression to renal failure. The client’s diet does not need to be decreased in carbohydrates, fats, or total calories.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Diabetes mellitus, Complications MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 26. A nurse assesses a client who has diabetes mellitus and notes that the client is awake and alert,

but shaky, diaphoretic, and weak. Five minutes after administering a half-cup (120 mL) of orange juice, the client’s signs and symptoms have not changed. What action would the nurse take next? a. Administer another half-cup (120 mL) of orange juice. b. Administer a half-ampule of dextrose 50% intravenously. c. Administer 10 units of regular insulin subcutaneously. d. Administer 1 mg of glucagon intramuscularly.

ANS: A

This patient is experiencing mild hypoglycemia. For mild hypoglycemic manifestations, the nurse would administer oral glucose in the form of orange juice. If the symptoms do not resolve immediately, the treatment would be repeated. The patient does not need intravenous dextrose, insulin, or glucagon.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Diabetes mellitus, Complications MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

27. A nurse reviews the laboratory results of a client who is receiving intravenous insulin. Which

would alert the nurse to intervene immediately? a. Serum chloride level of 98 mEq/L (98 mmol/L) b. Serum calcium level of 8.8 mg/dL (2.2 mmol/L) c. Serum sodium level of 132 mEq (132 mmol/L) d. Serum potassium level of 2.5 mEq/L (2.5 mmol/L) ANS: D

Insulin activates the sodium–potassium ATPase pump, increasing the movement of potassium from the extracellular fluid into the intracellular fluid, resulting in hypokalemia. In hyperglycemia, hypokalemia can also result from excessive urine loss of potassium. The chloride level is normal. The calcium and sodium levels are slightly low, but this would not be related to hyperglycemia and insulin administration.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Diabetes mellitus, Drug therapy MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 28. A nurse teaches a client with diabetes mellitus about sick-day management. Which statement

would the nurse include in this client’s teaching? a. “When ill, avoid eating or drinking to reduce vomiting and diarrhea.” b. “Monitor your blood glucose levels at least every 4 hours while sick.” c. “If vomiting, do not use insulin or take your oral antidiabetic agent.” d. “Try to continue your prescribed exercise regimen even if you are sick.”

ANS: B

When ill, the client should monitor his or her blood glucose at least every 4 hours. The client should continue taking the medication regimen while ill. The client should continue to eat and drink as tolerated but should not exercise while sick.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Diabetes mellitus, Complications MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 29. The nurse is caring for a client who has diabetes mellitus. The nurse administers 6 units of

regular insulin and 10 units of NPH insulin at 7:00 a.m. (0700). At which time would the nurse assess the client for potential hypoglycemia related to the NPH insulin? a. 8:00 a.m. (0800) b. 4:00 p.m. (1600) c. 8:00 p.m. (2000) d. 11:00 p.m. (2300) ANS: B

Neutral protamine Hagedorn (NPH) is an intermediate-acting insulin with an onset of 1.5 hours, peak of 4 to 12 hours, and duration of action of 22 hours. Checking the client at 0800 would be too soon. Checking the patient at 2000 and 2300 would be too late. The nurse would check the patient at 1600 (4:00 p.m.).

DIF: Understanding TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Diabetes mellitus, Drug therapy

MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 30. When teaching a client recently diagnosed with type 1 diabetes mellitus, the client states, “I

will never be able to stick myself with a needle.” How would the nurse respond? a. “I can give your injections to you while you are here in the hospital.” b. “Everyone gets used to giving themselves injections. It really does not hurt.” c. “Your disease will not be managed properly if you refuse to administer the shots.” d. “Tell me what it is about the injections that are concerning you.”

ANS: D

Devote as much teaching time as possible to insulin injection and blood glucose monitoring.

Clients with newly diagnosed diabetes are often fearful of giving themselves injections. If the client is worried about giving the injections, it is best to try to find out what specifically is causing the concern, so it can be addressed. Giving the injections for the client does not promote self-care ability. Telling the client that others give themselves injections may cause the client to feel bad. Stating that you don’t know another way to manage the disease is dismissive of the client’s concerns.

DIF: Applying TOP: Integrated Process: Caring KEY: Diabetes mellitus, Psychosocial response MSC: Client Needs Category: Psychosocial Integrity 31. A nurse assesses a client with diabetes mellitus who self-administers subcutaneous insulin.

The nurse notes a spongy, swelling area at the site the client uses most frequently for insulin injection. What action would the nurse take? a. Apply ice to the site to reduce inflammation. b. Consult the provider for a new administration route. c. Assess the client for other signs of cellulitis. d. Instruct the client to rotate sites for insulin injection.

ANS: D

The client’s tissue has been damaged from continuous use of the same site. The client would be educated to rotate sites. The damaged tissue is not caused by cellulitis or any type of infection, and applying ice may cause more damage to the tissue. Insulin can only be administered subcutaneously and intravenously. It would not be appropriate or practical to change the administration route.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Diabetes mellitus, Drug therapy MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 32. After teaching a client who is newly diagnosed with type 2 diabetes mellitus, the nurse

assesses the client’s understanding. Which statement made by the client indicates a need for additional teaching? a. “I should increase my intake of vegetables with higher amounts of dietary fiber.” b. “My intake of saturated fats should be no more than 10% of my total calorie intake.” c. “I should decrease my intake of protein and eliminate carbohydrates from my diet.” d. “My intake of water is not restricted by my treatment plan or medication regimen.”

ANS: C

The client should not completely eliminate carbohydrates from the diet, and should reduce protein if microalbuminuria is present. The client should increase dietary intake of complex carbohydrates, including vegetables, and decrease intake of fat. Water does not need to be restricted unless kidney failure is present.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Diabetes mellitus, Diet therapy MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 33. A nurse reviews laboratory results for a client with diabetes mellitus who is prescribed an

intensified insulin regimen:  Fasting blood glucose: 75 mg/dL (4.2 mmol/L)  Postprandial blood glucose: 200 mg/dL (11.1 mmol/L)  Hemoglobin A1C level: 5.5% How would the nurse interpret these laboratory findings? a. Increased risk for developing ketoacidosis b. Good control of blood glucose c. Increased risk for developing hyperglycemia d. Signs of insulin resistance ANS: B

The client is maintaining blood glucose levels within the defined ranges for goals in an intensified regimen. Because the client’s glycemic control is good, he or she is not at higher risk for ketoacidosis or hyperglycemia and is not showing signs of insulin resistance.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Analysis KEY: Diabetes mellitus, Diagnostic tests MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 34. A nurse reviews the chart and new prescriptions for a client with diabetic ketoacidosis:

Vital Signs and Assessment Laboratory Results Medications Blood pressure: 90/62 mm Hg Serum potassium: 2.6 Potassium chloride 40 Pulse: 120 beats/min mEq/L (2.6 mmol/L) mEq/L (40 mmol/L) IV Respiratory rate: 28 breaths/min bolus STAT Urine output: 20 mL/hr via Increase IV fluid to 100 catheter mL/hr What action would the nurse take? a. Administer the potassium and then consult with the primary health care provider about the fluid prescription. b. Increase the intravenous rate and then consult with the primary health care provider about the potassium prescription. c. Administer the potassium first before increasing the infusion flow rate for the client. d. Increase the intravenous flow rate before administering the potassium to the client.

ANS: B

The client is acutely ill and is severely dehydrated and hypokalemic, requiring more IV fluids and potassium. However, potassium would not be infused unless the urine output is at least 30 mL/hr. The nurse would first increase the IV rate and then consult with the primary health care provider about the potassium.

DIF: Applying TOP: Integrated Process: Nursing Process: Analysis KEY: Diabetes mellitus, Complications MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 35. The nurse is caring for a newly admitted older adult who has a blood glucose of 300 mg/dL

(16.7 mmol/L), a urine output of 185 mL in the past 8 hours, and a blood urea nitrogen (BUN) of 44 mg/dL (15.7 mmol/L). What diabetic complication does the nurse suspect? a. Diabetic ketoacidosis (DKA) b. Severe hypoglycemia c. Chronic kidney disease (CKD) d. Hyperglycemic-hyperosmolar state (HHS) ANS: D

The client most likely has diabetes mellitus type 2 and has a high blood glucose causing increased blood osmolarity and dehydration, as evidenced by an insufficient urinary output and increased BUN. Older adults are at the greatest risk for dehydration due to age-related physiologic changes.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Diabetes mellitus, Complications MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 36. The nurse is caring for a newly admitted client who is diagnosed with

hyperglycemic-hyperosmolar state (HHS). What is the nurse’s priority action at this time? a. Assess the client’s blood glucose level. b. Monitor the client’s urinary output every hour. c. Establish intravenous access to provide fluids. d. Give regular insulin per agency policy.

ANS: C

The first priority in caring for a client with HHS is to increase blood volume to prevent shock or severe hypotension from dehydration. The nurse would monitor vital signs, urinary output, and blood glucose to determine if interventions were effective. Regular insulin is also indicated but not as the first priority action.

MULTIPLE RESPONSE 1. A nurse assesses adults at a health fair. Which adults would the nurse counsel to be tested for

diabetes? (Select all that apply.) a. A 56-year-old African-American male b. A 22-year-old female with a 30-lb (13.6 kg) weight gain during pregnancy c. A 60-year-old male with a history of liver trauma d. A 48-year-old female with a sedentary lifestyle e. A 50-year-old male with a body mass index greater than 25 kg/m2 f. A 28-year-old female who gave birth to a baby weighing 9.2 lb (4.2 kg) ANS: A, D, E, F

Risk factors for type 2 diabetes include certain ethnic/racial groups (African Americans, American Indians, and Hispanics), obesity and physical inactivity, and giving birth to large babies. Liver trauma and a 30-lb (13.6 kg) gestational weight gain are not risk factors.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Diabetes mellitus, Health screening MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 2. A nurse assesses a patient who is experiencing diabetic ketoacidosis (DKA). For which

assessment findings would the nurse monitor the client? (Select all that apply.) a. Deep and fast respirations b. Decreased urine output c. Tachycardia d. Dependent pulmonary crackles e. Orthostatic hypotension ANS: A, C, E

DKA leads to dehydration, which is manifested by tachycardia and orthostatic hypotension.

Usually, patients have Kussmaul respirations, which are fast and deep. Increased urinary output (polyuria) is severe. Because of diuresis and dehydration, peripheral edema and crackles do not occur.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Diabetes mellitus, Complications MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. A nurse teaches a client with diabetes mellitus about foot care. Which statements would the

nurse include in this client’s teaching? (Select all that apply.) a. “Do not walk around barefoot.” b. “Soak your feet in a tub each evening.” c. “Trim toenails straight across with a nail clipper.” d. “Treat any blisters or sores with Epsom salts.” e. “Wash your feet every other day.”

ANS: A, C

Clients who have diabetes mellitus are at high risk for wounds on the feet secondary to peripheral neuropathy and poor arterial circulation. The client would be instructed to not walk around barefoot or wear sandals with open toes. These actions place the client at higher risk for skin breakdown of the feet. The client would be instructed to trim toenails straight across with a nail clipper. Feet should be washed daily with lukewarm water and soap, but feet should not be soaked in the tub. The client should contact the primary health care provider immediately if blisters or sores appear and should not use home remedies to treat these wounds.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Diabetes mellitus, Complications MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 4. A nurse provides diabetic education at a public health fair. Which disorders would the nurse

include as complications of diabetes mellitus? (Select all that apply.) a. Stroke b. Kidney failure c. Blindness d. Respiratory failure e. Cirrhosis

ANS: A, B, C

Complications of diabetes mellitus are caused by macrovascular and microvascular changes.

Macrovascular complications include coronary artery disease, cerebrovascular disease, and peripheral vascular disease. Microvascular complications include nephropathy, retinopathy, and neuropathy. Respiratory failure and cirrhosis are not complications of diabetes mellitus.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Diabetes mellitus, Complications MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. A nurse collaborates with the interprofessional team to develop a plan of care for a client who

is newly diagnosed with diabetes mellitus. Which team members would the nurse include in this interprofessional team meeting? (Select all that apply.) a. Registered dietitian nutritionist b. Clinical pharmacist c. Occupational therapist d. Primary health care provider e. Speech–language pathologist ANS: A, B, D

When planning care for a client newly diagnosed with diabetes mellitus, the nurse would collaborate with a registered dietitian nutritionist, clinical pharmacist, and primary health care provider. The focus of treatment for a newly diagnosed client would be nutrition, medication therapy, and education. The nurse could also consult with a diabetic educator. There is no need for occupational therapy or speech therapy at this time.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Diabetes mellitus, Collaborative care MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 6. The nurse is caring for a client who has severe hypoglycemia and is experiencing a seizure.

What actions will the nurse take at this time? (Select all that apply.) a. Administer glucagon 1 mg subcutaneously. b. Be sure the bed side rails are in the up position. c. Notify the primary health care provider immediately. d. Monitor the client’s blood glucose level. e. Increase the intravenous infusion rate immediately.

ANS: A, B, C, D

The client who has severe hypoglycemia often has a blood sugar of less than 20 mg/dL (1.0 mmol/L) and may be unconscious or seizing. Therefore, the client cannot swallow and needs glucagon. To keep the client safe during the seizure, the nurse ensures that the side rails are up to prevent the client from falling out of bed. The nurse would also monitor the client’s blood sugar to evaluate the effectiveness of the interventions.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Acute diabetic complications MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 7. The nurse is caring for a client who has diabetes mellitus type 1 and is experiencing

hypoglycemia. Which assessment findings will the nurse expect? (Select all that apply.)

a. b. c. d. e. f.

Warm, dry skin Nervousness Rapid deep respirations Dehydration Ketoacidosis Blurred vision

ANS: B, F

The client who has hypoglycemia is often anxious, nervous, and possibly confused. Due to lack of glucose, vision may be blurred or the client may report diplopia (double vision).

Clients who have hyperglycemia from diabetes mellitus type 1 have warm skin, Kussmaul respirations that are rapid and deep, dehydration due to elevated blood glucose, and ketoacidosis.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Diabetes mellitus, Complications MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

Chapter 60: Assessment of the Renal/Urinary System Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse reviews the urinalysis of a client and notes the presence of glucose. What action

would the nurse take? a. Document findings and continue to monitor the client. b. Contact the primary health care provider and recommend a 24-hour urine test. c. Review the client’s recent dietary selections over 3 days. d. Perform a finger stick blood glucose assessment.

ANS: D

Glucose normally is not found in the urine. The normal renal threshold for glucose is about 220 mg/dL (12.2 mmol/L), which means that a person whose blood glucose is less than 220 mg/dL (12.2 mmol/L) will not have glucose in the urine. A positive finding for glucose on urinalysis indicates high blood sugar. The most appropriate action would be to perform a blood glucose assessment. The client needs further evaluation for this abnormal result; therefore, documenting and continuing to monitor are not appropriate. Requesting a 24-hour urine test or reviewing the client’s dietary selections will not assist the nurse to make a clinical decision related to this abnormality.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Urinary, Renal system, Diagnostic tests MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 2. A nurse reviews the health history of a client with an oversecretion of renin. Which disorder

would the nurse correlate with this assessment finding? a. Alzheimer disease b. Hypertension c. Diabetes mellitus d. Viral hepatitis ANS: B

Renin is secreted when special cells in the distal convoluted tubule, called the macula densa, sense changes in blood volume and pressure. When the macula densa cells sense that blood volume, blood pressure, or blood sodium levels are low, renin is secreted. Renin then converts angiotensinogen into angiotensin I. This leads to a series of reactions that cause secretion of the hormone aldosterone. This hormone increases kidney reabsorption of sodium and water, increasing blood pressure, blood volume, and blood sodium levels. Inappropriate or excessive renin secretion is a major cause of persistent hypertension. Renin has no impact on Alzheimer disease, diabetes mellitus, or viral hepatitis.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Urinary, Renal system, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. A nurse reviews the urinalysis results of a client and notes a urine osmolality of 1200

mOsm/kg (1200 mmol/kg). Which action would the nurse take? a. Contact the primary health care provider to recommend a low-sodium diet.

b. Prepare to administer an intravenous diuretic. c. Encourage the client to drink more fluids. d. Obtain a suction device and implement seizure precautions.

ANS: C

Normal urine osmolality ranges from 300 to 900 mOsm/kg (300 to 900 mmol/kg). This client’s urine is more concentrated, indicating dehydration. The nurse would encourage the client to drink more water. Dehydration can be associated with elevated serum sodium levels.

Although a low-sodium diet may be appropriate for this client, this diet change will not have a significant impact on urine osmolality. A diuretic would increase urine output and decrease urine osmolality further. Low serum sodium levels, not elevated serum levels, place the client at risk for seizure activity. These options would further contribute to the client’s dehydration or elevate the osmolality.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Urinary, Renal system, Assessment MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 4. A nurse assesses a client with renal insufficiency and a low red blood cell count. The client

asks, “Is my anemia related to my kidney problem?” How would the nurse respond? a. “Red blood cells produce erythropoietin, which increases blood flow to the kidneys.” b. “Your anemia and kidney problem are related to inadequate vitamin D and a loss of bone density.” c. “Erythropoietin is usually released from the kidneys and stimulates red blood cell production in the bone marrow.” d. “Kidney insufficiency inhibits active transportation of red blood cells throughout the blood.”

ANS: C

Erythropoietin is produced in the kidney and is released in response to decreased oxygen tension in the renal blood supply. Erythropoietin stimulates red blood cell production in the bone marrow. Anemia and renal insufficiency are not manifestations of vitamin D deficiency.

The kidneys do not play a role in the transportation of red blood cells or any other cells in the blood.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Urinary, Renal system, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. A nurse contacts the primary health care provider after reviewing a client’s laboratory results

and noting a blood urea nitrogen (BUN) of 35 mg/dL (12.5 mmol/L) and a serum creatinine of 1.0 mg/dL (88.4 mcmol/L). What collaborative care measure would the nurse recommend? a. Intravenous fluids b. Hemodialysis c. Fluid restriction d. Urine culture and sensitivity ANS: A

Normal BUN is 10 to 20 mg/dL (3.6 to 7.1 mmol/L). Normal creatinine is 0.6 to 1.2 mg/dL (53.0 to 106.1 mcmol/L) (males) or 0.5 to 1.1 mg/dL (44.2 to 97.2 mcmol/L) (females).

Creatinine is more specific for kidney function than BUN, because BUN can be affected by several factors (dehydration, high-protein diet, and catabolism). This client’s creatinine is normal, which suggests a nonrenal cause for the elevated BUN. A common cause of increased BUN is dehydration, so the nurse would recommend giving the client more fluids, not placing the client on fluid restrictions. Hemodialysis is not an appropriate treatment for dehydration.

The lab results do not indicate an infection; therefore, a urine culture and sensitivity are not appropriate.

DIF: Applying TOP: Integrated Process: Nursing Process: Analysis KEY: Urinary, Renal system, Diagnostic tests MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 6. The nurse is assessing a group of clients for their risk of kidney disease. Which racial/ethnic

group is at the greatest risk as they age? a. Latino Americans b. African Americans c. Jewish Americans d. Asian Americans ANS: B

Older African Americans have a greater age-related decrease in glomerular filtration rate when compared to other racial-ethnic groups. In addition, blood flow decreases and sodium excretion is less effective in older hypertensive African Americans. These changes make this group most at risk for kidney disease.

DIF: Remembering TOP: Integrated Process: Culture and Spirituality KEY: Kidney disorders, Human Development MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 7. A nurse cares for a client with a urine specific gravity of 1.040. What action would the nurse

take? a. Obtain a urine culture and sensitivity. b. Place the client on restricted fluids. c. Assess the client’s creatinine level. d. Increase the client’s fluid intake.

ANS: D

Normal specific gravity for urine is 1.005 to 1.030. A high specific gravity can occur with dehydration, decreased kidney blood flow (often because of dehydration), and presence of antidiuretic hormone. Increasing the client’s fluid intake would be a beneficial intervention.

Assessing the creatinine or obtaining a urine culture would not provide data necessary for the nurse to make a clinical decision.

DIF: Understanding TOP: Integrated Process: Nursing Process: Implementation KEY: Urinary, Renal system, Diagnostic tests MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort

8. A nurse reviews a client’s laboratory results. Which results from the client’s urinalysis would

the nurse recognize as abnormal? a. pH of 5.6 b. Ketone bodies present c. Specific gravity of 1.020 d. Clear and yellow color ANS: B

Ketone bodies are by-products of incomplete metabolism of fatty acids. Normally, no ketones are present in urine. Ketone bodies are produced when fat sources are used instead of glucose to provide cellular energy. A pH between 4.6 and 8, specific gravity between 1.005 and 1.030, and clear yellow urine are normal findings in a urinalysis.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Urinary, Renal system, Diagnostic tests MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 9. A nurse cares for a client who is recovering from a closed percutaneous kidney biopsy. The

client states, “My pain has suddenly increased from a 3 to a 10 on a scale of 0-10.” Which action would the nurse take first? a. Reposition the client on the operative side. b. Administer the prescribed opioid analgesic. c. Assess the client’s pulse rate and blood pressure. d. Examine the color of the client’s urine.

ANS: C

An increase in the intensity of pain after a percutaneous kidney biopsy is a symptom of possible internal hemorrhage. A change in vital signs (elevated pulse and decreased blood pressure) can indicate that hemorrhage is occurring.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Urinary, Renal system, Assessment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 10. The nurse delegates completing a bladder scan to assistive personnel (AP). Which action by

the AP indicates that the nurse must provide additional instructions when delegating this task? a. Selecting the female icon for all female patients and male icon for all male patients b. Telling the client, “This test measures the amount of urine in your bladder.” c. Applying ultrasound gel to the scanning head and removing it when finished d. Taking at least two readings using the aiming icon to place the scanning head ANS: A

The AP should use the female icon for women who have not had a hysterectomy. This allows the scanner to subtract the volume of the uterus from readings. If a woman has had a hysterectomy, the AP should choose the male icon. The AP should explain the procedure to the client, apply gel to the scanning head and clean it after use, and take at least two readings.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Urinary, Renal system, Delegation MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care

MULTIPLE RESPONSE 1. A nurse reviews a client’s laboratory results. Which results from the client’s urinalysis would

the nurse identify as normal? (Select all that apply.) a. pH: 6 b. Specific gravity: 1.015 c. Protein: 1.2 mg/dL d. Glucose: negative e. Nitrate: small f. Leukocyte esterase: positive ANS: A, B, D

The pH, specific gravity, and glucose are all within normal ranges. The other values are abnormal.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Urinary, Renal system, Diagnostic tests MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. The nurse is preparing a client for a percutaneous kidney biopsy. Which laboratory tests

results would the nurse review prior to the procedure? (Select all that apply.) a. Hemoglobin b. Hematocrit c. Sodium d. Potassium e. Platelet count f. Prothrombin time ANS: A, B, E, F

Kidneys are very vascular and the client is at risk for bleeding after a biopsy. Therefore, it is essential that the nurse review preprocedure laboratory test results for anemia and coagulation problems.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Urinary, Renal system, Diagnostic tests MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. A nurse assesses a client recovering from a cystoscopy. Which assessment findings would

alert the nurse to urgently contact the primary health care provider? (Select all that apply.) a. Decrease in urine output b. Tolerating oral fluids c. Prescription for metformin d. Blood clots present in the urine e. Burning sensation when urinating ANS: A, D

The nurse would monitor urine output and contact the primary health care provider if urine output decreases or becomes absent. The nurse would also assess for blood in the client’s urine. The urine may be pink-tinged, but gross bleeding or blood clots should not be present.

If bleeding is present, the nurse would urgently contact the primary health care provider.

Tolerating oral fluids is a positive outcome and does not need intervention. Metformin would be a concern if the patient received dye; no dye is used in a cystoscopy procedure. The client may experience a burning sensation when urinating after this procedure; this would not require a call to the primary health care provider.

DIF: Applying TOP: Integrated Process: Nursing Process: Analysis KEY: Urinary, Renal system, Diagnostic tests MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 4. A nurse prepares a client for a percutaneous kidney biopsy. What actions should the nurse

take prior to this procedure? (Select all that apply.) a. Keep the client NPO for 4 to 6 hours. b. Review coagulation study results. c. Maintain strict bedrest in a supine position. d. Assess for blood in the client’s urine. e. Administer client’s antihypertensive medications.

ANS: A, B, E

Prior to a percutaneous kidney biopsy, the patient should be NPO for 4 to 6 hours.

Coagulation studies should be completed to prevent bleeding after the biopsy. Blood pressure medications should be administered to prevent hypertension before and after the procedure.

There is no need to keep the patient on bedrest or assess for blood in the client’s urine prior to the procedure; these interventions should be implemented after a percutaneous kidney biopsy.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Urinary, Renal system, Diagnostic tests MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 5. A nurse plans care for an older adult patient. Which interventions should the nurse include in

this client’s plan of care to promote kidney health? (Select all that apply.) a. Ensure adequate fluid intake. b. Leave the bathroom light on at night. c. Encourage use of the toilet every 6 hours. d. Delegate bladder training instructions to the assistive personnel (AP). e. Provide thorough perineal care after each voiding. f. Assess for urinary retention and urinary tract infection.

ANS: A, B, E, F

The nurse should ensure that the client receives adequate fluid intake and has adequate lighting to ambulate safely to the bathroom at night, encourage the client to use the toilet every 2 hours, provide thorough perineal care after each voiding, and assess for urinary retention and urinary tract infections. The nurse would not delegate any teaching to the AP, including bladder training instructions. The AP may participate in bladder training activities, including encouraging and assisting the client to the bathroom at specific times.

DIF: Understanding TOP: Integrated Process: Nursing Process: Planning and Implementation

KEY: Urinary, Renal system, Safety MSC: Client Needs Category: Health Promotion and Maintenance

Chapter 61: Concepts of Care for Patients With Urinary Problems Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. The nurse assesses a client who has possible bladder cancer. What common assessment

finding associated with this type of cancer would the nurse expect? a. Urinary retention b. Urinary incontinence c. Painless hematuria d. Difficulty urinating ANS: C

The classic and most common finding in clients who have bladder cancer is painless and intermittent hematuria that can be with gross or microscopic. Dysuria, frequency, and urgency occur in clients who have bladder infection or obstruction.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Bladder cancer, Signs and symptoms MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A nurse reviews the laboratory findings of a client with a urinary tract infection (bacterial

cystitis). The laboratory report notes a “shift to the left” in the client’s white blood cell count.

What action would the nurse take? a. Request that the laboratory perform a differential analysis on the white blood cells. b. Notify the primary health care provider and start an intravenous line for parenteral antibiotics. c. Ask assistive personnel (AP) to strain the client’s urine for renal calculi. d. Assess the client for a potential allergic reaction and anaphylactic shock.

ANS: B

An increase in band cells creates a “shift to the left.” A left shift most commonly occurs with urosepsis and is seen rarely with uncomplicated urinary tract infections. The nurse will be administering antibiotics, most likely via IV, so he or she would notify the primary health care provider and prepare to give the antibiotics. The shift to the left is part of a differential white blood cell count. The nurse would not need to strain urine for stones. Allergic reactions are associated with elevated eosinophil cells, not band cells.

DIF: Applying TOP: Integrated Process: Nursing Process: Analysis KEY: Cystitis, Diagnostic tests MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. A nurse cares for a postmenopausal client who has had two episodes of bacterial urethritis in

the last 6 months. The client asks, “I never have urinary tract infections. Why is this happening now?” How would the nurse respond? a. “Your immune system becomes less effective as you age.” b. “Low estrogen levels can make the tissue more susceptible to infection.” c. “You should be more careful with your personal hygiene in this area.” d. “It is likely that you have an untreated sexually transmitted disease.”

ANS: B

Low estrogen levels decrease moisture and secretions in the perineal area and cause other tissue changes, predisposing it to the development of infection. Urethritis is most common in postmenopausal women for this reason. Although immune function does decrease with aging and sexually transmitted diseases are a known cause of urethritis, the most likely reason in this patient is low estrogen levels. Personal hygiene usually does not contribute to this disease process.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Cystitis, Risk factors MSC: Client Needs Category: Health Promotion and Maintenance 4. After teaching a client with bacterial cystitis who is prescribed phenazopyridine, the nurse

assesses the client’s understanding. Which statement made by the client indicates a correct understanding of the teaching? a. “I will not take this drug with food or milk.” b. “I will have my partners tested for STIs.” c. “An orange color in my urine should not alarm me.” d. “I will drink two glasses of cranberry juice daily.”

ANS: C

Phenazopyridine discolors urine, most commonly to a deep reddish orange. Many clients think that they have blood in their urine when they see this. In addition, the urine can permanently stain clothing. There are no dietary restrictions or needs while taking this medication.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Cystitis, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 5. After teaching a client who has stress incontinence, the nurse assesses the client’s

understanding. Which statement made by the client indicates a need for further teaching? a. “I will limit my total intake of fluids.” b. “I must avoid drinking alcoholic beverages.” c. “I must avoid drinking caffeinated beverages.” d. “I shall try to lose about 10% of my body weight.”

ANS: A

Limiting fluids concentrates urine and can irritate tissues, leading to increased incontinence or cystitis. Many people try to manage incontinence by limiting fluids. Alcoholic and caffeinated beverages are bladder stimulants. Obesity increases intra-abdominal pressure, causing incontinence.

DIF: Understanding KEY: Cystitis, Management

TOP: Integrated Process: Teaching/Learning MSC: Client Needs Category: Physiological Integrity

6. The nurse teaches a client who has stress incontinence methods to regain more urinary

continence. Which health teaching is the most important for the nurse to include for this client? a. What type of incontinence pads to use? b. What types of liquids to drink and when?

c. Need to perform intermittent catheterizations. d. How to do Kegel exercises to strengthen muscles?

ANS: D

The client who has stress incontinence needs to strengthen the muscles of the pelvic floor using Kegel exercises. Catheterizations would not help with incontinence. Incontinence pads may need to be used by this client but that is not the most important thing to teach, and it does not help the client regain more control over his or her bladder.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Urinary incontinence, Management MSC: Client Needs Category: Health Promotion and Maintenance 7. After delegating care to assistive personnel (AP) for a client who is prescribed habit training

to manage incontinence, a nurse evaluates the AP’s understanding. Which action indicates that the AP needs additional teaching? a. Toileting the client after breakfast b. Changing the client’s incontinence brief when wet c. Encouraging the client to drink fluids d. Recording the client’s incontinence episodes ANS: B

Habit training is undermined by the use of absorbent incontinence briefs or pads. The nurse should reeducate the AP on the technique of habit training. The AP should continue to toilet the client after meals, encourage the client to drink fluids, and record incontinent episodes.

DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Urinary incontinence, Delegation MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 8. A nurse plans care for a client with overflow incontinence. Which intervention does the nurse

include in this client’s plan of care to assist with elimination? a. Stroke the medial aspect of the thigh. b. Use intermittent catheterization. c. Provide digital anal stimulation. d. Use the Valsalva maneuver.

ANS: D

In patients with overflow incontinence, the voiding reflex arc is not intact. Mechanical pressure, such as that achieved through the Valsalva maneuver (holding the breath and bearing down as if to defecate), can initiate voiding. Stroking the medial aspect of the thigh or providing digital anal stimulation requires the reflex arc to be intact to initiate elimination.

Due to the high risk for infection, intermittent catheterization should only be implemented when other interventions are not successful.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Urinary incontinence, Management MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 9. A client with pneumonia and dementia is admitted with an indwelling urinary catheter in

place. During interprofessional rounds the following day, which question would the nurse ask the primary health care provider?

a. b. c. d.

“Do you want daily weights on this client?”

“Will the client be able to return home?”

“May we discontinue the indwelling catheter?”

“Should we get another chest x-ray today?”

ANS: C

An indwelling urinary catheter dramatically increases the risks of urinary tract infection and urosepsis. Nursing staff should ensure that catheters are left in place only as long as they are medically needed. The nurse would inquire about removing the catheter. All other questions might be appropriate, but because of client safety, this question takes priority.

DIF: Applying TOP: Integrated Process: Nursing Process: Analysis KEY: Infection control MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 10. After teaching a client with a history of renal calculi, the nurse assesses the client’s

understanding. Which statement made by the client indicates a correct understanding of the teaching? a. “I should drink at least 3 L of fluid every day.” b. “I will eliminate all dairy or sources of calcium from my diet.” c. “Aspirin and aspirin-containing products can lead to stones.” d. “The doctor can give me antibiotics at the first sign of a stone.”

ANS: A

Dehydration contributes to the precipitation of minerals to form a stone. Although increased intake of calcium causes hypercalcemia and leads to excessive calcium filtered into the urine, if the client is well hydrated, the calcium will be excreted without issues. Dehydration increases the risk for supersaturation of calcium in the urine, which contributes to stone formation. The nurse would encourage the client to drink more fluids, not decrease calcium intake. Ingestion of aspirin or aspirin-containing products does not cause a stone. Antibiotics neither prevent nor treat a stone.

DIF: Applying KEY: Urolithiasis

TOP: Integrated Process: Teaching/Learning MSC: Client Needs Category: Health Promotion and Maintenance

11. A nurse cares for a client who has kidney stones from gout ricemia. Which medication does

the nurse anticipate administering? a. Phenazopyridine b. Doxycyline c. Tolterodine d. Allopurinol ANS: D

Stones caused by hyperuricmia caused by gout or other reason respond to allopurinol.

Phenazopyridine is given to clients with urinary tract infections. Doxycycline is an antibiotic.

Tolterodine is an anticholinergic with smooth muscle-relaxant properties.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Urolithiasis, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

12. A nurse assesses a client who is recovering from extracorporeal shock-wave lithotripsy for

renal calculi. The nurse notes an ecchymotic area on the client’s right lower back. What action would the nurse take? a. Administer fresh-frozen plasma. b. Apply an ice pack to the site. c. Place the client in the prone position. d. Obtain serum coagulation test results.

ANS: B

The shock waves from lithotripsy can cause bleeding into the tissues through which the waves pass. Application of ice can reduce the extent and discomfort of the bruising. Although coagulation test results and fresh-frozen plasma are used to assess and treat bleeding disorders, ecchymosis after this procedure is not unusual and does not warrant a higher level of intervention. Changing the client’s position will not decrease bleeding.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Urolithiasis, Management MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 13. A nurse obtains the health history of a client with a suspected diagnosis of bladder cancer.

Which question would the nurse ask when determining this client’s risk factors? a. “Do you smoke cigarettes?” b. “Do you use any alcohol?” c. “Do you use recreational drugs?” d. “Do you take any prescription drugs?”

ANS: A

Smoking is known to be a factor that greatly increases the risk of bladder cancer. Alcohol use, recreational drug use, and prescription drug use (except medications that contain phenacetin) are not known to markedly increase the risk of developing bladder cancer.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Bladder cancer, Health screening MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 14. A nurse teaches a young female client who is prescribed cephalexin for a urinary tract

infection. Which statement would the nurse include in this client’s teaching? a. “Use a second form of birth control while on this medication.” b. “You will experience increased menstrual bleeding while on this drug.” c. “You may experience an irregular heartbeat while on this drug.” d. “Watch for blood in your urine while taking this medication.”

ANS: A

The client should use a second form of birth control because antibiotic therapy reduces the effectiveness of estrogen-containing contraceptives. She should not experience increased menstrual bleeding, an irregular heartbeat, or blood in her urine while taking the drug.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Cystitis, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

15. A nurse teaches a client with functional urinary incontinence. Which statement would the

nurse include in this client’s teaching? a. “You must clean around your catheter daily with soap and water.” b. “You will need to be on your drug therapy for life.” c. “Operations to repair your bladder are available, and you can consider these.” d. “You might want to get pants with elastic waistbands.”

ANS: D

Functional urinary incontinence occurs as the result of problems not related to the client’s bladder, such as trouble ambulating or difficulty accessing the toilet. One desired outcome is that the client will be able to manage his or her clothing independently. Elastic waistband slacks that are easy to pull down and back up can help the client get on the toilet in time to void. The other instructions do not relate to functional urinary incontinence.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Urinary incontinence, Self-management MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 16. The nurse assesses a client with a history of urinary incontinence who presents with extreme

dry mouth, constipation, and an inability to void. Which question would the nurse ask first? a. “Are you drinking plenty of water?” b. “What medications are you taking?” c. “Have you tried laxatives or enemas?” d. “Has this type of thing ever happened before?”

ANS: B

Some types of incontinence or other health problems are treated with anticholinergic medications. Anticholinergic side effects include dry mouth, constipation, and urinary retention. The nurse needs to assess the client’s medication list to determine whether the he or she is taking an anticholinergic medication. The other questions are not as helpful to understanding the current situation.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Urinary incontinence, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 17. A nurse teaches a client who is starting urinary bladder training. Which statement would the

nurse include in this client’s teaching? a. “Use the toilet when you first feel the urge, rather than at specific intervals.” b. “Initially try to use the toilet at least every half hour for the first 24 hours.” c. “Try to consciously hold your urine until the scheduled toileting time.” d. “The toileting interval can be increased once you have been continent for a week.”

ANS: C

The client should try to hold urine consciously until the next scheduled toileting time.

Toileting should occur at specific intervals during the training. The interval can be increased once the client becomes comfortable with the interval.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Urinary incontinence, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance

18. A nurse assesses a client who presents with renal calculi. Which question would the nurse

ask? a. “Do any of your family members have this problem?” b. “Do you drink any cranberry juice?” c. “Do you urinate after sexual intercourse?” d. “Do you experience burning with urination?”

ANS: A

There is a strong association between family history and stone formation and recurrence.

Nephrolithiasis is associated with many genetic variations; therefore, the nurse should ask whether other family members have also had renal stones. The other questions do not refer to renal calculi but instead are questions that should be asked of a patient with a urinary tract infection.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Urolithiasis, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 19. The nurse is caring for a client with urinary incontinence. The client states, “I am so

embarrassed. My bladder leaks like a young child’s bladder.” How would the nurse respond? a. “I understand how you feel. I would be mortified.” b. “Incontinence pads will minimize leaks in public.” c. “I can teach you strategies to help control your incontinence.” d. “More people experience incontinence than you might think.”

ANS: C

The nurse would accept and acknowledge the client’s concerns, and assist the client to learn techniques that will allow control of urinary incontinence. The nurse would not diminish the client’s concerns with the use of pads or stating statistics about the occurrence of incontinence.

DIF: Applying TOP: Integrated Process: Caring KEY: Urinary incontinence, Coping MSC: Client Needs Category: Psychosocial Integrity MULTIPLE RESPONSE 1. A nurse assesses a client who has had two episodes of bacterial cystitis in the last 6 months.

Which question(s) would the nurse ask? (Select all that apply.) a. “How much water do you drink every day?” b. “Do you take estrogen replacement therapy?” c. “Does anyone in your family have a history of cystitis?” d. “Are you on steroids or other immune-suppressing drugs?” e. “Do you drink grapefruit juice or orange juice daily?”

ANS: A, B, D

Fluid intake, estrogen levels, and immune suppression all can increase the chance of recurrent cystitis. Family history is usually insignificant, and cranberry juice, not grapefruit or orange juice, has been found to increase the acidic pH and reduce the risk for bacterial cystitis.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Bacterial cystitis, Assessment

MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. The nurse is caring for a client who is diagnosed with urinary tract infection (UTI). What

common urinary signs and symptoms does the nurse expect? (Select all that apply.) a. Dysuria b. Frequency c. Burning d. Fever e. Chills f. Hematuria ANS: A, B, C, F

Fever and chills may occur in clients who have a UTI if the infection has expanded beyond the bladder into the kidneys. However, these symptoms are not urinary signs and symptoms.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: UTI, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. The nurse is planning health teaching for a client starting mirabegron for urinary incontinence.

What health teaching would the nurse include? (Select all that apply.) a. “Monitor blood tests carefully if you are prescribed warfarin.” b. “Avoid crowds and individuals with infection.” c. “Report any fever to your primary health care provider.” d. “Take your blood pressure frequently at home.” e. “Report palpitations or chest soreness that may occur.”

ANS: A, D

This drug can cause increase blood pressure and, therefore, the client’s blood pressure should be monitored. Mirabegron can increase the effect of warfarin causing bleeding or bruising.

The client will need additional coagulation studies to ensure that the INR is within a therapeutic range.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Urinary incontinence, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. A client asks the nurse why she has urinary incontinence. What risk factors would the nurse

recall in preparing to respond to the client’s question? (Select all that apply.) a. Diuretic therapy b. Anorexia nervosa c. Stroke d. Dementia e. Arthritis f. Parkinson disease ANS: A, C, D, E, F

Drugs, such as diuretics, cause frequent voiding, often in large amounts. Diseases or disorders that limit mobility, such as stroke, arthritis, and Parkinson disease, can prevent an individual from getting to the bathroom in a timely manner. Mental/behavioral problems, such as dementia, impair cognition and the ability to recognize when he or she needs to void.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Urinary incontinence, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. A nurse cares for clients with urinary incontinence. Which types of incontinence are correctly

paired with their description? (Select all that apply.) a. Stress incontinence—urine loss with physical exertion b. Urge incontinence—loss of urine upon feeling the need to void c. Functional incontinence—urine loss results from abnormal detrusor contractions d. Overflow incontinence—constant dribbling of urine e. Reflex incontinence—leakage of urine without lower urinary tract disorder ANS: A, B, D

Stress incontinence is a loss of urine with physical exertion, coughing, sneezing, or exercising.

Urge incontinence presents with an abrupt and strong urge to void and usually has a large amount of urine released with each occurrence. Overflow incontinence occurs with bladder distention and results in a constant dribbling of urine. Functional incontinence is the leakage of urine caused by factors other than a disorder of the lower urinary tract. Reflex incontinence results from abnormal detrusor contractions from a neurologic abnormality.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Urinary incontinence, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. A nurse teaches a client about self-management after experiencing a urinary calculus treated

by lithotripsy. Which statements would the nurse include in this client’s discharge teaching?

(Select all that apply.) a. “Finish the prescribed antibiotic even if you are feeling better.” b. “Drink at least 3 L of fluid each day.” c. “The bruising on your back may take several weeks to resolve.” d. “Report any blood present in your urine.” e. “It is normal to experience pain and difficulty urinating.”

ANS: A, B, C

The client should be taught to finish the prescribed antibiotic to ensure that he or she does not get a urinary tract infection. The client should drink at least 3 L of fluid daily to dilute potential stone-forming crystals, prevent dehydration, and promote urine flow. After lithotripsy, the client should expect bruising that may take several weeks to resolve. The client should also experience blood in the urine for several days. The client should report any pain, fever, chills, or difficulty with urination to the primary health care provider as these may signal the beginning of an infection or the formation of another stone.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Urolithiasis, Health teaching MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 7. After treating several young women for urinary tract infections (UTIs), the college nurse plans

an educational offering on reducing the risk of getting a UTI. What information does the nurse include? (Select all that apply.) a. Void before and after each act of intercourse. b. Consider changing to spermicide from birth control pills.

c. Do not douche or use scented feminine products. d. Wear loose-fitting nylon panties. e. Wipe or clean the perineum from front to back.

ANS: A, E

Woman can reduce their risk of contracting UTIs by voiding before and after intercourse, not douching or using scented feminine products, and wiping from front to back. If spermicides are currently used, the woman should consider another form of birth control. Loose-fitting cotton underwear is best.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Urinary incontinence, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance

Chapter 62: Concepts of Care for Patients with Kidney Disorders Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse assesses a client with polycystic kidney disease (PKD). Which assessment finding

would alert the nurse to immediately contact the primary health care provider? a. Flank pain b. Periorbital edema c. Bloody and cloudy urine d. Enlarged abdomen ANS: B

Periorbital edema would not be a finding related to PKD and would be investigated further.

Flank pain and a distended or enlarged abdomen occur in PKD because the kidneys enlarge and displace other organs. Urine can be bloody or cloudy as a result of cyst rupture or infection.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Polycystic kidney disease, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. The nurse is caring for a client who has chronic pyelonephritis. What assessment finding

would the nurse expect? a. Fever b. Flank pain c. Hypertension d. Nausea and vomiting ANS: C

The client who has chronic pyelonephritis has renal damage and therefore has hypertension.

The other assessment findings commonly occur in clients with acute pyelonephritis.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Renal disease, Chronic pyelonephritis MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. After teaching a client with early polycystic kidney disease (PKD) about nutritional therapy,

the nurse assesses the client’s understanding. Which statement made by the client indicates a correct understanding of the teaching? a. “I will take a laxative every night before going to bed.” b. “I must increase my intake of dietary fiber and fluids.” c. “I shall only use salt when I am cooking my own food.” d. “I’ll eat white bread to minimize gastrointestinal gas.”

ANS: B

Clients with PKD often have constipation, which can be managed with increased fiber, exercise, and drinking plenty of water. Laxatives would be used cautiously. Clients with PKD would be on a restricted salt diet, which includes not cooking with salt. White bread has a low-fiber count and would not be included in a high-fiber diet.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Polycystic kidney disease, Health teaching MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 4. A nurse cares for a middle-age female client with diabetes mellitus who is being treated for

the third episode of acute pyelonephritis in the past year. The client asks, “What can I do to help prevent these infections?” How would the nurse respond? a. “Test your urine daily for the presence of ketone bodies and proteins.” b. “Use tampons rather than sanitary napkins during your menstrual period.” c. “Drink more water and empty your bladder more frequently during the day.” d. “Keep your hemoglobin A1C under 9% by keeping your blood sugar controlled.”

ANS: C

Clients with long-standing diabetes mellitus are at risk for pyelonephritis for many reasons.

Chronically elevated blood glucose levels spill glucose into the urine, changing the pH, and providing a favorable climate for bacterial growth. The neuropathy associated with diabetes reduces bladder tone and reduces the client’s sensation of bladder fullness. Thus, even with large amounts of urine, the client voids less frequently, allowing stasis and overgrowth of microorganisms. Increasing fluid intake (specifically water) and voiding frequently prevent stasis and bacterial overgrowth. Testing urine and using tampons will not help prevent pyelonephritis. A hemoglobin A1C of 9% is too high.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Pyelonephritis, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 5. A nurse evaluates a client with acute glomerulonephritis (GN). Which assessment finding

would the nurse recognize as a positive response to the prescribed treatment? a. The client lost 11 lb (5 kg) in the past 10 days. b. The client’s urine specific gravity is 1.048. c. No blood is observed in the client’s urine. d. The client’s blood pressure is 152/88 mm Hg. ANS: A

Fluid retention is a major feature of acute GN. This weight loss represents fluid loss, indicating that the glomeruli are performing the function of filtration. A urine specific gravity of 1.048 is high. Blood is not usually seen in GN, so this finding would be expected. A blood pressure of 152/88 mm Hg is too high; this may indicate kidney damage or fluid overload.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Glomerulonephritis, Management MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. After teaching a client with nephrotic syndrome and a normal glomerular filtration, the nurse

assesses the client’s understanding. Which statement made by the client indicates a correct understanding of the diet therapy for this condition? a. “I must decrease my intake of fat.” b. “I will increase my intake of protein.” c. “A decreased intake of carbohydrates will be required.” d. “An increased intake of vitamin C is necessary.”

ANS: B

In nephrotic syndrome, the renal loss of protein is significant, leading to hypoalbuminemia and edema formation. If glomerular filtration is normal or near normal, increased protein loss would be matched by increased intake of protein. The client would not need to adjust fat, carbohydrates, or vitamins based on this disorder.

DIF: Applying TOP: Integrated Process: Nursing Process: Evaluation KEY: Nephrotic syndrome, Diet therapy MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 7. A nurse assesses a client who is recovering from a radical nephrectomy for renal cell

carcinoma. The nurse notes that the client’s blood pressure has decreased from 134/90 to 100/56 mm Hg and urine output is 20 mL for this past hour. What action would the nurse take? a. Position the client to lay on the surgical incision. b. Measure the specific gravity of the client’s urine. c. Administer intravenous pain medications. d. Assess the rate and quality of the client’s pulse.

ANS: D

The nurse would first fully assess the client for signs of volume depletion and shock, and then notify the primary health care provider. The extensive nature of the surgery and the proximity of the surgery to the adrenal gland put the client at risk for hemorrhage and adrenal insufficiency. Hypotension is a clinical manifestation associated with both hemorrhage and adrenal insufficiency. Hypotension is particularly dangerous for the remaining kidney, which must receive adequate perfusion to function effectively. Repositioning the patient, measuring specific gravity, and administering pain medication would not provide data necessary to make an appropriate clinical decision, nor are they appropriate interventions at this time.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Renal cancer, Perioperative nursing MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 8. The nurse is admitting a client who has acute glomerulonephritis caused by beta

streptococcus. What drug therapy would the nurse expect to be prescribed for this client? a. Antihypertensives b. Antilipidemics c. Antidepressants d. Antibiotics ANS: D

Beta streptococcus is a bacterium that can cause acute glomerulonephritis, so antibiotic therapy is indicated.

DIF: Understanding TOP: Integrated Process: Planning and Implementation KEY: Glomerulonephritis, Drug therapy MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 9. After teaching a client with hypertension secondary to renal disease, the nurse assesses the

client’s understanding. Which statement made by the client indicates a need for additional teaching? a. “I can prevent more damage to my kidneys by managing my blood pressure.”

b. “If I have increased urination at night, I need to drink less fluid during the day.” c. “I need to see the registered dietitian to discuss limiting my protein intake.” d. “It is important that I take my antihypertensive medications as directed.”

ANS: B

The client should not restrict fluids during the day due to increased urination at night. Clients with renal disease may be prescribed fluid restrictions, and would be assessed thoroughly for potential dehydration. Increased nocturnal voiding can be decreased by consuming fluids earlier in the day. Blood pressure control is needed to slow the progression of renal dysfunction. When dietary protein is restricted, refer the client to the registered dietitian nutritionist as needed.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Kidney disorders, Self-management MSC: Client Needs Category: Health Promotion and Maintenance 10. A nurse cares for a client who has pyelonephritis. The client states, “I am embarrassed to talk

about my symptoms.” How would the nurse respond? a. “I am a professional. Your symptoms will be kept in confidence.” b. “I understand. Elimination is a private topic and shouldn’t be discussed.” c. “Take your time. It is okay to use words that are familiar to you.” d. “You seem anxious. Would you like a nurse of the same gender to care for you?”

ANS: C

Clients may be uncomfortable discussing issues related to elimination and the genitourinary area. The nurse would encourage the client to use language that is familiar to the client. The nurse must assess the client and cannot take the time to stop the discussion or find another nurse to complete the assessment.

DIF: Applying TOP: Integrated Process: Caring KEY: Pyelonephritis, Psychosocial response MSC: Client Needs Category: Psychological Integrity MULTIPLE RESPONSE 1. A nurse assesses a client who has a family history of polycystic kidney disease (PKD). Which

assessment findings would the nurse expect? (Select all that apply.) a. Nocturia b. Flank pain c. Increased abdominal girth d. Dysuria e. Hematuria f. Diarrhea ANS: B, C, E

Clients with PKD experience abdominal distention that manifests as flank pain and increased abdominal girth. Bloody urine is also present with tissue damage secondary to PKD. Clients with PKD often experience constipation, but would not report nocturia or dysuria.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Polycystic kidney disease, Assessment

MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A nurse assesses a client with nephrotic syndrome. Which assessment findings would the

nurse expect? (Select all that apply.) a. Proteinuria b. Hypoalbuminemia c. Dehydration d. Lipiduria e. Dysuria f. Costovertebral angle (CVA) tenderness ANS: A, B, D

Nephrotic syndrome is caused by glomerular damage and is characterized by proteinuria (protein level higher than 3.5 g/24 hr), hypoalbuminemia, edema, and lipiduria. Fluid overload leading to edema and hypertension is common with nephrotic syndrome; dehydration does not occur. Dysuria is present with cystitis. CVA tenderness is present with inflammatory changes in the kidney.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Nephrotic syndrome, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. A nurse assesses a client who is recovering from a nephrostomy. Which assessment findings

would alert the nurse to urgently contact the primary health care provider? (Select all that apply.) a. Clear drainage b. Bloody drainage at site c. Patient reports headache d. Foul-smelling drainage e. Urine draining from site ANS: B, D, E

After a nephrostomy, the nurse would assess the client for complications and urgently notify the primary health care provider if drainage decreases or stops, drainage is cloudy or foul smelling, the nephrostomy site leaks blood or urine, or the client has back pain. Clear drainage is normal. A headache would be an unrelated finding.

DIF: Applying TOP: Integrated Process: Nursing Process: Analysis KEY: Renal surgery, Perioperative nursing MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 4. A nurse teaches a client with polycystic kidney disease (PKD). Which statements would the

nurse include in this client’s discharge teaching? (Select all that apply.) a. “Take your blood pressure every morning.” b. “Weigh yourself at the same time each day.” c. “Adjust your diet to prevent diarrhea.” d. “Contact your provider if you have visual disturbances.” e. “Assess your urine for renal stones.”

ANS: A, B, D

A client who has PKD would measure and record his or her blood pressure and weight daily, limit salt intake, and adjust dietary selections to prevent constipation. The client should notify the primary health care provider if urine smells foul or has blood in it, as these are signs of a urinary tract infection or glomerular injury. The client should also notify the provider if visual disturbances are experienced, as this is a sign of a possible berry aneurysm, which is a complication of PKD. Diarrhea and renal stones are not manifestations or complications of PKD; therefore, teaching related to these concepts would be inappropriate.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Polycystic kidney disease, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 5. The nurse is reviewing the results of a client’s urinalysis. The client has a diagnosis of acute

glomerulonephritis. Which urine findings would the nurse expect? (Select all that apply.) a. Presence of protein b. Presence of red blood cells c. Presence of white blood cells d. Acidic urine e. Dilute urine ANS: A, C, D

The nurse would expect all of these findings except that the urine is usually concentrated with a high specific gravity.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Glomerulonephritis, Diagnostic tests MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. The nurse is assessing a client with acute pyelonephritis. What assessment findings would the

nurse expect? (Select all that apply.) a. Fever b. Chills c. Tachycardia d. Tachypnea e. Flank or back pain f. Fatigue ANS: A, B, C, D, E, F

All of these assessment findings commonly occur in clients who have acute pyelonephritis because this health problem is a kidney infection.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Acute pyelonephritis, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

Chapter 63: Concepts of Care for Patients with Acute Kidney Injury and Chronic Kidney Disease Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. The nurse is assessing a client with a diagnosis of prerenal acute kidney injury (AKI). Which

condition would the nurse expect to find in the patient’s recent history? a. Pyelonephritis b. Dehydration c. Bladder cancer d. Kidney stones ANS: B

Prerenal causes of AKI are related to a decrease in perfusion, such as in clients who have prolonged dehydration. Pyelonephritis is an intrinsic or intrarenal cause of AKI related to kidney damage. Bladder cancer and kidney stones are postrenal causes of AKI related to urine flow obstruction.

DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Acute kidney injury, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A marathon runner comes into the clinic and states “I have not urinated very much in the last

few days.” The nurse notes a heart rate of 110 beats/min and a blood pressure of 86/58 mm Hg. Which action by the nurse is most appropriate? a. Give the client a bottle of water immediately. b. Start an intravenous line for fluids. c. Teach the patient to drink 2 to 3 L of water daily. d. Perform an electrocardiogram.

ANS: A

This athlete is mildly dehydrated as evidenced by the higher heart rate and lower blood pressure. The nurse can start hydrating the client with a bottle of water first, followed by teaching the patient to drink 2 to 3 L of water each day. An intravenous line may be needed later, after the patient’s degree of dehydration is assessed. An electrocardiogram is not necessary at this time.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Renal system, Dehydration MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 3. A client comes into the emergency department with a serum creatinine of 2.2 mg/dL (1944

mcmol/L) and a blood urea nitrogen (BUN) of 24 mL/dL (8.57 mmol/L). What question would the nurse ask first when taking this client’s history? a. “Have you been taking any aspirin, ibuprofen, or naproxen recently?” b. “Do you have anyone in your family with renal failure?” c. “Have you had a diet that is low in protein recently?” d. “Has a relative had a kidney transplant lately?”

ANS: A

There are some medications that are nephrotoxic, such as the nonsteroidal anti-inflammatory drugs ibuprofen, aspirin, and naproxen. This would be a good question to initially ask the patient since both the serum creatinine and BUN are elevated, indicating some renal problems.

A diet high in protein could be a factor in an increased BUN. DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Renal system, Assessment MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 4. A client is admitted with acute kidney injury (AKI) and a urine output of 2000 mL/day. What

is the major concern of the nurse regarding this patient’s care? a. Edema and pain b. Cardiac and respiratory status c. Electrolyte and fluid imbalance d. Mental health status ANS: C

This client may have an inflammatory cause of AKI with proteins entering the glomerulus and holding the fluid in the filtrate, causing polyuria. Electrolyte loss and fluid balance are essential. Edema and pain are not usually a problem with fluid loss. There could be changes in the client’s cardiac, respiratory, and mental health status if the electrolyte imbalance is not treated.

DIF: Applying TOP: Integrated Process: Nursing Process: Analysis KEY: Acute kidney injury, Analysis MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. A client with acute kidney injury (AKI) has a blood pressure of 76/55 mm Hg. The primary

health care provider prescribed 1000 mL of normal saline to be infused over 1 hour to maintain perfusion. The client starts to develop shortness of breath. What is the nurse’s priority action? a. Calculate the mean arterial pressure (MAP). b. Ask for insertion of a pulmonary artery catheter. c. Take the client’s pulse. d. Decrease the rate of the IV infusion.

ANS: D

The nurse would assess that the client could be developing fluid overload and respiratory distress and slow down the normal saline infusion. The calculation of the MAP also reflects perfusion. The insertion of a pulmonary artery catheter would evaluate the client’s hemodynamic status, but this would not be the initial or priority action by the nurse. Vital signs are also important after adjusting the intravenous infusion.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Acute kidney injury, Nursing intervention MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 6. A client has a serum potassium level of 6.5 mEq/L (6.5 mmol/L), a serum creatinine level of 2

mg/dL (176 mcmol/L), and a urine output of 350 mL/day. What is the best action by the nurse?

a. b. c. d.

Place the client on a cardiac monitor immediately.

Teach the client to limit high-potassium foods.

Continue to monitor the client’s intake and output.

Ask to have the laboratory redraw the blood specimen.

ANS: A

The best action by the nurse would be to check the cardiac status with a monitor.

High-potassium levels can lead to dysrhythmias. The other choices are logical nursing interventions for acute kidney injury but not the best immediate action.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Renal system, Nursing intervention MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 7. A client with diabetes mellitus type 2 has been well controlled with metformin. The client is

scheduled for magnetic resonance imaging (MRI) scan with contrast. What priority would the nurse take at this time? a. Teach the client about the purpose of the MRI. b. Assess the client’s blood urea nitrogen and creatinine. c. Tell the client to withhold metformin for 24 hours before the MRI. d. Ask the client if he or she is taking antibiotics.

ANS: C

Contrast media can be nephrotoxic (damaging to the kidneys). Metformin can also be nephrotoxic and the client should not be exposed to two agents. Clients who have diabetes are already at risk for renal damage.

DIF: Understanding TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Renal system, Risk factors MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 8. A client is started on continuous venovenous hemofiltration (CVVH). Which finding would

require immediate action by the nurse? a. Potassium level of 5.5 mEq/L (5.5 mmol/L) b. Sodium level of 138 mEq/L (138 mmol/L) c. Blood pressure of 76/58 mm Hg d. Pulse rate of 88 beats/min ANS: C

Hypotension can be a problem with CVVH if replacement fluid does not provide enough volume to maintain blood pressure. The nurse needs to monitor for ongoing fluid and electrolyte replacement. The sodium level is normal and the potassium level is slightly elevated, which could be normal findings for someone with acute kidney injury. A pulse rate of 88 beats/min is within usual limits.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Renal system, Dialysis, Nursing intervention MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 9. The nurse is caring for four clients with chronic kidney disease (CKD). Which client would

the nurse assess first upon initial rounding?

a. b. c. d.

Client with a blood pressure of 158/90 mm Hg Client with Kussmaul respirations Client with skin itching from head to toe Client with halitosis and stomatitis

ANS: B

Kussmaul respirations indicate that the client has metabolic acidosis which is a complication of CKD. The client is increasing the rate and depth of breathing to excrete carbon dioxide through the lungs to lower serum pH. Hypertension is common in most patients with CKD, and skin itching increases with calcium–phosphate imbalances and elevations of nitrogenous wastes, another common finding in CKD. Uremia from CKD causes ammonia to be formed, resulting in the common findings of halitosis and stomatitis.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Analysis KEY: Chronic kidney disease, Assessment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 10. The nurse is teaching assistive personnel (AP) about fluid restriction for a client who has

acute kidney injury (AKI). The client’s 24-hour urinary output is 120 mL. How much fluid would the client be allowed to have over the next 24 hours? a. 380 mL b. 500 mL c. 620 mL d. 750 mL ANS: C

The general principle for fluid restriction for clients is that they may have a daily fluid intake of 500 mL plus the amount of their urinary output. In this case, 120 mL urinary output plus 500 mL equals 620 mL fluid allowance.

DIF: Understanding TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Acute kidney injury, Nursing intervention MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 11. A client with chronic kidney disease (CKD) is refusing to take his medication and has missed

two hemodialysis appointments. What is the best initial action for the nurse? a. Discuss what the treatment regimen means to the client. b. Refer the client to a mental health nurse practitioner. c. Reschedule the appointments to another date and time. d. Discuss the option of peritoneal dialysis.

ANS: A

The initial action for the nurse is to assess anxiety, coping styles, and the client’s acceptance of the required treatment for CKD. The client may be in denial of the diagnosis. While rescheduling hemodialysis appointments may help, and referral to a mental health practitioner and the possibility of peritoneal dialysis are all viable options, assessment of the client’s acceptance of the treatment would come first.

DIF: Applying TOP: Integrated Process: Caring KEY: Chronic kidney disease, Coping MSC: Client Needs Category: Psychosocial Integrity

12. A client is taking furosemide 40 mg/day for management of early chronic kidney disease

(CKD). To assess the therapeutic effect of the medication, what action of the nurse is best? a. Obtain daily weights of the client. b. Auscultate heart and breath sounds. c. Palpate the client’s abdomen. d. Assess the client’s diet history.

ANS: A

Furosemide is a loop diuretic that helps reduce fluid overload and hypertension in patients with early stages of CKD. One kilogram of weight equals about 1 L of fluid retained in the client, so daily weights are necessary to monitor the response of the client to the medication.

Heart and breath sounds would be assessed if there is fluid retention, as in heart failure.

Palpation of the client’s abdomen is not necessary, but the nurse would check for edema. The diet history of the client would be helpful to assess electrolyte replacement since potassium is lost with this diuretic, but this does not assess the effectiveness of the medication.

DIF: Applying TOP: Integrated Process: Nursing Process: Evaluation KEY: Chronic kidney disease, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 13. A 70-kg adult client with chronic kidney disease (CKD) is on a 40-g protein diet. The patient

has a reduced glomerular filtration rate and is not undergoing dialysis. Which result would be of most concern to the nurse? a. Albumin level of 2.5 g/dL (3.63 mcmol/L) b. Phosphorus level of 5 mg/dL (1.62 mmol/L) c. Sodium level of 135 mEq/L (135 mmol/L) d. Potassium level of 5.5 mEq/L (5.5 mmol/L) ANS: A

Protein restriction is necessary with CKD due to the buildup of waste products from protein breakdown. The nurse would be concerned with the low albumin level since this indicates that the protein in the diet is not enough for the client’s metabolic needs. The electrolyte values are not related to the protein-restricted diet.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Analysis KEY: Chronic kidney disease, Diet therapy MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 14. The nurse is teaching a client with chronic kidney disease (CKD) about the sodium restriction

needed in the diet to prevent edema and hypertension. Which statement by the client indicates that more teaching is needed? a. “I will probably lose weight by cutting out potato chips.” b. “I will cut out bacon with my eggs every morning.” c. “My cooking style will change by not adding salt.” d. “I am thrilled that I can continue to eat fast food.”

ANS: D

Fast-food restaurants usually serve food that is high in sodium. This statement indicates that more teaching needs to occur. The other statements show a correct understanding of the teaching.

DIF: Remembering

TOP: Integrated Process: Teaching/Learning

KEY: Chronic kidney disease, Renal diet MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 15. A client is placed on fluid restriction because of chronic kidney disease (CKD). Which

assessment finding would alert the nurse that the client’s fluid balance is stable at this time? a. Decreased calcium levels b. Increased phosphorus levels c. No adventitious sounds in the lungs d. Increased edema in the legs ANS: C

The absence of adventitious sounds upon auscultation of the lungs indicates a lack of fluid overload and fluid balance in the client’s body. Decreased calcium levels and increased phosphorus levels are common findings with CKD. Edema would indicate a fluid imbalance.

DIF: Applying TOP: Integrated Process: Nursing Process: Analysis KEY: Chronic kidney disease, Analysis MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 16. The charge nurse is orienting a new nurse about care for an assigned client with an

arteriovenous (AV) fistula for hemodialysis in her left arm. Which action by the float nurse would be considered unsafe? a. Palpating the access site for a bruit or thrill b. Using the right arm for a blood pressure reading c. Administering intravenous fluids through the AV fistula d. Checking distal pulses in the left arm ANS: C

The nurse would not use the arm with the AV fistula for intravenous infusion, blood pressure readings, or venipuncture. Compression and infection can result in the loss of the AV fistula.

The AV fistula would be monitored by auscultating or palpating the access site. Checking the distal pulse would be an appropriate assessment.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Chronic kidney disease, Safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 17. A client is having a peritoneal dialysis treatment. The nurse notes an opaque color to the

effluent. What is the priority action by the nurse? a. Warm the dialysate solution in a microwave before instillation. b. Obtain a sample of the effluent and send to the laboratory. c. Flush the tubing with normal saline to maintain patency of the catheter. d. Check the peritoneal catheter for kinking and curling.

ANS: B

An opaque or cloudy effluent is the first sign of peritonitis. A sample of the effluent would need to be sent to the laboratory for culture and sensitivity in order to administer the correct antibiotic. Warming the dialysate in a microwave and flushing the tubing are not safe actions by the nurse. Checking the catheter for obstruction is a viable option but will not treat the peritonitis.

DIF: Applying

TOP: Integrated Process: Nursing Process: Planning and Implementation

KEY: Chronic kidney disease, Safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 18. The nurse is teaching a client how to increase the flow of dialysate into the peritoneal cavity

during dialysis. Which statement by the client demonstrates a correct understanding of the teaching? a. “I should leave the drainage bag above the level of my abdomen.” b. “I could flush the tubing with normal saline if the flow stops.” c. “I should take a stool softener every morning to avoid constipation.” d. “My diet should have low fiber in it to prevent any irritation.”

ANS: C

Inflow and outflow problems of the dialysate are best controlled by preventing constipation. A daily stool softener is the best option for the client. The drainage bag should be below the level of the abdomen. Flushing the tubing will not help with the flow. A diet high in fiber will also help with a constipation problem.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Chronic kidney disease, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 19. A nurse reviews the laboratory values of a client who returned from kidney transplantation 12

hours ago: Sodium 136 mEq/L (135 mmol/L) Potassium 5 mEq/L (5 mmol/L) Blood urea nitrogen (BUN) 44 mg/dL (15.7 mmol/L) Serum creatinine 2.5 mg/dL (221 mcmol/L) What initial intervention would the nurse anticipate? a. Start hemodialysis immediately. b. Discuss the need for peritoneal dialysis. c. Increase the dose of immunosuppression. d. Return the client to surgery for exploration.

ANS: C

The client may need a higher dose of immunosuppressive medication as evidenced by the elevated BUN and serum creatinine levels. This increased dose may reverse the possible acute rejection of the transplanted kidney. The client does not need hemodialysis, peritoneal dialysis, or further surgery at this point.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Analysis KEY: Renal transplantation, Analysis MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 20. The nurse administers epoetin alfa to a client who has chronic kidney disease (CKD). Which

laboratory test value would the nurse monitor to determine this drug’s effectiveness? a. Potassium b. Sodium c. Renin d. Hemoglobin ANS: D

The purpose of giving epoetin alfa to a client with CKD is to manage anemia by stimulating the bone marrow to produce more red blood cells. Therefore, monitoring the client’s hemoglobin, hematocrit, and red blood cell count would indicate if the drug was effective.

DIF: Remembering TOP: Integrated Process: Nursing Process: Evaluation KEY: Chronic kidney disease, Drug therapy MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 21. A client with chronic kidney disease (CKD) has an elevated serum phosphorus level. What

drug would the nurse anticipate to be prescribed for this client? a. Calcium acetate b. Doxycyline c. Magnesium sulfate d. Lisinopril ANS: A

The client with CKD often has a high phosphorus level which tends to lower the calcium level in an inverse relationship, and causes osteodystrophy. To prevent this bone disease, the client needs to take a drug that can bind with phosphorus for elimination via the GI tract. When phosphorus is lowered to within normal limits, normal calcium levels may be restored.

DIF: Remembering TOP: Integrated Process: Nursing Process: Analysis KEY: Chronic kidney disease, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies MULTIPLE RESPONSE 1. The nurse is caring for five clients on the medical-surgical unit. Which clients would the nurse

consider to be at risk for postrenal acute kidney injury (AKI)? (Select all that apply.) a. Client with prostate cancer b. Client with blood clots in the urinary tract c. Client with ureterolithiasis d. Client with severe burns e. Client with lupus ANS: A, B, C

Urine flow obstruction, such as prostate cancer, blood clots in the urinary tract, and kidney stones (ureterolithiasis), causes postrenal AKI. Severe burns would be a prerenal cause. Lupus would be an intrarenal cause for AKI. DIF: Understanding TOP: Integrated Process: Nursing Process: Analysis KEY: Renal system, Risk factors MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A nurse is caring for a postoperative 70-kg client who had major blood loss during surgery.

Which findings by the nurse would prompt immediate action to prevent acute kidney injury?

(Select all that apply.) a. Urine output of 100 mL in 4 hours b. Urine output of 500 mL in 12 hours c. Large amount of sediment in the urine d. Amber, odorless urine

e. Blood pressure of 90/60 mm Hg ANS: A, C, E

The low urine output, sediment, and blood pressure would be reported to the primary health care provider. Postoperatively, the nurse would measure intake and output, check the characteristics of the urine, and report sediment, hematuria, and urine output of less than 0.5 mL/kg/hr for 3 to 4 hours. A urine output of 100 mL is low, but a urine output of 500 mL in 12 hours would be within normal limits. Perfusion to the kidneys is compromised with low blood pressure. The amber odorless urine is normal.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Renal system, Assessment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 3. A client is hospitalized in the oliguric phase of acute kidney injury (AKI) and is receiving

tube feedings. The nurse is teaching the client’s spouse about the renal-specific formulation for the enteral solution compared to standard formulas. What components would be discussed in the teaching plan? (Select all that apply.) a. Lower sodium b. Higher calcium c. Lower potassium d. Higher phosphorus e. Higher calories ANS: A, C, E

Many clients with AKI are too ill to meet caloric goals and require tube feedings with renal-specific formulas that are lower in sodium, potassium, and phosphorus, and higher in calories than are standard formulas.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Chronic kidney disease, Diet therapy MSC: Client Needs Category: Health Promotion and Maintenance 4. The nurse is caring for a client with a new diagnosis of chronic kidney disease. Which priority

complications would the nurse anticipate? (Select all that apply.) a. Dehydration b. Anemia c. Hypertension d. Dysrhythmias e. Heart failure ANS: B, C, D, E

The client who has CKD has fluid overload and electrolyte imbalances, especially hyperkalemia, that can cause hypertension, heart failure, and dysrhythmias. Anemia results because erythropoietin production by the kidneys is decreased.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Chronic kidney disease, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

5. A nurse is giving discharge instructions to a client recently diagnosed with chronic kidney

disease (CKD). Which statements made by the client indicate a correct understanding of the teaching? (Select all that apply.) a. “I can continue to take antacids to relieve heartburn.” b. “I need to ask for an antibiotic when scheduling a dental appointment.” c. “I’ll need to check my blood sugar often to prevent hypoglycemia.” d. “The dose of my pain medication may have to be adjusted.” e. “I should watch for bleeding when taking my anticoagulants.”

ANS: B, C, D, E

In discharge teaching, the nurse must emphasize that the client needs to have an antibiotic prophylactically before dental procedures to prevent infection. There may be a need for dose reduction in medications if the kidney is not excreting them properly (antacids with magnesium, antibiotics, antidiabetic drugs, insulin, opioids, and anticoagulants).

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Chronic kidney disease, Drug therapy MSC: Client Needs Category: Health Promotion and Maintenance 6. A client is undergoing hemodialysis. The client’s blood pressure at the beginning of the

procedure was 136/88 mm Hg, and now it is 110/54 mm Hg. What actions would the nurse perform to maintain blood pressure? (Select all that apply.) a. Adjust the rate of extracorporeal blood flow. b. Place the patient in the Trendelenburg position. c. Stop the hemodialysis treatment. d. Administer a 250-mL bolus of normal saline. e. Contact the primary health care provider.

ANS: A, B, D

Hypotension occurs often during hemodialysis treatments as a result of vasodilation from the warmed dialysate. Modest decreases in blood pressure, as is the case with this client, can be maintained with rate adjustment, Trendelenburg positioning, and a fluid bolus. If the blood pressure drops considerably after two boluses and cooling dialysate, the hemodialysis can be stopped and the primary health care provider contacted.

DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Hemodialysis, Safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 7. A client is unsure of the decision to undergo peritoneal dialysis (PD) and wishes to discuss the

advantages of this treatment with the nurse. Which statements by the nurse are correct regarding PD? (Select all that apply.) a. “You will not need vascular access to perform PD.” b. “There is less restriction of protein and fluids.” c. “You will have no risk for infection with PD.” d. “You have flexible scheduling for the exchanges.” e. “It takes less time than hemodialysis treatments.”

ANS: A, B, D

PD is based on exchanges of waste, fluid, and electrolytes in the peritoneal cavity. There is no need for vascular access. Protein is lost in the exchange, which allows for more protein and fluid in the diet. There is flexibility in the time for exchanges, but the treatment takes a longer period of time compared to hemodialysis. There still is risk for infection with PD, especially peritonitis.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Dialysis, Health teaching MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort

Chapter 64: Assessment of the Reproductive System Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. The nurse is developing a teaching plan for a client who is scheduled for her first

Papanicolaou test. What instruction by the nurse is the most accurate? a. “The timing of the Pap smear does not matter.” b. “Sexual intercourse will not interfere with the results.” c. “Results can be interpreted immediately in the office.” d. “Results are best if you do not douche 24 hours before the test.”

ANS: D

In order to prevent false interpretation, the client must not douche, use vaginal medications or deodorants, or have sexual intercourse for at least 24 hours before the Pap smear. Timing is important, with the test scheduled between the client’s menstrual periods so that the menstrual flow does not interfere with laboratory analysis. The specimens are placed on a glass slide and sent to the laboratory for examination and cannot be interpreted immediately.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Reproductive assessment, Cancer screening MSC: Client Needs Category: Health Promotion and Maintenance 2. The nurse is assessing the reproductive history of a 68-year-old postmenopausal woman.

Which finding is cause for immediate action by the nurse? a. Vaginal dryness b. No Papanicolaou test for 3 years c. Bleeding from the vagina d. Leakage of urine ANS: C

Vaginal bleeding is not normal for the postmenopausal woman. Vaginal dryness and leakage of urine are common findings in adults of this age range. Pap tests may not be needed for women over 65 who have had regular cervical cancer testing with normal results.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Reproductive assessment, Older adult MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. The nurse is reviewing discharge instructions with a client who has just experienced an

endometrial biopsy. Which finding would be reported to the primary health care provider immediately? a. Mild cramping b. Slight chills and fever c. Spotting of blood d. Fatigue after anesthesia ANS: B

Chills and fever could indicate an infection and would be reported immediately to the primary health care provider . Mild cramping, spotting, and fatigue are normal findings after an endometrial biopsy; however, anesthesia may or may not be used.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Reproductive assessment, Diagnostic testing MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 4. A client is concerned about her irregular menstrual periods since she has increased her daily

workouts at the gym to 2 hours each day. What is the nurses’ best response? a. “Do you want to talk about the need for that much exercise?” b. “Exercise is healthy but can decrease body fat and cause irregular periods.” c. “Bingeing and purging can cause electrolyte problems in your body.” d. “Anorexic behavior can result in decreased estrogen levels.”

ANS: B

There needs to be a certain level of body fat and weight to maintain regular menstrual cycles.

The client has only indicated that she has increased her workouts. There is no indication that she has anorexic or bingeing and purging behaviors. The question about wanting to talk about needing that much exercise sounds judgmental.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Reproductive assessment MSC: Client Needs Category: Health Promotion and Maintenance 5. A client is having a hysterosalpingogram. What action by the nurse is most important? a. Assist the client in sitting up after the procedure. b. Provide the client with a pad to avoid dye stains on the clothes. c. Teach her to take all antibiotics prescribed until finished. d. Inform the client that the procedure may cause shoulder pain.

ANS: A

During the procedure, the client may experience light-headedness, so the nurse would assist her with sitting up afterwards for safety. The nurse does provide a pad to prevent any staining from the dye and does inform the client of the possibility of shoulder pain, but an action to prevent injury is more important. Antibiotics are not prescribed afterward.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Reproductive assessment, Client safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 6. The mother of an 18-year-old girl asks the nurse which screening her daughter would receive

now based on evidence-based recommendations. Which suggestion by the nurse is best? a. Papanicolaou test b. Human papilloma virus (HPV) test c. Mammogram d. No screenings at this time ANS: D

Since the daughter is only 18, it is not recommended that she receive any of these screenings.

Pap screenings are recommended to start at age 21. The HPV test is not recommended for screening but can be used for women who had an abnormal Pap test result. A mammogram is recommended for women aged 40 or older since cancers are more able to be distinguished from normal glandular tissue at that age.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Reproductive issues, Screening MSC: Client Needs Category: Health Promotion and Maintenance 7. A client is scheduled for a laparoscopy to remove endometriosis tissue. Which response by the

client alerts the nurse of the need for further teaching? a. “The surgeon told me that carbon dioxide would be infused into my pelvic cavity.” b. “There will be one or more small incisions in order to visualize all of the organs.” c. “There will be some shoulder pain after the procedure that may last 48 hours.” d. “I can return to jogging my 3-mile (5 km) routine in a few days.”

ANS: D

The client is taught that she should not participate in strenuous activity for a week after the procedure. Carbon dioxide is infused into the pelvic cavity to visualize the organs. There are only one or more small incisions with this procedure. The referred shoulder pain that will occur only lasts 48 hours.

DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Reproductive assessment, Health teaching MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 8. A 67-year-old male client had serum laboratory tests performed during his annual

examination. The nurse reviews his results, as follows: testosterone: 680 ng/dL (23.6 nmol/L); prostate-specific antigen: 10 ng/mL (10 mcg/L); prolactin: 5 ng/mL (217.4 pmol). What action by the nurse is best? a. Assess for possible galactorrhea with breast discharge. b. Note the possibility of a testicular tumor. c. Communicate that results were normal. d. Prepare the client for further diagnostic testing.

ANS: D

The prostate-specific antigen is increased from the normal of 0 to 2.5, which could indicate benign prostatic hyperplasia or prostate cancer. Further testing would have to be done. The other values are within the normal range for males.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Reproductive assessment, Prostate cancer MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 9. A 72-year-old woman is being assessed by the nurse for an annual physical. Which finding is

of concern to the nurse? a. Thinning of pubic hair b. Increased size of the uterus c. Decreased size of the clitoris d. Loss of tone of the pelvic ligaments

ANS: B

An increased size of the uterus is an abnormal finding and would be assessed further. Normal changes in the reproductive system related to aging include the graying and thinning of pubic hair, decreased size of the labia majora and clitoris, and loss of tone and elasticity of the pelvic ligaments and connective tissue. The uterus would normally be decreased, not increased, in size due to changes in hormonal levels and atrophy.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Reproductive assessment, Older adult MSC: Client Needs Category: Health Promotion and Maintenance MULTIPLE RESPONSE 1. The nurse is assessing a client for reproductive health problems. What assessments are most

important? (Select all that apply.) a. Bleeding b. Pain c. Sexual orientation d. Masses e. Discharge ANS: A, B, D, E

Bleeding, pain, masses, and discharge are common health problems that bring a client to a primary health care provider. Sexual orientation is not considered a health problem. Sexual activity would be assessed as part of the client’s history.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Reproductive assessment, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. The nurse is reviewing discharge plans with a client who is recovering from a cervical biopsy.

Which statements indicate good understanding by the client? (Select all that apply.) a. “I can return to work this afternoon.” b. “I cannot carry my toddler for 2 weeks.” c. “I cannot douche until the biopsy site is healed.” d. “I need to wait for about 2 weeks to have intercourse.” e. “I can use a regular tampon this evening for bleeding.” f. “I cannot wash my perineum for 24 hours.”

ANS: B, C, D

The client would not douche, have intercourse, or use tampons until the biopsy site is healed.

The client would rest for 24 hours after the procedure and would not lift heavy objects. The client would be taught to keep the perineum clean and dry by using antiseptic rinses and changes pads frequently.

DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Reproductive assessment, Diagnostic testing MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

Chapter 65: Concepts of Care for Patients with Breast Disorders Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. The nurse is teaching a 45-year-old woman about her fibrocystic breast changes. Which

statement by the client indicates a lack of understanding? a. “This condition will become malignant over time.” b. “I understand that hormone-based drugs have serious adverse effects.” c. “One cup of coffee in the morning should be enough for me.” d. “This condition makes it more difficult to examine my breasts.”

ANS: A

Fibrocystic breast changes do not increase a woman’s chance of developing breast cancer.

Hormone-based drugs can be used in severe cases to suppress the over-secretion of estrogen.

Serious adverse effects include thrombotic events and an increased risk for uterine cancer.

Limiting caffeine intake may give relief for tender breasts. The fibrocystic changes to the breasts make it more difficult to examine the breasts because of fibrotic changes and lumps.

DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Breast disorders, Fibrocystic changes MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. The nurse is examining a woman’s breast and notes multiple small mobile lumps. Which

question would be most appropriate for the nurse to ask? a. “When was your last mammogram at the clinic?” b. “How many cans of caffeinated soda do you drink in a day?” c. “Do the small lumps seem to change with your menstrual period?” d. “Do you have a first-degree relative who has breast cancer?”

ANS: C

The most appropriate question would be one that relates to benign lesions that usually change in response to hormonal changes within a menstrual cycle. Reduction of caffeine in the diet has been shown to give relief in fibrocystic breast changes, but research has not found that it has a significant impact. Questions related to the client’s last mammogram or breast cancer history are not related to the nurse’s assessment.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Breast disorders, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. The nurse is working with a male client who has gynecomastia. What action by the nurse is

most appropriate? a. Teach the client to perform self-breast examination. b. Review the plan for chemotherapy after surgery. c. Educate him on the side effects of tamoxifen. d. Assess his usual daily alcohol intake.

ANS: C

Gynecomastia is enlarged breast tissue in men. It is from an enlarged ridge of glandular breast tissue and is benign. The client does not need to perform SBE nor will he undergo chemotherapy. Tamoxifen is one drug used to treat the condition, so the nurse would educate the client on the medication. Alcohol is not related.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Breast disorders, Gynecomastia MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. Which finding in a female client by the nurse would receive the highest priority for further

diagnostics? a. Tender moveable masses throughout the breast tissue b. Nipple discharge without a palpable mass c. Nontender fixed mass in the upper outer quadrant of the breast d. Small, painful mass under warm reddened skin and nipple discharge ANS: C

Malignant lesions are fixed, hard and irregularly shaped and this lesion would be the priority for further diagnostic study. The other lesions are benign breast disorders. The client with nipple discharge but no palpable mass most likely has intraductal papilloma. The client who has nipple discharge but also has a mass under warm, red, edematous skin most likely has ductal ectasia.

DIF: Applying TOP: Integrated Process: Nursing Process: Analysis KEY: Breast cancer, Nursing assessment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 5. A nurse has taught a female client about the modifiable risk factors for breast cancer. Which

statement made by the client indicates that more teaching is needed? a. “I am fortunate that I breast-fed each of my three children for 12 months.” b. “It looks as though I need to start working out at the gym more often.” c. “I am glad that we can still have wine with every evening meal.” d. “When I have menopausal symptoms, I must avoid hormone replacement therapy.”

ANS: C

Modifiable risk factors can help prevent breast cancer. The client should lessen alcohol intake and not have wine 7 days a week. Breast-feeding, regular exercise, maintaining a normal weight, and avoiding hormone replacement are also strategies for breast cancer prevention.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Breast cancer, Risk factors MSC: Client Needs Category: Health Promotion and Maintenance 6. A younger woman from an unfamiliar culture is at high risk for breast cancer and is

considering a prophylactic mastectomy and oophorectomy. What action by the nurse is most appropriate? a. Discourage this surgery since the woman is still of childbearing age. b. Reassure the client that reconstructive surgery is as easy as breast augmentation. c. Inform the client that this surgery removes all mammary tissue and cancer risk. d. Offer to include support people, such as the male partner, in the decision making.

ANS: D

The cultural aspects of decision making need to be considered. In some cultures, the man often makes the decisions for care of the female. The woman may want to make the decision with other support people or by herself. The nurse must maintain sensitivity to cultural, religious, and personal beliefs when it comes to this personal decision. Women with a high risk for breast cancer can consider prophylactic surgery. If reconstructive surgery is considered, the procedure is more complex and will have more complications compared to a breast augmentation. There is a small risk that breast cancer can still develop in the remaining mammary tissue.

DIF: Applying TOP: Integrated Process: Caring MSC: Client Needs Category: Psychosocial Integrity

KEY: Breast cancer, Culture

7. A client has just returned from a right radical mastectomy. Which action by the assistive

personnel (AP) would require the nurse consider to intervene? a. Checking the amount of urine in the catheter collection bag b. Elevating the right arm on a pillow c. Taking the blood pressure on the right arm d. Encouraging the client to squeeze a rolled washcloth ANS: C

Health care professionals need to avoid the arm on the side of the surgery for blood pressure measurement, injections, or blood draws. Since lymph nodes are removed, lymph drainage would be compromised. The pressure from the blood pressure cuff could promote swelling.

Infection could occur with injections and blood draws. Checking urine output, elevation of the affected arm on a pillow, and encouraging beginning exercises are all safe postoperative interventions.

DIF: Applying TOP: Integrated Process: Nursing Process: Analysis KEY: Breast cancer, Postoperative care MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 8. A client is discharged to home after a modified radical mastectomy with two drainage tubes.

Which statement by the client would indicate that further teaching is needed? a. “I am glad that these tubes will fall out at home when I finally shower.” b. “I should measure the drainage each day to make sure it is less than an ounce (30 mL).” c. “I should be careful how I lie in bed so that I will not kink the tubing.” d. “If there is a foul odor from the drainage, I will contact my primary health care provider.”

ANS: A

The drainage tubes (such as a Jackson–Pratt drain) lie just under the skin but need to be removed by the health care professional in about 1 to 3 weeks at an office visit. Drainage should be less than 30 mL for three consecutive days. The client should be aware of her positioning to prevent kinking of the tubing. A foul odor from the drainage may indicate an infection; the primary health care would be contacted immediately.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Breast cancer, Health teaching MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

9. During dressing changes, the nurse assesses a client who had breast reconstruction. Which

finding would cause the nurse to take immediate action? a. Slightly reddened incisional area b. Blood pressure of 128/75 mm Hg c. Temperature of 99° F (37.2° C) d. Dusky color of the breast flap ANS: D

A dusky color of the breast flap could indicate poor tissue perfusion. The nurse would notify the primary health care provider to preserve the tissue. It is normal to have a slightly reddened incision as the skin heals. The blood pressure is within normal limits and the temperature is slightly elevated but would be monitored.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Breast cancer, Postoperative care MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 10. A client is starting hormonal therapy with tamoxifen to lower the risk for breast cancer. What

information needs to be explained by the nurse regarding the action of this drug? a. It blocks the release of luteinizing hormone. b. It interferes with cancer cell division. c. It selectively blocks estrogen in the breast. d. It inhibits DNA synthesis in rapidly dividing cells.

ANS: C

Tamoxifen reduces the estrogen available to breast tumors to stop or prevent growth. This drug does not block the release of luteinizing hormone to prevent the ovaries from producing estrogen; leuprolide does this. Chemotherapy agents interfere with cancer cell division. Newer research supports treatment with tamoxifen for 10 years to prevent recurrence.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Breast cancer, Medications MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 11. A client is placed on a medical regimen of doxorubicin (Adriamycin), cyclophosphamide, and

fluorouracil for breast cancer. Which side effect seen in the client would the nurse report to the primary health care provider immediately? a. Shortness of breath b. Nausea and vomiting c. Hair loss d. Mucositis ANS: A

Doxorubicin can cause cardiotoxicity with symptoms of extreme fatigue, shortness of breath, chronic cough, and edema. These need to be reported as soon as possible to the primary health care provider. Nausea, vomiting, hair loss, and mucositis are common problems associated with chemotherapy regimens.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Breast cancer, Chemotherapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

12. A client is concerned about the risk of lymphedema after a mastectomy. Which response by

the nurse is best? a. “You do not need to worry about lymphedema since you did not have radiation therapy.” b. “Be careful not to injure that arm or get any infection in that arm.” c. “Numbness, tingling, and swelling are common sensations after a mastectomy.” d. “The risk for lymphedema is a real threat and can be very self-limiting.”

ANS: B

Injury and infection are risk factors for lymphedema; therefore, the client needs to be cautious with activities using the affected arm. Radiation therapy is just one of the factors that could cause lymphedema. Other risk factors include obesity and presence of axillary disease. The symptoms of lymphedema are heaviness, aching, fatigue, numbness, tingling, and swelling, and are not common after the surgery. Women with lymphedema live fulfilling lives.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Breast cancer, Postoperative nursing MSC: Client Needs Category: Health Promotion and Maintenance 13. A woman diagnosed with breast cancer had these laboratory tests performed at an office visit:

Alkaline phosphatase 125 U/L (2.2 mckat/L) Total calcium 12 mg/dL (3 mmol/L) Hematocrit 39% (0.39) Hemoglobin 14 g/dL (140 mmol/L) Which test results indicate to the nurse that some further diagnostics are needed? a. Elevated alkaline phosphatase and calcium suggests bone involvement. b. Only alkaline phosphatase is decreased, suggesting liver metastasis. c. Hematocrit and hemoglobin are decreased, indicating anemia. d. The elevated hematocrit and hemoglobin indicate dehydration.

ANS: A

The alkaline phosphatase (normal value 30 to 120 U/L [0.5 to 2.0 mckat/L]) and total calcium (normal value 9 to 10.5 mg/dL [2.25 to 2.63 mmol/L]) levels are both elevated, suggesting bone metastasis. Both the hematocrit and hemoglobin are within normal limits for females.

DIF: Applying TOP: Integrated Process: Nursing Process: Analysis KEY: Breast cancer, Laboratory values MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential MULTIPLE RESPONSE 1. The nurse is taking a history of a 68-year-old woman. What assessment findings would

indicate a high risk for the development of breast cancer? (Select all that apply.) a. Age greater than 65 years b. Increased breast density c. Osteoporosis d. Multiparity e. Genetic factors f. Early menarche ANS: A, B, E, F

Risk factors for breast cancer include advancing age, family and genetic history, early menarche, late menopause, postmenopausal obesity, physical inactivity, combined hormonal therapies, alcohol consumption, and lack of breast feeding.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Breast cancer, Risk factors MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 2. The nurse is formulating a teaching plan according to evidence-based breast cancer screening

guidelines for a 50-year-old woman with low risk factors. Which diagnostic methods would be included in the plan? (Select all that apply.) a. Annual mammogram b. Magnetic resonance imaging (MRI) c. Breast ultrasound d. Breast self-awareness e. Clinical breast examination f. Self-breast examination ANS: A, D, E

Guidelines from the American Cancer Society include annual mammograms for low risk women starting at the age of 45 and continuing through the age of 54. At 55, women can continue annual mammography or change to every 2 years. MRI and ultrasound are done for abnormal findings or for high risk women. Breast self-awareness is important so women can detect changes early. Current data shows that SBE is not a valuable screening tool.

Asymptomatic women 40 and older should have a clinical breast exam annually.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Breast cancer, Health promotion MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 3. After a breast examination, the nurse is documenting assessment findings that indicate

possible breast cancer. Which abnormal findings need to be included as part of the client’s electronic medical record? (Select all that apply.) a. Peau d’orange b. Dense breast tissue c. Nipple retraction d. Mobile mass at 2 o’clock e. Nontender axillary nodes f. Skin ulceration ANS: A, C, D, F

In the documentation of a breast mass, skin changes such as dimpling (peau d’orange), nipple retraction, and whether the mass is fixed or movable are charted. The location of the mass should be stated by the “face of a clock.” Skin ulceration is also a common sign. Dense breast tissue and nontender axillary nodes are not abnormal assessment findings that may indicate breast cancer.

DIF: Remembering TOP: Integrated Process: Communication and Documentation KEY: Breast cancer, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

4. A woman is interested in alternative and complementary treatments for the nausea and

vomiting caused by the side effects of chemotherapy for breast cancer. Which therapies wound the nurse suggest? (Select all that apply.) a. Acupuncture b. Chiropractic c. Journaling d. Aromatherapy e. Shiatsu f. Black cohosh ANS: A, D, E

Alternative and complementary measures are chosen by many women. For nausea and vomiting, the best choices would be acupuncture, aromatherapy, and shiatsu. Chiropractic treatments would help pain. Journaling would be beneficial for fear and anxiety. Black cohosh is frequently used for hot flashes.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Breast cancer, Complementary and alternative treatments MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

Chapter 66: Concepts of Care for Patients With Gynecologic Problems Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse is caring for a woman who had hysteroscopic surgery for uterine leiomyomas. On

initial assessment, the nurse notes the following: pulse: 114 beats/min, respiratory rate: 20 breaths/minute, crackles in bilateral lung bases. What action by the nurse takes priority? a. Assess the client for pain. b. Call the Rapid Response Team. c. Obtain an oxygen saturation. d. Delegate a temperature.

ANS: B

The fluid that is used during this procedure to distend the uterine cavity can be absorbed, leading to fluid overload. This client has signs of fluid overload which can be critical. The nurse would notify the Rapid Response Team first, then perform the other actions.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Gynecologic problems, Critical rescue MSC: Client Needs Category: Safe and Effective Care Environment 2. The nurse is educating a client on the prevention of toxic shock syndrome (TSS). Which

statement by the client indicates a lack of understanding? a. “I need to change my tampon every 8 hours during the day.” b. “At night, I should use a feminine pad rather than a tampon.” c. “If I don’t use tampons, I should not get TSS.” d. “It is best if I wash my hands before inserting the tampon.”

ANS: A

Tampons need to be changed every 3 to 6 hours to avoid infection by such organisms as Staphylococcus aureus. All of the other responses are correct: use of feminine pads at night, not using tampons at all, and washing hands before tampon insertion are all strategies to prevent TSS. DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Gynecologic problems, Toxic shock syndrome, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance 3. A client is admitted to the emergency department with toxic shock syndrome. Which action

by the nurse is the most important? a. Administer IV fluids to maintain fluid and electrolyte balance. b. Remove the tampon as the source of infection. c. Collect a blood specimen for culture and sensitivity. d. Transfuse the client to manage low blood count.

ANS: B

The source of infection should be removed first. All of the other answers are possible interventions depending on the client’s symptoms and vital signs, but removing the tampon is the priority.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Gynecologic problems, Toxic shock syndrome MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 4. The nurse is caring for a postoperative client following an anterior colporrhaphy. What action

can be delegated to the assistive personnel (AP)? a. Reviewing the hematocrit and hemoglobin results b. Teaching the client to avoid lifting her 4-year-old grandson c. Assessing the level of pain and any drainage d. Drawing a shallow hot bath for comfort measures ANS: D

The AP is able to provide comfort through a bath. The registered nurse would review any laboratory results, complete any teaching, and assess pain and discharge.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Gynecologic problems, Delegation MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 5. A nurse receives hand-off report on four postoperative clients who each had total

hysterectomies. Which client would the nurse assess first upon initial rounding? a. Vaginal hysterectomy: two saturated perineal pads in 2 hours b. Abdominal: temperature of 99° F (37.2° C), blood pressure of 116/74 mm Hg c. Vaginal: opened incisional edges and moderate bleeding d. Abdominal: urinary catheter output of 150 mL in the last 3 hours ANS: A

Normal vaginal bleeding after a vaginal hysterectomy should be less than one saturated perineal pad in 4 hours. Two saturated pads in such a short time could indicate hemorrhage, which is a priority. The client with the slight temperature elevation needs to be assessed for possible infection, but not as the priority. A vaginal hysterectomy would not result in an incision the nurse could observe separating. The urinary output is normal.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Gynecologic problems, Postoperative nursing care MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 6. A client has undergone a vaginal hysterectomy with a bilateral salpingo-oophorectomy. She is

concerned about a loss of libido. What intervention by the nurse would be best? a. Suggest increasing vitamins and supplements daily. b. Discuss the value of a balanced diet and exercise. c. Reinforce that weight gain may be inevitable. d. Teach that estrogen cream inserted vaginally may help.

ANS: D

Use of vaginal estrogen cream and gentle dilation can help with vaginal changes and loss of libido. Weight gain and masculinization are misperceptions after a vaginal hysterectomy.

Vitamins, supplements, a balanced diet, and exercise are helpful for healthy living, but are not necessarily going to increase libido.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Gynecologic problems, Sexuality

MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 7. A client has recently been diagnosed with type II endometrial cancer and will be treated with

brachytherapy. What statement by the client indicates a need for further education on this treatment? a. “Each treatment will take only 20 to 30 minutes.” b. “I have to be alone in the room during treatment so I don’t expose others.” c. “I can get up and walk around or read in a chair during the treatments.” d. “I need to report any heavy vaginal bleeding or severe diarrhea.”

ANS: B

Type II endometrial cancer is likely to invade the uterine wall and metastasize. Treatment with brachytherapy is intended to prevent recurrence. During the treatment, which lasts 20 to 30 minutes each, the woman must remain on bedrest to avoid dislodging the radioactive source. The source emits radiation while it is in place, so the woman is in the treatment room by herself. Once it is removed, she has no restrictions on being around others. She would need to report any heavy vaginal bleeding or severe diarrhea.

DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Reproductive problems, Brachytherapy MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 8. The outpatient clinic nurse has assessed a woman who reports a month-long history of feeling

full, urinary frequency, and bloating. What action by the nurse is best? a. Obtain a clean catch urine specimen. b. Instruct the client on a 3-day diet history. c. Facilitate having a pelvic ultrasound. d. Teach the woman about CA-125 test.

ANS: D

Evidence shows that women with ovarian cancer often have recognizable, early signs such as abdominal bloating, urinary frequency or urgency, feeling full or difficulty eating, and pelvic pain. The nurse should “think ovarian” and facilitate the client having a CA-125 blood test, which is a cancer antigen test. The other actions may or may not be needed, but with these symptoms, the client needs to be evaluated for ovarian cancer.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Gynecologic problems, Ovarian cancer MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 9. The nurse has educated a community group of risk factors for ovarian cancer. Which

statement by a participant shows the need for reviewing the information? a. “This is a disease of young women.” b. “Never being pregnant increases my risk.” c. “Difficulty conceiving is a risk factor.” d. “Having endometriosis is one of the risks.”

ANS: A

Ovarian cancer usually strikes women who are middle age or older. Nulliparity, difficulty conceiving, and endometriosis all increase risk and are correct statements.

DIF: Analyzing

TOP: Integrated Process: Teaching/Learning

KEY: Gynecologic problems, Ovarian cancer MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 10. A nurse has taken an informed consent to a woman who is having a transvaginal repair of a

prolapsed uterus. What client statement indicates a need for more information? a. “The mesh they use may become infected.” b. “I may still need to do my Kegel exercises.” c. “I will watch for any signs of infection.” d. “I know how to use the incentive spirometer.”

ANS: A

Mesh is not used in the transvaginal approach as it has been discontinued in this country. The other statements show good understanding.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Gynecologic problems, Health teaching MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 11. A 25-year-old woman is concerned about contracting HPV. What information by the nurse is

most appropriate? a. “HPV is a benign infection that usually clears up on its own.” b. “You are too old to receive the HPV vaccination.” c. “We can provide HPV testing along with your Pap smear.” d. “HPV is not a common sexually transmitted disease.”

ANS: C

HPV DNA testing can be done at the same time as the pap smear. Most women have HPV infection during their lives; however, it is not always benign. Two types, 16 and 18 are responsible for about 70% of cervical cancers. The vaccination with Gardasil 9 can be given up to age 45.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Gynecologic problems, Cervical cancer MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies MULTIPLE RESPONSE 1. A 28-year-old client is diagnosed with uterine leiomyoma and is experiencing severe

symptoms. Which actions by the nurse are the most appropriate at this time? (Select all that apply.) a. Teach nonpharmacologic comfort measures. b. Discuss the high risk of infertility with this diagnosis. c. Relieve anxiety by relaxation techniques and education. d. Discuss in detail the side effects of laparoscopic surgery. e. Review complete blood count for possible iron deficiency anemia.

ANS: A, C, E

With uterine leiomyomas or fibroids, heavy bleeding is the predominant symptom, with anxiety occurring because of fears of cancer or infertility. Interventions would be directed to the heavy bleeding and anxiety relief, such as relaxation techniques and education about the pathophysiology and possible treatment of the fibroids. While many women do not experience pain with this condition, some do, so the nurse would teach nonpharmacologic comfort measures. The nurse could suggest resources to give more information about the diagnosis.

Discussion of the possibility of infertility and side effects of laparoscopic surgery is premature and may increase the anxiety.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Gynecologic problems, Leiomyoma MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 2. The nurse is giving discharge instructions to a client who had a total abdominal hysterectomy

with a vaginal repair. Which statements by the client indicate a need for further teaching?

(Select all that apply.) a. “I should not have any problems driving to see my mother, who lives 3 hours away.” b. “Now that I have time off from work, I can return to my exercise routine next week.” c. “My granddaughter weighs 23 lb (10.5 kg) so I need to refrain from picking her up.” d. “I will have to limit the number of times that I climb our stairs at home to fewer than five times a day.” e. “I need to refrain from sexual intercourse for 4 to 6 weeks.” f. “When I do resume intercourse, I will use a water-based lubricant and go slowly.”

ANS: A, B

Driving and sitting for extended periods of time should be avoided until the surgeon gives permission. For 2 to 6 weeks, exercise participation should also be avoided. All of the other responses demonstrate adequate knowledge for discharge. The client should not lift anything heavier than 10 lb (4.5 kg), should limit stair climbing, and should refrain from sexual intercourse. When intercourse is resumed, the client should use water-based lubricant and proceed slowly as the vaginal walls are tighter. This may temporarily cause some pain.

DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Gynecologic problems, Health teaching MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. The nurse is taking the history of a 24-year-old client diagnosed with cervical cancer. What

possible risk factors would the nurse assess? (Select all that apply.) a. Smoking b. Multiple births c. Poor diet d. Nulliparity e. Younger than 18 at first intercourse f. Infections with HPV ANS: A, B, F

Smoking, multiple births, and infection with HPV are all risk factors for cervical cancer.

Nulliparity is a risk factor for endometrial cancer. Poor diet could lead to decreased immunity, which is a risk, but is not directly related. Giving birth before the age of 17 is a risk factor.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Cervical cancer, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. A client is scheduled to start external beam radiation therapy (EBRT) for her endometrial

cancer. Which teaching by the nurse is accurate? (Select all that apply.) a. “You will need to be hospitalized during this therapy.” b. “Your skin needs to be inspected daily for any breakdown.” c. “It is not wise to stay out in the sun for long periods of time.” d. “The perineal area may become damaged with the radiation.” e. “The technician applies new site markings before each treatment.” f. “You will not be radioactive or pose any danger to anyone else.”

ANS: B, C, D, F

EBRT is usually performed in ambulatory care and does not require hospitalization. The client needs to know to evaluate the skin, especially in the perineal area, for any breakdown, and avoid sunbathing. The technician does not apply new site markings, so the client needs to avoid washing off the markings that indicate the treatment site.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Endometrial cancer, Radiation therapy, Health teaching MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 5. The nurse is teaching a client who is undergoing brachytherapy about what to immediately

report to her primary health care provider . Which signs and symptoms would be included in this teaching? (Select all that apply.) a. Constipation for 3 days b. Temperature of 99° F (37.2° C) c. Abdominal pain d. Visible blood in the urine e. Heavy vaginal bleeding f. Urinary retention ANS: C, D, E

Health teaching for a client having brachytherapy would emphasize reporting abdominal pain, visible blood in the urine, and heavy vaginal bleeding. Severe diarrhea (not constipation), urethral burning, extreme fatigue, and a fever over 100° F (37.7° C) would also be reported.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Gynecologic problems, Brachytherapy, Health teaching MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 6. A client has recurrent vulvovaginitis. Which statements by the client indicate a need for

further teaching? (Select all that apply.) a. “I can take a long, hot bath to relieve itching.” b. “I need to take all of my antibiotics as prescribed.” c. “I should avoid having sex until my infection is gone.”

d. “I should not douche or use feminine hygiene sprays.” e. “I should use antibacterial soap to clean the area.” f. “I should switch to wearing only cotton underwear.”

ANS: A, B, E

Clients should avoid hot water baths as they may increase the itching and infection. They may take warm or tepid sitz baths for 30 minutes several times a day to relieve itching. Clients should cleanse the inner labia mucosa with water, not soap, during a bath or shower. All of the other options are correct.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Gynecologic problems, Comfort measures MSC: Client Needs Category: Health Promotion and Maintenance 7. The nurse is doing home care teaching for a client who has undergone cryotherapy. Which

statements by the client indicate a correct understanding of the instructions? (Select all that apply.) a. “I can resume my weight-lifting exercise class tomorrow.” b. “I should not use tampons, douche, or have sexual activity.” c. “I should shower rather than take a tub bath.” d. “There may be a lot of bleeding for a few days.” e. “There should be little or no discomfort.”

ANS: B, C, E

Cryotherapy involves freezing of cervical cancer cells and is often painless. Clients are restricted from heavy lifting. They may have a heavy watery discharge for several weeks, but should report any heavy bleeding, foul-smelling drainage, or a fever. The other options are correct.

DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Gynecologic problems, Health teaching MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

Chapter 67: Concepts of Care for Clients With Male Reproductive Problems Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. The nurse is conducting a history on a male client to determine the severity of symptoms

associated with prostate enlargement. Which finding is cause for prompt action by the nurse? a. Hematuria b. Urinary hesitancy c. Postvoid dribbling d. Weak urinary stream ANS: A

Hematuria, especially at the start or end of the urine stream, could indicate infection due to possible urine retention and would cause the nurse to act promptly. Common symptoms of benign prostatic hyperplasia are urinary hesitancy, postvoid dribbling, and a weak urinary stream due to the enlarged prostate causing bladder outlet obstruction.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Male reproductive problems, BPH MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 2. A client is diagnosed with benign prostatic hyperplasia and seems sad and irritable. After

assessing the client’s behavior, which statement by the nurse would be the most appropriate? a. “The urine incontinence should not prevent you from socializing.” b. “You seem depressed and should seek more pleasant things to do.” c. “It is common for men at your age to have changes in mood.” d. “Nocturia could cause interruption of your sleep and cause changes in mood.”

ANS: D

Frequent visits to the bathroom during the night could cause sleep interruptions and affect the client’s mood and mental status. Telling the client his symptoms should not lead to less socialization is patronizing. Instructing the client to seek more pleasant things to do also is patronizing. Neither statement has any information the client could find useful. The statement about age has no validity and again does not offer useful information.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Male reproductive problems, Caring MSC: Client Needs Category: Psychosocial Integrity 3. A nurse is providing education to a new 55-year-old African-American client about screening

for prostate cancer. What action by the nurse is most appropriate? a. Inform the client that recommendations vary, so screening is a personal choice. b. Let the client know that as an African American, he should be screened annually. c. Teach the client that he is in a high risk group and should discuss screening. d. Give the client written information that discourages screening until age 70.

ANS: C

Clients in certain high risk groups should discuss screening for prostate cancer with their primary health care providers at age 45. High risk groups include African Americans and men with a first-degree relative who was diagnosed with prostate cancer before the age of 65. This new client will be encouraged to discuss screening even though he is past the age of initial discussion. Recommendations do vary somewhat, but he is in a recognized high risk group.

The nurse would not say that he “should” be screened annually. Screening is not recommended for men over the age of 70.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Male reproductive problems, Secondary prevention MSC: Client Needs Category: Health Promotion and Maintenance 4. The nurse is teaching a client with benign prostatic hyperplasia (BPH). What statement

indicates the client needs further information? a. “There should be no problem with drinking wine with dinner each night.” b. “I am so glad that I weaned myself off of coffee about a year ago.” c. “I need to inform my allergist that I cannot take my normal antihistamine.” d. “My routine of drinking a quart (liter) of water first thing in the morning needs to change.”

ANS: A

Caffeine and alcohol have diuretic effects and so the nurse would teach about avoiding or limiting their intake. The statement about drinking wine indicates a need for further instruction. Antihistamines can cause urinary retention. Clients are taught to avoid drinking large quantities of fluid at one time.

DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Male reproductive problems, Health teaching MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. A client has returned from a transurethral resection of the prostate with a continuous bladder

irrigation. Five hours after the operation, the nurse notes the drainage is bright red with clots.

What action should the nurse take first? a. Review the most recent hemoglobin and hematocrit. b. Take vital signs and begin immediate irrigation with sterile water. c. Notify the primary health care provider immediately. d. Remind the client not to pull on the catheter.

ANS: B

Bright red urinary drainage with clots may indicate arterial bleeding. The nurse would notify the primary health care provider immediately and begin irritating the catheter with sterile normal saline (not sterile water). The nurse can delegate the vital signs. The nurse would review hemoglobin and hematocrit and would remind the client not to pull on the catheter for all clients with bladder irrigation. But for this client who may be bleeding the nurse would take further action to address the problem.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Male reproductive problems, Continuous bladder irrigation MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

6. A new nurse care for several client after radical prostatectomies for prostate cancer. What

action by the nurse indicates a need to review care measures for this type of client? a. Delegates emptying and recording contents of the drainage devices. b. Administers a suppository to the client who reports constipation. c. Removes the sequential compression stockings on ambulatory clients. d. Discusses long-term complications such as erectile dysfunction.

ANS: B

After a radical prostatectomy, the nurse would not provide a rectal suppository for constipation. All rectal treatments are contraindicated. The nurse would delegate emptying and recording drainage, remove the sequential pressure devices when clients begin ambulating, and discuss long-term complications of the operation.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Male reproductive problems, Postoperative nursing care MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 7. A client with metastatic prostate cancer has been prescribed leuprolide, a bisphosphonate, and

flutamide. Which statement by the client warrants further investigation by the nurse? a. “I go for a short walk each day, even when I am very tired.” b. “My wife has noticed my eyes looking a little yellow.” c. “I ordered some looser shirts to hide my enlarging breasts.” d. “Now I understand my wife’s hot flashes with menopause.”

ANS: B

Flutamide is an antiandrogen drug that can cause liver toxicity. The nurse would follow up on the statement that the client’s eyes may be looking a little yellow which could indicate the onset of this adverse effect. Leuprolide can cause osteoporosis, hot flashes, and gynecomastia.

The statements regarding weight-bearing exercise, enlarging breasts, and hot flashes are not cause for concern.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Male reproductive problems, Hormone therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 8. The nurse is providing preoperative education to a client prior to having an orchiectomy for

testicular cancer. What statement by the client indicates the need to review the information? a. “I can still function sexually without one of my testes.” b. “I will investigate sperm banking before the operation.” c. “There should be no effect on my ability to reproduce.” d. “Testicular self-exam will be important on the remaining testis.”

ANS: C

Oligospermia and azoospermia are common in clients with testicular function and can affect reproduction. The statement that there will be no effect on reproduction requires the nurse to review the information with the client. Sperm banking is an option prior to treatment to store sperm for future use. Normal sexual function is possible with one testis. Self-examination of the remaining testis is important for early detection of another tumor.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Male reproductive problems, Testicular cancer MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

9. The nurse has provided postvasectomy discharge instructions to the client. What statement by

the client demonstrates good understanding? a. “We can have unprotected intercourse as soon as I have healed.” b. “An ice pack to my scrotum will help with the swelling.” c. “I need to report signs of infection, swelling, or bruising right away.” d. “The stitches can be removed here in the office in 7 to 10 days.”

ANS: B

After vasectomy, clients are instructed to use birth control until the 3-month semen analysis shows that the procedure has worked, to use an ice pack intermittently for 24 to 48 hours, that swelling and bruising are normal, and the bandage can be removed in 48 hours. There are no sutures to be removed.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Male reproductive problems, Vasectomy, Health teaching MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 10. A client comes to the clinic with concerns about an enlarged left testicle and heaviness in his

lower abdomen. Which diagnostic test would the nurse expect to be ordered? a. Alpha-fetoprotein (AFP) b. Prostate-specific antigen (PSA) c. Serum acid phosphatase (PAP) d. C-reactive protein (CRP) ANS: A

These are symptoms of possible testicular cancer. AFP is a tumor marker that is elevated in testicular cancer. PSA and PAP testing is used in testing for prostate cancer and its metastasis.

CRP is diagnostic for inflammatory conditions.

DIF: Remembering TOP: Integrated Process: Nursing Process: Analysis KEY: Male reproductive problems, Laboratory values MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 11. A client presents to the emergency department reporting vomiting, severe lower abdominal

pain, and a tender mass above one testis. What action by the nurse is most important? a. Have the client rate pain using the 0-10 scale. b. Prepare to administer an IV opioid analgesic. c. Determine when he last ate or drank anything. d. Assess risk factors for testicular cancer.

ANS: C

This client has signs and symptoms of testicular torsion, which is a surgical emergency. For client safety, the nurse assesses last oral intake. Rating the pain is an important intervention too but is not related to safety. The client cannot have opioids prior to signing a surgical consent. The client does not have signs and symptoms of testicular cancer.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Male reproductive problems, Testicular torsion MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

12. A client returned from a transurethral resection of the prostate 8 hours ago with a continuous

bladder irrigation. The client reports headache and dizziness. What action by the nurse is most appropriate? a. Consider starting a blood transfusion. b. Slow the bladder irrigation down. c. Report the findings to the surgeon immediately. d. Take the vital signs every 15 minutes.

ANS: C

Headache, dizziness, and shortness of breath are symptoms of possible TURP syndrome in which the irrigation fluid is absorbed, putting strain on the client’s heart. The nurse notifies the primary health care provider immediately as the client may need intensive care monitoring. There is no data indicating the client needs a blood transfusion, plus that would add even more fluid in the system. The irrigant may need to be slowed but that is not the first action the nurse would take. Vital signs do need to be taken frequently in this situation, but the nurse notifies the primary health care provider first.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Implementation KEY: Male reproductive problems, Fluid and electrolyte imbalance MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 13. The nurse is teaching an uncircumcised 65-year-old client about self-management of a urinary

catheter in preparation for discharge to his home. What statement indicates the client needs more information? a. “I have to wash the outside of the catheter once a day with soap and water. b. “I should take extra time to clean the catheter site by pushing the foreskin back.” c. “The drainage bag needs to be changed at least once a week and as needed.” d. “I should pour a solution of vinegar and water through the tubing and bag.”

ANS: A

The first few inches (centimeters) of the catheter must be washed daily starting at the penis and washing outward with soap and water. The other options are correct for self-management of a urinary catheter in the home setting.

DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Male reproductive problems, Catheter management, Health teaching MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential MULTIPLE RESPONSE 1. The nurse is teaching a client about side effects and adverse reactions of a PDE5 inhibitor.

What information does the nurse include? (Select all that apply.) a. Refrain from eating citrus fruit within 24 hours of taking the medication. b. Stop using this drug if your primary health care provider prescribes a nitrate. c. Do not drink alcohol before having sexual intercourse. d. Muscle cramps, nausea, and vomiting are possible if you take more than 1 pill a day. e. Take this medication within 30 to 60 minutes of having sexual intercourse. f. Change positions slowly especially if you also take an anti-hypertensive drug.

ANS: B, C, D, F

A PDE5 inhibitor is used to treat erectile dysfunction. The client should avoid grapefruit or grapefruit juice while taking these drugs. Taking a PDE5 inhibitor along with a nitrate can cause a profound drop in blood pressure. Alcohol may interfere with the ability to have an erection. Muscle cramps, nausea, and vomiting are possible side effects if more than 1 pill a day are taken. Each medication has its own directions for how soon to take it before intercourse, from 15 minutes to 2 hours. Any PDE5 drug can lower blood pressure so the nurse alerts the client of safety precautions.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Male reproductive problems, Medications, Health teaching MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 2. A client is interested in learning about the risk factors for prostate cancer. Which factors does

the nurse include in the teaching? (Select all that apply.) a. First-degree relative with prostate cancer b. Smoking c. Obesity d. Advanced age e. Eating too much red meat f. Race ANS: A, D, E, F

Risk factors for prostate cancer include having a first-degree relative with the disease, advanced age, and African-American race. Smoking, obesity, and eating too much red meat are not considered risk factors. Research is exploring the relationship with diet.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Male reproductive problems, Prostate cancer MSC: Client Needs Category: Health Promotion and Maintenance 3. A client came to the clinic with erectile dysfunction. What are some possible causes of this

condition that the nurse could discuss with the client during history taking? (Select all that apply.) a. Recent prostatectomy b. Long-term hypertension c. Diabetes mellitus d. Hour-long exercise sessions e. Consumption of beer each night f. Taking long hot baths ANS: A, B, C, E

Organic erectile dysfunction can be caused by surgical procedures, vascular diseases such as hypertension and its treatment, diabetes mellitus, and alcohol consumption. There is no evidence that exercise or hot baths are related to this problem.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Male reproductive problems, Erectile dysfunction MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

Chapter 68: Concepts of Care for Transgender Patients Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse is reviewing the chart of a new client in the family medicine clinic and notes that the

client is identified as “George Smith.” The nurse enters the room and finds a woman in a skirt.

What action by the nurse is best? a. Apologize and declare confusion about the client. b. Ask Mrs. Smith where her husband is right now. c. Ask the client about preferred forms of address. d. Explain that the chart must contain an error.

ANS: C

The nurse may encounter transgender clients whose outward appearance does not match their demographic data. In this case, the nurse should greet the client and ask the client to explain his or her preferred forms of address. Lengthy apologies can often create embarrassment. The nurse should not assume that the client is not present in the room. The chart may or may not contain errors, but that is not related to determining how the client prefers to be addressed.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Transgender care, Therapeutic communication MSC: Client Needs Category: Psychosocial Integrity 2. A nurse is providing health teaching to a middle-age male-to-female (MtF) client who has

undergone gender-reaffirming surgery. What information is most important to this patient? a. “Be sure to have an annual prostate examination.” b. “Continue your normal health screenings.” c. “Try to avoid being around people who are ill.” d. “You should have an annual flu vaccination.”

ANS: A

The MtF client retains the prostate, so annual screening examinations for prostate cancer remain important. The other statements are good general health teaching ideas for any patient.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Transgender care, Secondary prevention MSC: Client Needs Category: Health Promotion and Maintenance 3. A transgender client is taking transdermal estrogen. What assessment finding does the nurse

report immediately to the primary health care provider? a. Breast tenderness b. Headaches c. Red, swollen calf d. Swollen ankles ANS: C

A red, swollen calf could be a sign of a deep-vein thrombosis, a known adverse effect of estrogen. The nurse reports this finding immediately. The other signs and symptoms are also side effects of estrogen, but do not need to be reported as a priority.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Transgender care, Feminizing drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. A transgender client taking spironolactone is in the internal medicine clinic reporting heart

palpitations. What action by the nurse takes priority? a. Draw blood to test serum potassium. b. Have the client lie down and rest. c. Obtain a STAT electrocardiogram (ECG). d. Take a set of vital signs.

ANS: C

Spironolactone is a potassium-sparing diuretic, and hyperkalemia can cause cardiac dysrhythmias. The nurse’s priority is to obtain an ECG, and then to facilitate a serum potassium level being drawn. Having the client lie down and obtaining vital signs are also important care measures, but are not the most important at this time.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Implementation KEY: Transgender care, Electrolyte imbalances MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 5. The nurse is teaching a transgender client about taking testosterone. What statement by the

client indicates good understanding? a. “My periods should stop immediately.” b. “Some effects can take up to a year to see.” c. “I am glad I don’t have to watch my diet.” d. “There are very few side effects since it’s a normal hormone.”

ANS: B

Testosterone is used as masculinizing drug therapy. Some desired effects may take up to a year to be noticed. Menses should stop within the first few months of therapy. Testosterone increases the risk of heart disease, so clients should follow a heart-healthy diet. Testosterone has several side effects, including acne, seborrhea, weight gain, edema, headaches, and possible psychosis.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Transgender care, Masculinizing drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 6. A client is preparing for MtF gender–affirming surgery. The client is worried about the voice

not sounding feminine enough. What action by the nurse is best? a. Ask if the client has considered vocal cord surgery to change the voice. b. Refer the client for vocal therapy with a speech–language pathologist. c. Teach the client that there will be no effect on the patient’s voice. d. Tell the client that the use of hormones will eventually change the voice.

ANS: B

Male-to-female clients can consult with a speech–language pathologist for vocal training to help with intonation and pitch. While vocal surgery is possible, it may not be the best first option due to cost and invasiveness. Telling the client that there will be no change to the voice does not give the client information to address the concern. While the hormones this client is taking will not affect the voice, simply stating that fact does not help the client manage this issue.

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Transgender care, Referrals, Communication MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 7. A client has returned from the postanesthesia care unit after a vaginoplasty. What comfort

measure does the nurse provide for this client? a. Apply ice to the perineum. b. Elevate the legs on pillows. c. Position the client on the left side. d. Raise the head of the bed.

ANS: A

Ice is applied to the perineum intermittently to reduce bruising, pain, and discomfort.

Elevating the legs on pillows is not recommended after a lengthy procedure in the lithotomy position, which predisposes the client to venous thromboembolism. Positioning the client on the left side and raising the head of the bed are not comfort measures related to this procedure.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Transgender care, Postoperative nursing care MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 8. A client had a vaginoplasty under epidural anesthetic. Which action by the nurse is most

important? a. Ensure that the urinary catheter is securely attached to the leg. b. Instruct the client not to try to get out of bed unassisted. c. Monitor the patient’s dressings and wound drainage. d. Position the Jackson–Pratt drain to the contralateral side.

ANS: B

Epidural anesthesia will cause the client to not be able to move (or feel) the legs for several hours. It is important for client safety that adequate help is available prior to this client trying to get out of bed. Securing the catheter to the leg and monitoring dressings and drainage are important for any client after surgery. Positioning the drain to the contralateral side is not needed.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Transgender care, Postoperative nursing care, Client safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 9. The nurse is reviewing information about FtM gender–affirming surgical options with a client.

What statement by the client indicates the need for further information? a. “A penile implant is inserted during the phalloplasty.” b. “Vaginal atrophy can occur and lead to itching.” c. “I will still need cervical cancer screening if I don’t have a total hysterectomy.”

d. “This surgery will have many psychologic benefits for me.”

ANS: A

The penile implant or prosthesis is not implanted with the original phalloplasty, but months later when the original operation has healed. The other statements are accurate regarding gender-affirming surgery.

DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Transgender care, Gender-affirming surgery MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 1. The nurse is reviewing possible complications from a phalloplasty. What factors does the

nurse include? (Select all that apply.) a. Wound infections b. Urethral complications c. Rectal injury d. Bleeding e. Donor site scarring f. Recurrent urinary tract infections ANS: A, B, C, D, E

Complications from phalloplasty include wound infections, urethral complications, rectal injuries, bleeding, and donor site scarring. Recurrent urinary tract infections are not a typical complication.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Transgender care, Gender-affirming surgery MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 2. A nurse is learning about the health care needs of individuals who identify as LGBTQIA+ and

transgender. Which terms are correctly defined? (Select all that apply.) a. Gender dysphoria—distress caused by incongruence between natal sex and gender identity. b. Gender identity—a person’s inner sense of being a male, a female, or an alternative gender. c. Natal sex—the sex one is born with or is assigned to at birth. d. Transgender—a person who dresses in the clothing of the opposite sex. e. Trans-woman—a male who identified or lives as a woman.

ANS: A, B, C, E

Gender dysphoria is emotional distress caused by the incongruence between natal sex (sex assigned at birth) and gender identity. Gender identity is a person’s inner sense of being a male, a female, or an alternative gender Natal sex describes the gender a person is born with or is assigned to at birth. Transgender is an adjective that describes individuals who self-identify as the opposite gender or a gender that does not match their natal sex. A trans-woman is a natal male who identifies and/or lives as a woman.

DIF: Remembering KEY: Transgender care

TOP: Integrated Process: Teaching/Learning MSC: Client Needs Category: Psychosocial Integrity

3. A nurse works with many transgender patients. What routine monitoring is important for the

nurse to facilitate in this population? (Select all that apply.) a. Lipid profile b. Liver function tests c. Mammograms if breast tissue is present d. Prostate-specific antigen (PSA) for natal males e. Renal profile f. Cervical cancer screening ANS: A, B, C, D, F

Common routine monitoring for this population includes lipid and liver panels, mammograms if any breast tissue is present, and PSA for natal males as the prostate is not removed during a vaginoplasty/penectomy. Cervical cancer screening is needed if the client has not had a total hysterectomy with a BSO. Renal profiles are not required based on treatment options for this population.

DIF: Remembering TOP: Integrated Process: Nursing Process: Implementation KEY: Transgender care, Secondary prevention MSC: Client Needs Category: Health Promotion and Maintenance

Chapter 69: Concepts of Care for Patients With Sexually Transmitted Infections Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse is assessing a client who presents with a scaly rash over the palms and soles of the

feet and the feeling of muscle aches and malaise. Which action by the nurse is most appropriate? a. Reassure the client that these lesions are not infectious. b. Assess the client for hearing loss and generalized weakness. c. Don gloves and further assess the client’s lesions. d. Take a history regarding any cardiovascular symptoms.

ANS: C

The client is displaying symptoms similar to secondary syphilis, with flulike symptoms and rash due to the spirochetes circulating throughout the bloodstream. Therefore, the nurse needs to further assess the client’s lesions with gloves since the client is highly contagious at this stage. Tertiary syphilis may display in the form of cardiovascular or central nervous system symptoms. Neurosyphilis can appear at any time, in any state, and can include hearing loss.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Sexually transmitted infections, Syphilis MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 2. A male client is diagnosed with primary syphilis. Which question by the nurse is a priority at

this time? a. “Have you been using latex condoms?” b. “Are you allergic to penicillin?” c. “When was your last sexual encounter?” d. “Do you have a history of sexually transmitted infections?”

ANS: B

Benzathine penicillin G is the evidence-based treatment for primary, secondary, and early latent syphilis. The client needs to be assessed for allergies before treatment. The other questions would be helpful in the client’s history of sexually transmitted infections but not as important as knowing whether the client is allergic to penicillin.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Sexually transmitted infections, Medications MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 3. A client with genital herpes has painful blisters on her vulva. After teaching the client

self-care measures, which statement indicates the need for further education? a. “Pouring water over my genitals will decrease the pain of urinating.” b. “I will wash my hands carefully after applying ointment.” c. “When I don’t have lesions, I am not contagious to my sexual partner.” d. “I should increase my fluid intake when I have open lesions.”

ANS: C

A client with genital herpes can still spread the disease when asymptomatic through viral shedding. The client is taught to use condoms with all sexual activity. Pouring water over the genitals (or urinating in the shower) will help decrease the pain of urine passing over open lesions. Good handwashing is important. Open lesions can lead to fluid loss so the client is taught to increase fluid intake.

DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Sexually transmitted infections, Genital herpes MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. A 30-year-old male client is asking the nurse about the vaccine for human papilloma virus

(HPV). Which statement by the nurse is accurate? a. “Gardasil protects against all HPV strains.” b. “You are too old to receive the vaccine.” c. “Only females can receive the vaccine.” d. “You will only need 1 dose of the vaccine.”

ANS: D

Gardasil is used to provide immunity for HPV types 6, 11, 16, and 18 and Gardasil 9 protects against 5 more strains. The vaccine is recommended for people aged 9 to 26 years of age, but Gardasil 9 can be given up to age 45. Both males and females can get the vaccine. Depending on the timing and type of vaccine, either 2 to 3 doses are required.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Sexually transmitted infections, HPV MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 5. A client with multiple sexual partners has been assessed for symptoms of dysuria and green,

malodorous vaginal discharge. The nurse administers and injection of ceftriaxone and gives the client a prescription for doxycycline. The client asks why two drugs are needed. What answer by the nurse is best? a. “It is very common to be infected with both gonorrhea and chlamydia.” b. “Giving two medications increases the chance of curing the infection.” c. “Some people are not affected by the injection and need more medication.” d. “This will prevent you from needing a 3-month follow-up test.”

ANS: A

This client has signs of gonorrhea. Co-infection with gonorrhea and chlamydia is common, so the client being treated for gonorrhea also needs treatment for chlamydia with oral antibiotics.

It is fairly accurate to say two medications increases the chance of cure, but does not really explain the situation. Giving the client two medications is not because some people are not affected by the injection nor is it to prevent needing a 3-month follow-up test. Testing for re-infection with chlamydia is recommended by the CDC. DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Sexually transmitted infections, Medications MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. While evaluating a client for treatment of gonorrhea, which question is the most important for

the nurse to ask? a. “Do you have a history of sexually transmitted infection?”

b. “When was your last sexual encounter?” c. “When did your symptoms begin?” d. “Can you remember your partners and contact them to get treated?”

ANS: D

Sexual partners, as well as the client, should be tested and treated for gonorrhea. Asking about sexually transmitted infection history, last sexual encounter, and onset of symptoms would be helpful with the history taking, but the priority is treating the client’s sexual partners to limit the spread of the infection.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Sexually transmitted infections, Gonorrhea MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 7. A client has been treated for syphilis with IM penicillin. The next day the client calls the

clinic to report fever, chills, achy muscles, and a worsening rash. What statement by the nurse is most appropriate? a. “You must be allergic to penicillin; over the counter antihistamines will help.” b. “Please go to the nearest emergency department if you develop shortness of breath.” c. “You can take acetaminophen or ibuprofen for the pain and achiness.” d. “I think you should come in to the clinic either today or tomorrow and be checked.”

ANS: C

This client has signs of a Jarisch-Herxheimer reaction which is caused when the organisms’ cell walls are disrupted and cellular contents are released rapidly. It is usually self-limiting and benign. Antipyretics and mild analgesics treat the symptoms. The client does not need to monitor for shortness of breath, come in to the clinic, or get antihistamines for an allergic reaction.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Sexually transmitted infections, Medication adverse reactions MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 8. A 24 year-old female has been diagnosed with genital warts. Which action by the nurse is

best? a. Encourage the client to complete STI screening. b. Recommend an over-the-counter wart treatment for genital tissue. c. Report the case to the Centers for Infection Control and Prevention (CDC). d. Discuss popular options for contraception.

ANS: A

Clients with HPV should be fully screened for other STIs since co-infection is common. Over the counter treatments should not be applied to genital tissue. HPV is not reportable.

Contraception is not related.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Sexually transmitted infections, HPV MSC: Client Needs Category: Health Promotion and Maintenance

9. A female client returned to the clinic with a yellow vaginal discharge after being treated for

Chlamydia infection 3 weeks ago. Which statement by the client alerts the nurse that there may be a recurrence of the infection? a. “I did practice abstinence while taking the medication.” b. “I took doxycycline two times a day for a week.” c. “I never told my boyfriend about the infection.” d. “I did drink wine when taking the medication for Chlamydia.”

ANS: C

There is a good possibility that the boyfriend reinfected the client after the medication regimen was finished. Both the client and the boyfriend need to be treated. The other statements were in compliance with the recommendations of abstinence and the usual medication regimen with doxycycline. Wine should not interfere with the treatment.

DIF: Applying TOP: Integrated Process: Nursing Process: Analysis KEY: Sexually transmitted infections, Chlamydia MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 10. A woman is admitted to the hospital for antibiotic therapy for pelvic inflammatory disease.

She is in pain, with a rating of 7 on a scale of 0-10. What comfort measure can the nurse delegate to assistive personnel (AP)? a. Administer acetaminophen with codeine. b. Apply an ice pack to the lower abdomen. c. Position the client in a semi-Fowler position. d. Teach the client to increase intake of fluids.

ANS: C

The client with pelvic inflammatory disease usually experiences lower abdominal tenderness.

The AP can position the client. Only the nurse can administer medications and perform teaching. A heating pad, not an ice pack, is used for comfort.

DIF: Applying TOP: Integrated Process: Caring KEY: Sexually transmitted infections, Pelvic inflammatory disease MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 11. A client with pelvic inflammatory disease is seen by the nurse 72 hours after starting oral

antibiotics. Which finding leads the nurse to take immediate action? a. Feelings of anger that her partner infected her b. Loose stools over the last 2 days c. Anorexia and nausea d. Chills and a temperature of 101° F (38.3° C) ANS: D

Chills and fever could indicate a persistent infection and the immediate need to alter the dose or type of antibiotic. Anger is a normal reaction to a sexually transmitted infection and the pain of pelvic inflammatory disease. Gastrointestinal symptoms are common side effects of antibiotics but not an immediate cause for intervention.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Sexually transmitted infections, Pelvic inflammatory disease MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

12. A college student seeks information from the school’s nurse about how to avoid sexually

transmitted infections (STIs) without abstinence as a choice. Which statement by the nurse is best? a. “Urinating after intercourse will eliminate the risk of infection.” b. “A vaccine can prevent genital warts caused by some strains of the human papilloma virus (HPV).” c. “Oral contraception can prevent pregnancy and STIs.” d. “Good handwashing helps prevent infection associated with STIs.” ANS: B

Gardasil and Gardasil 9 are used to provide immunity for HPV types 6, 11, 16, and 18 and others that are high risk for cervical cancer and genital warts. While there is some truth that urination after intercourse may decrease the risk of infection by flushing out organisms, it does not eliminate the risk of contaminating bacteria traveling up the urethra or from skin-to-skin contact. The other statements are not accurate.

DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Sexually transmitted infections, Health teaching MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 13. A client has a positive HSV-2 test but is asymptomatic. What action by the nurse is best? a. Encourage the client to have frequent STI screening. b. Teach the client ways to prevent getting STIs. c. Provide the same education as if the client were symptomatic. d. Inform the client that partner notification is unnecessary.

ANS: B DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Sexually transmitted infections, Herpes MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 1. A primary care clinic sees some clients with sexually transmitted infections. Which diseases

would the nurse be required to report to the local authority? (Select all that apply.) a. Chlamydia b. Gonorrhea c. Syphilis d. Human immune deficiency virus e. Pelvic inflammatory disease f. Human papilloma virus ANS: A, B, C, D

Chlamydia, gonorrhea, syphilis, human immune deficiency virus (HIV), and acquired immune deficiency syndrome (AIDS) are all reportable to local authorities in every state. Pelvic inflammatory disease and HPV do not need to be reported.

DIF: Remembering TOP: Integrated Process: Communication and Documentation KEY: Sexually transmitted infections MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

2. A nurse wants to reduce the risk potential for transmission of chlamydia and gonorrhea with a

client diagnosed with both infections. Which items should be included in the client’s teaching plan? (Select all that apply.) a. Expedited partner therapy b. Abstinence until therapy is completed c. Use of intrauterine devices d. Proper use of condoms e. Rescreening for infection f. Use of oral contraception ANS: A, B, D, E

As part of client/partner education, the nurse should explain the expedited partner therapy (practice of treating both sexual partners by providing medication to the client for the partner).

The nurse should also emphasize the need for abstinence from sexual intercourse until treatment is finished, proper use of condoms, and rescreening for reinfection 3 to 12 months after treatment. The use of an intrauterine device and oral contraception is not part of the plan.

DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Sexually transmitted infections, Health teaching MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 3. A client being treated for syphilis visits the office with a possible allergic reaction to

benzathine penicillin G. Which abnormal findings would the nurse expect to document?

(Select all that apply.) a. Red rash b. Shortness of breath c. Heart irregularity d. Chest tightness e. Anxiety f. Confusion ANS: A, B, D, E

The nurse should keep all clients at the office for at least 30 minutes after the administration of benzathine penicillin G. Allergic signs and symptoms consist of rash, shortness of breath, chest tightness, and anxiety. Heart irregularity and confusion are not seen as an allergic manifestation.

DIF: Remembering TOP: Integrated Process: Communication and Documentation KEY: Sexually transmitted infections, Syphilis, Medication adverse effects MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. A client has pelvic inflammatory disease (PID). What complications does the nurse monitor

the client for? (Select all that apply.) a. Chronic pelvic pain b. Infertility c. Ectopic pregnancy d. Tubo-ovarian abscess e. Peri-hepatitis f. Pancreatitis

ANS: A, B, C, D, E

Possible complications of PID include chronic pelvic pain, infertility, ectopic pregnancy, tubo-ovarian abscess, peri-hepatitis, inflammation of the liver capsule, and inflammation of the peritoneal surfaces of the anterior right upper quadrant.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Sexually transmitted infections, Pelvic inflammatory disease MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 5. The nurse is teaching a client who is taking an oral antibiotic for treatment of a sexually

transmitted infection (STI). Which statements by the client indicate a correct understanding of the treatment? (Select all that apply.) a. “I need to drink at least eight glasses of fluid each day with my antibiotic.” b. “I should read the instructions to see if I can take the medication with food.” c. “Antacids should not interfere with the effectiveness of the antibiotic.” d. “I need to wait 7 days after this injection to engage in intercourse.” e. “It should not matter if I skip a couple of doses of the antibiotic.”

ANS: A, B, D

When a client is being treated with an oral antibiotic for an STI, 8 to 10 glasses of fluid should be routine, medication instructions should be reviewed, and at least a week break should occur between the antibiotic and sexual intercourse to allow for the medication’s full effects if the medication was given in a single dose. Use of antacids and missing doses could decrease the effectiveness of the antibiotic.

DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Sexually transmitted infections, Health teaching MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies