CURRENT Medical Diagnosis and Treatment 2023 Test Bank
Chapter 1. Disease Prevention & Health Promotion
1. Which of the following behaviors indicates the highest potential for spreading infections among clients? The nurse: 1)
disinfects dirty hands with antibacterial soap.
2)
allows alcohol-based rub to dry for 10 seconds.
3)
washes hands only after leaving each room.
4)
uses cold water for medical asepsis. 2. What is the most frequent cause of the spread of infection among institutionalized patients?
1)
Airborne microbes from other patients
2)
Contact with contaminated equipment
3)
Hands of healthcare workers
4)
Exposure from family members 3. Which of the following nursing activities is of highest priority for maintaining medical asepsis?
1)
Washing hands
2)
Donning gloves
3)
Applying sterile drapes
4)
Wearing a gown
4. A patient infected with a virus but who does not have any outward sign of the disease is considered a: 1)
pathogen.
2)
fomite.
3)
vector.
4)
carrier.
5. A patient is admitted to the hospital with tuberculosis. Which precautions must the nurse institute when caring for this patient? 1)
Droplet transmission
2)
Airborne transmission
3)
Direct contact
4)
Indirect contact
6. A patient becomes infected with oral candidiasis (thrush) while receiving intravenous antibiotics to treat a systemic infection. Which type of infection has the patient developed? 1)
Endogenous nosocomial
2)
Exogenous nosocomial
3)
Latent
4)
Primary
7. A patient admitted to the hospital with pneumonia has been receiving antibiotics for 2 days. His condition has stabilized, and his temperature has returned to normal. Which stage of infection is the patient most likely experiencing? 1)
Incubation
2)
Prodromal
3)
Decline
4)
Convalescence
8. The nurse assists a surgeon with central venous catheter insertion. Which action is necessary to help maintain sterile technique? 1)
Closing the patients door to limit room traffic while preparing the sterile field
2)
Using clean procedure gloves to handle sterile equipment
3)
Placing the nonsterile syringes containing flush solution on the sterile field
4)
Remaining 6 inches away from the sterile field during the procedure
9. A patient develops localized heat and erythema over an area on the lower leg. These findings are indicative of which secondary defense against infection? 1)
Phagocytosis
2)
Complement cascade
3)
Inflammation
4)
Immunity
10. The patient suddenly develops hives, shortness of breath, and wheezing after receiving an antibiotic. Which antibody is primarily responsible for this patients response?
1)
IgA
2)
IgE
3)
IgG
4)
IgM 11. What type of immunity is provided by intravenous (IV) administration of immunoglobulin G?
1)
Cell-mediated
2)
Passive
3)
Humoral
4)
Active
12. A patient asks the nurse why there is no vaccine available for the common cold. Which response by the nurse is correct? 1)
The virus mutates too rapidly to develop a vaccine.
2)
Vaccines are developed only for very serious illnesses.
3)
Researchers are focusing efforts on an HIV vaccine.
4) 1
The virus for the common cold has not been identified.
. A patient who has a temperature of 101F (38.3C) most likely requires: 1)
acetaminophen (Tylenol).
2)
increased fluids.
3)
bedrest.
4)
tepid bath.
14. Why is a lotion without petroleum preferred over a petroleum-based product as a skin protectant? It: 1)
Prevents microorganisms from adhering to the skin.
2)
Facilitates the absorption of latex proteins through the skin.
3)
Decreases the risk of latex allergies.
4)
Prevents the skin from drying and chaffing. 15. For which range of time must a nurse wash her hands before working in the operating
room?
1)
1 to 2 minutes
2)
2 to 4 minutes
3)
2 to 6 minutes
4)
6 to 10 minutes
16. How should the nurse dispose of the breakfast tray of a patient who requires airborne isolation? 1)
Place the tray in a specially marked trash can inside the patients room.
2)
Place the tray in a special isolation bag held by a second healthcare worker at the patients door.
3)
Return the tray with a note to dietary services so it can be cleaned and reused for the next meal.
4) 1 Carry the tray to an isolation trash receptacle located in the dirty utility room and dispose of it there. . How much liquid soap should the nurse use for effective hand washing? At least: 1)
2 mL
2)
3 mL
3)
6 mL
4)
7 mL
18. To assure effectiveness, when should the nurse stop rubbing antiseptic hand solution over all surfaces of the hands? 1)
When fingers feel sticky
2)
After 5 to 10 seconds
3)
When leaving the clients room
4)
Once fingers and hands feel dry
19. A patient is admitted to the hospital for chemotherapy and has a low white blood cell count. Which precaution should the staff take with this patient? 1)
Contact
2)
Protective
3)
Droplet
4)
Airborne
20. While donning sterile gloves, the nurse notices the edges of the glove package are slightly yellow. The yellow area is over 1 inch away from the gloves and only appears to be on the outside of the glove package. What is the best action for the nurse to take at this point? 1)
Continue using the gloves inside the package because the package is intact.
2)
Remove gloves from sterile field and use a new pair of sterile gloves.
3)
Throw all supplies away that were to be used and begin again.
4)
Use the gloves and make sure the yellow edges of the package do not touch the client. 21. The nurse is removing personal protective equipment (PPE). Which item should be removed
first? 1)
Gown
2)
Gloves
3)
Face shield
4)
Hair covering
22. A nurse is splashed in the face by body fluid during a procedure. Prioritize the nurses actions, listing the most important one first. A.
Contact employee health
B.
Complete an incident report
C.
Wash the exposed area
D.
Report to another nurse that she is leaving the immediate area.
1)
1, 2, 3, 4
2)
2, 3, 4, 1
3)
3, 4, 1, 2
4)
4, 1, 2, 3
Multiple Response Identify one or more choices that best complete the statement or answer the question. 1. In which situation would using standard precautions be adequate? Select all that apply.
1)
While interviewing a client with a productive cough
2)
While helping a client to perform his own hygiene care
3)
While aiding a client to ambulate after surgery
4)
While inserting a peripheral intravenous catheter
2. Which of the following protect(s) the body against infection? Select all that apply. 1)
Eating a healthy well-balanced diet
2)
Being an older adult or an infant
3)
Leisure activities three times a week
4)
Exercising for 30 minutes 5 days a week
3. The nurse is teaching a group of newly hired nursing assistive personnel (NAP) about proper hand washing. The nurse will know that the teaching was effective if the NAP demonstrate what? Select all that apply. The NAP: 1)
uses a paper towel to turn off the faucet.
2)
holds fingertips above the wrists while rinsing off the soap.
3)
removes all rings and watch before washing hands.
4)
cleans underneath each fingernail.
4. Alcohol-based solutions for hand hygiene can be used to combat which types of organisms? Select all that apply. 1)
Virus
2)
Bacterial spores
3)
Yeast
4)
Mold
5. A patient with tuberculosis is scheduled for computed tomography (CT). How should the nurse proceed? Select all that apply. 1)
Question the order because the patient must remain in isolation.
2)
Place an N-95 respirator mask on the patient and transport him to the test.
3)
Place a surgical mask on the patient and transport him to CT lab.
4)
Notify the computed tomography department about precautions prior to transport.
True/False Indicate whether the statement is true or false. 1. Bacteria are necessary for human health and well-being. Chapter 1. Disease prevention Answer Section MULTIPLE CHOICE 1.
ANS: 3
Patients acquire infection by contact with other patients, family members, and healthcare equipment. But most infection among patients is spread through the hands of healthcare workers. Hand washing interrupts the transmission and should be done before and after all contact with
patients, regardless of the diagnosis. When the hands are soiled, healthcare staff should use antibacterial soap with warm water to remove dirt and debris from the skin surface. When no visible dirt is present, an alcohol-based rub should be applied and allowed to dry for 10 to 15 seconds. 2.
ANS: 3
Patients are exposed to microbes by contact (direct contact, airborne, or otherwise) with other patients, family members, and contaminated healthcare equipment. Some of these are pathogenic (cause illness) and some are nonpathogenic (do not cause illness). But most microbes causing infection among patients are spread by direct contact on the hands of healthcare workers. 3.
ANS: 1
Scrupulous hand washing is the most important part of medical asepsis. Donning gloves, applying sterile drapes before procedures, and wearing a protective gown may be needed to ensure asepsis, but they are not the mostimportant aspect because microbes causing most healthcare-related infections are transmitted by lack of or ineffective hand washing. 4.
ANS: 4
Some people might harbor a pathogenic organism, such as the human immunodeficiency virus within their body, and yet do not acquire the disease/infection. These individuals, called carriers, have no outward sign of active disease, yet they can pass the infection to others. A pathogen is an organism capable of causing disease. A fomite is a contaminated object that transfers a pathogen, such as pens, stethoscopes, and contaminated needles. A vector is an organism that carries a pathogen to a susceptible host through a portal for entry into the body. An example of a vector is a mosquito or tick that bites or stings. 5.
ANS: 2
The organisms responsible for measles and tuberculosis, as well as many fungal infections, are spread through airborne transmission. Neisseria meningitidis, the organism that causes meningitis, is spread through droplet transmission. Pathogens that cause diarrhea, such as Clostridium difficile, are spread by direct contact. The common cold can be spread by indirect contact or droplet transmission. 6.
ANS: 1
Thrush in this patient is an example of an endogenous, nosocomial infection. This type of infection arises from suppression of the patients normal flora as a result of some form of treatment, such as antibiotics. Normal flora usually keep yeast from growing in the mouth. In exogenous nosocomial infection, the pathogen arises from the healthcare environment. A latent infection causes no symptoms for long periods. An example of a latent infection is human immunodeficiency virus infection. A primary infection is the first infection that occurs in a patient. 7.
ANS: 3
The stage of decline occurs when the patients immune defenses, along with any medical therapies (in this case antibiotics), are successfully reducing the number of pathogenic microbes. As a result, the signs and symptoms of infection begin to fade. Incubation is the stage between the invasion by the organism and the onset of symptoms. During the incubation stage, the patient does not know he is infected and is capable of infecting others. The prodromal stage is characterized by the first appearance of vague symptoms. Convalescence is characterized by tissue repair and a return to heal as the organisms disappear. 8.
ANS: 1
To maintain sterile technique, the nurse should close the patients door and limit the number of persons entering and exiting the room because air currents can carry dust and microorganisms. Sterile gloves, not clean gloves, should be used to handle sterile equipment. Placing nonsterile syringes on the sterile field contaminates the field. One foot, not 6 inches, is required between people and the sterile field to prevent contamination. 9.
ANS: 3
The classic signs of inflammation, a secondary defense against infection, are erythema (redness) and localized heat. The secondary defenses phagocytosis (process by which white blood cells engulf and destroy pathogens) and the complement cascade (process by which blood proteins trigger the release of chemicals that attack the cell membranes of pathogens) do not produce visible findings. Immunity is a tertiary defense that protects the body from future infection.
10.
ANS: 2
The patient is most likely experiencing an allergic response to the antibiotic. IgE is the antibody primarily responsible for this allergic response. The antibodies IgA, IgG, and IgM are not involved in the allergic
response. IgA antibodies protect the body from in fighting viral and bacterial infections. IgG antibioties are the only type that cross the placenta in a pregnant women to protect her unborn baby (fetus). IgM are the first antibodies made in response to infection. 11.
ANS: 2
Intravenous administration of immunoglobulin G provides the patient with passive immunity. Immunoglobulin G does not provide cell-mediated, humoral, or active immunity. Passive immunity occurs when antibodies are transferred by antibodies from an immune host, such as from a placenta to a fetus. Passive immunity is short-lived. Active immunity is longer lived and comes from the host itself. Humoral immunity occurs by secreted antibodies binding to antigens. Cell-mediated immunity does not involve antibodies but rather fight infection from macrophages that kills pathogens. 12.
ANS: 1
More than 200 viruses are known to cause the common cold. These viruses mutate too rapidly to develop a vaccine. Although some researchers are focusing efforts on a vaccine for HIV infection, others continue to research the common cold.
13.
ANS: 2
Fever, a common defense against infection, increases water loss; therefore, additional fluid is needed to supplement this loss. Acetaminophen and a tepid bath are not necessary for this low- grade fever because fever is beneficial in fighting infection. Adequate rest, not necessarily bedrest, is necessary with a fever. 14.
ANS: 3
Nonpetroleum-based lotion is preferred because it prevents the absorption of latex proteins through the skin, which can cause latex allergy. Both types of lotion prevent the skin from drying and becoming chafed. Neither prevents microorganisms from adhering to the skin. 15.
ANS: 3
In a surgical setting, hands should be washed for 2 to 6 minutes, depending on the type of soap used. 16.
ANS: 2
Patients who require airborne isolation are served meals on disposable dishes and trays. To dispose of the tray, the nurse inside the room must wear protective garb and place the tray and its
contents inside a special isolation bag that is held by a second healthcare worker at the patients door. The items must be placed on the inside of the bag without touching the outside of the bag. 17.
ANS: 2
APIC guidelines dictate that 3 to 5 mL of liquid soap is necessary for effective hand washing.
18.
ANS: 4
The nurse should rub the antiseptic hand solution over all surfaces of the hands until the solution dries, usually 10 to 15 seconds, to ensure effectiveness. 19.
ANS: 2
Protective isolation is used to protect those patients who are unusually vulnerable to organisms brought in by healthcare workers. Such patients include those with low white blood cell counts, with burns, and undergoing chemotherapy. Some hospital units, such as neonatal intensive care units and labor and delivery suites, also use forms of protective isolation. 20.
ANS: 2
The gloves should be thrown away because the gloves are likely to be contaminated from an outside source. The supplies do not have to be thrown away because they have not been contaminated. 21.
ANS: 2
The gloves are removed first because they are usually the most contaminated PPE and must be removed to avoid contamination of clean areas of the other PPE during their removal. The gown is removed second, then the mask or face shield, and finally, the hair covering. 22.
ANS: 3
If a nurse becomes exposed to body fluid, she should first wash the area, tell another nurse she is leaving the area, contact the infection control or employee health nurse immediately, and complete an incident report. It is most important to remove the source of contamination (body fluid) as soon as possible after exposure to help prevent the nurses from becoming infected. The other activities can wait until that is done. MULTIPLE RESPONSE 1. ANS: 3, 4 Standard precautions should be instituted with all clients whenever there is a possibility of coming in contact with blood, body fluids (except sweat), excretions, secretions, mucous membranes, and breaks in the skin (e.g., while inserting a peripheral IV). When interviewing a client, if the disease is not spread by air or droplets, there is no likelihood of the nurses encountering body fluids. If the disease is spread by air or droplets, then droplet or airborne precautions would be needed in addition to standard precautions. If giving a complete bed bath or performing oral hygiene, the nurse would need to use standard precautions (gloves); if merely assisting a client to perform those ADLs, it is not necessary. No exposure to body fluids is likely when helping a client to ambulate after surgery. 2. ANS: 1, 3, 4 Nutrition, hygiene, rest, exercise, stress reduction, and immunization protect the body against infection. Illness, injury, medical treatment, infancy or old age, frequent public contact, and various lifestyle factors can make the body more susceptible to infection. 3. ANS: 1, 3, 4
Hand washing requires at least 15 seconds of washing, which includes lathering all surfaces of the hands and fingers to be effective. The fingers should be held lower than the wrists. 4. ANS: 1, 3, 4
If there is potential for contact with bacterial spores, hands must be washed with soap and water; alcohol-based solutions are ineffective against bacterial spores. 5. ANS: 3, 4 Transporting a patient who requires airborne precautions should be limited; however, when necessary the patient should wear a surgical mask (an N-95 respirator mask is not required) that covers the mouth and nose to prevent the spread of infection. Moreover, the department where the patient is being transported should be notified about the precautions before transport. TRUE/FALSE 1.
ANS: T
Organisms that normally inhabit the body, called normal flora, are essential for human health and wellbeing. They keep pathogens in check. In the intestine, these flora function to aid digestion and promote the release of vitamin K, vitamin B12, thiamine, and riboflavin.
Chapter 1 Health Promotion (Part 2) 1. A client informs the nurse that he has quit smoking because his father died from lung cancer 3 months ago. Based on his motivation, smoking cessation should be recognized as an example of which of the following? 1)
Healthy living
2)
Health promotion
3)
Wellness behaviors
4)
Health protection
2. A patient with morbid obesity was enrolled in a weight loss program last month and has attended four weekly meetings. But now he believes he no longer needs to attend meetings because he has learned what to do. He informs the nurse facilitator about his decision to quit the program. What should the nurse tell him?
1) By now you have successfully completed the steps of the change process. You should be able to successfully lose the rest of the weight on your own.
2) Although you have learned some healthy habits, you will need at least another 6 weeks before you can quit the program and have success.
3) You have done well in this program. However, it is important to continue in the program to learn how to maintain weight loss. Otherwise, you are likely to return to your previous lifestyle.
4)
You have entered the determination stage and are ready to make positive changes that
you can keep for the rest of your life. If you need additional help, you can come back at a later time. 3. The school nurse at a local elementary school is performing physical fitness assessments on the third-grade children. When assessing students cardiorespiratory fitness, the most appropriate test is to have the students: 1)
Step up and down on a 12-inch bench.
2)
Perform the sit-and-reach test.
3)
Run a mile without stopping, if they can.
4)
Perform range-of-motion exercises.
4. In the Leavell and Clark model of health protection, the chief distinction between the levels of prevention is: 1)
The point in the disease process at which they occur.
2)
Placement on the Wheels of Wellness.
3)
The level of activity required to achieve them.
4)
Placement in the Model of Change.
5. The muscle strength of a woman weighing 132 pounds who is able to lift 72 pounds would be recorded as which of the following? 1)
1.83
2)
Moderate
3)
0.55
4)
18.3%
6. Which is one of the greatest concerns with heavy and chronic use of alcohol in teens and young adults? 1)
Liver damage
2)
Unintentional death
3)
Tobacco use
4)
Obesity
7. A 55-year-old man suffered a myocardial infarction (heart attack) three months ago. During his hospitalization, he had stents inserted in two locations in the coronary arteries. He was also placed on a cholesterol-lowering agent and two antihypertensives. What type of care is he receiving? 1)
Primary prevention
2)
Secondary prevention
3)
Tertiary prevention
4) 8
Health promotion
Health screening activities are designed to: 1)
Detect disease at an early stage.
2)
Determine treatment options.
3)
Assess lifestyle habits.
4) 9
Identify healthcare beliefs.
Which individuals should receive annual lipid screening? 1)
All overweight children
2)
All adults 20 years and older
3)
Persons with total cholesterol greater than 150 mg/dL
4)
Persons with HDL less than 40 mg/dL
10. A mother of three young children is newly diagnosed with breast cancer. She is intensely committed to fighting the cancer. She believes she can control her cancer to some degree with a positive attitude and feelings of inner strength. Which of the following traits is she demonstrating that is linked to health and healing? 1)
Invincibility
2)
Hardiness
3)
Baseline strength
4)
Vulnerability
Multiple Response Identify one or more choices that best complete the statement or answer the question. 1. The World Health Organizations definition of health includes which of the following? Choose all that apply. 1)
Absence of disease
2)
Physical well-being
3)
Mental well-being
4)
Social well-being
2. According to Penders health promotion model, which variables must be considered when planning a health promotion program for a client? Choose all that apply.
1)
Individual characteristics and experiences
2)
Levels of prevention
3)
Behavioral outcomes
4)
Behavior-specific cognitions and affect
3. Goals for Healthy People 2020 include which of the following? Choose all that apply. 1)
Eliminate health disparities among various groups.
2)
Decrease the cost of healthcare related to tobacco use.
3)
Increase the quality and years of healthy life.
4)
Decrease the number of inpatient days annually.
4. The nurse is implementing a wellness program based on data gathered from a group of lowincome seniors living in a housing project. He is using the Wheels of Wellness as a model for his planned interventions. Which of the following interventions would be appropriate based on this model? Choose all that apply. 1)
Creating a weekly discussion group focused on contemporary news
2)
Facilitating a relationship between local pastors and residents of subsidized housing
3)
Coordinating a senior tutorial program for local children at the housing center
4)
Establishing an on-site healthcare clinic operating one day per week
5. The nurse working in an ambulatory care program asks questions about the clients locus of control as a part of his assessment because of which of the following? Choose all that apply. 1)
People who feel in charge of their own health are the easiest to motivate toward change.
2) People who feel powerless about preventing illness are least likely to engage in health promotion activities.
3) People who respond to direction from respected authorities often prefer a health promotion program that is supervised by a health provider.
4)
People who feel in charge of their own health are less motivated by health promotion activities.
6. Health promotion programs assist a person to advance toward optimal health. Which of the following activities might such programs include? Choose all that apply. 1)
Disseminating information
2)
Changing lifestyle and behavior
3)
Prescribing medications to treat underlying disorders
4) 7
Environmental control programs
Which of the following actions demonstrate how nurses promote health? 1)
Role modeling
2)
Educating patients and families
3)
Counseling
4)
Providing support
Completion Complete each statement. 1. A middle-aged woman performs breast self-examination monthly. This intervention is considered to be prevention.
2.
refers to nursing actions performed to help clients to achieve an optimal state of health.
3. What is the name of the nursing theorist who defines health as having three elements: a high level of overall physical, mental, and social functioning; a general adaptive-maintenance level of daily functioning; and the absence of illness (or the presence of efforts that lead to its absence)?
Chapter 1. Health Promotion (Part 2) Answer Section MULTIPLE CHOICE 1.
ANS: 4
Although health promotion and health protection may involve the same activities, their difference lies in the motivation for action. Health protection is motivated by a desire to avoid illness. Health promotion is motivated by the desire to increase wellness. Smoking cessation may also be a wellness behavior and may be considered a step toward healthy living; however, neither of these addresses motivation for action. Comprehension 2.
ANS: 3
Prochaska and Diclemente identified four stages of change: the contemplation stage, the determination stage, the action stage, and the maintenance stage. This patient demonstrates behaviors typical of the action stage. If a participant exits a program before the end of the maintenance stage, relapse is likely to occur as the individual resumes his previous life style.
3.
ANS: 3
Field tests for running are good for children and can be utilized when assessing cardiorespiratory fitness. The step test is appropriate for adults. The 12-inch bench height is too high for young children. The sitand-reach test as well as range-of-motion exercises would be appropriate when assessing flexibility. 4.
ANS: 1
Leavell and Clark identified three levels of activities for health protection: primary, secondary, and tertiary. Interventions are classified according to the point in the disease process in which they occur. 5.
ANS: 3
Muscle strength measures the amount of weight a muscle (or group of muscles) can move at one time. This is recorded as a ratio of weight pushed (or lifted) divided by body weight. A woman weighing 132 pounds who is able to lift 72 pounds has a ratio of 72 divided by 132, or 0.55. 6.
ANS: 2
Heavy and chronic use of alcohol and use of illicit drugs increase the risk of disease and injuries and intentional death (suicide and homicide). Although alcohol as a depressant slows metabolism, chronic
alcohol use is more likely associated with poor nutrition, which may or may not lead to obesity. Chronic alcohol use causes damage to liver cells over time in the later years. Alcohol intake is often associated with tobacco and recreational drug use; however, the risk of unintentional injury, such as car accident, suicide, or violence, is more concerning than smoking. 7.
ANS: 3
Primary prevention activities are designed to prevent or slow the onset of disease. Activities such as eating healthy foods, exercising, wearing sunscreen, obeying seat-belt laws, and getting immunizations are examples of primary level interventions. Secondary prevention activities detect illness so it can be treated in the early stages. Tertiary prevention focuses on stopping the disease from progressing and returning the individual to the pre-illness phase. The patient has an established disease and is receiving care to stop the disease from progressing. 8.
ANS: 1
Health screening activities are designed to detect disease at an early stage so that treatment can begin before there is an opportunity for disease to spread or become debilitating. 9.
ANS: 1
The American Academy of Pediatrics take a targeted approach, recommending that overweight children receive cholesterol screening, regardless of family history or other risk factors for cardiovascular disease. The American Heart Association recommends that all adults age 20 years or older have a fasting lipid panel at least once every 5 years. If total cholesterol is 200 mg/dL or greateror HDL is less than 40 mg/dLfrequent monitoring is required. 10.
ANS: 2
Research has also demonstrated that in the face of difficult life events, some people develop hardiness rather than vulnerability. Hardiness is a quality in which an individual experiences high levels of stress yet does not fall ill. There are three general characteristics of the hardy person: control (belief in the ability to control the experience), commitment (feeling deeply involved in the activity producing stress), and challenge (the ability to view the change as a challenge to grow). These traits are associated with a strong resistance to negative feelings that occur under adverse circumstances. MULTIPLE RESPONSE 1. ANS: 2, 3, 4
The World Health Organization defines health as a state of complete physical, mental, and social wellbeing, not merely the absence of disease of infirmity. 2. ANS: 1, 3, 4 Pender identified three variables that affect health promotion: individual characteristics and experiences, behavior-specific cognitions and affect, and behavioral outcomes. Levels of prevention were identified by Leavell and Clark; three levels relate to health protection. The levels differ based on their timing in the illness cycle.
3. ANS: 1, 3 The four overarching goals of Healthy People 2020 are to 1) increase the quality and years of healthy life, free of disease, injury, and premature death, 2) eliminate health disparities and improve health for all groups of people, 3) create physical and social environments for people to live a healthy life, and 4) promote healthy development for people in all stages of life. 4. ANS: 1, 2, 3, 4 The Wheels of Wellness model identifies the following dimensions of health: emotional, intellectual, physical, spiritual, social/family, and occupational. A weekly discussion group stimulates intellectual health. A relationship between local pastors and those living in subsidized housing creates a climate for spiritual health. A tutorial program offered by seniors to local children will facilitate occupational health. An on-site healthcare clinic addresses physical health. 5. ANS: 1, 2, 3 Identifying a persons locus of control helps the nurse determine how to approach a client about health promotion. People who feel powerless about preventing illness are least likely to engage in health promotion activities. People who respond to direction from respected authorities often prefer a health promotion program that is supervised by a health provider. Clients who feel in charge of their own health are the easiest to motivate toward positive change. 6. ANS: 1, 2, 4 Health promotion programs may be categorized into four types: disseminating information; programs for changing lifestyle and behavior; environmental control programs; and wellness appraisal and health risk assessment programs. Prescribing medications to treat underlying disorders is an activity that fosters health focused at an individual level rather than at a group program level. 7. ANS: 1, 2, 3, 4 Nurses promote health by acting as role models, counseling, providing health education, and providing and facilitating support. 1. ANS: secondary Secondary prevention activities detect illness so that it can be treated in the early stages. Health activities such as mammograms, testicular examinations, regular physical examinations, blood pressure and diabetes screenings, and tuberculosis skin tests are examples of secondary interventions. Primary prevention activities are designed to prevent or slow the onset of disease and promote health. Activities such as eating healthy foods, exercising, wearing sunscreen, obeying seat-belt laws, and getting immunizations are examples of primary level interventions. Tertiary prevention focuses on stopping the disease from progressing and returning the individual to the pre-illness phase.
Chapter 2. Common Symptoms
1. The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds? a.
Wheezes
b.
Bronchial sounds
c.
Bronchophony
d.
Whispered pectoriloquy
ANS: A Wheezes are caused by air squeezed or compressed through passageways narrowed almost to closure by collapsing, swelling, secretions, or tumors, such as with acute asthma or chronic emphysema.
2. A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he has had a runny nose for a week. When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and intercostal retractions. The nurses next action should be to: a.
Assure the mother that these signs are normal symptoms of a cold.
b.
Recognize that these are serious signs, and contact the physician.
c.
Ask the mother if the infant has had trouble with feedings.
d. Perform a complete cardiac assessment because these signs are probably indicative of early heart failure. ANS: B The infant is an obligatory nose breather until the age of 3 months. Normally, no flaring of the nostrils and no sternal or intercostal retraction occurs. Significant retractions of the sternum and intercostal muscles and nasal flaring indicate increased inspiratory effort, as in pneumonia, acute airway obstruction, asthma, and atelectasis; therefore, immediate referral to the physician is warranted. These signs do not indicate heart failure, and an assessment of the infants feeding is not a priority at this time.
3. A teenage patient comes to the emergency department with complaints of an inability to breathe and a sharp pain in the left side of his chest. The assessment findings include cyanosis, tachypnea, tracheal deviation to the right, decreased tactile fremitus on the left, hyperresonance on the left, and decreased breath sounds on the left. The nurse interprets that these assessment findings are consistent with: a.
Bronchitis.
b.
Pneumothorax.
c.
Acute pneumonia.
d.
Asthmatic attack.
ANS: B With a pneumothorax, free air in the pleural space causes partial or complete lung collapse. If the pneumothorax is large, then tachypnea and cyanosis are evident. Unequal chest expansion, decreased or absent tactile fremitus, tracheal deviation to the unaffected side, decreased chest
expansion, hyperresonant percussion tones, and decreased or absent breath sounds are found with the presence of pneumothorax.
4. The nurse has just recorded a positive iliopsoas test on a patient who has abdominal pain. This test is used to confirm a(n): a.
Inflamed liver.
b.
Perforated spleen.
c.
Perforated appendix.
d.
Enlarged gallbladder.
ANS: C An inflamed or perforated appendix irritates the iliopsoas muscle, producing pain in the RLQ.
5.
Which statement indicates that the nurse understands the pain experienced by an older adult?
a.
Older adults must learn to tolerate pain.
b.
Pain is a normal process of aging and is to be expected.
c.
Pain indicates a pathologic condition or an injury and is not a normal process of aging.
d.
Older individuals perceive pain to a lesser degree than do younger individuals.
ANS: C Pain indicates a pathologic condition or an injury and should never be considered something that an older adult should expect or tolerate. Pain is not a normal process of aging, and no evidence suggests that pain perception is reduced with aging.
6. In assessing the tonsils of a 30 year old, the nurse notices that they are involuted, granular in appearance, and appear to have deep crypts. What is correct response to these findings? a.
Refer the patient to a throat specialist.
b.
No response is needed; this appearance is normal for the tonsils.
c.
Continue with the assessment, looking for any other abnormal findings.
d.
Obtain a throat culture on the patient for possible streptococcal (strep) infection.
ANS: B The tonsils are the same color as the surrounding mucous membrane, although they look more granular and their surface shows deep crypts. Tonsillar tissue enlarges during childhood until puberty and then involutes.
7. The nurse is obtaining a health history on a 3-month-old infant. During the interview, the mother states, I think she is getting her first tooth because she has started drooling a lot. The nurses best response would be: a.
Youre right, drooling is usually a sign of the first tooth.
b.
It would be unusual for a 3 month old to be getting her first tooth.
c.
This could be the sign of a problem with the salivary glands.
d.
She is just starting to salivate and hasnt learned to swallow the saliva.
ANS: D In the infant, salivation starts at 3 months. The baby will drool for a few months before learning to swallow the saliva. This drooling does not herald the eruption of the first tooth, although many parents think it does.
8. The nurse is assessing an 80-year-old patient. Which of these findings would be expected for this patient? a.
Hypertrophy of the gums
b.
Increased production of saliva
c.
Decreased ability to identify odors
d.
Finer and less prominent nasal hair
ANS: C
The sense of smell may be reduced because of a decrease in the number of olfactory nerve fibers. Nasal hairs grow coarser and stiffer with aging. The gums may recede with aging, not hypertrophy, and saliva production decreases.
9. The nurse is palpating the sinus areas. If the findings are normal, then the patient should report which sensation? a.
No sensation
b.
Firm pressure
c.
Pain during palpation
d.
Pain sensation behind eyes
ANS: B The person should feel firm pressure but no pain. Sinus areas are tender to palpation in persons with chronic allergies or an acute infection (sinusitis).
10. A 60-year-old man has just been told that he has benign prostatic hypertrophy (BPH). He has a friend who just died from cancer of the prostate. He is concerned this will happen to him. Howshould the nurse respond? a.
The swelling in your prostate is only temporary and will go away.
b.
We will treat you with chemotherapy so we can control the cancer.
c.
It would be very unusual for a man your age to have cancer of the prostate.
d.
The enlargement of your prostate is caused by hormonal changes, and not cancer.
ANS: D The prostate gland commonly starts to enlarge during the middle adult years. BPH is present in 1 in 10 men at the age of 40 years and increases with age. It is believed that the hypertrophy is caused by hormonal imbalance that leads to the proliferation of benign adenomas. The other responses are not appropriate.
11. A patient reports excruciating headache pain on one side of his head, especially around his eye, forehead, and cheek that has lasted approximately to 2 hours, occurring once or twice each day. The nurse should suspect: a.
Hypertension.
b.
Cluster headaches.
c.
Tension headaches.
d.
Migraine headaches.
ANS: B Cluster headaches produce pain around the eye, temple, forehead, and cheek and are unilateral and always on the same side of the head. They are excruciating and occur once or twice per day and last to 2 hours each.
12. A patient says that she has recently noticed a lump in the front of her neck below her Adams apple that seems to be getting bigger. During the assessment, the finding that leads the nurse to suspect that this may not be a cancerous thyroid nodule is that the lump (nodule): a.
Is tender.
b.
Is mobile and not hard.
c.
Disappears when the patient smiles.
d.
Is hard and fixed to the surrounding structures.
ANS: BPainless, rapidly growing nodules may be cancerous, especially the appearance of a single nodule in a young person. However, cancerous nodules tend to be hard and fixed to surrounding structures, not mobile.
Chapter 3. Preoperative Evaluation & Perioperative Management MULTIPLE CHOICE 1. The nurse is identifying diagnoses appropriate for a client scheduled for a surgical procedure. Which of the following is a diagnosis commonly used for preoperative client?
1.
Anxiety
2.
Sleep deprivation
3.
Excess fluid volume
4.
Disturbed body image
ANS: 1 The preoperative experience may be one of the most tension-producing periods of hospitalization. The nursing diagnosis anxiety is commonly used for preoperative clients. The other diagnoses are not commonly used as preoperative diagnoses. 2. The preoperative nurse cares for the client until the client progresses into the intraoperative phase of care which begins when the client:
1.
signs the surgical consent form.
2.
arrives at the surgical suite doors.
3.
is transferred to the postanesthesia care unit.
4.
accepts that surgery is pending.
ANS: 2 The preoperative period ends and the intraoperative period begins when the patient and family are at the door to the surgical suites. Intraoperative care does not begin when the client signs the surgical consent form, is transferred to the postanesthesia care unit, or accepts that surgery is pending. 3. The nurse is ensuring that a client is able to make knowledgeable decisions regarding an upcoming surgery and can provide informed consent. What is the responsibility of the nurse regarding informed consent?
1.
Explain the surgical options
2.
Explain the operative risks
3.
Describe the operative procedure to be done
4.
Witness a patients signature
ANS: 4 The nurse may concurrently sign that he has witnessed a patients signature. It is the physicians responsibility to explain the other answer choices. PTS: 1 DIF: Apply REF: Decision Strategies and Informed Consent 4.A client being prepared for surgery has a pulse oximeter placed on one digit of his hand. The nurse is applying this device to monitor the clients:
1.
oxygen level.
2.
heart rate.
3.
blood pressure.
4.
urine output.
ANS: 1 Pulse oximeters are used to precisely identify the clients peripheral tissue oxygenation. Pulse oximeters are not to measure heart rate, blood pressure, or urine output. PTS: 1 DIF: Analyze REF: Trends
5.A client is scheduled for surgery in 2 weeks. Which of the following should the nurse instruct the client regarding healthy lifestyle behaviors?
1.
Eat nutritious meals.
2.
If obese, cut calories before the surgery.
3.
If sedentary, exercise more before the surgery.
4.
Stop all prescribed medications.
ANS: 1 The client should be encouraged to adopt healthy dietary, rest, and exercise habits before the surgery. A client who has not followed healthy lifestyle habits should not suddenly make these changes before a surgical procedure. The nurse should encourage the client to eat nutritious meals. A client who is obese should not be encouraged to cut calories before the surgery. The client who is sedentary should not be encouraged to suddenly exercise before the surgery. The client should not be instructed to stop prescribed medications unless a physician has prescribed this action. PTS: 1 DIF: Apply REF: Time Frames and Tasks 6. The nurse wants to reduce the stress level for a preoperative client. Which of the following communication techniques can the nurse use to achieve this result?
1.
Allow the client to be alone before the surgery.
2.
Observe and ask the client if there is anything that can be done to help reduce her anxiety.
3.
Refer to the client by her first name.
4.
Make tasteful jokes or comments to help the client laugh.
ANS: 2 Strategies to reduce preoperative stress include observing and asking the client if there is anything that can be done to help reduce her anxiety. Leaving the client alone before the surgery will not help reduce stress. Referring to the client by her first name might be considered unprofessional and should not be done. Making jokes is also not a professional behavior and should not be done by the nurse. PTS: 1 DIF: Apply REF: Nurse/Patient Communication 7. Which of the following can the nurse do to help an elderly client scheduled for a surgical procedure?
1.
Work at a slower pace.
2.
Speed up the pace so the client has time to rest.
3.
Talk to family members and leave the client alone.
4.
Send them to the surgical holding area in advance.
ANS: 1 When caring for elderly clients, pace is important. Nurses should slow the pace. The nurse should not ignore the client. The nurse should also not send the client to the surgical holding area in advance since this could prove to be uncomfortable for the elderly client. PTS:1DIF:ApplyREF:Age-Related Issues 8. The nurse is concerned that a client scheduled for surgery will be at risk for hypothermia. Which of the following did the nurse assess in this client to determine the risk?
1.
Client is a vegetarian.
2.
Client exercises 5 days a week for 30 minutes.
3.
Client has a history of congestive heart failure.
4.
Clint is 48 years old.
ANS: 3 Clients at risk for hypothermia include the very young, the very old, those with a history of heart disease, those with a bleeding tendency, having complex surgery, and having surgery on a large body area that will be exposed. Being a vegetarian or exercising does not predispose a client to developing hypothermia during surgery. PTS:1DIF:AnalyzeREF:Environmental Safety 9. The nurse is concerned that a client may have an undocumented allergy to latex when which of the following is assessed?
1.
Recent episode of appendicitis
2.
Recovered from bronchitis 3 months ago
3.
Allergy to specific foods
4.
Does not like to wear wool clothing
ANS: 3 Risk factors for latex allergy include a history of allergies, for example, food allergies or contact dermatitis (eczema). Appendicitis and bronchitis do not increase the clients risk of a latex allergy. The clients not wearing wool clothing does not increase the clients risk of a latex allergy. PTS: 1 DIF: Analyze REF: Personal Patient Safety 10. The nurse is providing a medication to reduce the preoperative clients anxiety. Which of the following medications is the nurse most likely providing to the client?
1.
Hydrogen ion antagonist
2.
Anticholinergic
3.
Calcium channel blocker
4.
Opioid
ANS: 4 Opioids provide analgesia, decrease anxiety, and provide sedation. Calcium channel blockers treat specific heart problems. Hydrogen ion antagonists are used to reduce gastric secretions. Anticholinergics are used to reduce oral and respiratory tract secretions. PTS:1DIF:ApplyREFharmacology 11. An elderly client scheduled for surgery is concerned that his wife is not going to be able to manage at home alone. Which of the following can the nurse do to help this client and spouse?
1.
Encourage the client to not worry about his spouse.
2.
Ask the client if the spouse would agree to having some help while he is hospitalized.
3.
Encourage the spouse to come and stay with the client in the hospital.
4.
Suggest the spouse stay in a hotel until the client is discharged.
ANS: 2
13.A client is hospitalized with kidney trauma resulting in lacerations to the parenchyma. Which of the following would be included in the management of this clients care?
1.
Bed rest with antibiotic therapy
2.
Restrict fluids
3.
Encourage early ambulation
4.
Nephrectomy
ANS: 1 In the case of parenchymal lacerations to the kidney, the client should be hospitalized, kept on bed rest, and provided with antibiotics until the urine clears. Restricting fluids and encouraging early ambulation would not be appropriate for this clients injuries. A nephrectomy is not indicated for this type of kidney trauma. PTS:1DIF:Analyze REF: Renal System Trauma: Planning and Implementation 14.The nurse is reviewing a clients risk factors for the development of renal cancer. Which of the following would be considered a risk factor for the development of this disease?
1.
Cigarette smoking
2.
Being underweight
3.
History of hypotension
4.
History of type 2 diabetes mellitus
ANS: 1 Cigarettes smoking doubles the risk of renal cell carcinoma. Obesity, not being underweight, is a risk factor. Hypertension, not hypotension, is a risk factor. Type 2 diabetes mellitus is not a risk factor for the development of the disease.
15.A client is scheduled for surgery to remove the bladder and create a urinary diversion. If the client has a history of complications after surgery, the type of urinary diversion that might be indicated would be:
1.
continent diversion with a surgical opening to the abdomen.
2.
continent diversion with a replacement bladder made out of intestine.
3.
noncontinent diversion with anastomose of the ureters to the anterior wall.
4.
noncontinent diversion with anastomose of the ureters to the rectum.
ANS: 3 Noncontinent urinary diversions are considered less technically demanding and are associated with the fewest postoperative complications. This type of diversion is performed by anastomosing the ureters to the anterior body wall. The rectum is not used as a site to anastomose the ureters. Continent diversions have more postoperative complications. PTS: 1 DIF: Analyze REF: Urinary Diversion: Surgery MULTIPLE RESPONSE 1.The nurse is instructing a client on ways to prevent urinary tract infections. Which of the following should be included in these instructions? (Select all that apply.)
1.
Drink cranberry juice.
2.
Drink eight glasses of water.
3.
Take baths instead of showers.
4.
Urinate before and after intercourse.
5.
In women, wipe back to front after voiding.
6.
Take the prescribed medication until the symptoms subside
ANS: 1, 2, 4
Interventions to reduce the onset of urinary tract infections include drinking cranberry juice and 6 to 8 glasses of water each day. The client should be instructed to urinate before and after intercourse. Women should wipe front to back when completing perineal care because of the close proximity of the urethra to the vagina and anus. Taking showers instead of baths helps prevent bacteria from entering the urethra while bathing. The client should be instructed to take the entire course of the prescribed medication and not just until the symptoms subside. PTS:1DIF:Apply REF: Patient Playbook: Considerations for Patient Teaching
2.A client is diagnosed with an upper urinary tract infection. Which structures are affected by this infection? (Select all that apply.)
1.
Bladder
2.
Kidney
3.
Prostate
4.
Ureters
5.
Urethra
6.
Rectum
ANS: 2, 4 Upper urinary tract infections are of the ureters or kidney. Lower urinary tract infections are infections of the urethra, bladder, or prostate. The rectum is not affected by an upper urinary tract infection. PTS: 1 DIF: Apply REF: Urinary Tract Infection: Pathophysiology 3.The nurse is instructing a client on ways to reduce formation of future kidney stones. Which of the following should be included in these instructions? (Select all that apply.)
1.
Drink plenty of fluids.
2.
Drink soft drinks.
3.
Limit the intake of spinach.
4.
Take a vitamin B-12 supplement or eat foods rich in vitamin B-12.
5.
Take a magnesium citrate supplement or eating foods rich in magnesium citrate.
6.
Adjust calcium intake.
ANS: 1, 3, 5, 6 Instructions to reduce the formation of kidney stones in the future include: drink plenty of fluids; avoid soft drinks; limit the intake of spinach to reduce urinary oxalate levels; vitamin B6 helps reduce the formation of kidney stones; magnesium citrate helps prevent the formation of kidney stones; and calcium intake should be adjusted to prevent the formation of kidney stones. PTS: 1 DIF: Apply REF: Patient Playbook: Self-Care Nutrition Advice
4.A client is diagnosed with renal vein thrombosis. The nurse realizes that which of the following could be indicated in this clients plan of care? (Select all that apply.)
1.
Corticosteroids
2.
Nephrectomy
3.
Anticoagulants
4.
Antihypertensives
5.
Surgical intervention
6.
Antibiotics
ANS: 1, 3, 5 Management of the client diagnosed with renal vein thrombosis includes corticosteroids, anticoagulants, and surgical removal of the thrombi. Nephrectomy, antihypertensives, and antibiotics are not indicated in the treatment of this disorder. 5.The nurse is assessing a client for type of urinary incontinence. Which of the following are considered types of this disorder? (Select all that apply.)
1.
Stress
2.
Radical
3.
Urge
4.
Temporary
5.
Overflow
6.
Functional
ANS: 1, 3, 5, 6 The four types of incontinence are stress, urge, overflow, and functional. Radical and temporary are not types of bladder incontinence.
Chapter 24. Nervous System Disorders MULTIPLE CHOICE 1.
For the client who is at risk for stroke, the most important guideline the nurse should teach is to:
1.
increase drinks with caffeine.
2.
monitor blood pressure.
3.
increase amounts of sodium in the diet.
4.
monitor weight and activity.
ANS: 2
Monitoring weight and activity is important, but the highest priority is monitoring the blood pressure. This is a modifiable risk factor that, when controlled, will decrease the risk of stroke. 2. The family of a client diagnosed with a stroke asks the nurse if this health problem is very common. The nurse should respond that in the United States a person has a stroke every:
1.
40 seconds.
2.
1 minutes.
3.
2 minutes.
4.
5 minutes.
ANS: 1 In the United States, a person has a stroke every 40 seconds, and 700,000 new or recurrent strokes each year. Strokes are the third leading cause of death in the United States behind heart disease and cancer and are the leading cause of long-term disability. PTS: 1 DIF: Apply REF: Cerebrovascular Accidents or Strokes
3.A client is being evaluated for a stroke. The nurse knows that one of the easiest and most common diagnostic tests used to differentiate between strokes is:
1.
computed tomography (CT).
2.
magnetic resonance imaging (MRI).
3.
electrocardiography (EEG).
4.
positron emission tomography (PET).
ANS: 1 The CT scan is widely available in most hospitals and is an important tool to differentiate between ischemic strokes and hemorrhagic stroke. It is the most common tool used to diagnose a stroke. An MRI is contraindicated in clients with metal implants or pacemakers, and it can exacerbate claustrophobia. An EEG will determine the presence of brain waves, and it is not a diagnostic test for a stroke. A PET scan determines brain tissue functioning but, it will not be able to differentiate between the types of strokes.
PTS:1DIF:AnalyzeREFiagnostic Tests 4.While instructing a client on stroke prevention, the nurse mentions medications that are useful in stroke prevention. The following medications are effective in preventing a stroke, EXCEPT:
1.
anticoagulants.
2.
antiplatelets.
3.
anticholinergics.
4.
neuroprotective agents.
ANS: 3 Although anticholinergic drugs have a variety of uses, stroke prevention is not one of them. All the other medications are used in a variety of ways to help with stroke prevention. PTS:1DIF:ApplyREFharmacology 5.A client is being seen in the emergency department experiencing symptoms of a stroke. The nurse realizes that the administration of a medication to break clots, such as tPA, should be administered within how many minutes of the client presenting to the emergency department?
1.
30 minutes
2.
60 minutes
3.
90 minutes
4.
120 minutes
ANS: 2 Medications like tPA should be given within 60 minutes of the clients arrival to the emergency department. This is why health care teams must have a plan to deal with stroke clients quickly and efficiently. PTS: 1 DIF: Analyze REF: Emergency Management 6.The nurse, caring for a client with a traumatic brain injury, realizes that the major cause of these types of injuries is:
1.
guns.
2.
sports.
3.
falls.
4.
motor vehicle crashes.
ANS: 4 Although all are major causes of traumatic brain injury, motor vehicle crashes account for 20% of all traumatic brain injuries. Reasons for motor vehicle accidents causing the most traumatic brain injuries include not wearing seat belts and driving while intoxicated. PTS: 1 DIF: Analyze REF: Brain Injuries: Etiology 7.A client is diagnosed with a mild brain injury. Which of the following is an example of a mild injury?
1.
Coma
2.
Locked-in syndrome
3.
Vegetative state
4.
Concussion
ANS: 4 A concussion is a mild form of brain trauma, and it accounts for 75% of all brain injuries. A moderate brain injury would result in the loss of consciousness ranging from a few minutes to hours and days or weeks of confusion. Coma, locked-in syndrome, and a vegetative state are all examples of severe brain injury. PTS: 1 DIF: Analyze REF: Brain Injuries: Pathophysiology 8. The nurse, caring for a client recovering from a traumatic brain injury, knows the client and the family are eligible for specific federal programs because of the:
1.
Health Brain Act.
2.
Associated Brain Act.
3.
Traumatic Brain Injury Act of 2008.
4.
Brain Protection Act.
ANS: 3 The Traumatic Brain Injury Act of 2008 is legislation that provides a framework for prevention of, education about, and research on traumatic brain injuries. The act also supports community living for people who have sustained a traumatic brain injury and their families. The other choices are not programs to assist clients who have sustained a traumatic brain injury or their families. PTS:1DIF:Analyze REF: Law in Practice: Traumatic Brain Injury Act of 2008 9. The nurse is planning care for a client diagnosed with increased intracranial pressure after a head injury. Which of the following interventions can be used to reduce increased intracranial pressure?
1.
Administer antibiotics as prescribed.
2.
Keep the head of the bed in the flat position.
3.
Administer corticosteroids and osmotic diuretics as prescribed.
4.
Perform range-of-motion exercises every hour.
ANS: 3
The administration of corticosteroids will decrease the swelling of the brain, and osmotic diuretics will decrease the fluid that is building up. This intervention will decrease the intracranial pressure. Antibiotics do not reduce intracranial pressure. Keeping the head of the bed in the flat position can increase intracranial pressure and not decrease it. Performing range-of- motion exercises every hour will not reduce intracranial pressure. PTS: 1 DIF: Apply REF: Management of Head Injury 10. Which of the following should be avoided when caring for a client diagnosed with increased intracranial pressure?
1.
Starting an intravenous access line
2.
Administering oxygen
3.
Placing the bed in Trendelenburg
4.
Placing the client on bed rest
ANS: 3 Intravenous access and supplemental oxygen are common interventions in the treatment of increased intracranial pressure. Placing the client on bed rest is a proper safety measure. Placing the bed in Trendelenburg position will increase blood flow to the brain and increase ICP. PTS: 1 DIF: Apply REF: Management of Head Injury 11.A client is being instructed on treatments available for a newly diagnosed brain tumor. The nurse realizes that this clients treatment could include all of the following EXCEPT:
1.
photo DNA therapy.
2.
radiation.
3.
chemotherapy.
4.
surgery.
ANS: 1 Photo DNA therapy is not a therapy. The other answers are common treatment modalities for patients with brain tumors in addition to photodynamic and adjunctive medication therapy. PTS: 1 DIF: Analyze REF: Brain Tumors: Planning and Implementation
12.A client diagnosed with an embolic stroke is not a candidate for tPA. The nurse realizes that the client might be eligible for which of the following forms of treatment?
1.
Carotid stenting
2.
Antiarrhythmic medication
3.
Intravenous fluid therapy
4.
Carotid endarterectomy
ANS: 1 In clients who are ineligible for tPA therapy, catheter-based treatment such as stenting may be an option. Carotid endarterectomy is used to prevent a stroke. Antiarrhythmic medication does not prevent a stroke. Intravenous fluid therapy does not prevent a stroke. PTS: 1 DIF: Analyze REF: Surgery 13.A client diagnosed with a brain tumor is going to receive chemotherapy. The nurse realizes that which of the following medications would most likely be prescribed for this clients treatment?
1.
Carmustine
2.
Digoxin
3.
Aminophylline
4.
Acetaminophen
ANS: 1 One of the biggest obstacles for chemotherapeutic agents when treating brain tumors is selecting a medication that will cross the blood-brain barrier. Carmustine can cross the blood-brain barrier. The other medications are not used as chemotherapy for brain tumors. PTS: 1 DIF: Analyze REF: Brain Tumors: Chemotherapy MULTIPLE RESPONSE 1.A client, being tested for a stroke, is not a candidate for tPA. Which of the following would be contraindicated for the use of tPA? (Select all that apply.)
1.
Minor ischemic stroke within 30 days
2.
Glucose level 120 mg/dL
3.
Blood pressure 190/120 mmHg
4.
Lumbar puncture 2 days ago
5.
Stroke onset 5 hours ago
6.
INR 1.0
ANS: 1, 3, 4, 5 Contraindications of tPA to treat an embolic stroke include minor ischemic stroke within the last 30 days, blood pressure greater an 185 mmHg systolic or greater than 110 mmHg diastolic, lumbar puncture within the last 3 days, and onset of stroke greater than 3 hours. Glucose level of 120 mg/dL and INR of 1.0 would not be contraindications for tPA therapy.
2. The nurse, planning care for a client recovering from a traumatic brain injury, is including interventions to prevent sympathetic storming. Which of the following should be included in this clients plan of care? (Select all that apply.)
1.
Medicate for pain prior to conducting a painful procedure.
2.
Elevated blood pressure indicates a sympathetic storm is ending.
3.
Continue suctioning until the clients heart rate is greater than 100 beats per minute.
4.
Cardiac arrhythmias indicate a drop in intracranial pressure.
5.
Provide beta-blockers as prescribed with symptoms of sympathetic storm.
6. If symptoms of sympathetic storm do not appear within 24 hours, the client will not develop this health problem.
ANS: 1, 5 The nurse should medicate the client for pain prior to conducting a painful procedure and provide betablockers as prescribed with symptoms of a sympathetic storm. An elevated blood pressure is a symptom
of sympathetic storm. An elevated heart rate is a symptom of sympathetic storming. Cardiac arrhythmias are also a symptom of a sympathetic storm and do not indicate a
drop in intracranial pressure. Symptoms of sympathetic storming can occur within 24 hours after a traumatic brain injury and can reoccur periodically during the recovery process. PTS: 1 DIF: Apply REF: Red Flag: Sympathetic Storming 3. The nurse is providing discharge instructions to a client recovering from a traumatic brain injury. Which of the following should be included in these instructions? (Select all that apply.)
1.
Return to a full schedule of work as soon as possible.
2.
Acquire medical clearance prior to returning to work that uses heavy equipment.
3.
Avoid the use of helmets.
4.
Limit the amount of alcoholic beverages.
5.
Avoid all illicit drug use.
6.
Eat a well-balanced diet.
ANS: 2, 5, 6 Discharge instructions for a client recovering from a traumatic brain injury should include: medical clearance is needed prior to returning to work that uses heavy equipment; avoid all illicit drug use; and eat a well-balanced diet. The client should be cautioned to avoid returning to a full schedule of work as soon as possible. The client should be encouraged to use helmets or other safety equipment to protect the head. The clients should be instructed to avoid all alcoholic beverages. PTS:1DIF:Apply REF: Patient Playbook: Education Topics for a Patient with a Brain Injury 4.A client asks the nurse to explain symptoms that would indicate the presence of a brain tumor. Which of the following should the nurse respond to this client? (Select all that apply.)
1.
There are no symptoms specific to a brain tumor.
2.
Dizziness is a common symptom.
3.
Ringing or buzzing in the ears can occur.
4.
Seizures may occur.
5.
A headache that gets worse in the afternoon is specific to a brain tumor..
6.
A headache is usually experienced by 50% of all people diagnosed with a brain tumor.
ANS: 2, 3, 4, 6 Symptoms of a brain tumor include dizziness, ringing or buzzing in the ears, seizures, and a headache. The headache of a brain tumor is usually worse in the morning and not the afternoon. There are symptoms associated with a brain tumor. PTS:1DIF:Apply REF: Brain Tumors: Assessment with Clinical Manifestations 5. The nurse is instructing a client diagnosed with a brain tumor on symptoms to immediately report to her physician. Which of the following should be included in these instructions? (Select all that apply.)
1.
New onset of seizures
2.
One-sided weakness
3.
Loss of balance
4.
Problems with vision
5.
Inability to talk
6.
Loss of appetite
ANS: 1, 2, 3, 4, 5 Brain tumor symptoms that require immediate attention include new onset of seizures, slow progressing hemiparesis, gait or balance disturbances, visual problems, hearing loss, and aphasia. Loss of appetite is not a brain tumor symptom. PTS:1DIF:Apply REF: Red Flag: Brain Tumor Symptoms that Require Immediate Attention
6. The nurse, caring for a client diagnosed with a brain tumor, is planning interventions to assist with swallowing and prevent aspiration. Which of the following would be appropriate for this client? (Select all that apply.)
1.
Instruct the client to tuck the chin with each swallow.
2.
Instruct the client to turn the head toward the strong side to swallow.
3.
Instruct the client to turn the head toward the weak side to swallow.
4.
Instruct the client to hold the breath while swallowing.
5.
Instruct the client to eat in a reclining position.
6.
Instruct the client to sit in an upright position when eating.
ANS: 1, 3, 4, 6 Interventions to assist a client with swallowing and prevent aspiration include have the client tuck the chin with each swallow, turn the head to the weak side to swallow, hold the breath while swallowing, and sitting in an upright position to swallow. The client should not be instructed to turn the head toward the strong side to swallow or to eat in a reclining position. 1.A client is diagnosed with a headache from a secondary cause. The nurse realizes this type of headache can be caused by:
1.
a tumor.
2.
tension.
3.
a migraine.
4.
cluster
ANS: 1 Primary headaches are identified when no organic cause can be found. A tumor headache is caused by a tumor and is classified as a secondary headache. PTS: 1 DIF: Analyze REF: Headache
2.The nurse should instruct a client diagnosed with migraine headaches to be careful not to overdose on acetaminophen (Tylenol). Which drug should the nurse tell the patient to avoid?
1.
Aleve
2.
Aspirin
3.
Ibuprofen
4.
Vicodin
ANS: 4 Vicodin, although a narcotic analgesic, also contains acetaminophen (Tylenol). It is very easy to overdose on the acetaminophen (Tylenol) component, which can lead to kidney damage. Aleve does not contain acetaminophen (Tylenol). Aspirin and ibuprofen do not contain acetaminophen (Tylenol). PTS: 1 DIF: Apply REF: Headache: Pharmacology 3.A client is diagnosed with seizures occurring because of hepatic encephalopathy. The nurse realizes that the cause for this clients seizures would be:
1.
physiological.
2.
iatrogenic.
3.
idiopathic.
4.
psychokinetic.
ANS: 1 The three major causes for seizures are physiological, iatrogenic, and idiopathic. Physiological seizures include those that occur with an acquired metabolic disorder such as hepatic encephalopathy. Iatrogenic causes include new medications or drug or alcohol use. Idiopathic causes include fevers, fatigue, or strong emotions. Psychokinetic is not a cause for seizures. 4.A client tells the nurse that he sees flashing lights that occur prior to the onset of a seizure. Which of the following phases of a seizure is this client describing to the nurse?
1.
Prodromal phase
2.
Aural phase
3.
Ictal phase
4.
Postictal phase
ANS: 2 In the aural phase a sensation or warning occurs, which the patient often remembers. This warning can be visual, auditory, gustatory, or visceral in nature. The prodromal phase of a seizure includes the signs or activity before the seizure such as a headache or feeling depressed. The ictal phase of a seizure is the actual seizure. The postictal phase is the period immediately following the seizure.
PTS: 1 DIF: Analyze REF: Seizures: Assessment with Clinical Manifestations 5.A client is experiencing a grand mal seizure. Which of the following should the nurse do during this seizure?
1.
Protect the clients head.
2.
Leave the client alone.
3.
Give water to the client to avoid dehydration.
4.
Place a finger in the clients mouth to avoid swallowing the tongue.
ANS: 1 One of the most important interventions for a nurse to perform during a seizure is to protect the clients head from injury. Never give a client a drink during a seizure. Placing a finger in the clients mouth could be very dangerous to the client and the nurse. Do not leave the client unattended during a seizure PTS: 1 DIF: Apply REF: Seizures: Planning and Implementation 6.A client is prescribed phenytoin (Dilantin) for a seizure disorder. Which of the following would indicate that the client is adhering to the medication schedule?
1.
The client is sleepy.
2.
The client is not experiencing seizures.
3.
The client no longer has headaches.
4.
The client is eating more food.
ANS: 2 Phenytoin (Dilantin) is a medication to control seizures. The absence of seizures indicates that the client is adhering to the medication schedule. Sleepiness, lack of headaches, or improved appetite are not indications that the medication is being used as prescribed. 7. The nurse is unable to insert an intravenous access line into a client who is currently experiencing a seizure. Which of the following routes can the nurse use to provide medication to the client at this time?
1.
Oral
2.
Intranasal
3.
Rectal
4.
Intramuscular
ANS: 2 For a client experiencing a seizure, oral medications and sharp objects can be dangerous and should not be used. Intranasally administered drugs are rapid and effective in treating a client experiencing an acute seizure. Intranasal delivery is more effective than rectal. PTS: 1 DIF: Apply REF: Red Flag: Intranasal Drug Delivery 8.
One of the most important things a nurse can teach a client about seizure control is to:
1.
take the medication every day as prescribed by the doctor.
2.
eat a balanced diet.
Medication is effective only if it is taken as prescribed, and suddenly stopping the medication can trigger an increase in seizure activity. Diet and exercise are important to a healthy lifestyle but do little to control seizure activity. PTS: 1 DIF: Apply REF: Seizures: Planning and Implementation 9. The nurse is instructing a client newly diagnosed with multiple sclerosis (MS). To determine the effectiveness of his teaching, the nurse would expect the client to state:
1.
It is best for me to be in a cold environment.
2.
I should avoid taking a hot bath.
3.
I should eat foods low in salt.
4.
I should be better in a week.
ANS: 2 The clinical manifestations of MS can be exacerbated by being in a hot, humid environment or by taking a hot bath. A cold environment and low-salt foods do not impact the symptoms of multiple sclerosis. If the client states that they will improve in a week, instruction has not been effective. PTS:1DIF:Analyze REF:Multiple Sclerosis: Assessment with Clinical Manifestations
10. An adult female in her 30s complains of numbness and tingling in the hands, fatigue, loss of coordination, incontinence, nystagmus, and ataxia. Which of the following health problems do these symptoms suggest to the nurse?
1.
Brain tumor
2.
Myasthenia gravis
Multiple sclerosis is more common in women of this age. These are symptoms, along with the age and sex of the patient, that are common to MS. These symptoms are not necessarily associated with a brain tumor. Weakness is the primary symptom associated with myasthenia gravis. Symptoms of diabetes include weight loss, blurred vision, excessive urination, thirst, and hunger. 11.
For a client diagnosed with Parkinsons disease, which of the following might be contraindicated?
1.
Performing range-of-motion exercises
2.
Drinking bottled water
3.
Instituting fall precautions
4.
Taking naps
ANS: 2 Some clients diagnosed with Parkinsons disease develop swallowing difficulties. Powders to thicken liquids and using an upright position will help with these difficulties. Clients diagnosed with Parkinsons disease will benefit from range-of-motion exercises and resting. The client diagnosed with Parkinsons disease should be placed on fall precautions. PTS: 1 DIF: Apply REF: Parkinsons Disease: Planning and Implementation 12.A client diagnosed with Parkinsons disease is beginning medication therapy. The nurse realizes that the goal of treatment for Parkinsons disease is to:
1.
improve sleep.
2.
reduce appetite.
3.
control tremor and rigidity.
4.
reduce the need for joint replacement surgery.