TEST BANK for Medical Surgical Nursing 10th Edition by Ignatavicius & Workman & Rebar & Heimgartner.

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

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