Test Bank for Medical Surgical Nursing 10th Edition by Lewis, Exams of General Surgery

Download Test Bank for Medical Surgical Nursing 10th Edition by Lewis and more Exams General Surgery in PDF only on Docsity! Test Bank for Medical Surgical Nursing 10th Edition by Lewis Table of Contents Section One – Concepts in Nursing Practice 1. Professional Nursing Practice 2. Health Disparities and Culturally Competent Care 3. Health History and Physical Examination 4. Patient and Caregiver Teaching 5. Chronic Illness and Older Adults 6. Stress and Stress Management 7. Sleep and Sleep Disorders 8. Pain 9. Palliative Care at End of Life 10. Substance Use Disorders Section Two – Pathophysiologic Mechanisms of Disease 11. Inflammation and Wound Healing 12. Genetics and Genomics 13. Altered Immune Responses and Transplantation 14. Infection and Human Immunodeficiency Virus Infection 15. Cancer 16. Fluid, Electrolyte, and Acid-Base Imbalances Section Three – Perioperative Care 17. Preoperative Care 18. Intraoperative Care ‘ 19. Postoperative Care Section Four – Problems Related to Altered Sensory Input 20. Assessment of Visual and Auditory Systems 21. Visual and Auditory Problems 22. Assessment of Integumentary System 23. Integumentary Problems 24. Burns Section Five – Problems of Oxygenation: Ventilation 25. Assessment of Respiratory System 26. Upper Respiratory Problems 27. Lower Respiratory Problems 28. Obstructive Pulmonary Diseases Section Six – Problems of Oxygenation: Transport 29. Assessment of Hematologic System 30. Hematologic Problems Section Seven – Problems of Oxygenation: Perfusion 31. Assessment of Cardiovascular System Wiab)o, im SURGICAL NURSING CS ss re ume Mt mols. LEWIS: BUCHER HEITKEMPER-HARDING KWONG -ROBERTS ©) CvOerd £1 eR COM ELSEVIER Copa wytted Matertal Chapter 01: Professional Nursing Practice Lewis: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. The nurse completes an admission database and explains that the plan of care and discharge goals will be developed with the patient’s input. The patient states, “How is this different from what the doctor does?” Which response would be most appropriate for the nurse to make? a. “The role of the nurse is to administer medications and other treatments prescribed by your doctor.” b. “The nurse’s job is to help the doctor by collecting information and communicating any problems that occur.” c. “Nurses perform many of the same procedures as the doctor, but nurses are with the patients for a longer time than the doctor.” d. “In addition to caring for you while you are sick, the nurses will assist you to develop an individualized plan to maintain your health.” ANS: D This response is consistent with the American Nurses Association (ANA) definition of nursing, which describes the role of nurses in promoting health. The other responses describe some of the dependent and collaborative functions of the nursing role but do not accurately describe the nurse’s role in the health care system. DIF: Cognitive Level: Understand (comprehension) REF: 3 TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 2. The nurse describes to a student nurse how to use evidence-based practice guidelines when caring for patients. Which statement, if made by the nurse, would be the most accurate? a. “Inferences from clinical research studies are used as a guide.” b. “Patient care is based on clinical judgment, experience, and traditions.” c. “Data are evaluated to show that the patient outcomes are consistently met.” d. “Recommendations are based on research, clinical expertise, and patient preferences.” ANS: D Evidence-based practice (EBP) is the use of the best research-based evidence combined with clinician expertise. Clinical judgment based on the nurse’s clinical experience is part of EBP, but clinical decision making should also incorporate current research and research-based guidelines. Evaluation of patient outcomes is important, but interventions should be based on research from randomized control studies with a large number of subjects. DIF: Cognitive Level: Remember (knowledge) REF: 15 TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 3. The nurse teaches a student nurse about how to apply the nursing process when providing patient care. Which statement, if made by the student nurse, indicates that teaching was successful? a. “The nursing process is a scientific-based method of diagnosing the patient’s health care problems.” b. “The nursing process is a problem-solving tool used to identify and treat patients’ health care needs.” c. “The nursing process is used primarily to explain nursing interventions to other health care professionals.” d. “The nursing process is based on nursing theory that incorporates the biopsychosocial nature of humans.” ANS: B The nursing process is a problem-solving approach to the identification and treatment of patients’ problems. Diagnosis is only one phase of the nursing process. The primary use of the nursing process is in patient care, not to establish nursing theory or explain nursing interventions to other health care professionals. DIF: Cognitive Level: Understand (comprehension) REF: 5 TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 4. A patient has been admitted to the hospital for surgery and tells the nurse, “I do not feel comfortable leaving my children with my parents.” Which action should the nurse take next? a. Reassure the patient that these feelings are common for parents. b. Have the patient call the children to ensure that they are doing well. c. Gather more data about the patient’s feelings about the child-care arrangements. d. Call the patient’s parents to determine whether adequate child care is being provided. ANS: C Because a complete assessment is necessary in order to identify a problem and choose an appropriate intervention, the nurse’s first action should be to obtain more information. The other actions may be appropriate, but more assessment is needed before the best intervention can be chosen. DIF: Cognitive Level: Apply (application) REF: 6 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 5. A patient who is paralyzed on the left side of the body after a stroke develops a pressure ulcer on the left hip. Which nursing diagnosis is most appropriate? a. Impaired physical mobility related to left-sided paralysis b. Risk for impaired tissue integrity related to left-sided weakness c. Impaired skin integrity related to altered circulation and pressure d. Ineffective tissue perfusion related to inability to move independently ANS: C The patient’s major problem is the impaired skin integrity as demonstrated by the presence of a pressure ulcer. The nurse is able to treat the cause of altered circulation and pressure by frequently repositioning the patient. Although left-sided weakness is a problem for the patient, the nurse cannot treat the weakness. The “risk for” diagnosis is not appropriate for this patient, who already has impaired tissue integrity. The patient does have ineffective tissue perfusion, but the impaired skin integrity diagnosis indicates more clearly what the health problem is. DIF: Cognitive Level: Apply (application) REF: 7 TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity Assessment requires RN education and scope of practice and cannot be delegated to an LPN/LVN or UAP. The other assignments made by the RN are appropriate. DIF: Cognitive Level: Apply (application) REF: 11 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 13. Which task is appropriate for the nurse to delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Complete the initial admission assessment and plan of care. b. Document teaching completed before a diagnostic procedure. c. Instruct a patient about low-fat, reduced sodium dietary restrictions. d. Obtain bedside blood glucose on a patient before insulin administration. ANS: D The education and scope of practice of the LPN/LVN include activities such as obtaining glucose testing using a finger stick. Patient teaching and the initial assessment and development of the plan of care are nursing actions that require registered nurse education and scope of practice. DIF: Cognitive Level: Apply (application) REF: 11 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 14. A nurse is assigned as a case manager for a hospitalized patient with a spinal cord injury. The patient can expect the nurse functioning in this role to perform which activity? a. Care for the patient during hospitalization for the injuries. b. Assist the patient with home care activities during recovery. c. Determine what medical care the patient needs for optimal rehabilitation. d. Coordinate the services that the patient receives in the hospital and at home. ANS: D The role of the case manager is to coordinate the patient’s care through multiple settings and levels of care to allow the maximal patient benefit at the least cost. The case manager does not provide direct care in either the acute or home setting. The case manager coordinates and advocates for care but does not determine what medical care is needed; that would be completed by the health care provider or other provider. DIF: Cognitive Level: Apply (application) REF: 9 TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 15. The nurse is caring for an older adult patient who had surgery to repair a fractured hip. The patient needs continued nursing care and physical therapy to improve mobility before returning home. The nurse will help to arrange for transfer of this patient to which facility? a. A skilled care facility c. A transitional care facility b. A residential care facility d. An intermediate care facility ANS: C Transitional care settings are appropriate for patients who need continued rehabilitation before discharge to home or to long-term care settings. The patient is no longer in need of the more continuous assessment and care given in acute care settings. There is no indication that the patient will need the permanent and ongoing medical and nursing services available in intermediate or skilled care. The patient is not yet independent enough to transfer to a residential care facility. DIF: Cognitive Level: Apply (application) REF: 8 TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 16. A home care nurse is planning care for a patient who has just been diagnosed with type 2 diabetes mellitus. Which task is appropriate for the nurse to delegate to the home health aide? a. Assist the patient to choose appropriate foods. b. Help the patient with a daily bath and oral care. c. Check the patient’s feet for signs of breakdown. d. Teach the patient how to monitor blood glucose. ANS: B Assisting with patient hygiene is included in home health-aide education and scope of practice. Assessment of the patient and instructing the patient in new skills, such as diet and blood glucose monitoring, are complex skills that are included in registered nurse education and scope of practice. DIF: Cognitive Level: Apply (application) REF: 11 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 17. The nurse is providing education to nursing staff on quality care initiatives. Which statement is an accurate description of the impact of health care financing on quality care? a. “If a patient develops a catheter-related infection, the hospital receives additional funding.” b. “Payment for patient care is primarily based on clinical outcomes and patient satisfaction.” c. “Hospitals are reimbursed for all costs incurred if care is documented electronically.” d. “Because hospitals are accountable for overall care, it is not nursing’s responsibility to monitor care delivered by others.” ANS: B Payment for health care services programs reimburses hospitals for their performance on overall quality-of-care measures. These measures include clinical outcomes and patient satisfaction. Nurses are responsible for coordinating complex aspects of patient care, including the care delivered by others, and identifying issues that are associated with poor quality care. Payment for care can be withheld if something happens to the patient that is considered preventable (e.g., acquiring a catheter-related urinary tract infection). DIF: Cognitive Level: Apply (application) REF: 4 TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 18. The nurse documenting the patient’s progress in the care plan in the electronic health record before an interprofessional discharge conference is demonstrating competency in which QSEN category? a. Patient-centered care c. Evidence-based practice b. Quality improvement d. Informatics and technology ANS: D The nurse is displaying competency in the QSEN area of informatics and technology. Using a computerized information system to document patient needs and progress and communicate vital information regarding the patient with the interprofessional care team members provides evidence that nursing practice standards related to the nursing process have been maintained during the care of the patient. DIF: Cognitive Level: Apply (application) REF: 13 TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment MULTIPLE RESPONSE 1. Which information will the nurse consider when deciding what nursing actions to delegate to a licensed practical/vocational nurse (LPN/LVN) who is working on a medical-surgical unit (select all that apply)? a. Institutional policies b. Stability of the patient c. State nurse practice act d. LPN/LVN teaching abilities e. Experience of the LPN/LVN ANS: A, B, C, E The nurse should assess the experience of LPN/LVNs when delegating. In addition, state nurse practice acts and institutional policies must be considered. In general, whereas the LPN/LVN scope of practice includes caring for patients who are stable, registered nurses should provide most of the care for unstable patients. Because the LPN/LVN scope of practice does not include patient education, this will not be part of the delegation process. DIF: Cognitive Level: Apply (application) REF: 11 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 2. The nurse is administering medications to a patient. Which actions by the nurse during this process are consistent with promoting safe delivery of care (select all that apply)? a. Throws away a medication that is not labeled b. Uses a hand sanitizer before preparing a medication c. Identifies the patient by the room number on the door d. Checks laboratory test results before administering a diuretic e. Gives the patient a list of current medications upon discharge ANS: A, B, D, E c. Explain the usual hospital routines for meal times, care, and family visits. d. Obtain further information about the patient’s cultural beliefs from a family member. ANS: B Because the patient has traditional health care beliefs, it is appropriate for the nurse to ask whether the patient would like a visit by a shaman or other cultural healer. There is no cultural reason for the nurse to avoid asking the patient questions because these questions are necessary to obtain health information. The patient (rather than the family) should be consulted about personal cultural beliefs. The hospital routines for meals, care, and visits should be adapted to the patient’s preferences rather than expecting the patient to adapt to the hospital schedule. DIF: Cognitive Level: Apply (application) REF: 24 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 5. The nurse is caring for an Asian patient who is being admitted to the hospital. Which action would be most appropriate for the nurse to take when interviewing this patient? a. Avoid eye contact with the patient. b. Observe the patient’s use of eye contact. c. Look directly at the patient when interacting. d. Ask a family member about the patient’s cultural beliefs. ANS: B Observation of the patient’s use of eye contact will be most useful in determining the best way to communicate effectively with the patient. Looking directly at the patient or avoiding eye contact may be appropriate, depending on the patient’s individual cultural beliefs. The nurse should assess the patient, rather than asking family members about the patient’s beliefs. DIF: Cognitive Level: Apply (application) REF: 25 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 6. A female staff nurse is assessing a male patient of Arab descent who is admitted with complaints of severe headaches. It is most important for the charge nurse to intervene if the nurse takes which action? a. The nurse explains the 0 to 10 intensity pain scale. b. The nurse asks the patient when the headaches started. c. The nurse sits down at the bedside and closes the privacy curtain. d. The nurse calls for a male nurse to bring a hospital gown to the room. ANS: C Many men of Arab ethnicity do not believe it is appropriate to be alone with any female except for their spouse. The other actions are appropriate. DIF: Cognitive Level: Apply (application) REF: 25 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 7. The nurse is caring for a patient who speaks a different language. If an interpreter is not available, which action by the nurse is most appropriate? a. Talk slowly so that each word is clearly heard. b. Speak loudly in close proximity to the patient’s ears. c. Repeat important words so that the patient recognizes their significance. d. Use simple gestures to demonstrate meaning while talking to the patient. ANS: D The use of gestures will enable some information to be communicated to the patient. The other actions will not improve communication with the patient. DIF: Cognitive Level: Understand (comprehension) REF: 31 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 8. The nurse plans care for a hospitalized patient who uses culturally based treatments. Which action by the nurse is best? a. Encourage the use of diagnostic procedures. b. Coordinate the use of folk treatments with ordered medical therapies. c. Ask the patient to discontinue the cultural treatments during hospitalization. d. Teach the patient that folk remedies will interfere with orders by the health care provider. ANS: B Many culturally based therapies can be accommodated along with the use of Western treatments and medications. The nurse should attempt to use both traditional folk treatments and the ordered Western therapies as much as possible. Some culturally based treatments can be effective in treating “Western” diseases. Not all folk remedies interfere with Western therapies. It may be appropriate for the patient to continue some culturally based treatments while he or she is hospitalized. DIF: Cognitive Level: Apply (application) REF: 22 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity 9. The nurse is caring for a newly admitted patient. Which intervention is the best example of a culturally appropriate nursing intervention? a. Insist family members provide most of the patient’s personal care. b. Maintain a personal space of at least 2 feet when assessing the patient. c. Ask permission before touching a patient during the physical assessment. d. Consider the patient’s ethnicity as the most important factor in planning care. ANS: C Many cultures consider it disrespectful to touch a patient without asking permission, so asking a patient for permission is always culturally appropriate. The other actions may be appropriate for some patients but are not appropriate across all cultural groups or for all individual patients. Ethnicity may not be the most important factor in planning care, especially if the patient has urgent physiologic problems. DIF: Cognitive Level: Understand (comprehension) REF: 28 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 10. A staff nurse expresses frustration that a Native American patient always has several family members at the bedside. Which action by the charge nurse is most appropriate? a. Remind the nurse that family support is important to this family and patient. b. Have the nurse explain to the family that too many visitors will tire the patient. c. Suggest that the nurse ask family members to leave the room during patient care. d. Ask about the nurse’s personal beliefs about family support during hospitalization. ANS: D The first step in providing culturally competent care is to understand one’s own beliefs and values related to health and health care. Asking the nurse about personal beliefs will help achieve this step. Reminding the nurse that this cultural practice is important to the family and patient will not decrease the nurse’s frustration. The remaining responses (suggest that the nurse ask family members to leave the room and have the nurse explain to family that too many visitors will tire the patient) are not culturally appropriate for this patient. DIF: Cognitive Level: Apply (application) REF: 23 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 11. An older Asian American patient tells the nurse that she has lived in the United States for 50 years. The patient speaks English and lives in a predominantly Asian neighborhood. Which action by the nurse is most appropriate? a. Include a shaman when planning the patient’s care. b. Avoid direct eye contact with the patient during care. c. Ask the patient about any special cultural beliefs or practices. d. Involve the patient’s oldest son to assist with health care decisions. ANS: C Further assessment of the patient’s health care preferences is needed before making further plans for culturally appropriate care. The other responses indicate stereotyping of the patient based on ethnicity and would not be appropriate initial actions. DIF: Cognitive Level: Apply (application) REF: 23 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity 12. The nurse plans health care for a community with a large number of recent immigrants from Vietnam. Which intervention is the most important for the nurse to implement? a. Hepatitis testing c. Contraceptive teaching b. Tuberculosis screening d. Colonoscopy information ANS: B Tuberculosis (TB) is endemic in many parts of Asia, and the incidence of TB is much higher in immigrants from Vietnam than in the general U.S. population. Teaching about contraceptive use, colonoscopy, and testing for hepatitis may also be appropriate for some patients but is not generally indicated for all members of this community. DIF: Cognitive Level: Apply (application) REF: 28 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 13. When doing an admission assessment for a patient, the nurse notices that the patient pauses before answering questions about the health history. Which action by the nurse is most appropriate? a. Interview a family member instead. b. Wait for the patient to answer the questions. c. Remind the patient that you have other patients who need care. d. Give the patient an assessment form listing the questions and a pen. ANS: B Chapter 03: Health History and Physical Examination Lewis: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A patient who is actively bleeding is admitted to the emergency department. Which approach is best for the nurse to use to obtain a health history? a. Briefly interview the patient while obtaining vital signs. b. Obtain subjective data about the patient from family members. c. Omit subjective data collection and obtain the physical examination. d. Use the health care provider’s medical history to obtain subjective data. ANS: A In an emergency situation, the nurse may need to ask only the most pertinent questions for a specific problem and obtain more information later. A complete health history will include subjective information that is not available in the health care provider’s medical history. Family members may be able to provide some subjective data, but only the patient will be able to give subjective information about the bleeding. Because the subjective data about the cause of the patient’s bleeding will be essential, obtaining the physical examination alone will not provide sufficient information. DIF: Cognitive Level: Apply (application) REF: 40 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 2. Immediate surgery is planned for a patient with acute abdominal pain. Which question by the nurse will elicit the most complete information about the patient’s coping-stress tolerance pattern? a. “Can you rate your pain on a 0 to 10 scale?” b. “What do you think caused this abdominal pain?” c. “How do you feel about yourself and your hospitalization?” d. “Are there other major problems that are a concern right now?” ANS: D The coping–stress tolerance pattern includes information about other major stressors confronting the patient. The health perception–health management pattern includes information about the patient’s ideas about risk factors. Feelings about self and the hospitalization are assessed in the self-perception–self-concept pattern. Intensity of pain is part of the cognitive–perceptual pattern. DIF: Cognitive Level: Apply (application) REF: 37 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 3. During the health history interview, a patient tells the nurse about periodic fainting spells. Which question by the nurse will best elicit any associated clinical manifestations? a. “How frequently do you have the fainting spells?” b. “Where are you when you have the fainting spells?” c. “Do the spells tend to occur at any special time of day?” d. “Do you have any other symptoms along with the spells?” ANS: D Asking about other associated symptoms will provide the nurse more information about all the clinical manifestations related to the fainting spells. Information about the setting is obtained by asking where the patient was and what the patient was doing when the symptom occurred. The other questions from the nurse are appropriate for obtaining information about chronology and frequency. DIF: Cognitive Level: Apply (application) REF: 35 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 4. The nurse records the following general survey of a patient: “The patient is a 50-yr-old Asian female attended by her husband and two daughters. Alert and oriented. Does not make eye contact with the nurse and responds slowly, but appropriately, to questions. No apparent disabilities or distinguishing features.” What additional information should the nurse add to this general survey? a. Nutritional status b. Intake and output c. Reasons for contact with the health care system d. Comments of family members about his condition ANS: A The general survey also describes the patient’s general nutritional status. The other information will be obtained when doing the complete nursing history and examination but is not obtained through the initial scanning of a patient. DIF: Cognitive Level: Understand (comprehension) REF: 39 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 5. A nurse performs a health history and physical examination with a patient who has a right leg fracture. Which assessment would be a pertinent negative finding? a. Patient has several bruised and swollen areas on the right leg. b. Patient states that there have been no other recent health problems. c. Patient refuses to bend the right knee because of the associated pain. d. Patient denies having pain when the area over the fracture is palpated. ANS: D The nurse expects that a patient with a leg fracture will have pain over the fractured area. The bruising and swelling and pain with bending are positive findings. Having no other recent health problems is neither a positive nor a negative finding with regard to a leg fracture. DIF: Cognitive Level: Apply (application) REF: 39 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 6. The nurse who is assessing an older adult with rectal bleeding asks, “Have you ever had a colonoscopy?” The nurse is performing what type of assessment? a. Focused assessment c. Detailed health assessment b. Emergency assessment d. Comprehensive assessment ANS: A A focused assessment is an abbreviated assessment used to evaluate the status of previously identified problems and monitor for signs of new problems. It can be done when a specific problem is identified. An emergency assessment is done when the nurse needs to obtain information about life-threatening problems quickly while simultaneously taking action to maintain vital function. A comprehensive assessment includes a detailed health history and physical examination of one body system or many body systems. It is typically done on admission to the hospital or onset of care in a primary care setting. DIF: Cognitive Level: Understand (comprehension) REF: 40 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 7. The nurse is preparing to perform a focused assessment for a patient complaining of shortness of breath. Which equipment will be needed? a. Flashlight c. Tongue blades b. Stethoscope d. Percussion hammer ANS: B A stethoscope is used to auscultate breath sounds. The other equipment may be used for a comprehensive assessment but will not be needed for a focused respiratory assessment. DIF: Cognitive Level: Understand (comprehension) REF: 40 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 8. The nurse plans to complete a physical examination of an alert, older patient. Which adaptations to the examination technique should the nurse include? a. Avoid the use of touch as much as possible. b. Use slightly more pressure for palpation of the liver. c. Speak softly and slowly when talking with the patient. d. Organize the sequence to minimize the position changes. ANS: D Older patients may have age-related changes in mobility that make it more difficult to change position. There is no need to avoid the use of touch when examining older patients. Less pressure should be used over the liver. Because the patient is alert, there is no indication that there is any age-related difficulty in understanding directions from the nurse. DIF: Cognitive Level: Apply (application) REF: 40 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 9. While the nurse is taking the health history, a patient states, “My mother and sister both had double mastectomies and were unable to be very active for weeks.” Which functional health pattern is represented by this patient’s statement? a. Activity–exercise b. Cognitive–perceptual c. Coping–stress tolerance d. Health perception–health management ANS: D The information in the patient statement relates to risk factors and important information about the family history. Identification of risk factors falls into the health perception–health maintenance pattern. Chapter 04: Patient and Caregiver Teaching Lewis: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A patient with newly diagnosed colon cancer has a nursing diagnosis of deficient knowledge about colon cancer. The nurse should initially focus on which learning goal for this patient? a. The patient will state ways of preventing the recurrence of the cancer. b. The patient will explore and select an appropriate colon cancer therapy. c. The patient will demonstrate coping skills needed to manage the disease. d. The patient will choose methods to minimize adverse effects of treatment. ANS: B Adults learn best when given information that can be used immediately. The first action the patient will need to take after a cancer diagnosis is to explore and choose a treatment option. The other goals may be appropriate as treatment progresses. DIF: Cognitive Level: Apply (application) REF: 47 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 2. After the nurse provides diet instructions for a patient with diabetes, the patient can restate the information but fails to make the recommended diet changes. How would the nurse best evaluate the patient’s situation? a. Learning did not occur because the patient’s behavior did not change. b. Choosing not to follow the diet is the behavior that resulted from learning. c. The nurse’s responsibility for helping the patient make diet changes has been fulfilled. d. The teaching methods were ineffective in helping the patient learn about the necessary diet changes. ANS: B Although the patient behavior has not changed, the patient’s ability to restate the information indicates that learning has occurred, and the patient is choosing at this time not to change the diet. The patient may be in the contemplation or preparation stage in the transtheoretical model. The nurse should reinforce the need for change and continue to provide information and assistance with planning for change. DIF: Cognitive Level: Apply (application) REF: 47 TOP: Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance 3. A patient is diagnosed with heart failure after being admitted to the hospital for shortness of breath and fatigue. Which teaching strategy, if implemented by the nurse, is most likely to be effective? a. Assure the patient that the nurse is an expert on management of heart failure. b. Teach the patient at each meal about the amounts of sodium in various foods. c. Discuss the importance of medication control in maintenance of long-term health. d. Refer the patient to a home health nurse for instructions on diet and fluid restrictions. ANS: B Principles of adult education indicate that readiness and motivation to learn are high when facing new tasks (e.g., learning about the sodium amounts in various food items) and when demonstration and practice of skills are available. Although a home health referral may be needed for this patient, teaching should not be postponed until discharge. Adult learners are independent. The nurse should act as a facilitator for learning, rather than as the expert. Adults learn best when the topic is of immediate usefulness. Long-term goals may not be very motivating. DIF: Cognitive Level: Apply (application) REF: 47 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 4. A patient who was admitted to the hospital with hyperglycemia and newly diagnosed diabetes mellitus is scheduled for discharge the second day after admission. When implementing patient teaching, what is the priority action for the nurse? a. Instruct about the increased risk for cardiovascular disease. b. Provide detailed information about dietary control of glucose. c. Teach glucose self-monitoring and medication administration. d. Give information about the effects of exercise on glucose control. ANS: C When time is limited, the nurse should focus on the priorities of teaching. In this situation, the patient should know how to test blood glucose and administer medications to control glucose levels. The patient will need further teaching about the role of diet, exercise, various medications, and the many potential complications of diabetes, but these topics can be addressed through planning for appropriate referrals. DIF: Cognitive Level: Apply (application) REF: 49 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 5. A patient states, “I told my husband I wouldn’t buy as much prepared food snacks, so I will go the grocery store to buy fresh fruit, vegetables, and whole grains.” When using the Transtheoretical Model of Health Behavior Change, the nurse identifies that this patient is in which stage of change? a. Preparation c. Maintenance b. Termination d. Contemplation ANS: A The patient’s statement indicating that the plan for change is being shared with someone else indicates that the preparation stage has been achieved. Contemplation of a change would be indicated by a statement like “I know I should exercise.” Maintenance of a change occurs when the patient practices the behavior regularly. Termination would be indicated when the change is a permanent part of the lifestyle. DIF: Cognitive Level: Understand (comprehension) REF: 48 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 6. While admitting a patient to the medical unit, the nurse determines that the patient has a hearing impairment. How should the nurse use this information to plan teaching and learning strategies? a. Motivation and readiness to learn will be affected. b. The family must be included in the teaching process. c. The patient will have problems understanding information. d. Written materials should be provided with verbal instructions. ANS: D The information that the patient has a hearing impairment indicates that the nurse should use written and verbal materials in teaching along with other strategies. The patient does not indicate a lack of motivation or an inability to understand new information. The patient’s decreased hearing does not necessarily imply that the family must be included in the teaching process. DIF: Cognitive Level: Understand (comprehension) REF: 51 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 7. A patient who is morbidly obese states, “I’ve recently made some changes in my life. I’ve decreased my fat intake, and I’ve stopped smoking.” Which statement, if made by the nurse, is the best initial response? a. “Although those are important, it is essential that you make other changes, too.” b. “Are you having any difficulty in maintaining the changes you have already made?” c. “Which additional changes in your lifestyle would you like to implement at this time?” d. “You have already accomplished changes that are important for the health of your heart.” ANS: D Positive reinforcement of the learner’s achievements is critical in making lifestyle changes. This patient is in the action stage of the Transtheoretical Model when reinforcement of the changes being made is an important nursing intervention. The other responses are also appropriate but are not the best initial response. DIF: Cognitive Level: Apply (application) REF: 53 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 8. The nurse is planning a teaching session with a patient newly diagnosed with migraine headaches. To assess a patient’s readiness to learn, which question should the nurse ask first? a. “What kind of work and leisure activities do you do?” b. “What information do you think you need right now?” c. “Can you describe the types of activities that help you learn new information?” d. “Do you have any religious beliefs that are inconsistent with the planned treatment?” ANS: B Motivation and readiness to learn depend on what the patient values and perceives as important. The other questions are also important in developing the teaching plan, but do not address what information most interests the patient at present. DIF: Cognitive Level: Apply (application) REF: 53 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 9. The nurse considers a nursing diagnosis of ineffective health maintenance related to low motivation for a patient with diabetes. Which finding would the nurse most likely use to support this nursing diagnosis? ANS: B The patient’s statement indicates that he or she is not considering smoking cessation. Ineffective health maintenance is defined as the inability to identify, manage, or seek out help to maintain health. DIF: Cognitive Level: Apply (application) REF: 47 TOP: Nursing Process: Diagnosis MSC: NCLEX: Health Promotion and Maintenance 16. An older Asian patient, who is seen at the health clinic, is diagnosed with protein malnutrition. What priority action should the nurse include in the teaching plan? a. Suggest the use of liquid supplements as a way to increase protein intake. b. Encourage the patient to increase the dietary intake of meat, cheese, and milk. c. Ask the patient to record the intake of all foods and beverages for a 3-day period. d. Focus on the use of combinations of beans and rice to improve daily protein intake. ANS: C Assessment is the first step in assisting a patient with health changes. The other answers may be appropriate for the patient, but the nurse will not be able to determine this until the assessment of the patient is complete. DIF: Cognitive Level: Apply (application) REF: 49 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 17. A middle-aged patient who has diabetes tells the nurse, “I want to know how to give my own insulin so I don’t have to bother my wife all the time.” What is the priority action of the nurse? a. Demonstrate how to draw up and administer insulin. b. Discuss the use of exercise to decrease insulin needs. c. Teach about differences between the various types of insulin. d. Provide handouts about therapeutic and adverse effects of insulin. ANS: A Adult education is most effective when focused on information that the patient thinks is needed right now. All of the indicated information will need to be included when planning teaching for this patient, but the teaching will be most effective if the nurse starts with the patient’s stated priority topic. DIF: Cognitive Level: Apply (application) REF: 47 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 18. The nurse plans to teach a patient and the caregiver how to manage high blood pressure (BP). Which action should the nurse take first? a. Give written information about hypertension to the patient and caregiver. b. Have the dietitian meet with the patient and caregiver to discuss a low-sodium diet. c. Teach the caregiver how to take the patient’s BP using a manual blood pressure cuff. d. Ask the patient and caregiver to select information from a list of high BP teaching topics. ANS: D Because adults learn best when given information that they view as being needed immediately, asking the caregiver and patient to prioritize learning needs is likely to be the most successful approach to home management of health problems. The other actions may also be appropriate, depending on what learning needs the caregiver and patient have, but the initial action should be to assess what the learners feel is important. DIF: Cognitive Level: Apply (application) REF: 47 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 19. A postoperative patient and caregiver need discharge teaching. Which actions included in the teaching plan can the nurse delegate to unlicensed assistive personnel (UAP)? a. Evaluate whether the patient and caregiver understand the teaching. b. Show the caregiver how to accurately check the patient’s temperature. c. Schedule the discharge teaching session with the patient and caregiver. d. Give the patient a pamphlet reinforcing teaching already done by the nurse. ANS: D Providing a pamphlet to a patient to reinforce previously taught material does not require nursing judgment and can safely be delegated to UAP. Demonstration of how to take a temperature accurately, determining the best time for teaching, and evaluation of the success of patient teaching all require judgment and critical thinking and should be done by the registered nurse. DIF: Cognitive Level: Apply (application) REF: 46 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 20. A family caregiver tells the home health nurse, “I feel like I can never get away to do anything for myself.” Which action is best for the nurse to take? a. Assist the caregiver in finding respite services. b. Assure the caregiver that the work is appreciated. c. Encourage the caregiver to discuss feelings openly with the nurse. d. Tell the caregiver that family members provide excellent patient care. ANS: A Respite services allow family caregivers to have time away from their caregiving responsibilities. The other actions may also be helpful, but the caregiver’s statement clearly indicates the need for some time away. DIF: Cognitive Level: Apply (application) REF: 49 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE 1. The nurse plans to provide instructions about diabetes to a patient who has a low literacy level. Which teaching strategies should the nurse use (select all that apply)? a. Discourage use of the Internet as a source of health information. b. Avoid asking the patient about reading abilities and level of education. c. Provide illustrations and photographs showing various types of insulin. d. Schedule one-to-one teaching sessions to practice insulin administration. e. Obtain CDs and DVDs that illustrate how to perform blood glucose testing. ANS: C, D, E For patients with low literacy, visual and hands-on learning techniques are most appropriate. The nurse will need to obtain as much information as possible about the patient’s reading level in order to provide appropriate learning materials. The nurse should guide the patient to Internet sites established by reputable heath care organizations such as the American Diabetes Association. DIF: Cognitive Level: Apply (application) REF: 52 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance b. Obtain extra medications for the patient to last for 4 to 6 months. c. Ensure transportation to appointments with the health care provider. d. Assess the patient for chronic diseases that are unique to rural areas. ANS: C Transportation can be a barrier to accessing health services in rural areas. The patient living in a rural area may lose the benefits of a familiar situation and social support by moving to an urban area. There are no chronic diseases unique to rural areas. Because medications may change, the nurse should help the patient plan for obtaining medications through alternate means such as the mail or delivery services, not by purchasing large quantities of the medications. DIF: Cognitive Level: Apply (application) REF: 64 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 7. Which nursing action will be most helpful in decreasing the risk for drug-drug interactions in an older adult? a. Teach the patient to have all prescriptions filled at the same pharmacy. b. Make a schedule for the patient as a reminder of when to take each medication. c. Instruct the patient to avoid taking over-the-counter (OTC) medications or supplements. d. Ask the patient to bring all medications, supplements, and herbs to each appointment. ANS: D The most information about drug use and possible interactions is obtained when the patient brings all prescribed medications, OTC medications, and supplements to every health care appointment. The patient should discuss the use of any OTC medications with the health care provider and obtain all prescribed medications from the same pharmacy, but use of supplements and herbal medications also need to be considered in order to prevent drug–drug interactions. Use of a medication schedule will help the patient take medications as scheduled, but will not prevent drug–drug interactions. DIF: Cognitive Level: Analyze (analysis) REF: 65 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 8. A patient who has just moved to a long-term care facility has a nursing diagnosis of relocation stress syndrome. Which action should the nurse include in the plan of care? a. Remind the patient that making changes is usually stressful. b. Discuss the reason for the move to the facility with the patient. c. Restrict family visits until the patient is accustomed to the facility. d. Have staff members write notes welcoming the patient to the facility. ANS: D Having staff members write notes will make the patient feel more welcome and comfortable at the long-term care facility. Discussing the reason for the move and reminding the patient that change is usually stressful will not decrease the patient’s stress about the move. Family member visits will decrease the patient’s sense of stress about the relocation. DIF: Cognitive Level: Apply (application) REF: 69 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity 9. An older patient complains of having “no energy” and feeling increasingly weak. The patient has had a 12-lb weight loss over the past year. Which action should the nurse take initially? a. Ask the patient about daily dietary intake. b. Schedule regular range-of-motion exercise. c. Discuss long-term care placement with the patient. d. Describe normal changes associated with aging to the patient. ANS: A In a frail older patient, nutrition is frequently compromised, and the nurse’s initial action should be to assess the patient’s nutritional status. Active range of motion may be helpful in improving the patient’s strength and endurance, but nutritional assessment is the priority because the patient has had a significant weight loss. The patient may be a candidate for long-term care placement, but more assessment is needed before this can be determined. The patient’s assessment data are not consistent with normal changes associated with aging. DIF: Cognitive Level: Analyze (analysis) REF: 65 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 10. The nurse is admitting an acutely ill, older patient to the hospital. Which action should the nurse take? a. Speak slowly and loudly while facing the patient. b. Obtain a detailed medical history from the patient. c. Perform the physical assessment before interviewing the patient. d. Ask a family member to go home and retrieve the patient’s cane. ANS: C When a patient is acutely ill, the physical assessment should be accomplished first to detect any physiologic changes that require immediate action. Not all older patients have hearing deficits, and it is insensitive of the nurse to speak loudly and slowly to all older patients. To avoid tiring the patient, much of the medical history can be obtained from medical records. After the initial physical assessment to determine the patient’s current condition, then the nurse could ask someone to obtain any assistive devices for the patient if applicable. DIF: Cognitive Level: Apply (application) REF: 70 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 11. The nurse cares for an alert, homeless older adult patient who was admitted to the hospital with a chronic foot infection. Which intervention is the most appropriate for the nurse to include in the discharge plan for this patient? a. Teach the patient how to assess and care for the foot infection. b. Refer the patient to social services for assessment of resources. c. Schedule the patient to return to outpatient services for foot care. d. Give the patient written information about shelters and meal sites. ANS: B An interprofessional approach, including social services, is needed when caring for homeless older adults. Even with appropriate teaching, a homeless individual may not be able to maintain adequate foot care because of a lack of supplies or a suitable place to accomplish care. Older homeless individuals are less likely to use shelters or meal sites. A homeless person may fail to keep appointments for outpatient services because of factors such as fear of institutionalization or lack of transportation. DIF: Cognitive Level: Analyze (analysis) REF: 65 TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 12. The home health nurse cares for an older adult patient who lives alone and takes several different prescribed medications for chronic health problems. Which intervention, if implemented by the nurse, would best encourage medication compliance? a. Use a marked pillbox to set up the patient’s medications. b. Discuss the option of moving to an assisted living facility. c. Remind the patient about the importance of taking medications. d. Visit the patient daily to administer the prescribed medications. ANS: A Because forgetting to take medications is a common cause of medication errors in older adults, the use of medication reminder devices is helpful when older adults have multiple medications to take. There is no indication that the patient needs to move to assisted living or that the patient does not understand the importance of medication compliance. Home health care is not designed for the patient who needs ongoing assistance with activities of daily living or instrumental ADLs. DIF: Cognitive Level: Apply (application) REF: 73 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 13. The home health nurse visits an older patient with mild forgetfulness. Which new information is of most concern to the nurse? a. The patient tells the nurse that a close friend recently died. b. The patient has lost 10 lb (4.5 kg) during the past month. c. The patient is cared for by a daughter during the day and stays with a son at night. d. The patient’s son uses a marked pillbox to set up the patient’s medications weekly. ANS: B A 10-pound weight loss may be an indication of elder neglect or depression and requires further assessment by the nurse. The use of a marked pillbox and planning by the family for 24-hour care are appropriate for this patient. It is not unusual that an 86-yr-old would have friends who have died. DIF: Cognitive Level: Apply (application) REF: 74 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 14. Which statement, if made by an older adult patient, would be of most concern to the nurse? a. “I prefer to manage my life without much help from other people.” b. “I take three different medications for my heart and joint problems.” c. “I don’t go on daily walks anymore since I had pneumonia 3 months ago.” d. “I set up my medications in a marked pillbox so I don’t forget to take them.” ANS: C Measurement and documentation of vital signs are included in UAP education and scope of practice. Obtaining patient health history, planning activities based on the patient assessment, and patient education are all actions that require critical thinking and will be done by the registered nurse. DIF: Cognitive Level: Apply (application) REF: 75 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment MULTIPLE RESPONSE 1. Which nursing actions will the nurse take to assess for possible malnutrition in an older adult patient (select all that apply)? a. Assess for depression. b. Review laboratory results. c. Determine food preferences. d. Inspect teeth and oral mucosa. e. Ask about transportation needs. ANS: A, B, D, E The laboratory results, especially albumin and cholesterol levels, may indicate chronic poor protein intake or high-fat or high-cholesterol intake. Transportation affects the patient’s ability to shop for groceries. Depression may lead to decreased appetite. Oral sores or teeth in poor condition may decrease the ability to chew and swallow. Food likes and dislikes are not necessarily associated with malnutrition. DIF: Cognitive Level: Apply (application) REF: 65 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance Chapter 06: Stress and Stress Management Lewis: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. An adult patient who arrived at the triage desk in the emergency department (ED) with minor facial lacerations after a motor vehicle accident has a blood pressure (BP) of 182/94. Which action by the nurse is appropriate? a. Start an IV line to administer antihypertensive medications. b. Recheck the blood pressure after the patient has been assessed. c. Discuss the need for hospital admission to control blood pressure. d. Teach the patient about the stroke risk associated with uncontrolled hypertension. ANS: B When a patient experiences an acute stressor, the BP increases. The nurse should plan to recheck the BP after the patient has stabilized and received treatment. This will provide a more accurate indication of the patient’s usual blood pressure. Elevated BP that occurs in response to acute stress does not increase the risk for health problems such as stroke, indicate a need for hospitalization, or indicate a need for IV antihypertensive medications. DIF: Cognitive Level: Apply (application) REF: 80 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 2. A female patient who initially came to the clinic with incontinence was recently diagnosed with endometrial cancer. She is usually well organized and calm, but the nurse who is giving her preoperative instructions observes that the patient is irritable, has difficulty concentrating, and yells at her husband. Which action should the nurse take? a. Ask the health care provider for a psychiatric referral. b. Focus teaching on preventing postoperative complications. c. Try to calm the patient before repeating any information about the surgery. d. Encourage the patient to combine the hysterectomy with surgery for bladder repair. ANS: C Because behavioral responses to stress include temporary changes such as irritability, changes in memory, and poor concentration, patient teaching will need to be repeated. It is also important to try to calm the patient by listening to her concerns and fears. Psychiatric referral will not necessarily be needed for her but that can better be evaluated after surgery. Focusing on postoperative care does not address the need for preoperative instruction such as the procedure, NPO instructions before surgery, date and time of surgery, medications to be taken or discontinued before surgery, and so on. The issue of incontinence is not immediately relevant in the discussion of preoperative teaching for her hysterectomy. DIF: Cognitive Level: Apply (application) REF: 81 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 3. An adult patient who is hospitalized after a motorcycle crash tells the nurse, “I didn’t sleep last night because I worried about missing work at my new job and losing my insurance coverage.” Which nursing diagnosis is appropriate to include in the plan of care? a. Anxiety c. Ineffective denial b. Defensive coping d. Risk prone health behavior ANS: A The information about the patient indicates that anxiety is an appropriate nursing diagnosis. The patient data do not support defensive coping, ineffective denial, or risk prone health behavior as problems for this patient. DIF: Cognitive Level: Apply (application) REF: 78 TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 4. A patient is extremely anxious about having a biopsy on a femoral lymph node. Which relaxation technique would be the best choice for the nurse to facilitate during the procedure? a. Yoga stretching c. Relaxation breathing b. Guided imagery d. Mindfulness meditation ANS: C Relaxation breathing is an easy relaxation technique to teach and use. The patient should remain still during the biopsy and not move or stretch any of his extremities. Meditation and guided imagery require more time to practice and learn. DIF: Cognitive Level: Apply (application) REF: 83 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 5. A patient who has frequent migraines tells the nurse, “My life feels chaotic and out of my control. I could not manage if anything else happens.” Which response should the nurse make initially? a. “Regular exercise may get your mind off the pain.” b. “Guided imagery can be helpful in regaining control.” c. “Tell me more about how your life has been recently.” d. “Your previous coping resources can be helpful to you now.” ANS: C The nurse’s initial strategy should be further assessment of the stressors in the patient’s life. Exercise, guided imagery, or understanding how to use coping strategies that worked in the past may be of assistance to the patient, but more assessment is needed before the nurse can determine this. DIF: Cognitive Level: Apply (application) REF: 86 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 6. A nurse prepares an adult patient with a severe burn injury for a dressing change. The nurse knows that this is a painful procedure and wants to try providing music to help the patient relax. Which action is best for the nurse to take? a. Use music composed by Mozart. b. Play music that does not have words. c. Ask the patient about music preferences. d. Select music that has 60 to 80 beats/minute. ANS: C Although music with 60 to 80 beats/min, music without words, and music composed by Mozart are frequently recommended to reduce stress, each patient responds individually to music and personal preferences are important. c. Ask about epigastric discomfort. d. Monitor for decreased respiratory rate. e. Check for elevated blood glucose levels. ANS: B, C, E The physiologic changes associated with the acute stress response can cause changes in appetite, increased gastric acid secretion, and increase blood glucose levels. In addition, stress causes an increase in respiratory and heart rates. DIF: Cognitive Level: Analyze (analysis) REF: 78 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity Chapter 07: Sleep and Sleep Disorders Lewis: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A patient complains of difficulty falling asleep and daytime fatigue for the past 6 weeks. What is the best initial action for the nurse to take in determining whether this patient has chronic insomnia? a. Schedule a polysomnograph (PSG). b. Teach the patient how to use an actigraph. c. Ask the patient to keep a 2-week sleep diary. d. Arrange for the patient to have a sleep study. ANS: C The diagnosis of insomnia is made on the basis of subjective complaints and an evaluation of a 1- to 2-week sleep diary completed by the patient. Actigraphy and PSG studies or sleep studies may be used for determining specific sleep disorders but are not necessary to make an initial insomnia diagnosis. DIF: Cognitive Level: Apply (application) REF: 91 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 2. A patient with chronic insomnia asks the nurse about ways to improve sleep quality. Which response by the nurse is accurate? a. Avoid exercise during the day. b. Keep the bedroom temperature warm. c. Read in bed for a few minutes each night. d. Go to bed at the same time every evening. ANS: D A regular evening schedule is recommended to improve sleep time and quality. Aerobic exercise may improve sleep quality but should occur at least 6 hours before bedtime. Reading in bed is discouraged for patients with insomnia. The bedroom temperature should be slightly cool. DIF: Cognitive Level: Apply (application) REF: 94 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 3. Which patient statement indicates a need for further teaching about extended-release zolpidem (Ambien CR)? a. “I should take the medication on an empty stomach.” b. “I will take the medication 1 to 2 hours before bedtime.” c. “I should not take this medication unless I can sleep for at least 6 hours.” d. “I will schedule activities that require mental alertness for later in the day.” ANS: B Benzodiazepine receptor agonists such as zolpidem work quickly and should be taken immediately before bedtime. The other patient statements are correct. DIF: Cognitive Level: Apply (application) REF: 94 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 4. The nurse cares for an unstable patient in the intensive care unit (ICU). Which intervention should the nurse include in the plan of care to improve this patient’s sleep quality? a. Ask all visitors to leave the ICU for the night. b. Lower the level of lighting from 8:00 PM until 7:00 AM. c. Avoid the use of opioids for pain relief during the evening. d. Schedule assessments to allow 4 hours of uninterrupted sleep. ANS: B Lowering the level of light will help mimic normal day/night patterns and maximize the opportunity for sleep. Although frequent assessments and opioid use can disturb sleep patterns, these actions are necessary for the care of unstable patients. For some patients, having a family member or friend at the bedside may decrease anxiety and improve sleep. DIF: Cognitive Level: Apply (application) REF: 96 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 5. What teaching should be included in the plan of care for a patient with narcolepsy? a. Driving an automobile may be possible with appropriate treatment of narcolepsy. b. Changes in sleep hygiene are ineffective in improving sleep quality in narcolepsy. c. Antidepressant drugs are prescribed to treat the depression caused by the disorder. d. Stimulant drugs should be used for less than a month because of the risk for abuse. ANS: A The accident rate FOR patients with narcolepsy who are receiving appropriate treatment is similar to the general population. Stimulant medications are used on an ongoing basis for patients with narcolepsy. The purpose of antidepressant drugs in the treatment of narcolepsy is the management of cataplexy, not to treat depression. Changes in sleep hygiene are recommended for patients with narcolepsy to improve sleep quality. DIF: Cognitive Level: Apply (application) REF: 98 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 6. Which action should the nurse manager promote as an evidence-based practice to support alertness for night shift nurses? a. Arrange for older staff members to work most night shifts. b. Provide a sleeping area for staff to use for napping at night. c. Post reminders about the relationship of sleep and alertness. d. Schedule nursing staff to rotate day and night shifts monthly. ANS: B Short onsite naps will improve alertness. Rotating shifts causes the most disruption in sleep habits. Reminding staff members about the impact of lack of sleep on alertness will not improve sleep or alertness. It is not feasible to schedule nurses based on their ages. DIF: Cognitive Level: Apply (application) REF: 100 TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 7. Which information regarding a patient’s sleep is most important for the nurse to communicate to the health care provider? a. A 21-yr-old student who takes melatonin to assist in sleeping when traveling from Chapter 08: Pain Lewis: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. Which question asked by the nurse will give the most information about the patient’s metastatic bone cancer pain? a. “How long have you had this pain?” b. “How would you describe your pain?” c. “How often do you take pain medication?” d. “How much medication do you take for the pain?” ANS: B Because pain is a multidimensional experience, asking a question that addresses the patient’s experience with the pain will elicit more information than the more specific information asked in the other three responses. All of these questions are appropriate, but the response beginning “How would you describe your pain?” is the best initial question. DIF: Cognitive Level: Analysis (analyze) REF: 102 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 2. A patient who has had good control for chronic pain using a fentanyl (Duragesic) patch reports rapid onset pain at a level 9 (0 to 10 scale) and requests “something for pain that will work quickly.” How will the nurse document the type of pain reported by this patient? a. Somatic pain c. Neuropathic pain b. Referred pain d. Breakthrough pain ANS: D Pain that occurs beyond the chronic pain already being treated by appropriate analgesics is termed breakthrough pain. Neuropathic pain is caused by damage to peripheral nerves or the central nervous system. Somatic pain is localized and arises from bone, joint, muscle, skin, or connective tissue. Referred pain is pain that is localized in uninjured tissue. DIF: Cognitive Level: Apply (application) REF: 108 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 3. The nurse teaches a student nurse about the action of ibuprofen. Which statement, if made by the student, indicates that teaching was effective? a. “The drug decreases pain impulses in the spinal cord.” b. “The drug decreases sensitivity of the brain to painful stimuli.” c. “The drug decreases production of pain-sensitizing chemicals.” d. “The drug decreases the modulating effect of descending nerves.” ANS: C Nonsteroidal antiinflammatory drugs (NSAIDs) provide analgesic effects by decreasing the production of pain-sensitizing chemicals such as prostaglandins at the site of injury. Transmission of impulses through the spinal cord, brain sensitivity to pain, and the descending nerve pathways are not affected by NSAIDs. DIF: Cognitive Level: Understand (comprehension) REF: 104 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 4. A nurse assesses a patient with chronic cancer pain who is receiving imipramine (Tofranil) in addition to long-acting morphine (MS Contin). Which statement, if made by the patient, indicates to the nurse that the patient is receiving adequate pain control? a. “I’m not anxious during the day.” b. “Every night I get 8 hours of sleep.” c. “I can accomplish activities without much discomfort.” d. “I feel less depressed since I’ve been taking the Tofranil.” ANS: C Imipramine is being used in this patient to manage chronic pain and improve functional ability. Although the medication is also prescribed for patients with depression, insomnia, and anxiety, the evaluation for this patient is based on improved pain control and activity level. DIF: Cognitive Level: Apply (application) REF: 116 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 5. A patient with chronic back pain has learned to control the pain with the use of imagery and hypnosis. The patient’s spouse asks the nurse how these techniques work. Which response by the nurse is accurate? a. “The strategies work by affecting the perception of pain.” b. “These techniques block the pain pathways of the nerves.” c. “These strategies prevent transmission of stimuli from the back to the brain.” d. “The therapies slow the release of chemicals in the spinal cord that cause pain.” ANS: A Cognitive therapies affect the perception of pain by the brain rather than affecting efferent or afferent pathways or influencing the release of chemical transmitters in the dorsal horn. DIF: Cognitive Level: Apply (application) REF: 121 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 6. A patient who is receiving sustained-release morphine sulfate (MS Contin) every 12 hours for chronic pain experiences level 9 (0 to 10 scale) breakthrough pain and anxiety. Which action by the nurse is appropriate for treating this change in assessment? a. Suggest amitriptyline 10 mg orally. b. Administer lorazepam (Ativan) 1 mg orally. c. Give ibuprofen (Motrin) 400 to 800 mg orally. d. Offer immediate-release morphine 30 mg orally. ANS: D The severe breakthrough pain indicates that the initial therapy should be a rapidly acting opioid, such as the immediate-release morphine. Lorazepam and amitriptyline may be appropriate to use as adjuvant therapy, but they are not likely to block severe breakthrough pain. Use of antianxiety agents for pain control is inappropriate because this patient’s anxiety is caused by the pain. DIF: Cognitive Level: Apply (application) REF: 108 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 7. A patient with chronic neck pain is seen in the pain clinic for follow-up. To evaluate whether the pain management is effective, which question is best for the nurse to ask? a. “Has there been a change in pain location?” b. “Can you describe the quality of your pain?” c. “How would you rate your pain on a 0 to 10 scale?” d. “Does the pain keep you from activities that you enjoy?” ANS: D The goal for the treatment of chronic pain usually is to enhance function and quality of life. The other questions are also appropriate to ask, but information about patient function is more useful in evaluating effectiveness. DIF: Cognitive Level: Apply (application) REF: 107 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 8. A patient with a deep partial thickness burn has been receiving hydromorphone through patient-controlled analgesia (PCA) for 1 week. The nurse caring for the patient during the previous shift reports that the patient wakes up frequently during the night complaining of pain. What action by the nurse is appropriate? a. Administer a dose of morphine every 1 to 2 hours from the PCA machine while the patient is sleeping. b. Consult with the health care provider about using a different treatment protocol to control the patient’s pain. c. Request that the health care provider order a bolus dose of morphine to be given when the patient awakens with pain. d. Teach the patient to push the button every 10 minutes for an hour before going to sleep, even if the pain is minimal. ANS: B PCAs are best for controlling acute pain. This patient’s history indicates a need for a pain management plan that will provide adequate analgesia while the patient is sleeping. Administering a dose of morphine when the patient already has severe pain will not address the problem. Teaching the patient to administer unneeded medication before going to sleep can result in oversedation and respiratory depression. It is illegal for the nurse to administer the morphine for a patient through PCA. DIF: Cognitive Level: Apply (application) REF: 107 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 9. The nurse assesses that a patient receiving epidural morphine has not voided for more than 10 hours. What action should the nurse take initially? a. Place an indwelling urinary catheter. b. Monitor for signs of narcotic overdose. c. Ask if the patient feels the need to void. d. Encourage the patient to drink more fluids. ANS: C Opioid agonist-antagonists can precipitate withdrawal if used in a patient who is physically dependent on mu agonist drugs such as morphine. The other medications are appropriate for the patient. DIF: Cognitive Level: Apply (application) REF: 114 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 16. The nurse is caring for a patient who had abdominal surgery yesterday and is receiving morphine through patient-controlled analgesia (PCA). What action by the nurse is a priority? a. Assessing for nausea c. Checking the respiratory rate b. Auscultating bowel sounds d. Evaluating for sacral redness ANS: C The patient’s respiratory rate is the highest priority of care while using PCA medication because of the possible respiratory depression. The other areas also require assessment but do not reflect immediately life-threatening complications. DIF: Cognitive Level: Analysis (analyze) REF: 115 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 17. A patient who has fibromyalgia reports pain at level 7 (0 to 10 scale). The patient tells the nurse, “I feel depressed because I ache too much to play golf.” Which patient goal has the highest priority when the nurse is developing the treatment plan? a. The patient will report pain at a level 2 of 10. b. The patient will be able to play a round of golf. c. The patient will exhibit fewer signs of depression. d. The patient will say that the aching has decreased. ANS: B For chronic pain, patients are encouraged to set functional goals such as being able to perform daily activities and hobbies. The patient has identified playing golf as the desired activity, so a pain level of 2 of 10 or a decrease in aching would be less useful in evaluating successful treatment. The nurse should also assess for depression, but the patient has identified the depression as being due to the inability to play golf, so the goal of being able to play golf is the most appropriate. DIF: Cognitive Level: Apply (application) REF: 107 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 18. A patient who has just started taking sustained-release morphine sulfate (MS Contin) for chronic arthritic joint pain after a traumatic injury complains of nausea and abdominal fullness. Which action should the nurse take initially? a. Administer the ordered antiemetic medication. b. Order the patient a clear liquid diet until the nausea decreases. c. Tell the patient that the nausea should subside in about a week. d. Consult with the health care provider about using a different opioid. ANS: A Nausea is frequently experienced with the initiation of opioid therapy, and antiemetics usually are prescribed to treat this expected side effect. The best choice would be to administer the antiemetic medication so the patient can eat. There is no indication that a different opioid is needed, although if the nausea persists, the health care provider may order a change of opioid. Although tolerance develops and the nausea will subside in about a week, it is not appropriate to allow the patient to continue to be nauseated. A clear liquid diet may decrease the nausea but may not provide needed nutrients for injury healing. DIF: Cognitive Level: Analyze (analysis) REF: 114 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 19. A patient with terminal cancer–related pain and a history of opioid abuse complains of breakthrough pain 2 hours before the next dose of sustained-release morphine sulfate (MS Contin) is due. Which action should the nurse take first? a. Use distraction by talking about things the patient enjoys. b. Suggest the use of alternative therapies such as heat or cold. c. Administer the prescribed PRN immediate-acting morphine. d. Consult with the doctor about increasing the MS Contin dose. ANS: C The patient’s pain requires rapid treatment, and the nurse should administer the immediate-acting morphine. Increasing the MS Contin dose and use of alternative therapies and distraction may also be needed, but the initial action should be to use the prescribed analgesic medications. DIF: Cognitive Level: Analyze (analysis) REF: 126 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 20. Which nursing action could the nurse delegate to unlicensed assistive personnel (UAP) when caring for a patient who is using a fentanyl (Duragesic) patch and a heating pad for treatment of chronic back pain? a. Check the skin under the heating pad. b. Count the respiratory rate every 2 hours. c. Ask the patient whether pain control is effective. d. Monitor sedation using the sedation assessment scale. ANS: B Obtaining the respiratory rate is included in UAP education and scope of practice. Assessment for sedation, pain control, and skin integrity requires more education and scope of practice. DIF: Cognitive Level: Apply (application) REF: 123 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 21. A patient who is using both a fentanyl (Duragesic) patch and immediate-release morphine for chronic cancer pain develops new-onset confusion, dizziness, and a decrease in respiratory rate. Which action should the nurse take first? a. Remove the fentanyl patch. b. Obtain complete vital signs. c. Notify the health care provider. d. Administer prescribed PRN naloxone ANS: A The assessment data indicate a possible overdose of opioid. The first action should be to remove the patch. Naloxone administration in a patient who has been chronically using opioids can precipitate withdrawal and would not be the first action. Notification of the health care provider and continued monitoring are also needed, but the patient’s data indicate that more rapid action is needed. The respiratory rate alone is an indicator for immediate action before obtaining blood pressure, pulse, and temperature. DIF: Cognitive Level: Analyze (analysis) REF: 118 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 22. The nurse reviews the medication orders for an older patient with arthritis in both hips who reports level 3 (0 to 10 scale) hip pain while ambulating. Which medication should the nurse offer as initial therapy? a. Naproxen 200 mg orally b. Oxycodone 5 mg orally c. Acetaminophen 650 mg orally d. Aspirin (acetylsalicylic acid) 650 mg orally ANS: C Acetaminophen is the best first-choice medication. The principle of “start low, go slow” is used to guide therapy when treating older adults because the ability to metabolize medications is decreased and the likelihood of medication interactions is increased. Nonopioid analgesics are used first for mild to moderate pain, although opioids may be used later. Aspirin and nonsteroidal antiinflammatory drugs are associated with a high incidence of gastrointestinal bleeding in older patients. DIF: Cognitive Level: Analyze (analysis) REF: 112 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 23. The nurse on a surgical inpatient unit is caring for several patients. Which patient should the nurse assess first? a. Patient with postoperative pain who received morphine sulfate IV 15 minutes ago b. Patient who received hydromorphone (Dilaudid) 1 hour ago and is currently asleep c. Patient who was treated for pain just prior to return from the postanesthesia care unit d. Patient with neuropathic pain who is scheduled to receive a dose of hydrocodone (Lortab) now ANS: C The risk for oversedation is greatest in the first 4 hours after transfer from the postanesthesia care unit. Patients should be reassessed 30 minutes after receiving IV opioids for pain. A scheduled oral medication does not need to be administered exactly at the scheduled time. A patient who falls asleep after pain medication can be allowed to rest. DIF: Cognitive Level: Analyze (analysis) REF: 115 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients Chapter 09: Palliative Care at End of Life Lewis: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. The nurse is caring for an unresponsive terminally ill patient who has 20-second periods of apnea followed by periods of deep and rapid breathing. Which action by the nurse would be appropriate? a. Suction the patient’s mouth. b. Administer oxygen via face mask. c. Document Cheyne-Stokes respirations. d. Place the patient in high Fowler’s position. ANS: C Cheyne-Stokes respirations are characterized by periods of apnea alternating with deep and rapid breaths. Cheyne-Stokes respirations are expected in the last days of life and are not position dependent. There is also no need for supplemental oxygen by face mask or suctioning the patient. DIF: Cognitive Level: Apply (application) REF: 132 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse is caring for an adolescent patient who is dying. The patient’s parents are interested in organ donation and ask the nurse how the health care providers determine brain death. Which response by the nurse accurately describes brain death determination? a. “If CPR does not restore a heartbeat, the brain cannot function.” b. “Brain death has occurred if there is not any breathing or brainstem reflexes.” c. “Brain death has occurred if a person has flaccid muscles and does not awaken.” d. “If respiratory efforts cease and no apical pulse is audible, brain death is present.” ANS: B The diagnosis of brain death is based on irreversible loss of all brain functions, including brainstem functions that control respirations and brainstem reflexes. The other descriptions describe other clinical manifestations associated with death but are insufficient to declare a patient brain dead. DIF: Cognitive Level: Apply (application) REF: 131 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 3. A patient in hospice is manifesting a decrease in all body system functions except for a heart rate of 124 beats/min and a respiratory rate of 28 breaths/min. Which statement, if made by the nurse to the patient’s family member, is most appropriate? a. “These vital signs will continue to increase until death finally occurs.” b. “These vital signs are an expected response now but will slow down later.” c. “These vital signs may indicate an improvement in the patient’s condition.” d. “These vital signs are a helpful response to the slowing of other body systems.” ANS: B An increase in heart and respiratory rate may occur before the slowing of these functions in a dying patient. Heart and respiratory rate typically slow as the patient progresses further toward death. In a dying patient, high respiratory and pulse rates do not indicate improvement or compensation, and it would be inappropriate for the nurse to indicate this to the family. DIF: Cognitive Level: Apply (application) REF: 132 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 4. A patient who has been diagnosed with inoperable lung cancer and has a poor prognosis plans a trip across the country “to settle some issues with family members.” The nurse recognizes that the patient is manifesting which psychosocial response to death? a. Protesting the unfairness of death b. Anxiety about unfinished business c. Fear of having lived a meaningless life d. Restlessness about the uncertainty of prognosis ANS: B The patient’s statement indicates that there is some unfinished family business that the patient would like to address before dying. There is no indication that the patient is protesting the prognosis, feels uncertain about the prognosis, or fears that life has been meaningless. DIF: Cognitive Level: Apply (application) REF: 132 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 5. A patient with terminal cancer is being admitted to a family-centered inpatient hospice. The patient’s spouse visits daily and cheerfully talks with the patient about wedding anniversary plans for the next year. When the nurse asks about any concerns, the spouse says, “I’m busy at work, but otherwise things are fine.” Which provisional nursing diagnosis is appropriate for the patient’s spouse? a. Ineffective coping related to lack of grieving b. Anxiety related to complicated grieving process c. Hopelessness related to knowledge deficit about cancer d. Caregiver role strain related to spouse’s complex care needs ANS: A The spouse’s behavior and statements indicate the absence of anticipatory grieving, which may lead to impaired adjustment as the patient progresses toward death. The spouse does not appear to feel overwhelmed, hopeless, or anxious. DIF: Cognitive Level: Apply (application) REF: 133 TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 6. As the nurse admits a patient in end-stage renal disease to the hospital, the patient tells the nurse, “If my heart or breathing stop, I do not want to be resuscitated.” Which action should the nurse take first? a. Place a “Do Not Resuscitate” (DNR) notation in the patient’s care plan. b. Invite the patient to add a notarized advance directive in the health record. c. Advise the patient to designate a person to make future health care decisions. d. Ask if the decision has been discussed with the patient’s health care provider. ANS: D A health care provider’s order should be written describing the actions that the nurses should take if the patient requires CPR, but the primary right to decide belongs to the patient or family. The nurse should document the patient’s request but does not have the authority to place the DNR order in the care plan. A notarized advance directive is not needed to establish the patient’s wishes. The patient may need a durable power of attorney for health care (or the equivalent), but this does not address the patient’s current concern with possible resuscitation. DIF: Cognitive Level: Apply (application) REF: 136 TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 7. A young adult patient with metastatic cancer, who is very close to death, appears restless. The patient keeps repeating, “I am not ready to die.” Which action is best for the nurse to take? a. Remind the patient that no one feels ready for death. b. Sit at the bedside and ask if there is anything the patient needs. c. Insist that family members remain at the bedside with the patient. d. Tell the patient that everything possible is being done to delay death. ANS: B Staying at the bedside and listening allows the patient to discuss any unresolved issues or physical discomforts that should be addressed. Stating that no one feels ready for death fails to address the individual patient’s concerns. Telling the patient that everything is being done does not address the patient’s fears about dying, especially because the patient is likely to die soon. Family members may not feel comfortable staying at the bedside of a dying patient, and the nurse should not insist that they remain there. DIF: Cognitive Level: Analyze (analysis) REF: 138 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 8. The nurse is caring for a terminally ill patient who is experiencing continuous and severe pain. How should the nurse schedule the administration of opioid pain medications? a. Plan around-the-clock routine administration of analgesics. b. Provide PRN doses of medication whenever the patient requests them. c. Suggest small analgesic doses to avoid decreasing the respiratory rate. d. Offer enough pain medication to keep the patient sedated and unaware of stimuli. ANS: A The principles of beneficence and nonmaleficence indicate that the goal of pain management in a terminally ill patient is adequate pain relief even if the effect of pain medications could hasten death. Administration of analgesics on a PRN basis will not provide the consistent level of analgesia the patient needs. Patients usually do not require so much pain medication that they are oversedated and unaware of stimuli. Adequate pain relief may require a dosage that will result in a decrease in respiratory rate. DIF: Cognitive Level: Apply (application) REF: 140 TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 9. The nurse is caring for a patient with lung cancer in a home hospice program. Which action by the nurse is appropriate? a. Discuss cancer risk factors and appropriate lifestyle modifications. b. Teach the patient about the purpose of chemotherapy and radiation. c. Encourage the patient to discuss past life events and their meanings. c. Obtain information from Filipino staff members about possible cultural needs. d. Remind family members that dying patients prefer to have someone at the bedside. ANS: B Because cultural beliefs may vary among people of the same ethnicity, the nurse’s best action is to assess the expectations of both the patient and family. The other actions may be appropriate, but the nurse can only plan for individualized culturally competent care after assessment of this patient and family. DIF: Cognitive Level: Analyze (analysis) REF: 134 TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment MULTIPLE RESPONSE 1. Which nursing actions for the care of a dying patient can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN) (select all that apply)? a. Provide postmortem care to the patient. b. Encourage the family members to talk with and reassure the patient. c. Determine how frequently physical assessments are needed for the patient. d. Teach family members about commonly occurring signs of approaching death. e. Administer the prescribed morphine sulfate sublingual as necessary for pain control. ANS: A, B, E Medication administration, psychosocial care, and postmortem care are included in LPN/LVN education and scope of practice. Patient and family teaching and assessment and planning of frequency for assessments are skills that require registered nurse level education and scope of practice. DIF: Cognitive Level: Apply (application) REF: 142 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment Chapter 10: Substance Use Disorders Lewis: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. Which assessment finding would alert the nurse to ask the patient about alcohol use? a. Low blood pressure c. Elevated temperature b. Decreased heart rate d. Abdominal tenderness ANS: D Abdominal pain associated with gastrointestinal tract and liver dysfunction is common in patients with chronic alcohol use. The other problems are not associated with alcohol use. DIF: Cognitive Level: Apply (application) REF: 151 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 2. The nurse plans postoperative care for a patient who smokes two packs of cigarettes daily. Which goal should the nurse include in the plan of care for this patient? a. Improve sleep c. Decrease diarrhea b. Enhance appetite d. Prevent sore throat ANS: A Insomnia is a characteristic of nicotine withdrawal. Diarrhea, sore throat, and anorexia are not symptoms associated with nicotine withdrawal. DIF: Cognitive Level: Apply (application) REF: 150 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity 3. A young adult patient scheduled for an annual physical examination arrives in the clinic smelling of cigarette smoke and carrying a pack of cigarettes. Which action will the nurse plan to take? a. Urge the patient to quit smoking as soon as possible. b. Avoid confronting the patient about smoking at this time. c. Wait for the patient to start a discussion about quitting smoking. d. Explain that the “cold turkey” method is most effective in stopping smoking. ANS: A Current national guidelines indicate that health care professionals should urge patients who smoke to quit smoking at every encounter. The other actions will not help decrease the patient’s health risks related to smoking. DIF: Cognitive Level: Apply (application) REF: 146 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 4. A patient admitted to the hospital after an automobile accident is alert and does not appear to be highly intoxicated. The blood alcohol concentration (BAC) is 110 mg/dL (0.11 mg%). Which action by the nurse is appropriate? a. Restrict oral and IV fluids. b. Maintain the patient on NPO status. c. Administer acetaminophen for headache. d. Monitor for hyperreflexia and diaphoresis. ANS: D The patient’s assessment data indicate probable physiologic dependence on alcohol, and the patient is likely to develop acute withdrawal such as anxiety, hyperreflexia, and sweating, which could be life threatening. Acetaminophen is not recommended because it is metabolized by the liver. Alcohol has a dehydrating effect so fluids should not be restricted and there is no indication that the patient should be NPO. DIF: Cognitive Level: Apply (application) REF: 155 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 5. An alcohol-intoxicated patient with a penetrating wound to the abdomen is undergoing emergency surgery. What will the nurse expect the patient to need during the perioperative period? a. An increased dose of the general anesthetic medication b. Interventions to prevent withdrawal symptoms within 2 hours c. Frequent monitoring for bleeding and respiratory complications d. Stimulation every hour to prevent prolonged postoperative sedation ANS: C Patients who are intoxicated at the time of surgery are at increased risk for problems with bleeding and respiratory complications such as aspiration. In an intoxicated patient, a lower dose of anesthesia is used because of the synergistic effect of the alcohol. Withdrawal is likely to occur later in the postoperative course because the medications used for anesthesia, sedation, and pain will delay withdrawal symptoms. The patient should be monitored frequently for oversedation but does not need to be stimulated. DIF: Cognitive Level: Apply (application) REF: 149 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity 6. A patient with alcohol dependence is admitted to the hospital with back pain following a fall. Twenty-four hours after admission, the patient becomes tremulous and anxious. Which action by the nurse is appropriate? a. Encourage increased oral intake. b. Insert an IV line and infuse fluids. c. Provide a quiet, well-lit environment. d. Administer opioids to provide sedation. ANS: C The patient’s symptoms suggest acute alcohol withdrawal, and a quiet and well-lit environment will help decrease agitation, delusions, and hallucinations. There is no indication that the patient is dehydrated. Benzodiazepines, rather than opioids, are used to prevent withdrawal. IV lines are avoided whenever possible. DIF: Cognitive Level: Apply (application) REF: 150 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 7. A patient with a history of heavy alcohol use is diagnosed with acute gastritis. Which statement by the patient indicates a willingness to stop alcohol use? a. “I am older and wiser now, and I can change my drinking behavior.” b. “Alcohol has never bothered my stomach before. I think I have the flu.” c. “People say that I drink too much, but I feel pretty good most of the time.” The priority is to ensure physiologic stability given that methamphetamine use can lead to complications such as myocardial infarction. The other actions are also appropriate but are not of as high a priority. DIF: Cognitive Level: Apply (application) REF: 146 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 14. A 73-yr-old patient is admitted for pancreatitis. Which tool would be the most appropriate for the nurse to use during the admission assessment? a. Mini-Mental State Examination b. Drug Abuse Screening Test (DAST-10) c. Screening Test-Geriatric Version (SMAST-G) d. Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) ANS: C Because alcohol use is a common factor associated with the development of pancreatitis, the first assessment step is to screen for alcohol use using a validated screening questionnaire. The SMAST-G is a short-form alcoholism screening instrument tailored specifically to the needs of the older adult. If the patient scores positively on the SMAST-G, then the CIWA-Ar would be a useful tool for determining treatment. The DAST-10 provides more general information regarding substance use. The Mini-Mental State Examination is used to screen for cognitive impairment. DIF: Cognitive Level: Apply (application) REF: 156 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 15. An older adult patient who has been taking alprazolam (Xanax) calls the clinic asking for a refill of the prescription 1 month before the alprazolam should need to be refilled. Which response by the nurse is best? a. “The prescription cannot be refilled for another month. What happened to all of your pills?” b. “Do you have muscle cramps and tremors if you don’t take the medication frequently?” c. “I will ask the health care provider to prescribe more pills, but you will not be able to have them until next month.” d. “I am concerned that you may be overusing those. Let’s make an appointment for you with the health care provider.” ANS: D The patient should be assessed for problems that are causing overuse of alprazolam, such as anxiety or memory loss. The other responses by the nurse will not allow for the needed assessment and possible referral for support services or treatment of drug dependence. DIF: Cognitive Level: Apply (application) REF: 152 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 16. A patient who has inhaled cocaine is admitted to the emergency department with palpitations and shortness of breath. What should the nurse do first? a. Infuse normal saline. b. Check oxygen saturation. c. Draw blood for drug screening. d. Obtain a 12-lead echocardiogram (ECG). ANS: B The priority here is to ensure that oxygenation is adequate. The other orders also should be accomplished as soon as possible but are not the first priority. DIF: Cognitive Level: Analyze (analysis) REF: 151 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 17. The nurse cares for an agitated patient who was admitted to the emergency department after taking a hallucinogenic drug and attempting to jump from a third-story window. Which nursing diagnosis should the nurse assign as the highest priority? a. Risk for injury related to altered perception b. Ineffective coping related to situational issues c. Ineffective health maintenance related to drug use d. Powerlessness related to loss of behavioral control ANS: A Although all the diagnoses may be appropriate for the patient, the highest priority is to address the patient’s immediate risk for injury. DIF: Cognitive Level: Analyze (analysis) REF: 152 OBJ: Special Questions: Prioritization TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity 18. A 25-yr-old patient comes to the emergency department with severe chest pain and agitation. Which action should the nurse take first? a. Ask about use of stimulant drugs. b. Start an IV for sedative administration. c. Assess orientation to person, place, and time. d. Check blood pressure, pulse, and respirations. ANS: D The patient has symptoms consistent with the use of cocaine or amphetamines and is at risk for fatal tachydysrhythmias or complications of hypertension such as stroke or myocardial infarction. The nurse also will ask about drug use and assess orientation, but these are not the priority actions. Naloxone may be given if the patient develops symptoms of central nervous system depression, but this patient’s current symptoms indicate stimulant use. DIF: Cognitive Level: Analyze (analysis) REF: 151 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 19. A patient presents to the emergency department with a blood alcohol concentration (BAC) of 0.18%. After reviewing the medication orders, which drug should the nurse administer first? a. Oral multivitamin daily b. Thiamine (vitamin B1) 100 mg daily c. Lorazepam (Ativan) 1 mg as needed d. Folic acid (Vitamin B9) 0.4 mg daily ANS: B Thiamine is given to all patients with alcohol intoxication to prevent Wernicke’s encephalopathy. Because Wernicke’s encephalopathy can be precipitated by the administration of glucose solutions, thiamine should be given before or concurrently with a dextrose solution. Lorazepam would not be appropriate while the patient still has an elevated BAC. Folic acid may also be administered but is not as important as thiamine. DIF: Cognitive Level: Analyze (analysis) REF: 149 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 20. Which information is most important for the nurse to report to the health care provider about a patient who has been using varenicline (Chantix)? a. The patient continues to smoke a few cigarettes every day. b. The patient complains of headaches that occur almost daily. c. The patient complains of new-onset sadness and depression. d. The patient says, “I have decided that I am not ready to quit.” ANS: C Adverse effects of varenicline include depression and attempted suicide. The patient’s symptoms require immediate assessment and discontinuation of the drug. The other information will also be reported, but it does not indicate any life-threatening problems associated with the medication. DIF: Cognitive Level: Analyze (analysis) REF: 148 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 21. A patient who has a history of ongoing opioid use is hospitalized for surgery. After a visit by a friend, the nurse finds that the patient is unresponsive with pinpoint pupils. Which prescribed medication will the nurse administer? a. Naloxone c. Clonidine (Catapres) b. Diazepam (Valium) d. Methadone (Dolophine) ANS: A The patient’s assessment indicates an opioid overdose, and naloxone should be given to prevent respiratory arrest. The other medications may be used to decrease symptoms associated with opioid withdrawal but would not be appropriate for an overdose. DIF: Cognitive Level: Apply (application) REF: 152 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 22. After receiving change-of-shift report on four patients who are undergoing substance use treatment, which patient will the nurse assess first? a. A patient who has just arrived for alcohol use treatment and states that the last drink was 2 hours ago b. A patient who is agitated and experiencing nausea, occasional vomiting, and diarrhea while withdrawing from heroin c. A patient who has tremors secondary to benzodiazepine withdrawal and whose last benzodiazepine use was 4 days ago d. A patient who is being treated for cocaine addiction and is irritable and disoriented, with a pulse rate of 112 beats/min ANS: C Chapter 11: Inflammation and Wound Healing Lewis: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. The nurse assesses a patient’s surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is appropriate? a. Obtain wound cultures. c. Notify the health care provider. b. Document the assessment. d. Assess the wound every 2 hours. ANS: B The incisional redness and warmth are indicators of the normal initial (inflammatory) stage of wound healing by primary intention. The nurse should document the wound appearance and continue to monitor the wound. Notification of the health care provider, assessment every 2 hours, and obtaining wound cultures are not indicated because the healing is progressing normally. DIF: Cognitive Level: Apply (application) REF: 165 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 2. A patient with an open leg lesion has a white blood cell (WBC) count of 13,500/µ L and a band count of 11%. What prescribed action should the nurse take first? a. Obtain cultures of the wound. b. Begin antibiotic administration. c. Continue to monitor the wound for drainage. d. Redress the wound with wet-to-dry dressings. ANS: A The increase in WBC count with the increased bands (shift to the left) indicates that the patient probably has a bacterial infection, and the nurse should obtain wound cultures. Antibiotic therapy and/or dressing changes may be started, but cultures should be done first. The nurse will continue to monitor the wound, but additional actions are needed as well. DIF: Cognitive Level: Analyze (analysis) REF: 161 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 3. A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding will the nurse expect next? a. Skin flushing c. Rising body temperature b. Muscle cramps d. Decreasing blood pressure ANS: C The patient’s complaints of feeling cold and shivering indicate that the hypothalamic set point for temperature has been increased and the temperature is increasing. Because associated peripheral vasoconstriction and sympathetic nervous system stimulation will occur, skin flushing and hypotension are not expected. Muscle cramps are not expected with chills and shivering or with a rising temperature. DIF: Cognitive Level: Apply (application) REF: 164 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 4. A young adult patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8° F (38.7° C) The patient reports having no discomfort. Which action by the nurse is appropriate? a. Apply a cooling blanket. b. Notify the health care provider. c. Check the patient’s temperature again in 4 hours. d. Give acetaminophen (Tylenol) prescribed PRN for pain. ANS: C Mild to moderate temperature elevations (<103° F) do not harm young adult patients and may benefit host defense mechanisms. The nurse should continue to monitor the temperature. Antipyretics are not indicated unless the patient is complaining of fever-related symptoms, and the patient does not require analgesics if not reporting discomfort. There is no need to notify the patient’s health care provider or to use a cooling blanket for a moderate temperature elevation. DIF: Cognitive Level: Apply (application) REF: 164 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 5. A patient’s 4  3-cm leg wound has a 0.4-cm black area in the center of the wound surrounded by yellow-green semiliquid material. Which dressing should the nurse apply to the wound? a. Dry gauze dressing c. Hydrocolloid dressing b. Nonadherent dressing d. Transparent film dressing ANS: C The wound requires debridement of the necrotic areas and absorption of the yellow-green slough. A hydrocolloid dressing such as DuoDerm would accomplish these goals. Transparent film dressings are used for clean wounds or approximated surgical incisions. Dry dressings will not debride the necrotic areas. Nonadherent dressings will not absorb wound drainage or debride the wound. DIF: Cognitive Level: Apply (application) REF: 169 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 6. The nurse notes that a patient’s open abdominal wound widens as it extends deeper into the abdomen. How would the nurse document this characteristic? a. Eschar c. Maceration b. Slough d. Undermining ANS: D Undermining is evident when a cotton-tipped applicator is placed in the wound and there is a narrower “lip” around the wound, which widens as the wound deepens. Eschar is a crusted cover over a wound. Slough and maceration refer to loosening friable tissue. DIF: Cognitive Level: Understand (comprehension) REF: 166 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 7. A patient with rheumatoid arthritis has been taking oral corticosteroids for 2 years. Which nursing action is most likely to detect early signs of infection in this patient? a. Monitor white blood cell counts. b. Check the skin for areas of redness. c. Measure the temperature every 2 hours. d. Ask about feelings of fatigue or malaise. ANS: D The earliest manifestation of an infection may be “just not feeling well.” Common clinical manifestations of inflammation and infection are frequently not present when patients receive immunosuppressive medications. DIF: Cognitive Level: Analyze (analysis) REF: 164 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 8. The nurse should plan to use a wet-to-dry dressing for which patient? a. A patient who has a pressure ulcer with pink granulation tissue b. A patient who has a surgical incision with pink, approximated edges c. A patient who has a full-thickness burn filled with dry, black material d. A patient who has a wound with purulent drainage and dry brown areas ANS: D Wet-to-dry dressings are used when there is minimal eschar to be removed. A full-thickness wound filled with eschar will require interventions such as surgical debridement to remove the necrotic tissue. Wet-to-dry dressings are not needed on approximated surgical incisions. Wet-to-dry dressings are not used on uninfected granulating wounds because of the damage to the granulation tissue. DIF: Cognitive Level: Apply (application) REF: 170 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 9. A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer. The base of the wound involves subcutaneous tissue. How should the nurse classify this pressure ulcer? a. Stage I c. Stage III b. Stage II d. Stage IV ANS: C A stage III pressure ulcer has full-thickness skin damage and extends into the subcutaneous tissue. A stage I pressure ulcer has intact skin with some observable damage such as redness or a boggy feel. Stage II pressure ulcers have partial-thickness skin loss. Stage IV pressure ulcers have full-thickness damage with tissue necrosis, extensive damage, or damage to bone, muscle, or supporting tissues. DIF: Cognitive Level: Understand (comprehension) REF: 173 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 10. A young male patient with paraplegia has a stage II sacral pressure ulcer and is being cared for at home by his family. To prevent further tissue damage, what instructions are most important for the nurse to teach the patient and family? a. Change the patient’s bedding frequently. b. Apply a hydrocolloid dressing over the ulcer. c. Change the patient’s position every 1 to 2 hours. d. Record the size and appearance of the ulcer weekly. LPN/LVN education and scope of practice include sterile dressing changes for stable patients. Initial wound assessments, patient teaching, and evaluation for possible poor wound healing or infection should be done by the registered nurse (RN). DIF: Cognitive Level: Apply (application) REF: 170 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 17. The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider? a. Blood glucose of 136 mg/dL b. Oral temperature of 101° F (38.3° C) c. Separation of the proximal wound edges d. Patient complaint of increased incisional pain ANS: C Wound separation 3 days postoperatively indicates possible wound dehiscence and should be immediately reported to the health care provider. The other findings will also be reported but do not require intervention as rapidly. DIF: Cognitive Level: Analyze (analysis) REF: 167 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 18. A patient who has diabetes is admitted for an exploratory laparotomy for abdominal pain. When planning interventions to promote wound healing, what is the nurse’s highest priority? a. Maintaining the patient’s blood glucose within a normal range b. Ensuring that the patient has an adequate dietary protein intake c. Giving antipyretics to keep the temperature less than 102° F (38.9° C) d. Redressing the surgical incision with a dry, sterile dressing twice daily ANS: A Elevated blood glucose will have an impact on multiple factors involved in wound healing. Ensuring adequate nutrition is also important for the postoperative patient, but a higher priority is blood glucose control. A temperature of 102° F will not impact adversely on wound healing, although the nurse may administer antipyretics if the patient is uncomfortable. Application of a dry, sterile dressing daily may be ordered, but frequent dressing changes for a wound healing by primary intention is not necessary to promote wound healing. DIF: Cognitive Level: Analyze (analysis) REF: 167 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 19. Which finding is most important for the nurse to communicate to the health care provider when caring for a patient who is receiving negative-pressure wound therapy? a. Low serum albumin level b. Serosanguineous drainage c. Deep red and moist wound bed d. Cobblestone appearance of wound ANS: A With negative pressure therapy, serum protein levels may decrease, which will adversely affect wound healing. The other findings are expected with wound healing. DIF: Cognitive Level: Analyze (analysis) REF: 169 OBJ: Special Questions: Prioritization MSC: NCLEX: Physiological Integrity 20. After the home health nurse teaches a patient’s family member about how to care for a sacral pressure ulcer, which finding indicates that additional teaching is needed? a. The family member uses a lift sheet to reposition the patient. b. The family member uses clean tap water to clean the wound. c. The family member dries the wound using a hair dryer on a low setting. d. The family member places contaminated dressings in a plastic grocery bag. ANS: C Pressure ulcers need to be kept moist to facilitate wound healing. The other actions indicate a good understanding of pressure ulcer care. DIF: Cognitive Level: Apply (application) REF: 175 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity SHORT ANSWER 1. A patient’s temperature has been 101° F (38.3° C) for several days. The patient’s normal caloric intake to meet nutritional needs is 2000 calories per day. Knowing that the metabolic rate increases 7% for each Fahrenheit degree above 100° in body temperature, how many total calories should the patient receive each day? ANS: 2140 calories DIF: Cognitive Level: Apply (application) REF: 164 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity OTHER 1. A patient who has an infected abdominal wound develops a temperature of 104° F (40° C). All the following interventions are included in the patient’s plan of care. In which order should the nurse perform the following actions? (Put a comma and a space between each answer choice [A, B, C, D]). a. Administer IV antibiotics. b. Sponge patient with cool water. c. Perform wet-to-dry dressing change. d. Administer acetaminophen (Tylenol). ANS: A, D, B, C The first action should be to administer the antibiotic because treating the infection that has caused the fever is the most important aspect of fever management. The next priority is to lower the high fever, so the nurse should administer acetaminophen to lower the temperature set point. A cool sponge bath should be done after the acetaminophen is given to lower the temperature further. The wet-to-dry dressing change will not have an immediate impact on the infection or fever and should be done last. DIF: Cognitive Level: Analyze (analysis) REF: 164 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity Asking about the concern uses the communication technique of clarifying for further assessment. The other options accurately indicate information about genetic testing, but the initial response by the nurse should be focused on assessment. DIF: Cognitive Level: Analyze (analysis) REF: 185 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 7. The nurse in the outpatient clinic has obtained health histories for these new patients. Which patient may need referral for genetic testing? a. A 20-yr-old patient whose maternal grandparents died after strokes at ages 80 and 82 b. A 20-yr-old patient with a positive pregnancy test whose first child has cerebral palsy c. A 30-yr-old patient who has a sibling with newly diagnosed polycystic kidney disease d. A 30-yr-old patient with a history of cigarette smoking who is complaining of dyspnea ANS: C The adult form of polycystic kidney disease is an autosomal dominant disorder and frequently it is asymptomatic until the patient is older. Presymptomatic testing will give the patient information that will be useful in guiding lifestyle and childbearing choices. The other patients do not have any indication of genetic disorders or need for genetic testing. DIF: Cognitive Level: Apply (application) REF: 182 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance Chapter 13: Altered Immune Responses and Transplantation Lewis: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. The nurse provides discharge instructions to a patient who has an immune deficiency involving the T lymphocytes. Which health screening should the nurse include in the teaching plan for this patient? a. Screening for allergies b. Screening for malignancies c. Screening for antibody deficiencies d. Screening for autoimmune disorders ANS: B Cell-mediated immunity is responsible for the recognition and destruction of cancer cells. Allergic reactions, autoimmune disorders, and antibody deficiencies are mediated primarily by B lymphocytes and humoral immunity. DIF: Cognitive Level: Apply (application) REF: 196 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 2. Which example should the nurse use to explain an infant’s “passive immunity” to a new mother? a. Vaccinations b. Breastfeeding c. Stem cells in peripheral blood d. Exposure to communicable diseases ANS: B Colostrum in breast milk provides passive immunity through antibodies from the mother. These antibodies protect the infant for a few months. However, memory cells are not retained, so the protection is not permanent. Active immunity is acquired by being immunized with vaccinations or having an infection. Stem cells are unspecialized cells used to repopulate a person's bone marrow after high-dose chemotherapy. DIF: Cognitive Level: Apply (application) REF: 192 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 3. A patient is being evaluated for possible atopic dermatitis. The nurse expects elevation of which laboratory value? a. IgE c. Basophils b. IgA d. Neutrophils ANS: A Serum IgE is elevated in an allergic response (type 1 hypersensitivity disorders). The eosinophil level will be elevated rather than neutrophil or basophil counts. IgA is located in body secretions and would not be tested when evaluating a patient who has symptoms of atopic dermatitis. DIF: Cognitive Level: Apply (application) REF: 194 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 4. An older adult patient who is having an annual check-up tells the nurse, “I feel fine, and I don’t want to pay for all these unnecessary cancer screening tests!” Which information should the nurse plan to teach this patient? a. Consequences of aging on cell-mediated immunity b. Decrease in antibody production associated with aging c. Impact of poor nutrition on immune function in older people d. Incidence of cancer-associated infections in older individuals ANS: A The primary impact of aging on immune function is on T cells, which are important for immune surveillance and tumor immunity. Antibody function is not affected as much by aging. Poor nutrition can also contribute to decreased immunity, but there is no evidence that it is a contributing factor for this patient. Although some types of cancer are associated with specific infections, this patient does not have an active infection. DIF: Cognitive Level: Apply (application) REF: 196 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 5. A patient who collects honey to earn supplemental income has developed a hypersensitivity to bee stings. Which statement, if made by the patient, would indicate a need for additional teaching? a. “I need to find a different way to earn extra money.” b. “I will take oral antihistamines before going to work.” c. “I will get a prescription for epinephrine and learn to self-inject it.” d. “I should wear a Medic-Alert bracelet indicating my allergy to bee stings.” ANS: B Because the patient is at risk for bee stings and the severity of allergic reactions tends to increase with added exposure to allergen, taking oral antihistamines will not adequately control the patient’s hypersensitivity reaction. The other patient statements indicate a good understanding of management of the problem. DIF: Cognitive Level: Apply (application) REF: 197 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 6. Which information about intradermal skin testing should the nurse teach to a patient with possible allergies? a. “Do not eat anything for about 6 hours before the testing.” b. “Take an oral antihistamine about an hour before the testing.” c. “Plan to wait in the clinic for 20 to 30 minutes after the testing.” d. “Reaction to the testing will take about 48 to 72 hours to occur.” ANS: C Allergic reactions usually occur within minutes after injection of an allergen, and the patient will be monitored for at least 20 minutes for anaphylactic reactions after the testing. Medications that might modify the response, such as antihistamines, should be avoided before allergy testing. There is no reason to be NPO for skin testing. Results with intradermal testing occur within minutes. DIF: Cognitive Level: Apply (application) REF: 200 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity ANS: A The patient’s history and symptoms indicate that the patient is experiencing graft-versus-host disease, in which the donated T cells attack the patient’s tissues. The history and symptoms are not consistent with rejection or delayed hypersensitivity. DIF: Cognitive Level: Application (apply) REF: 210 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 14. A patient seeks care in the emergency department after sharing needles for heroin injection with a friend who has hepatitis B. To provide immediate protection from infection, what medication will the nurse expect to administer? a. Corticosteroids c. Hepatitis B vaccine b. Gamma globulin d. Fresh frozen plasma ANS: B The patient should first receive antibodies for hepatitis B from injection of gamma globulin. The hepatitis B vaccination series should be started to provide active immunity. Fresh frozen plasma and corticosteroids will not be effective in preventing hepatitis B in the patient. DIF: Cognitive Level: Apply (application) REF: 192 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 15. The nurse teaches a patient about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions? a. “I need to be monitored closely for development of malignant tumors.” b. “After a couple of years I will be able to stop taking the cyclosporine.” c. “If I develop acute rejection episode, I will need additional types of drugs.” d. “The drugs are combined to inhibit different ways the kidney can be rejected.” ANS: B Cyclosporine, a calcineurin inhibitor, will need to be continued for life. The other patient statements are accurate and indicate that no further teaching is necessary about those topics. DIF: Cognitive Level: Apply (application) REF: 209 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 16. An older adult patient has a prescription for cyclosporine following a kidney transplant. Which information in the patient’s health history has implications for planning patient teaching about the medication at this time? a. The patient restricts salt to 2 grams per day. b. The patient eats green leafy vegetables daily. c. The patient drinks grapefruit juice every day. d. The patient drinks 3 to 4 quarts of fluid each day. ANS: C Grapefruit juice can increase the toxicity of cyclosporine. The patient should be taught to avoid grapefruit juice. Normal fluid and sodium intake or eating green leafy vegetables will not affect cyclosporine levels or renal function. DIF: Cognitive Level: Apply (application) REF: 209 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 17. A patient is admitted to the hospital with acute rejection of a kidney transplant. Which intervention will the nurse prepare for this patient? a. Testing for human leukocyte antigen (HLA) match b. Administration of immunosuppressant medications c. Insertion of an arteriovenous graft for hemodialysis d. Placement of the patient on the transplant waiting list ANS: B Acute rejection is treated with the administration of additional immunosuppressant drugs such as corticosteroids. Because acute rejection is potentially reversible, there is no indication that the patient will require another transplant or hemodialysis. There is no indication for repeat HLA testing. DIF: Cognitive Level: Apply (application) REF: 208 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 18. The charge nurse is assigning semiprivate rooms for new admissions. Which patient could safely be assigned as a roommate for a patient who has acute rejection of an organ transplant? a. A patient who has viral pneumonia b. A patient with second-degree burns c. A patient who is recovering from an anaphylactic reaction to a bee sting d. A patient with graft-versus-host disease after a recent bone marrow transplant ANS: C There is no increased exposure to infection from a patient who had an anaphylactic reaction. Treatment for a patient with acute rejection includes administration of additional immunosuppressants and the patient should not be exposed to increased risk for infection as would occur from patients with viral pneumonia, graft-versus-host disease, and burns. DIF: Cognitive Level: Apply (application) REF: 201 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 19. A patient in the health care provider’s office for allergen testing using the cutaneous scratch method develops itching and swelling at the skin site. Which action should the nurse take first? a. Monitor the patient’s edema. b. Administer a dose of epinephrine. c. Provide a prescription for oral antihistamines d. Ask the patient about the use of new skin products. ANS: B Rapid administration of epinephrine when excessive itching or swelling at the skin site is observed can prevent the progression to anaphylaxis. The initial symptoms of anaphylaxis are itching and edema at the site of the exposure. The nurse should not wait and assess for development of additional edema. Hypotension, tachycardia, dilated pupils, and wheezes occur later. Exposure to skin products does not address the immediate concern of a possible anaphylactic reaction. DIF: Cognitive Level: Analyze (analysis) REF: 202 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 20. A patient is anxious and reports difficulty breathing after being stung by a wasp. What is the nurse’s priority action? a. Provide high-flow oxygen. c. Assess the patient’s airway. b. Administer antihistamines. d. Remove the stinger from the site. ANS: C The initial action with any patient with difficulty breathing is to assess and maintain the airway. The patient’s symptoms of anxiety and difficulty breathing may have other causes than anaphylaxis, so additional assessment is warranted. The other actions are part of the emergency management protocol for anaphylaxis, but the priority is airway assessment and maintenance. DIF: Cognitive Level: Analysis (analyze) REF: 202 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 21. Immediately after the nurse administers an intracutaneous injection of an allergen on the forearm, the patient complains of itching at the site, weakness, and dizziness. What action should the nurse take first? a. Apply antiinflammatory cream. b. Place a tourniquet above the site. c. Administer subcutaneous epinephrine. d. Reschedule the patient’s other allergen tests. ANS: B Application of a tourniquet will decrease systemic circulation of the allergen and should be the first reaction. The other actions may occur, but the tourniquet application slows the allergen progress into the patient’s system, allowing treatment of the anaphylactic response. A local antiinflammatory cream may be applied to the site of a cutaneous test if the itching persists. Epinephrine will be needed if the allergic reaction progresses to anaphylaxis. Other testing may be delayed and rescheduled after development of anaphylaxis. DIF: Cognitive Level: Analysis (analyze) REF: 201 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 22. A clinic patient is experiencing an allergic reaction to an unknown allergen. Which action is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Perform a focused physical assessment. b. Obtain the health history from the patient. c. Teach the patient about the various diagnostic studies. d. Administer a skin test by the cutaneous scratch method. ANS: D LPN/LVNs are educated and licensed to administer medications under the supervision of an RN. RN-level education and the scope of practice include assessment of health history, focused physical assessment, and patient teaching. DIF: Cognitive Level: Apply (application) REF: 200 Chapter 14: Infection and Human Immunodeficiency Virus Infection Lewis: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. The nurse is advising a clinic patient who was exposed a week ago to human immunodeficiency virus (HIV) through unprotected sexual intercourse. The patient’s antigen and antibody test has just been reported as negative for HIV. What instructions should the nurse give to this patient? a. “You will need to be retested in 2 weeks.” b. “You do not need to fear infecting others.” c. “Since you don’t have symptoms and you have had a negative test, you do not have HIV).” d. “We won’t know for years if you will develop acquired immunodeficiency syndrome (AIDS).” ANS: A HIV screening tests detect HIV-specific antibodies or antigens, but typically it takes a several week delay after initial infection before HIV can be detected on a screening test. Combination antibody and antigen tests (also known as fourth-generation tests) decrease the window period to within 3 weeks after infection. It is not known based on this information whether the patient is infected with HIV or can infect others. DIF: Cognitive Level: Apply (application) REF: 221 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 2. A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4+ T-cell count of less than 200 cells/L. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is correct? a. “The patient will develop symptomatic HIV infection within 1 year.” b. “The patient meets the criteria for a diagnosis of acute HIV infection.” c. “The patient will be diagnosed with asymptomatic chronic HIV infection.” d. “The patient has developed acquired immunodeficiency syndrome (AIDS).” ANS: D Development of PCP meets the diagnostic criteria for AIDS. The other responses indicate earlier stages of HIV infection than is indicated by the PCP infection. DIF: Cognitive Level: Understand (comprehension) REF: 221 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 3. A patient informed of a positive rapid antibody test result for human immunodeficiency virus (HIV) is anxious and does not appear to hear what the nurse is saying. What action by the nurse is most important at this time? a. Teach the patient how to reduce risky behaviors. b. Inform the patient about the available treatments. c. Remind the patient about the need to return for retesting to verify the results. d. Ask the patient to identify individuals who had intimate contact with the patient. ANS: C After an initial positive antibody test result, the next step is retesting to confirm the results. A patient who is anxious is not likely to be able to take in new information or be willing to disclose information about the HIV status of other individuals. DIF: Cognitive Level: Analyze (analysis) REF: 222 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 4. A patient who is diagnosed with acquired immunodeficiency syndrome (AIDS) tells the nurse, “I feel obsessed with morbid thoughts about dying.” Which response by the nurse is appropriate? a. “Thinking about dying will not improve the course of AIDS.” b. “Do you think that taking an antidepressant might be helpful?” c. “Can you tell me more about the thoughts that you are having?” d. “It is important to focus on the good things about your life now.” ANS: C More assessment of the patient’s psychosocial status is needed before taking any other action. The statements, “Thinking about dying will not improve the course of AIDS” and “It is important to focus on the good things in life” or suggesting an antidepressant discourage the patient from sharing any further information with the nurse and decrease the nurse’s ability to develop a trusting relationship with the patient. DIF: Cognitive Level: Apply (application) REF: 227 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 5. A pregnant woman with asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The patient states, “I am very nervous about making my baby sick.” Which information will the nurse include when teaching the patient? a. The antiretroviral medications used to treat HIV infection are teratogenic. b. Most infants born to HIV-positive mothers are not infected with the virus. c. Because it is an early stage of HIV infection, the infant will not contract HIV. d. Her newborn will be born with HIV unless she uses antiretroviral therapy (ART). ANS: B Only 25% of infants born to HIV-positive mothers develop HIV infection, even when the mother does not use ART during pregnancy. The percentage drops to 2% when ART is used. Perinatal transmission can occur at any stage of HIV infection (although it is less likely to occur when the viral load is lower). ART can safely be used in pregnancy, although some ART drugs should be avoided. DIF: Cognitive Level: Understand (comprehension) REF: 219 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 6. Which patient exposure by the nurse is most likely to require postexposure prophylaxis when the patient’s human immunodeficiency virus (HIV) status is unknown? a. Needle stick injury with a suture needle during a surgery b. Splash into the eyes while emptying a bedpan containing stool c. Needle stick with a needle and syringe used for a venipuncture d. Contamination of open skin lesions with patient vaginal secretions ANS: C Puncture wounds are the most common means for workplace transmission of blood-borne diseases, and a needle with a hollow bore that had been contaminated with the patient’s blood would be a high-risk situation. The other situations described would be much less likely to result in transmission of the virus. DIF: Cognitive Level: Analyze (analysis) REF: 219 TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 7. A young adult female patient who is human immunodeficiency virus (HIV) positive has a new prescription for efavirenz (Sustiva). Which information is most important to include in the medication teaching plan? a. Take this medication on an empty stomach. b. Take this medication with a full glass of water. c. You may have vivid and bizarre dreams as a side effect. d. Continue to use contraception while taking this medication. ANS: D To prevent harm, it is most critical to inform patients that efavirenz can cause fetal anomalies and should not be used in patients who may be or may become pregnant. The other information is also accurate, but it does not directly prevent harm. The medication should be taken on an empty stomach with water and patients should be informed that many people who use the drug have reported vivid and sometimes bizarre dreams. DIF: Cognitive Level: Analyze (analysis) REF: 224 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 8. A patient who is human immunodeficiency virus (HIV)-infected has a CD4+ cell count of 400/µ L. Which factor is most important for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient? a. CD4+ cell count trajectory b. HIV genotype and phenotype c. Patient’s tolerance for potential medication side effects d. Patient’s ability to follow a complex medication regimen ANS: D Drug resistance develops quickly unless the patient takes ART medications on a strict, regular schedule. In addition, drug resistance endangers both the patient and community. The other information is also important to consider, but patients who are unable to manage and follow a complex drug treatment regimen should not be considered for ART. DIF: Cognitive Level: Analyze (analysis) REF: 223 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 9. The nurse will most likely prepare a medication teaching plan about antiretroviral therapy (ART) for which patient? a. Patient who is currently HIV negative but has unprotected sex with multiple partners b. Patient who was infected with HIV 15 years ago and now has a CD4+ count of 840/µ L c. HIV-positive patient with a CD4+ count of 160/µ L who drinks a fifth of whiskey daily