NURSING MISC all med surge exams and quizzes

NURSING MISC all med surge exams and quizzes MedSurge Quiz 1 - 36 37 38 39 1. A nurse is admitting a patient with an immunodefciency to the medical unit. In planning the care of this patient, the nurse should assess ...

NURSING MISC all med surge exams and quizzes MedSurge Quiz 1 - 36 37 38 39 1. A nurse is admitting a patient with an immunodefciency to the medical unit. In planning the care of this patient, the nurse should assess for what common sign of immunodefciency? a. Chronic diarrhea 2. A nurse is caring for a patient who has an immunodefciency. What assessment fnding should prompt the nurse to consider the possibility that the patient is developing an infection? a. Persistent diarrhea 3. The nurse is applying standard precautions in the care of a patient who has an immunodefciency. What are key elements of standard precautions? Select all that apply. a. Using appropriate personal protective equipment b. Using safe injection practices c. Performing hand hygiene 4. A home health nurse is reinforcing health education with a patient who is immunosuppressed and his family. What statement best suggests that the patient has understood the nurse's teaching? a. “My family needs to understand that I'll probably need lifelong treatment.” 5. The nurse is preparing to administer IVIG to a patient who has an immunodefciency. What nursing guideline should the nurse apply? a. Administer pretreatment medications as ordered 30 minutes prior to infusion. 6. A nurse has created a plan of care for an immunodefcient patient, specifying that care providers take the patient's pulse and respiratory rate for a full minute. What is the rationale for this aspect of care? a. These patients' blunted inflammatory responses can cause subtle changes in status. 7. A nurse is providing health education regarding self-care to a patient with an immunodefciency. What teaching point should the nurse emphasize? a. The need for thorough oral hygiene 8. A patient's primary immunodefciency disease is characterized by the inability of white blood cells to initiate an inflammatory response to infectious organisms. What is this patient's most likely diagnosis? a. Hyperimmunoglobulinemia E syndrome 9. A nurse is working with a patient who was diagnosed with HIV several months earlier. The nurse should recognize that a patient with HIV is considered to have AIDS at the point when the CD4+ T-lymphocyte cell count drops below what threshold? a. 200 cells/mm3 of blood 10. A patient has been diagnosed with AIDS complicated by chronic diarrhea. What nursing intervention would be appropriate for this patient? a. Obtain a stool culture to identify possible pathogens. 11. An 18-year-old pregnant female has tested positive for HIV and asks the nurse if her baby is going to be born with HIV. What is the nurse's best response? a. “It's possible that your baby could contract HIV, either before, during, or after delivery.” 12. Since the emergence of HIV/AIDS, there have been signifcant changes in epidemiologic trends. Members of what group currently have the greatest risk of contracting HIV?a. Gay, bisexual, and other men who have sex with men 13. A hospital patient is immunocompromised because of stage 3 HIV infection and the physician has ordered a chest radiograph. How should the nurse most safely facilitate the test? a. Arrange for a portable x-ray machine to be used 14. A patient's current antiretroviral regimen includes nucleoside reverse transcriptase inhibitors (NRTIs). What dietary counseling will the nurse provide based on the patient's medication regimen? a. Take this medication without regard to meals. 15. A nurse is performing the admission assessment of a patient who has AIDS. What components should the nurse include in this comprehensive assessment? Select all that apply. a. Current medication regimen b. Identifcation of patient's support system c. Immune system function d. History of sexual practices 16. A patient is in the primary infection stage of HIV. What is true of this patient's current health status? a. The patient is infected with HIV but lacks HIV-specifc antibodies. 17. A nurse is aware of the need to assess patients' risks for anaphylaxis. What health care procedure constitutes the highest risk for anaphylaxis? a. Computed tomography with contrast solution 18. A patient with multiple food and environmental allergies tells the nurse that he is frustrated and angry about having to be so watchful all the time and wonders if it is really worth it. What would be the nurse's best response? a. “I can only imagine how you feel. Would you like to talk about it? 19. A nurse is caring for a patient who has allergic rhinitis. What intervention would be most likely to help the patient meet the goal of improved breathing pattern? a. Modify the environment to reduce the severity of allergic symptoms. 20. The nurse in an allergy clinic is educating a new patient about the pathology of the patient's health problem. What response should the nurse describe as a possible consequence of histamine release? a. Contraction of bronchial smooth muscle 21. A patient has presented with signs and symptoms that are consistent with contact dermatitis. What aspect of care should the nurse prioritize when working with this patient? a. Identifying the offending agent, if possible 22. A patient's rheumatoid arthritis (RA) has failed to respond appreciably to frst-line treatments and the primary care provider has added prednisone to the patient's drug regimen. What principle will guide this aspect of the patient's treatment? a. The drug should be used for as short a time as possible. 23. A patient with SLE has come to the clinic for a routine check-up. When auscultating the patient's apical heart rate, the nurse notes the presence of a distinct “scratching” sound. What is the nurse's most appropriate action? a. Inform the primary care provider that a friction rub may be present. 24. A nurse is educating a patient with gout about lifestyle modifcations that can help control the signs and symptoms of the disease. What recommendation should the nurse make? a. Limiting intake of alcohol25. A nurse is planning the care of a patient who has a long history of chronic pain, which has only recently been diagnosed as fbromyalgia. What nursing diagnosis is most likely to apply to this woman's care needs? a. Ineffective Role Performance Related to Pain Test Bank Questions Not On Quiz 1 CHP 36 1. A teenager is diagnosed with cellulitis of the right knee and fails to respond to oral antibiotics. He then develops osteomyelitis of the right knee, prompting a detailed diagnostic workup that reveals a phagocytic disorder. This patient faces an increased risk of what complication? a. Neutropenia 2. A patient is admitted for the treatment of a primary immunodefciency and intravenous immunoglobulin (IVIG) is ordered. What should the nurse monitor for as a potential adverse effect of IVIG administration? a. Anaphylaxis 3. A young couple visits the nurse practitioner stating that they want to start a family. The husband states that his brother died of a severe infection at age 6 months. He says he never knew what was wrong but his mother had him undergo ìblood testingî as a child. Based on these statements, what health problem should the nurse practitioner suspect? a. X-linked agammaglobulinemia 4. The parents of a 1-month-old infant bring their child to the pediatrician with symptoms of congestive heart failure. The infant is ultimately diagnosed with DiGeorge syndrome. What will prolong this infant's survival? a. Thymus gland transplantation 5. A patient who has received a heart transplant is taking cyclosporine, an immunosuppressant. What should the nurse emphasize during health education about infection prevention? a. Perform frequent hand-washing 6. The nurse is caring for a patient who has a diagnosis of paroxysmal nocturnal hemoglobinuria. When planning this patient's care, the nurse should recognize the patient's heightened risk of what complication? a. Venous thromboembolism 7. A patient diagnosed with common variable immune defciency (CVID) has been admitted to the acute medicine unit. When reviewing this patient's laboratory fndings, the nurse should prioritize what values? a. Hemoglobin and vitamin B12 8. Patient teaching regarding infection prevention for the patient with an immunodefciency includes which of the following guidelines? a. Cook all food thoroughly 9. A nurse has admitted a patient diagnosed with severe combined immunodefciency disease (SCID) to the unit. The patient's orders include IVIG. How will the patient's dose of IVIG be determined? a. The dose will be determined by the patient's response 10. IVIG has been ordered for the treatment of a patient with an immunodefciency. Which of the following actions should the nurse perform before administering this blood product? a. Weigh the patient before administration to verify the correct dose. 11. A patient with a diagnosis of common variable immunodefciency begins to develop thick, sticky, tenacious sputum. The patient has a history of episodes ofpneumonia at least one time per year for the last 10 years. What does the nurse suspect the patient is developing? a. Bronchiectasis 12. A nurse is admitting an adolescent patient with a diagnosis of ataxiatelangiectasis. Which of the following nursing diagnoses should the nurse include in the patient's plan of care? a. Risk for Falls Due to Loss of Muscle Coordination 13. A 20-year-old patient with an immunodefciency is admitted to the unit with an acute episode of upper airway edema. This is the ffth time in the past 3 months that the patient has had such as episode. As the nurse caring for this patient, you know that the patient may have a defciency of what? a. C1esterase inhibitor 14. A patient with Wiskott-Aldrich syndrome is admitted to the medical unit. The nurse caring for the patient should prioritize which of the following? a. Protective isolation 15. The nurse is admitting a patient to the unit with a diagnosis of ataxiatelangiectasia. The nurse's assessment should reflect the patient's increased risk for what complication? a. Cancer 16. The nurse is working with the interdisciplinary team to care for a patient who has recently been diagnosed with severe combined immunodefciency disease (SCID). What treatment is likely of most beneft to this patient? a. Hematopoietic stem cell transplantation (HSCT) 17. A patient has been admitted with a phagocytic cell disorder and the nurse is reviewing the most common health problems that accompany these disorders. The nurse should identify which of the following? Select all that apply. a. Chronic otitis media b. Cutaneous abscesses c. Pneumonia 18. A nurse is caring for a patient with a phagocytic cell disorder. The patient states, ìMy specialist says that I will likely be cured after I get my treatment tomorrow. To what treatment is the patient most likely referring? a. Hematopoietic stem cell transplantation 19. A nurse educator is explaining that patients with primary immunodefciencies are living longer than in past decades because of advances in medical treatment. This increased longevity is associated with an increased risk of what? a. Cancer 20. The nurse educator is differentiating primary immunodefciency diseases from secondary immunodefciencies. What is the defning characteristic of primary immunodefciency diseases? a. They have a genetic origin 21. The nurse is caring for a patient with an immunodefciency who has experienced sudden malaise. The nurse's colleague states, ìI'm pretty sure that it's not an infection, because the most recent blood work looks fne.î What principle should guide the nurse's response to the colleague? a. Immunodefcient patients will usually exhibit subtle and atypical signs of infection 22. A patient with a diagnosis of primary immunodefciency informs the nurse that he has been experiencing a new onset of a dry cough and occasional shortness of breath. After determining that the patient's vital signs are within reference ranges, what action should the nurse take?a. Assess the patient for signs and symptoms of infection 23. A nurse is preparing to administer a scheduled dose of IVIG to a patient who has a diagnosis of severe combined immunodefciency disease (SCID). What medication should the nurse administer prior to initiating the infusion? a. Diphenhydramine 24. An immunocompromised patient is being treated in the hospital. The nurse's assessment reveals that the patient's submandibular lymph nodes are swollen, a fnding that represents a change from the previous day. What is the nurse's most appropriate action? a. Inform the patient's primary care provider of this fnding 25. A nurse caring for a patient who has an immunosuppressive disorder knows that continual monitoring of the patient is critical. What is the primary rationale behind the need for continual monitoring? a. So that early signs of impending infection can be detected and treated 26. A nurse is planning the care of a patient who requires immunosuppression to ensure engraftment of depleted bone marrow during a transplantation procedure. What is the most important component of infection control in the care of this patient? a. Thorough and consistent hand hygiene 27. A home health nurse is caring for a patient who has an immunodefciency. What is the nurse's priority action to help ensure successful outcomes and a favorable prognosis? a. Encourage the patient and family to be active partners in the management of theimmunodefciency 28. A nurse is preparing to discharge a patient with an immunodefciency. When preparing the patient for self-infusion of IVIG in the home setting, what education should the nurse prioritize? a. Signs and symptoms of adverse reactions 29. A home health nurse will soon begin administering IVIG to a new patient on a regular basis. What teaching should the nurse provide to the patient? a. Expected benefts and outcomes of the treatment 30. The home health nurse is assessing a patient who is immunosuppressed following a liver transplant. What is the most essential teaching for this patient and the family? a. The need to report any slight changes in the patient's health status 31. Family members of an immunocompromised patient have asked the nurse why antibiotics are not being given to the patient in order to prevent infection. How should the nurse best respond? a. Using antibiotics to prevent infections can cause the growth of drug-resistant bacteria 32. A 6-month-old infant has been diagnosed with X-linked agammaglobulinemia and the parents do not understand why their baby did not develop an infection during the frst months of life. The nurse should describe what phenomenon? a. Passive acquired immunity CHP 37 1. A clinic nurse is caring for a patient admitted with AIDS. The nurse has assessed that the patient is experiencing a progressive decline in cognitive, behavioral, and motor functions. The nurse recognizes that these symptoms are most likely relatedto the onset of what complication? a. HIV encephalopathy 2. A nurse is assessing a 28-year-old man with HIV who has been admitted with pneumonia. In assessing the patient, which of the following observations takes immediate priority? a. Tachypnea and restlessness 3. A patient has come into the free clinic asking to be tested for HIV infection. The patient asks the nurse how the test works. The nurse responds that if the testing shows that antibodies to the AIDS virus are present in the blood, this indicates what? a. The patient has been infected with HIV 4. The mother of two young children has been diagnosed with HIV and expresses fear of dying. How should the nurse best respond to the patient? a. Can you tell me what concerns you most about dying? 5. The nurse is addressing condom use in the context of a health promotion workshop. When discussing the correct use of condoms, what should the nurse tell the attendees? a. Hold the condom by the cuff upon withdrawal 6. A nurse is planning the care of a patient with AIDS who is admitted to the unit with Pneumocystis pneumonia (PCP). Which nursing diagnosis has the highest priority for this patient? a. Ineffective Airway Clearance 7. A public health nurse is preparing an educational campaign to address a recent local increase in the incidence of HIV infection. The nurse should prioritize which of the following interventions? a. Educational programs that focus on control and prevention 8. During the admission assessment of an HIV-positive patient whose CD4+ count has recently fallen, the nurse carefully assesses for signs and symptoms related to opportunistic infections. What is the most common life-threatening infection? a. Pneumocystis pneumonia 9. A nurse is performing an admission assessment on a patient with stage 3 HIV. After assessing the patient's gastrointestinal system and analyzing the data, what is most likely to be the priority nursing diagnosis? a. Diarrhea 10. A patient with a recent diagnosis of HIV infection expresses an interest in exploring alternative and complementary therapies. How should the nurse best respond? a. Many patients with HIV use some type of alternative therapy and, as with most health treatments, there are benefts and risks 11. A patient was tested for HIV using enzyme immunoassay (EIA) and results were positive. The nurse should expect the primary care provider to order what test to confrm the EIA test results? a. Western blot test 12. The nurse's plan of care for a patient with stage 3 HIV addresses the diagnosis of Risk for Impaired Skin Integrity Related to Candidiasis. What nursing intervention best addresses this risk? a. Providing thorough oral care before and after meals 13. A patient with HIV infection has begun experiencing severe diarrhea. What is the most appropriate nursing intervention to help alleviate the diarrhea? a. Administer antidiarrheal medications on a scheduled basis, as ordered14. A nurse is caring for a patient hospitalized with AIDS. A friend comes to visit the patient and privately asks the nurse about the risk of contracting HIV when visiting the patient. What is the nurse's best response? a. AIDS isn't transmitted by casual contact 15. A patient with HIV has a nursing diagnosis of Risk for Impaired Skin Integrity. What nursing intervention best addresses this risk? a. Utilize a pressure-reducing mattress (or low-air loss beds) 16. A nurse would identify that a colleague needs additional instruction on standard precautions when the colleague exhibits which of the following behaviors? a. The nurse puts on a second pair of gloves over soiled gloves while performing a bloody procedure 17. A nurse is addressing the incidence and prevalence of HIV infection among older adults. What principle should guide the nurse's choice of educational interventions? a. Many older adults do not see themselves as being at risk for HIV infection 18. A 16-year-old has come to the clinic and asks to talk to a nurse. The nurse asks the teen what she needs and the teen responds that she has become sexually active and is concerned about getting HIV. The teen asks the nurse what she can do keep from getting HIV. What would be the nurse's best response? a. Other than abstinence, only the consistent and correct use of condoms is effective in preventing HIV 19. A patient's primary infection with HIV has subsided and an equilibrium now exists between HIV levels and the patient's immune response. This physiologic state is known as which of the following? a. Viral set point 20. A patient with HIV will be receiving care in the home setting. What aspect of self-care should the nurse emphasize during discharge education? a. Importance of personal hygiene 21. A patient is beginning an antiretroviral drug regimen shortly after being diagnosed with HIV. What nursing action is most likely to increase the likelihood of successful therapy? a. Addressing possible barriers to adherence 22. The nurse is caring for a patient who has been admitted for the treatment of AIDS. In the morning, the patient tells the nurse that he experienced night sweats and recently ìcoughed up some blood.î What is the nurse's most appropriate action? a. Place the patient on respiratory isolation and inform the physician (Note: this is a sign of possible TB) 23. A patient has come into contact with HIV. As a result, HIV glycoproteins have fused with the patient's CD4+ T-cell membranes. This process characterizes what phase in the HIV life cycle? a. Attachment 24. An HIV-infected patient presents at the clinic for a scheduled CD4+ count. The results of the test are 45 cells/μL, and the nurse recognizes the patient's increased risk for Mycobacterium avium complex (MAC disease). The nurse should anticipate the administration of what drug? a. Azithromycin 25. A patient with HIV is admitted to the hospital because of chronic severe diarrhea. The nurse caring for this patient should expect the physician to orderwhat drug for the management of the patient's diarrhea? a. Sandostatin 26. A patient with AIDS is admitted to the hospital with AIDS-related wasting syndrome and AIDS-related anorexia. What drug has been found to promote signifcant weight gain in AIDS patients by increasing body fat stores? a. Megestrol 27. A nurse is completing a nutritional status of a patient who has been admitted with AIDS-related complications. What components should the nurse include in this assessment? Select all that apply. a. Serum albumin level b. Weight history c. BMI d. BUN level 28. A nurse is assessing the skin integrity of a patient who has AIDS. When performing this inspection, the nurse should prioritize assessment of what skin surfaces? a. Peri-anal region and oral mucosa 29. A hospital nurse has experienced percutaneous exposure to an HIV-positive patient's blood as a result of a needlestick injury. The nurse has informed the supervisor and identifed the patient. What action should the nurse take next? a. Report to the emergency department or employee health department 30. The nurse care plan for a patient with AIDS includes the diagnosis of Risk for Impaired Skin Integrity. What nursing intervention should be included in the plan of care? a. Keep the patient's bed linens free of wrinkles 31. A patient who has AIDS is being treated in the hospital and admits to having periods of extreme anxiety. What would be the most appropriate nursing intervention? a. Teach the patient guided imagery 32. A patient who has AIDS has been admitted for the treatment of Kaposi's sarcoma. What nursing diagnosis should the nurse associate with this complication of AIDS? a. Impaired Skin Integrity Related to Kaposi's Sarcoma b. (This is a disease that involves the endothelial layer of blood and lymphatic vessels. This malignancy does not directly affect swallowing or bowel motility and it doesn’t constitute a risk for disuse syndrome) CHP 38 1. A patient with a family history of allergies has suffered an allergic response based on a genetic predisposition. This atopic response is usually mediated by what immunoglobulin? a. Immunoglobulin E 2. An ofce worker takes a cupcake that contains peanut butter. He begins wheezing, with an inspiratory stridor and air hunger and the occupational health nurse is called to the ofce. The nurse should recognize that the worker is likely suffering from which type of hypersensitivity? a. Anaphylactic (type 1) 3. A patient is learning about his new diagnosis of asthma with the asthma nurse. What medication has the ability to prevent the onset of acute asthmaexacerbations? a. Montelukast (Singulair) 4. A nurse is preparing a patient for allergy skin testing. Which of the following precautionary steps is most important for the nurse to follow? a. Emergency equipment should be readily available 5. A patient who is scheduled for a skin test informs the nurse that he has been taking corticosteroids to help control his allergy symptoms. What nursing intervention should the nurse implement? a. The patient's test should be cancelled until he is off his corticosteroids (and/or antihistamines, including OTC allergy meds b/c all of these suppress skin test reactivity and should be stopped 48 to 96 hours before testing, depending on the duration of their activity) 6. A patient has developed severe contact dermatitis with burning, itching, cracking, and peeling of the skin on her hands. What should the nurse teach the patient to do? a. Keep her hands well-moisturized at all times (powdered latex gloves can cause contact dermatitis) 7. A patient with severe environmental allergies is scheduled for an immunotherapy injection. What should be included in teaching the patient about this treatment? a. The patient will remain in the clinic to be monitored for 30 minutes following theinjection 8. The nurse is providing care for a patient who has experienced a type I hypersensitivity reaction. What condition is an example of such a reaction? a. Anaphylactic reaction after a bee sting Feedback:Anaphylactic (type I) hypersensitivity is an immediate reaction mediated by IgE antibodies and requires previous exposure to the specifc antigen. Skin reactions are more commonly type IV and myasthenia gravis is thought to be a type II reaction. Rheumatoid arthritis is not a type I hypersensitivity reaction. 9. A nurse is caring for a teenage girl who has had an anaphylactic reaction after a bee sting. The nurse is providing patient teaching prior to the patient's discharge. In the event of an anaphylactic reaction, the nurse informs the patient that she should self- administer epinephrine in what site? a. Thigh 10. A nurse has included the nursing diagnosis of Risk for Latex Allergy Response in a patient's plan of care. The presence of what chronic health problem would most likely prompt this diagnosis? a. Spina bifda 11. A patient has a documented history of allergies presents to the clinic. She states that she is frustrated by her chronic nasal congestion, anosmia (inability to smell) and inability to concentrate. The nurse should identify which of the following nursing diagnoses? a. Ineffective Individual Coping with Chronicity of Condition and Need for Environmental Modifcation 12. A patient's decline in respiratory and renal function has been attributed to Goodpasture syndrome, which is a type II hypersensitivity reaction. What pathologic process underlies the patient's health problem? a. The patient's body has mistakenly identifed a normal constituent of the body as foreign 13. A child is undergoing testing for food allergies after experiencingunexplained signs and symptoms of hypersensitivity. What food items would the nurse inform the parents are common allergens? a. Eggs and wheat The most common causes of food allergies are seafood (lobster, shrimp, crab, clams, fsh), legumes (peanuts, peas, beans, licorice), seeds (sesame, cottonseed, caraway, mustard, flaxseed, sunflower seeds), tree nuts, berries, egg white, buckwheat, milk, and chocolate. 14. A patient has been admitted to the emergency department with signs of anaphylaxis following a bee sting. The nurse knows that if this is a true allergic reaction the patient will present with what alteration in laboratory values? a. Increased eosinophils 15. After the completion of testing, a child's allergies have been attributed to her family's cat. When introducing the family to the principles of avoidance therapy, the nurse should promote what action? a. Removing the cat from the family's home 16. The nurse is providing health education to the parents of a toddler who has been diagnosed with food allergies. What should the nurse teach this family about the child's health problem? a. Many children outgrow their food allergies in a few years if they avoid the offending foods 17. A child has been diagnosed with a severe walnut allergy after suffering an anaphylactic reaction. What is a priority for health education? a. The need for the parents to carry an epinephrine pen 18. An adolescent patient's history of skin hyperreactivity and inflammation has been attributed to atopic dermatitis. The nurse should recognize that this patient consequently faces an increased risk of what health problem? a. Asthma 19. The nurse is planning the care of a patient who has a diagnosis of atopic dermatitis, which commonly affects both of her hands and forearms. What risk nursing diagnosis should the nurse include in the patient's care plan? a. Risk for Disturbed Body Image Related to Skin Lesions 20. A patient has been brought to the emergency department by EMS after being found unresponsive. Rapid assessment reveals anaphylaxis as a potential cause of the patient's condition. The care team should attempt to assess for what potential causes of anaphylaxis? Select all that apply a. Foods b. Medications c. Insect stings 21. A school nurse is caring for a child who appears to be having an allergic response. What should be the initial action of the school nurse? a. Assess for signs and symptoms of anaphylaxis 22. A patient is receiving a transfusion of packed red blood cells. Shortly after initiation of the transfusion, the patient begins to exhibit signs and symptoms of a transfusion reaction. The patient is suffering from which type of hypersensitivity? a. Cytotoxic (type II) 23. Which of the following individuals would be the most appropriate candidate for immunotherapy? a. A patient with severe allergies to grass and tree pollen 24. A nurse has asked the nurse educator if there is any way to predict theseverity of a patient's anaphylactic reaction. What would be the nurse's best response? a. The faster the onset of symptoms, the more severe the reaction 25. A nurse knows of several patients who have achieved adequate control of their allergy symptoms using over-the-counter antihistamines. Antihistamines would be contraindicated in the care of which patient? a. A pregnant woman at 30 weeks' gestation 26. A patient has been living with seasonal allergies for many years, but does not take antihistamines, stating, ìWhen I was young I used to take antihistamines, but they always put me to sleep.î How should the nurse best respond? a. The newer antihistamines are different than in years past, and cause lesssedation 27. A child has been transported to the emergency department (ED) after a severe allergic reaction. The ED nurse is evaluating the patient's respiratory status. How should the nurse evaluate the patient's respiratory status? Select all that apply. a. Assess breath sounds b. Measure the child’s oxygen saturation by oximeter c. Monitor the child’s respiratory pattern d. Assess the child’s respiratory rate 28. A nurse at an allergy clinic is providing education for a patient starting immunotherapy for the treatment of allergies. What education should the nurse prioritize? a. The importance of keeping appointments for desensitization procedures (b/c dosages are adjusted on a weekly basis, and missed appts may interfere w/the dosage adjustment) 29. A patient was prescribed an oral antibiotic for the treatment of sinusitis. The patient has now stopped, stating she developed a rash shortly after taking the frst dose of the drug. What is the nurse's most appropriate response? a. Refer the woman to her primary care provider to have the medication changed 30. A patient has sought care, stating that she developed hives overnight. The nurse's inspection confrms the presence of urticaria. What type of allergic hypersensitivity reaction has the patient developed? a. Type I 31. The nurse is providing care for a patient who has a diagnosis of hereditary angioedema. When planning this patient's care, what nursing diagnosis should be prioritized? a. Risk for Impaired Gas Exchange Related to Airway Obstruction 32. A junior nursing student is having an observation day in the operating room. Early in the day, the student tells the OR nurse that her eyes are swelling and she is having trouble breathing. What should the nurse suspect? a. Anaphylaxis due to a latex allergy 33. The nurse is creating a care plan for a patient suffering from allergic rhinitis. Which of the following outcomes should the nurse identify? a. Improved coping with lifestyle modifcations 34. A 5-year-old boy has been diagnosed with a severe food allergy. What is an important parameter to address when educating the parents of this child about his allergy and care? a. Wear a medical identifcation bracelet 35. A patient is brought to the emergency department (ED) in a state ofanaphylaxis. What is the ED nurse's priority for care? a. Protect the patient's airway CHP 39 1. A patient is suspected of having rheumatoid arthritis and her diagnostic regimen includes aspiration of synovial fluid from the knee for a defnitive diagnosis. The nurse knows that which of the following procedures will be involved? a. Arthocentesis 2. A nurse is providing care for a patient who has just been diagnosed as being in the early stage of rheumatoid arthritis. The nurse should anticipate the administration of which of the following? a. Methotrexate (Rheumatrex) 3. A nurse is performing the initial assessment of a patient who has a recent diagnosis of systemic lupus erythematosus (SLE). What skin manifestation would the nurse expect to observe on inspection? a. Butterfly rash 4. A clinic nurse is caring for a patient with suspected gout. While explaining the pathophysiology of gout to the patient, the nurse should describe which of the following? a. Increased uric acid levels 5. A patient's decreased mobility is ultimately the result of an autoimmune reaction originating in the synovial tissue, which caused the formation of pannus. This patient has been diagnosed with what health problem? a. Rheumatoid arthritis (RA) 6. A nurse is performing the health history and physical assessment of a patient who has a diagnosis of rheumatoid arthritis (RA). What assessment fnding is most consistent with the clinical presentation of RA? a. Joint stiffness, especially in the morning 7. A patient has a diagnosis of rheumatoid arthritis and the primary care provider has now prescribed cyclophosphamide (Cytoxan). The nurse's subsequent assessments should address what potential adverse effect? a. Infection 8. A clinic nurse is caring for a patient newly diagnosed with fbromyalgia. When developing a care plan for this patient, what would be a priority nursing diagnosis for this patient? a. Fatigue Related to Pain 9. A nurse is assessing a patient for risk factors known to contribute to osteoarthritis. What assessment fnding would the nurse interpret as a risk factor? a. The patient's body mass index is 34 (obese). 10. A patient is undergoing diagnostic testing to determine the etiology of recent joint pain. The patient asks the nurse about the difference between osteoarthritis (OA) and rheumatoid arthritis (RA). What is the best response by the nurse? a. OA is a considered a noninflammatory joint disease. RA is characterized byinflamed, swollen joints 11. A patient with systemic lupus erythematosus (SLE) is preparing for discharge. The nurse knows that the patient has understood health education when the patient makes what statement? a. I'll make sure to monitor my body temperature on a regular basis 12. A patient with an exacerbation of systemic lupus erythematosus (SLE) has been hospitalized on the medical unit. The nurse observes that the patientexpresses angerand irritation when her call bell isn't answered immediately. What would be the most appropriate response? a. "You seem like you're feeling angry. Is that something that we could talk about?" 13. A nurse is caring for a 78-year-old patient with a history of osteoarthritis (OA). When planning the patient's care, what goal should the nurse include? a. The patient will express satisfaction with her ability to perform ADLs 14. A patient who has been newly diagnosed with systemic lupus erythematosus (SLE) has been admitted to the medical unit. Which of the following nursing diagnoses is the most plausible inclusion in the plan of care? a. Fatigue Related to Anemia 15. The nurse is preparing to care for a patient who has scleroderma. The nurse refers to resources that describe CREST syndrome. Which of the following is a component of CREST syndrome? a. Raynaud's phenomenon 16. Allopurinol (Zyloprim) has been ordered for a patient receiving treatment for gout. The nurse caring for this patient knows to assess the patient for bone marrow suppression, which may be manifested by which of the following diagnostic fndings? a. Decreased platelets 17. A patient with rheumatic disease is complaining of stomatitis. The nurse caring for the patient should further assess the patient for the adverse effects of what medications? a. Gold-containing compounds (Stomatitis is associated with gold therapy) 18. A nurse is planning patient education for a patient being discharged home with a diagnosis of rheumatoid arthritis. The patient has been prescribed antimalarials for treatment, so the nurse knows to teach the patient to self-monitor for what adverse effect? a. Visual changes (caused by anti-malaria meds, so regular ophthalmologic exams are necessary) 19. A nurse is working with a patient with rheumatic disease who is being treated with salicylate therapy. What statement would indicate that the patient is experiencing adverse effects of this drug? a. “I have this ringing in my ears that just won’t go away” (Tinnitis is associated with salicylate therapy) 20. Patient develops hirsutism, what is this associated with? a. Corticosteroid therapy 21. A patient has been admitted to a medical unit with a diagnosis of polymyalgia rheumatica (PMR). The nurse should be aware of what aspects of PMR? Select all that apply. a. PMR has an association with the genetic marker HLA-DR4 b. Immunoglobulin deposits occur in PMR c. PMR occurs predominately in Caucasians 22. A nurse is providing care for a patient who has a recent diagnosis of giant cell arteritis (GCA). What aspect of physical assessment should the nurse prioritize? a. Assessment for headaches and jaw pain 23. A nurse is caring for a patient who is suspected of having giant cell arteritis (GCA). What laboratory tests are most useful in diagnosing this rheumaticdisorder? Select all that apply. a. Erythrocyte sedimentation rate b. C-reactive protein 24. A community health nurse is performing a visit to the home of a patient who has a history of rheumatoid arthritis (RA). On what aspect of the patient's health should the nurse focus most closely during the visit? a. The patients functional status 25. A 21-year-old male has just been diagnosed with a spondyloarthropathy. What will be a priority nursing intervention for this patient? a. Teaching about symptom management 26. A patient with SLE asks the nurse why she has to come to the ofce so often for ìcheck-ups.î What would be the nurse's best response? a. Taking care of you in the best way involves monitoring your disease activity andhow well the prescribed treatment is working 27. A patient is diagnosed with giant cell arteritis (GCA) and is placed on corticosteroids. A concern for this patient is that he will stop taking the medication as soon as he starts to feel better. Why must the nurse emphasize the need for continued adherence to the prescribed medication? a. To avoid complications such as blindness 28. A patient with polymyositisis experiencing challenges with activities of daily living as a result of proximal muscle weakness. What is the most appropriate nursing action? a. Facilitate referrals to occupational and physical therapy 29. A nurse is creating a teaching plan for a patient who has a recent diagnosis of scleroderma. What topics should the nurse address during health education? Select all that apply. a. Managing Raynaud’s-type symptoms b. Smoking cessation c. The importance of vigilant skin care 30. A 40-year-old woman was diagnosed with Raynaud's phenomenon several years earlier and has sought care because of a progressive worsening of her symptoms. The patient also states that many of her skin surfaces are ìstiff, like the skin is being stretched from all directions.î The nurse should recognize the need for medical referral for the assessment of what health problem? a. Scleroderma Scleroderma starts insidiously with Raynaud's phenomenon and swelling in the hands. Later, the skin and the subcutaneous tissues become increasingly hard and rigid and cannot be pinched up from the underlying structures. This progression of symptoms is inconsistent with GCA, FM, or RA 31. A patient with rheumatoid arthritis comes to the clinic complaining of pain in the joint of his right great toe and is eventually diagnosed with gout. When planning teaching for this patient, what management technique should the nurse emphasize? a. Restrict consumption of foods high in purines 32. A clinic nurse is caring for a patient diagnosed with rheumatoid arthritis (RA). The patient tells the nurse that she has not been taking her medication because she usually cannot remove the childproof medication lids. How can the nurse best facilitate the patient's adherence to her medication regimen? a. Encourage her to have her pharmacy replace the tops withalternatives that are easier to open 33. A nurse's plan of care for a patient with rheumatoid arthritis includes several exercise-based interventions. Exercises for patients with rheumatoid disorders should have which of the following goals? a. Preserve and increase range of motion while limiting joint stress 34. A patient has just been told by his physician that he has scleroderma. The physician tells the patient that he is going to order some tests to assess for systemic involvement. The nurse knows that priority systems to be assessed include what? a. Gastrointestinal 35. A nurse is providing care for a patient who has a rheumatic disorder. The nurse's comprehensive assessment includes the patient's mood, behavior, LOC, and neurologic status. What is this patient's most likely diagnosis? a. Systemic lupus erythematosus (SLE) 36. A patient with rheumatoid arthritis comes into the clinic for a routine checkup. On assessment the nurse notes that the patient appears to have lost some of her ability to function since her last ofce visit. Which of the following is the most appropriate action? a. Arrange for the patient to be assessed in her home environment 37. A nurse is assessing a patient with rheumatoid arthritis. The patient expresses his intent to pursue complementary and alternative therapies. What fact should underlie the nurse's response to the patient? a. Evidence shows minimal benefts from most CAM therapies MedSurge Quiz 2 – 60 61 62 1. While assessing a dark-skinned patient at the clinic, the nurse notes the presence of patchy, milky white spots. The nurse knows that this fnding is characteristic of what diagnosis? a. Vitiligo 2. A nurse is reviewing gerontologic considerations relating to the care of patients with dermatologic problems. What vulnerability results from the age-related loss of subcutaneous tissue? a. Diminished protection of tissues and organs 3. The nurse is performing an initial assessment of a patient who has a raised, pruritic rash. The patient denies taking any prescription medication and denies any allergies. What would be an appropriate question to ask this patient at this time? a. “Do you take any OTC drugs or herbal preparations?” 4. A nurse is conducting a health interview and is assessing for integumentary conditions that are known to have a genetic component. What assessment question is most appropriate? a. “Does anyone in your family have eczema or psoriasis?” 5. A patient with human immunodefciency virus (HIV) has sought care because of the recent development of new skin lesions. The nurse should interpret these lesions as most likely suggestive of what? a. A reduction in the patients CD4 count 6. A nurse is working with a patient who has a diagnosis of Cushing syndrome. When completing a physical assessment, the nurse should specifcally observe for what integumentary manifestation? a. Hirsutism 7. An 82-year-old patient is being treated in the hospital for a sacral pressure ulcer.What age-related change is most likely to affect the patient's course of treatment? a. Increased time required for wound healing 8. A young student is brought to the school nurse after falling off a swing. The nurse is documenting that the child has bruising on the lateral aspect of the right arm. What term will the nurse use to describe bruising on the skin in documentation? a. Ecchymoses 9. A nurse educator is teaching a group of medical nurses about Kaposi's sarcoma. What would the educator identify as characteristics of endemic Kaposi's sarcoma? Select all that apply. a. Affects people predominately in the eastern half of Africa b. Affects men more than women c. Can progress to lymphadenopathic forms 10. A nurse is caring for a patient whose skin cancer will soon be removed by excision. Which of the following actions should the nurse perform? a. Teach the patient about self-care after treatment 11. A public health nurse is participating in a health promotion campaign that has the goal of improving outcomes related to skin cancer in the community. What action has the greatest potential to achieve this goal? a. Educating participants about the early signs and symptoms of skin cancer 12. A patient with a chronic diabetic wound is being discharged after receiving a skin graft to aid wound healing. What direction should the nurse include in home care instructions? a. Protect the graft from direct sunlight and temperature extremes 13. A 35-year-old kidney transplant patient comes to the clinic exhibiting new skin lesions. The diagnosis is Kaposi's sarcoma. The nurse caring for this patient recognizes that this is what type of Kaposi's sarcoma? a. Immunosuppression-related 14. A nurse practitioner is seeing a 16-year-old male patient who has come to the dermatology clinic for treatment of acne. The nurse practitioner would know that the treatment may consist of which of the following medications? a. Benzoyl peroxide and erythromycin (Benzamycin) 15. A patient comes to the dermatology clinic requesting the removal of a portwine stain on his right cheek. The nurse knows that the procedure especially useful in treating cutaneous vascular lesions such as port-wine stains is what? a. Laser treatment 16. A nurse is providing care for a patient who has psoriasis. The nurse is aware of the sequelae that can result from this health problem. Following the appearance of skin lesions, the nurse should prioritize what assessment? a. Assessment of the patient’s joints for pain and decreased range of motion 17. An emergency department nurse has just admitted a patient with a burn. What characteristic of the burn will primarily determine whether the patient experiences a systemic response to this injury? a. The total body surface area (TBSA) affected by the burn b. The length of time since the burn c. The location of burned skin surfaces d. The source of the burn (Explanation: Systemic effects are a result of several variables. However, TBSA and wound severity are considered the major factors that affect the presence or absence ofsystemic effects) 18. An emergency department nurse learns from the paramedics that they are transporting a patient who has suffered injury from a scald from a hot kettle. What variables will the nurse consider when determining the depth of burn? a. The causative agent b. The patient’s preinjury health status c. The patient’s prognosis for recovery d. The circumstances of the accident (Don’t get this question confused with the one before it. The following factors are considered in determining the depth of a burn: how the injury occurred, causative agent (such as flame or scalding liquid), temperature of the burning agent, duration of contact with the agent, and thickness of the skin. The patient's preinjury status, circumstances of the accident, and prognosis for recovery are important, but are not considered when determining the depth of the burn) 19. A patient has experienced burns to his upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action? a. Assess the patient’s peripheral pulses distal to the dressing 20. A home care nurse is performing a visit to a patient's home to perform wound care following the patient's hospital treatment for severe burns. While interacting with the patient, the nurse should assess for evidence of what complication? a. PTSD 21. A nurse who is taking care of a patient with burns is asked by a family member why the patient is losing so much weight. The patient is currently in the intermediate phase of recovery. What would be the nurse's most appropriate response to the family member? a. “His body has consumed his fat deposits for fuel because his calorie intake is lower than normal” 22. A patient who is in the acute phase of recovery from a burn injury has yet to experience adequate pain control. What pain management strategy is most likely to meet this patient's needs? a. A patient-controlled analgesia (PCA) system 23. A nurse is teaching a patient with a partial-thickness wound how to wear his elastic pressure garment. How would the nurse instruct the patient to wear this garment? a. Continuously 24. A patient has sustained a severe burn injury and is thought to have an impaired intestinal mucosal barrier. Since this patient is considered at an increased risk for infection, what intervention will best assist in avoiding increased intestinal permeability and prevent early endotoxin translocation? a. Early enteral feeding 25. A nurse who provides care on a burn unit is preparing to apply a patient's ordered topical antibiotic ointment. What action should the nurse perform when administering this medication? a. Apply a layer of ointment approximately 1/16 inch thick Test Bank Questions Not On Quiz 2CHP 60 1. A nurse is aware that the outer layer of the skin consists of dead cells that contain large amounts of keratin. The physiologic functions of keratin include which of the following? Select all that apply. a. Physically repelling pathogens b. Preventing fluid loss 2. When planning the skin care of a patient with decreased mobility, the nurse is aware of the varying thickness of the epidermis. At what location is the epidermal layer thickest? a. The palms of the hands (& soles of the feet) 3. The nurse in an ambulatory care center is admitting an older adult patient who has bright red moles on the skin. Benign changes in elderly skin that appear as bright red moles are termed what? a. Cherry angiomas 4. While waiting to see the physician, a patient shows the nurse skin areas that are flat, nonpalpable, and have had a change of color. The nurse recognizes that the patient is demonstrating what? a. Macules 5. An African American is admitted to the medical unit with liver disease. To correctly assess this patient for jaundice, on what body area should the nurse look for yellow discoloration? a. Sclera 6. A nurse is doing a shift assessment on a group of patients after frst taking report. An elderly patient is having her second dose of IV antibiotics for a diagnosis of pneumonia. The nurse notices a new rash on the patient's chest. The nurse should ask what priority question regarding the presence of a reddened rash? a. “Are you allergic to any foods or medications” 7. A gerontologic nurse is teaching a group of nursing students about integumentary changes that occur in older adults. How should these students best integrate these changes into care planning? a. By protecting older adults against shearing injuries 8. A patient is diagnosed with atrial fbrillation and the physician orders Coumadin (warfarin). For what skin lesion should the nurse monitor this patient? a. Ecchymosis 9. A new patient has come to the dermatology clinic to be assessed for a reddened rash on his abdomen. What diagnostic test would most likely be ordered to identify the causative allergen? a. Patch testing (performed to identify substances to which the pt has developed an allergy. Skin scrapings are done for suspected fungal lesions. A skin biopsy is completed to rule out malignancy and to establish an exact diagnosis of skin lesions. A Tzanck smear is used to examine cells from blistering skin conditions such as herpes zoster) 10. A patient with a suspected malignant melanoma is referred to the dermatology clinic. The nurse knows to facilitate what diagnostic test to rule out a skin malignancy? a. Skin biopsy 11. A nurse is explaining the importance of sunlight on the skin to a woman with decreased mobility who rarely leaves her house. The nurse would emphasize that ultraviolet light helps to synthesize what vitamin? a. Vitamin D 12. The outer layer of the epidermis provides the most effective barrier topenetration of the skin by environmental factors. Which of the following is an example of penetration by an environmental factor? a. An insect bite 13. A nurse in a dermatology clinic is reading the electronic health record of a new patient. The nurse notes that the patient has a history of a primary skin lesion. What is an example of a primary skin lesion? a. Pustule 14. An unresponsive Caucasian patient has been brought to the emergency room by EMS. While assessing this patient, the nurse notes that the patient's face is a cherry-red color. What should the nurse suspect? a. Carbon monoxide poisoning (causes a bright cherry red color in the face & upper torso in light-skinned persons. In dark-skinned persons, there will be a cherry red color to nail beds, lips, and oral mucosa. When anemia occurs in light-skinned persons, the skin has generalized pallor. Anemia in darkskinned persons manifests as a yellow-brown coloration. Jaundice appears as a yellow coloration of the sclerae. Uremia gives a yellow-orange tinge to the skin) 15. A nurse is providing an educational presentation addressing the topic of ìProtecting Your Skin.î When discussing the anatomy of the skin with this group, the nurse should know that what cells are responsible for producing the pigmentation of the skin? a. Melanocytes 16. A wound care nurse is reviewing skin anatomy with a group of medical nurses. Which area of the skin would the nurse identify as providing a cushion between the skin layers, muscles, and bones? a. Subcutaneous tissues 17. A young student comes to the school nurse and shows the nurse a mosquito bite. As the nurse expects, the bite is elevated and has serous fluid contained in the dermis. How would the nurse classify this lesion? a. Wheal 18. While assessing a 25-year-old female, the nurse notes that the patient has hair on her lower abdomen. Earlier in the health interview, the patient stated that her menses are irregular. The nurse should suspect what type of health problem? a. Hormonal imbalance 19. A nurse is preparing to perform the physical assessment of a newly admitted patient. During which of the following components of the assessment should the nurse wear gloves? Select all that apply. a. Palpation of a rash on the patient’s trunk b. Palpation of a lesion on the patient’s upper back 20. A patient with an exceptionally low body mass index has been admitted to the emergency department with signs and symptoms of hypothermia. The nurse should know that this patient's susceptibility to heat loss is related to atrophy of what skin component? a. Subcutaneous tissue 21. An 80-year-old patient is brought to the clinic by her son. The son asks the nurse why his mother has gotten so many ìspotsî on her skin. What would be an appropriate response by the nurse? a. “As people age, they normally develop uneven pigmentation in their skin” 22. An older adult patient is diagnosed with a vitamin D defciency. What would be an appropriate recommendation by the nurse?a. Spend time outdoors at least twice per week 23. A nurse in the emergency department (ED) is triaging a 5-year-old who has been brought to the ED by her parents for an outbreak of urticaria. What would be the most appropriate question to ask this patient and her family? a. “Has she eaten any new foods today?” 24. A nurse practitioner working in a dermatology clinic fnds an open lesion on a patient who is being assessed. What should the nurse do next? a. Assess the characteristics of the lesions 25. The nurse is performing a comprehensive assessment of a patient's skin surfaces and intends to assess moisture, temperature, and texture. The nurse should perform this component of assessment in what way? a. By palpating the patient’s skin 26. A nurse is assessing the skin of a patient who has been diagnosed with bacterial cellulitis on the dorsal portion of the great toe. When reviewing the patient's health history, the nurse should identify what comorbidity as increasing the patient's vulnerability to skin infections? a. Diabetes 27. Assessment of a patient's leg reveals the presence of a 1.5-cm circular region of necrotic tissue that is deeper than the epidermis. The nurse should document the presence of what type of skin lesion? a. Ulcer 28. A new patient presents at the clinic and the nurse performs a comprehensive health assessment. The nurse notes that the patient's fngernail surfaces are pitted. The nurse should suspect the presence of what health problem? a. Psoriasis 29. A patient's health assessment has resulted in a diagnosis of alopecia areata. What nursing diagnosis should the nurse most likely associate with this health problem? a. Disturbed Body Image 30. A patient is suspected of developing an allergy to an environmental substance and has been given a patch test. During the test, the patient develops fne blisters, papules, and severe itching. The nurse knows that this is indicative of what strength reaction? a. Moderately positive (the development of redness, fne elevations, or itching is considered a weak positive reaction; fne blisters, papules, and severe itching indicate a moderately positive reaction; and blisters, pain, and ulceration indicate a strong positive reaction) 31. A dermatologist has asked the nurse to assist with examination of a patient's skin using a Wood's light. This test will allow the physician to assess for which of the following? a. Unusual patterns of pigmentation on the patient’s skin (this test makes it possible to differentiate epidermal from dermal lesions, and hypopigmented and hyperpigmented lesions from normal skin) 32. A patient presents at the dermatology clinic with suspected herpes simplex. The nurse knows to prepare what diagnostic test for this condition? a. Tzanck smear (this test is used to examine cells from blistering skin conditions, such as herpes zoster, varicella, herpes simplex, and all forms of pemphigus. The secretions from a suspected lesion are applied to a glass slide, stained, and examined)CHP 61 1. A nurse is caring for a patient who has been diagnosed with psoriasis. The nurse is creating an education plan for the patient. What information should be included in this plan? a. Use caution when taking nonprescription medications 2. A nurse is planning the care of a patient with herpes zoster. What medication, if administered within the frst 24 hours of the initial eruption, can arrest herpes zoster? a. Acyclovir (Zovirax) 3. A patient with squamous cell carcinoma has been scheduled for treatment of this malignancy. The nurse should anticipate that treatment for this type of cancer will primarily consist of what intervention? a. Surgical excision 4. When writing a plan of care for a patient with psoriasis, the nurse would know that an appropriate nursing diagnosis for this patient would be what? a. Impaired Skin Integrity Related to Scaly Lesions 5. A patient who has sustained third-degree facial burns and a facial fracture is undergoing reconstructive surgery and implantation of a prosthesis. The nurse has identifed a nursing diagnosis of Disturbed Body Image Related to Disfgurement. What would be an appropriate nursing intervention related to this diagnosis? a. Teaching the patient how to use and care for the prosthesis 6. While performing an initial assessment of a patient admitted with appendicitis, the nurse observes an elevated blue-black lesion on the patient's ear. The nurse knows that this lesion is consistent with what type of skin cancer? a. Malignant melanoma 7. A nurse is providing care for a patient who has developed Kaposi's sarcoma secondary to HIV infection. The nurse should be aware that this form of malignancy originates in what part of the body? a. Endothelial cells lining small blood vessels 8. A patient requires a full-thickness graft to cover a chronic wound. How is the donor site selected? a. An area matching the color and texture of the skin at the surgical site is selected 9. A patient has just been told that he has malignant melanoma. The nurse caring for this patient should anticipate that the patient will undergo what treatment? a. Wide excision 10. A nurse is leading a health promotion workshop that is focusing on cancer prevention. What action is most likely to reduce participants' risks of basal cell carcinoma (BCC)? a. Teaching participants to limit their sun exposure 11. A patient diagnosed with a stasis ulcer has been hospitalized. There is an order to change the dressing and provide wound care. Which activity should the nurse frst perform when providing wound care? a. Perform hand hygiene 12. A patient comes to the clinic complaining of a red rash of small, fluid-flled blisters and is suspected of having herpes zoster. What presentation is most consistent with herpes zoster? a. Grouped vesicles in linear patches along a dermatome 13. A patient presents at the free clinic with a black, wart-like lesion on his face, stating, ìI've done some research, and I'm pretty sure I have malignant melanoma.îSubsequent diagnostic testing results in a diagnosis of seborrheic keratosis. The nurse should recognize what signifcance of this diagnosis? a. The patient requires no treatment unless he fnds the lesion to be cosmetically unacceptable (they’re benign) 14. A patient is admitted to the intensive care unit with what is thought to be toxic epidermal necrolysis (TEN). When assessing the health history of the patient, the nurse would be alert to what precipitating factor? a. Recent administration of new medications (This is usually triggered by a reaction to medications. Antibiotics, anti-seizure agents, butazones, and sulfonamides are the most frequent medications implicated) 15. A patient has received a diagnosis of irritant contact dermatitis. What action should the nurse prioritize in the patient's subsequent care? a. Helping the patient identify and avoid the offending agent 16. A nurse is caring for a patient whose chemical injury has necessitated a skin graft to his left hand. The nurse enters the room and observes that the patient is performing active range of motion (ROM) exercises with the affected hand. How should the nurse best respond? a. Remind the patient of the need to immobilize the graft to facilitate healing 17. A school nurse has sent home four children who show evidence of pediculosis capitis. What is an important instruction the nurse should include in the note being sent home to parents? a. Nits may have to be manually removed from the child’s hair shafts (treatment for headlice should begin promptly and may require manual removal of nits following medicating shampoo. Head lice are not r/t lack of hygiene. Treatment is necessary b/c the condition will not resolve spontaneously within 1 week) 18. A patient has just been diagnosed with psoriasis and frequently has lesions around his right eye. What should the nurse teach the patient about topical corticosteroid use on these lesions? a. Cataract development is possible 19. A nurse is caring for a patient who has a diagnosis of bullous pemphigoid and who is being treated on the medical unit. When providing hygiene for this patient, the nurse should perform which of the following actions? a. Apply cornstarch to the patient’s skin after bathing to facilitate mobility 20. A nurse is caring for a patient admitted to the medical unit with a diagnosis of pemphigus vulgaris. When writing the care plan for this patient, what nursing diagnoses should be included? Select all that apply. a. Risk for Infection r/t Lesions b. Impaired Skin Integrity r/t Epidermal Blisters c. Disturbed Body Image r/t Presence of Skin Lesions d. Acute Pain r/t Disruption in Skin Integrity 21. A patient's blistering disorder has resulted in the formation of multiple lesions in the patient's mouth. What intervention should be included in the patient's plan of care? a. Provide chlorhexidine solution for rinsing the patient's mouth (hypertonic solutions would be likely to cause pain and further skin disruptions) 22. When caring for a patient with toxic epidermal necrolysis (TEN), the critical care nurse assesses frequently for high fever, tachycardia, and extreme weaknessand fatigue. The nurse is aware that these fndings are potential indicators of what? Select all that apply a. Epidermal necrosis b. Increased metabolic needs c. Possible gastrointestinal mucosal sloughing 23. A nurse is assessing a teenage patient with acne vulgaris. The patient's mother states, ìI keep telling him that this is what happens when you eat as much chocolate as he does.î What aspect of the pathophysiology of acne should inform the nurse's response? a. Diet is thought of play a minimal role in the development of acne (it’s not believed to play a major role in acne therapy. A change in diet is not known to exacerbate symptoms) 24. A nurse is providing self-care education to a patient who has been receiving treatment for acne vulgaris. What instruction should the nurse provide to the patient? a. Wash your face with water and gentle soap each morning and evening 25. A patient has just undergone surgery for malignant melanoma. Which of the following nursing actions should be prioritized? a. Anticipate the need for, and administer, appropriate analgesic medications 26. A patient has recently been diagnosed with advanced malignant melanoma and is scheduled for a wide excision of the tumor on her chest. In writing the plan of care for this patient, what major nursing diagnosis should the nurse include? a. Defcient Knowledge about Early Signs of Melanoma (the fact that the patient's disease was not reported until an advanced stage suggests that the patient lacked knowledge about skin lesions) 27. A 65-year-old man presents at the clinic complaining of nodules on both legs. The man tells the nurse that his son, who is in medical school, encouraged him to seek prompt care and told him that the nodules are related to the fact that he is Jewish. What health problem should the nurse suspect? a. Classic Kaposi’s Sarcoma (occurs predominantly in men of Mediterranean or Jewish ancestry between 40 and 70 years of age. Most patients have nodules or plaques on the lower extremities that rarely metastasize beyond this area. Classic KS is chronic, relatively benign, and rarely fatal) 28. A 55-year-old woman is scheduled to have a chemical face peel. The nurse is aware that the patient is likely seeking treatment for which of the following? a. Wrinkles near the lips and eyes (it doesn’t remove acne scars, vascular lesions, or reshape the eyes) 29. A 30-year-old male patient has just returned from the operating room after having a ìflapî done following a motorcycle accident. The patient's wife asks the nurse about the major complications following this type of surgery. What would be the nurse's best response? a. “The major complication is when the blood supply fails and the tissue in the flap dies” 30. An older adult resident of a long-term care facility has been experiencing generalized pruritus that has become more severe in recent weeks. What intervention should the nurse add to this resident's plan of care? a. Avoid using hot water during the patient’s baths 31. A patient has a diagnosis of seborrhea and has been referred to the dermatology clinic, where the nurse contributes to care. When planning thispatient's care, the nurse should include which of the following nursing diagnoses? a. Disturbed Body Image r/t Excess Sebum Production 32. A nurse is working with a family whose 5 year-old daughter has been diagnosed with impetigo. What educational intervention should the nurse include in this family's care? a. Teaching about the importance of maintaining high standards of hygiene (Impetigo is associated with unhygienic conditions; educational interventions to address this are appropriate. The disease is contagious, thus vesicles should not be manually burst. Because of the bacterial etiology, corticosteroids are ineffective) CHP 62 1. A patient is brought to the emergency department from the site of a chemical fre, where he suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment fndings, what is the depth of the burn on the patient's arm? a. Full-thickness 2. The current phase of a patient's treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the patient is in what phase of burn care? a. Acute (the acute or intermediate phase of burn care follows the emergent/resuscitative phase and begins 48 to 72 hours after the burn injury. During this phase, attention is directed toward continued assessment and maintenance of respiratory and circulatory status, fluid and electrolyte balance, and gastrointestinal function. Infection prevention, burn wound care (i.e., wound cleaning, topical antibacterial therapy, wound dressing, dressing changes, wound dÈbridement, and wound grafting), pain management, and nutritional support are priorities at this stage. Priorities during the emergent or immediate resuscitative phase include frst aid, prevention of shock and respiratory distress, detection and treatment of concomitant injuries, and initial wound assessment and care. The priorities during the rehabilitation phase include prevention of scars and contractures, rehabilitation, functional and cosmetic reconstruction, and psychosocial counseling) 3. A patient in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what? a. Hyperkalemia, hyponatremia, elevated hct & metabolic acidosis 4. A patient has experienced an electrical burn and has developed thick eschar over the burn site. Which of the following topical antibacterial agents will the nurse expect the physician to order for the wound? a. Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream 5. An occupational health nurse is called to the floor of a factory where a worker has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to ìcool the burn.î How should the nurse cool the burn? a. Wrap cool towels around the affected extremity intermittently 6. A nurse on a burn unit is caring for a patient in the acute phase of burn care. While performing an assessment during this phase of burn care, the nurse recognizes that airway obstruction related to upper airway edema may occur up to how long after the burn injury?a. 2 days 7. A patient has been admitted to a burn intensive care unit with extensive fullthickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurse's immediate, priority concern when planning this patient's care? a. Fluid status 8. The nurse is preparing the patient for mechanical dÈbridement and informs the patient that this will involve which of the following procedures? a. Removal of eschar until the point of pain and bleeding occurs (achieved through the use of surgical scissors, scalpels, or forceps to remove the eschar until the point of pain and bleeding occurs. Mechanical dÈbridement can also be accomplished through the use of topical enzymatic dÈbridement agents. The spontaneous separation of dead tissue from the viable tissue is an example of natural dÈbridement. Shaving the burned skin layers and early wound closure are examples of surgical dÈbridement) 9. A patient with a partial-thickness burn injury had Biobrane applied 2 weeks ago. The nurse notices that the Biobrane is separating from the burn wound. What is the nurse's most appropriate intervention? a. Trim away the separated Biobrane 10. A nurse is caring for a patient who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis? a. Acute pain 11. A triage nurse in the emergency department (ED) receives a phone call from a frantic father who saw his 4-year-old child tip a pot of boiling water onto her chest. The father has called an ambulance. What would the nurse in the ED receiving the call instruct the father to do? a. Immerse the child in a cool bath 12. A patient is brought to the ED by paramedics, who report that the patient has partial- thickness burns on the chest and legs. The patient has also suffered smoke inhalation. What is the priority in the care of a patient who has been burned and suffered smoke inhalation? a. Airway management (systemic threats from a burn are the greatest threat to life. The ABCs of all trauma care apply during the early post-burn period) 13. A patient arrives in the emergency department after being burned in a house fre. The patient's burns cover the face and the left forearm. What extent of burns does the patient most likely have? a. 18% (when estimating the percentage of body area or burn surface area that has been burned, the Rule of Nines is used: the face is 9%, and the forearm is 9% for a total of 18% in this patient) 14. A nurse is caring for a patient in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values? a. Sodium defcit (anticipated fluid and electrolyte changes that occur during the emergent/resuscitative phase of burn injury include sodium defcit, potassium excess, base-bicarbonate defcit, and elevated hematocrit. PT does not typically decrease) 15. A nurse is developing a care plan for a patient with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. What is the best rationale for this intervention? a. To prevent contractures16. A patient's burns have required a homograft. During the nurse's most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurse's most appropriate response? a. Inform the primary care provider promptly b/c the graft may need to be removed 17. A nurse has reported for a shift at a busy burns and plastics unit in a large university hospital. Which patient is most likely to have life-threatening complications? a. A 4-year-old scald victim burned over 24% of the body 18. A patient is brought to the emergency department with a burn injury. The nurse knows that the frst systemic event after a major burn injury is what? a. Hemodynamic instability 19. A patient with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the patient closely for what signs of the onset of burn shock? a. Decreased BP 20. An emergency department nurse has just received a patient with burn injuries brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the patient's body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period? a. Administer IV fluids 21. A patient's burns are estimated at 36% of total body surface area; fluid resuscitation has been ordered in the emergency department. After establishing intravenous access, the nurse should anticipate the administration of what fluid? a. Lactated Ringer's 22. A patient is admitted to the burn unit after being transported from a facility 1000 miles away. The patient has burns to the groin area and circumferential burns to both upper thighs. When assessing the patient's legs distal to the wound site, the nurse should be cognizant of the risk of what complication? a. Ischemia 23. A patient experienced a 33% TBSA burn 72 hours ago. The nurse observes that the patient's hourly urine output has been steadily increasing over the past 24 hours. How should the nurse best respond to this fnding? a. Recognize that the patient is experiencing an expected onset of diuresis 24. A public health nurse has reviewed local data about the incidence and prevalence of burn injuries in the community. These data are likely to support what health promotion effort? a. Education about home safety 25. A nurse is performing a home visit to a patient who is recovering following a long course of inpatient treatment for burn injuries. When performing this home visit, the nurse should do which of the following? a. Assess the patient's psychosocial state 26. A nurse is caring for a patient with burns who is in the later stages of the acute phase of recovery. The plan of nursing care should include which of the following nursing actions? a. Prevention of venous thromboembolism 27. A patient is in the acute phase of a burn injury. One of the nursing diagnoses in the plan of care is Ineffective Coping Related to Trauma of Burn Injury. What interventions appropriately address this diagnosis? Select all that applya. Promote truthful communication b. Teach the patient coping strategies c. Provide positive reinforcement 28. A patient who was burned in a workplace accident has completed the acute phase of treatment and the plan of care has been altered to prioritize rehabilitation. What nursing action should be prioritized during this phase of treatment? a. Provide education to the patient and family 29. A burn patient is transitioning from the acute phase of the injury to the rehabilitation phase. The patient tells the nurse, ìI can't wait to have surgery to reconstruct my face so I look normal again.î What would be the nurse's best response? a. “That's something that you and your doctor will likely talk about after your scarsmature” 30. The nurse caring for a patient who is recovering from full-thickness burns is aware of the patient's risk for contracture and hypertrophic scarring. How can the nurse best mitigate this risk? a. Encourage physical activity and range of motion exercises (which help to reduce contractures and hypertrophic scarring) 31. While performing a patient's ordered wound care for the treatment of a burn, the patient has made a series of sarcastic remarks to the nurse and criticized her technique. How should the nurse best interpret this patient's behavior? a. The patient may be experiencing anger about his circumstances that he isdeflecting toward the nurse Test Bank Questions for CHP 41 42 43 (NO quiz for these, but they were on Exam 1) ^^^**********END OF EXAM 1 CONTENT**********^^^ **********START OF EXAM 2 CONTENT********** Med Surge Quiz 3 - 66 67 CHP 66 Question 1 See full question A female patient is diagnosed with a right-sided stroke. The patient is now experiencing hemianopsia. How might the nurse help the patient manage her potential sensory and perceptional difculties? You Selected: • Place the patient's extremities where she can see them. Correct response: • Place the patient's extremities where she can see them. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 1984. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 1984 Question 2 See full question When preparing to discharge a patient home, the nurse has met with the family and warned them that the patient may exhibit unexpected emotional responses. The nurseshould teach the family that these responses are typically a result of what cause? You Selected: • Frustration around changes in function and communication Correct response: • Frustration around changes in function and communication Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 1986. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 1986 Question 3 See full question A patient is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this patient is aware that an absolute contraindication for thrombolytic therapy is what? You Selected: • Evidence of hemorrhagic stroke Correct response: • Evidence of hemorrhagic stroke Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 1977. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 1977 Question 4 See full question A patient with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the patient's cardiac and neurologic status, the nurse monitors the patient for signs of what complication? You Selected: • Bleeding Correct response: • Bleeding Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 1979. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 1979 Question 5 See full question A patient has recently begun mobilizing during the recovery from an ischemic stroke. To protect the patient's safety during mobilization, the nurse should perform what action? You Selected: • Avoid mobilizing the patient in the early morning or late evening. Correct response: • Have a colleague follow the patient closely with a wheelchair. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 67:Management of Patients With Cerebrovascular Disorders, p. 1982. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 1982 Question 6 See full question The nurse is performing stroke risk screenings at a hospital open house. The nurse has identifed four patients who might be at risk for a stroke. Which patient is likely at the highest risk for a hemorrhagic stroke? You Selected: • White male, age 60, with history of uncontrolled hypertension Correct response: • White male, age 60, with history of uncontrolled hypertension Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 1988. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 1988 Question 7 See full question A patient who has experienced an ischemic stroke has been admitted to the medical unit. The patient's family in adamant that she remain on bed rest to hasten her recovery and to conserve energy. What principle of care should inform the nurse's response to the family? You Selected: • The patient should mobilize as soon as she is physically able. Correct response: • The patient should mobilize as soon as she is physically able. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 1982. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 1982 Question 8 See full question A patient diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse knows that teaching for the patient and family needs to begin as soon as the patient is settled on the unit and will continue until the patient is discharged. What will family education need to include? You Selected: • How to correctly modify the home environment Correct response: • How to correctly modify the home environment Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 1992. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 1992 Question 9 See full question A community health nurse is giving an educational presentation about stroke and heart disease at the local senior citizens center. What nonmodifable risk factor for stroke should the nurse cite? You Selected:• Female gender Correct response: • Advanced age Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 1976. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 1976 Question 10 See full question After a subarachnoid hemorrhage, the patient's laboratory results indicate a serum sodium level of less than 126 mEq/L. What is the nurse's most appropriate action? You Selected: • Prepare the patient for thrombolytic therapy as ordered. Correct response: • Prepare to administer 3% NaCl by IV as ordered. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 1992. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 1992 Question 11 See full question The nurse is caring for a patient diagnosed with an ischemic stroke and knows that effective positioning of the patient is important. Which of the following should be integrated into the patient's plan of care? You Selected: • The patient should be placed in a Trendelenberg position two to three times daily to promote cerebral perfusion. Correct response: • The patient should be placed in a prone position for 15 to 30 minutes several times a day. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 1982. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 1982 Question 12 See full question After a major ischemic stroke, a possible complication is cerebral edema. Nursing care during the immediate recovery period from an ischemic stroke should include which of the following? You Selected: • Positioning to avoid hypoxia Correct response: • Positioning to avoid hypoxia Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 1979. Chapter 67:Management of Patients With Cerebrovascular Disorders - Page 1979 Question 13 See full question A patient has been admitted to the ICU after being recently diagnosed with an aneurysm and the patient's admission orders include specifc aneurysm precautions. What nursing action will the nurse incorporate into the patient's plan of care? You Selected: • Maintain the patient on complete bed rest. Correct response: • Maintain the patient on complete bed rest. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 1991. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 1991 Question 14 See full question A patient has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize? You Selected: • Generalized seizure Correct response: • Generalized seizure Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 66: Management of Patients With Neurologic Dysfunction, p. 1960. Chapter 66: Management of Patients With Neurologic Dysfunction - Page 1960 Question 15 See full question The neurologic ICU nurse is admitting a patient following a craniotomy using the supratentorial approach. How should the nurse best position the patient? You Selected: • Maintain head of bed (HOB) elevated at 30 to 45 degrees. Correct response: • Maintain head of bed (HOB) elevated at 30 to 45 degrees. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 66: Management of Patients With Neurologic Dysfunction, p. 1954. Chapter 66: Management of Patients With Neurologic Dysfunction - Page 1954 Question 16 See full question A nurse is collaborating with the interdisciplinary team to help manage a patient's recurrent headaches. What aspect of the patient's health history should the nurse identify as a potential contributor to the patient's headaches? You Selected: • The patient takes vasodilators for the treatment of angina. Correct response: • The patient takes vasodilators for the treatment of angina. Explanation:Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 66: Management of Patients With Neurologic Dysfunction, p. 1968. Chapter 66: Management of Patients With Neurologic Dysfunction - Page 1968 Question 17 See full question A hospital patient has experienced a seizure. In the immediate recovery period, what action best protects the patient's safety? You Selected: • Place the patient in a side-lying position. Correct response: • Place the patient in a side-lying position. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 66: Management of Patients With Neurologic Dysfunction, p. 1966. Chapter 66: Management of Patients With Neurologic Dysfunction - Page 1966 Question 18 See full question A nurse is working in the neurologic intensive care unit and admits from the emergency department a patient with an inoperable brain tumor. Upon entering the room, the nurse observes that the patient is positioned like the person in part B of the accompanying image. Which posturing is the patient exhibiting? You Selected: • Decorticate Correct response: • Decerebrate Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 66: Management of Patients With Neurologic Dysfunction, pp. 1937-1938. Chapter 66: Management of Patients With Neurologic Dysfunction - Page 1937-1938 Question 19 See full question A nurse is working in the neurologic intensive care unit and admits from the emergency department a patient with a severe head injury. Upon entering the room, the nurse observes that the patient is positioned like part A of the accompanying image. Which posturing is the patient exhibiting? You Selected: • Decerebrate Correct response: • Decorticate Explanation: Reference: [ Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical SurgicalNursing, 12th ed. Philadelphia: Lippincott Williams & Wilkins, 2010, Chapter 61: Management of Patients With Neurologic Dysfunction, pp. 1859-1861. Chapter 66: Management of Patients With Neurologic Dysfunction - Page 1859-1861 Question 20 See full question A nurse working in the neurologic intensive care unit admits from the emergency department a patient with an inoperable brain tumor. Upon entering the room, the nurseobserves that the patient is positioned like part B of the accompanying image. Based on this initial observation, what would the nurse predict about this patient's prognosis? You Selected: • fatal Correct response: • poor Explanation: Reference: [ Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical SurgicalNursing, 12th ed. Philadelphia: Lippincott Williams & Wilkins, 2010, Chapter 61: Management of Patients With Neurologic Dysfunction, pp. 1859-1861. Chapter 66: Management of Patients With Neurologic Dysfunction - Page 1859-1861 Question 21 See full question A clinic nurse is caring for a patient diagnosed with migraine headaches. During the patient teaching session, the patient questions the nurse regarding alcohol consumption. What would the nurse be correct in telling the patient about the effects of alcohol? You Selected: • Alcohol causes vasodilation of the blood vessels. Correct response: • Alcohol causes vasodilation of the blood vessels. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 66: Management of Patients With Neurologic Dysfunction, p. 1970. Chapter 66: Management of Patients With Neurologic Dysfunction - Page 1970 Question 22 See full question A patient is recovering from intracranial surgery performed approximately 24 hours ago and is complaining of a headache that the patient rates at 8 on a 10-point pain scale. What nursing action is most appropriate? You Selected: • Administer morphine sulfate as ordered. Correct response: • Administer morphine sulfate as ordered. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 66: Management of Patients With Neurologic Dysfunction, p. 1955. Chapter 66: Management of Patients With Neurologic Dysfunction - Page 1955 Question 23 See full question A nurse is providing education about migraine headaches to a community group. The cause of migraines has not been clearly demonstrated, but is related to vascular disturbances. A member of the group asks about familial tendencies. The nurse's correct reply will be which of the following? You Selected: • "There is a strong familial tendency." Correct response: • "There is a strong familial tendency." Explanation: Reference:[ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 66: Management of Patients With Neurologic Dysfunction, p. 1967. Chapter 66: Management of Patients With Neurologic Dysfunction - Page 1967 Question 24 See full question A patient has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the patient's ICP increases and condition worsens, the nurse knows to assess for indications of approaching death. These indications include which of the following? You Selected: • Loss of brain stem reflexes Correct response: • Loss of brain stem reflexes Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 66: Management of Patients With Neurologic Dysfunction, p. 1952. Chapter 66: Management of Patients With Neurologic Dysfunction - Page 1952 Question 25 See full question The nurse is caring for a patient whose recent health history includes an altered LOC. What should be the nurse's frst action when assessing this patient? You Selected: • Assessing the patient's verbal response Correct response: Assessing the patient's verbal response MedSurg Quiz 4 – 68 69 70 Question 1 See full question A patient with a spinal cord injury has experienced several hypotensive episodes. How can the nurse best address the patient's risk for orthostatic hypotension? You Selected: • Monitor the patient's BP before and during position changes. Correct response: • Monitor the patient's BP before and during position changes. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 68: Management of Patients With Neurologic Trauma, p. 2018. Chapter 68: Management of Patients With Neurologic Trauma - Page 2018 Question 2 See full question A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classifed as? You Selected: • An intracerebral hematoma Correct response: • An intracerebral hematoma Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-SurgicalNursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 68: Management of Patients With Neurologic Trauma, p. 2000. Chapter 68: Management of Patients With Neurologic Trauma - Page 2000 Question 3 See full question A patient with a head injury has been increasingly agitated and the nurse has consequently identifed a risk for injury. What is the nurse's best intervention for preventing injury? You Selected: • Pad the side rails of the patient's bed. Correct response: • Pad the side rails of the patient's bed. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 68: Management of Patients With Neurologic Trauma, p. 2005. Chapter 68: Management of Patients With Neurologic Trauma - Page 2005 Question 4 See full question The staff educator is precepting a nurse new to the critical care unit when a patient with a T2 spinal cord injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the patient closely, what would be the nurse's most appropriate action? You Selected: • Prepare for interventions to increase the patient's BP. Correct response: • Prepare for interventions to increase the patient's BP. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 68: Management of Patients With Neurologic Trauma, p. 2014. Chapter 68: Management of Patients With Neurologic Trauma - Page 2014 Question 5 See full question The nurse caring for a patient with a spinal cord injury notes that the patient is exhibiting early signs and symptoms of disuse syndrome. Which of the following is the most appropriate nursing action? You Selected: • Increase the frequency of ROM exercises. Correct response: • Increase the frequency of ROM exercises. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 68: Management of Patients With Neurologic Trauma, p. 2021. Chapter 68: Management of Patients With Neurologic Trauma - Page 2021 Question 6 See full question A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient? You Selected: • Bradycardia and hypertensionCorrect response: • Bradycardia and hypertension Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 68: Management of Patients With Neurologic Trauma, p. 2010. Chapter 68: Management of Patients With Neurologic Trauma - Page 2010 Question 7 See full question A patient who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the patient's current health status is most likely to have precipitated this event? You Selected: • The patient's urinary catheter became occluded. Correct response: • The patient's urinary catheter became occluded. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 68: Management of Patients With Neurologic Trauma, p. 2017. Chapter 68: Management of Patients With Neurologic Trauma - Page 2017 Question 8 See full question The nurse recognizes that a patient with a SCI is at risk for muscle spasticity. How can the nurse best prevent this complication of an SCI? You Selected: • Perform passive ROM exercises as ordered. Correct response: • Perform passive ROM exercises as ordered. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 68: Management of Patients With Neurologic Trauma, p. 2022. Chapter 68: Management of Patients With Neurologic Trauma - Page 2022 Question 9 See full question A male patient presents to the clinic complaining of a headache. The nurse notes that the patient is guarding his neck and tells the nurse that he has stiffness in the neck area. The nurse suspects the patient may have meningitis. What is another well-recognized sign of this infection? You Selected: • Positive Kernig's sign Correct response: • Positive Kernig's sign Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies, p. 2027. Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies - Page 2027Question 10 See full question A middle-aged woman has sought care from her primary care provider and undergone diagnostic testing that has resulted in a diagnosis of MS. What sign or symptom is most likely to have prompted the woman to seek care? You Selected: • Difculty in coordination Correct response: • Difculty in coordination Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies, p. 2035. Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies - Page 2035 Question 11 See full question A patient with suspected Creutzfeldt-Jakob disease (CJD) is being admitted to the unit. The nurse would expect what diagnostic test to be ordered for this patient? You Selected: • EEG Correct response: • EEG Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies, p. 2033. Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies - Page 2033 Question 12 See full question The nurse is caring for a 77-year-old woman with MS. She states that she is very concerned about the progress of her disease and what the future holds. The nurse should know that elderly patients with MS are known to be particularly concerned about what variables? Select all that apply. You Selected: • Becoming a burden on the family • Increasing disability • Possible nursing home placement Correct response: • Possible nursing home placement • Increasing disability • Becoming a burden on the family Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies, p. 2035. Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies - Page 2035 Question 13 See full question A patient diagnosed with Bell's palsy is being cared for on an outpatient basis. Duringhealth education, the nurse should promote which of the following actions? You Selected: • Applying a protective eye shield at night Correct response: • Applying a protective eye shield at night Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies, p. 2049. Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies - Page 2049 Question 14 See full question A patient with Guillain-Barré syndrome has experienced a sharp decline in vital capacity. What is the nurse's most appropriate action? You Selected: • Prepare to assist with intubation. Correct response: • Prepare to assist with intubation. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies, p. 2045. Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies - Page 2045 Question 15 See full question The nurse caring for a patient diagnosed with Guillain-Barré syndrome is planning care with regard to the clinical manifestations associated this syndrome. The nurse's communication with the patient should reflect the possibility of what sign or symptom of the disease? You Selected: • Vocal paralysis Correct response: • Vocal paralysis Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies, p. 2047. Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies - Page 2047 Question 16 See full question A 48-year-old patient has been diagnosed with trigeminal neuralgia following recent episodes of unilateral face pain. The nurse should recognize what implication of this diagnosis? You Selected: • The patient needs to be assessed for MS. Correct response: • The patient needs to be assessed for MS. Explanation:Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies, p. 2048. Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies - Page 2048 Question 17 See full question The nurse is developing a plan of care for a patient with Guillain-Barré syndrome. Which of the following interventions should the nurse prioritize for this patient? You Selected: • Using the incentive spirometer as prescribed Correct response: • Using the incentive spirometer as prescribed Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies, p. 2045. Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies - Page 2045 Question 18 See full question The nurse is caring for a patient who is scheduled for a cervical discectomy the following day. During health education, the patient should be made aware of what potential complications? You Selected: • Hematoma at the surgical site Correct response: • Hematoma at the surgical site Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 70: Management of Patients With Oncologic or Degenerative Neurologic Disorders, p. 2075. Chapter 70: Management of Patients With Oncologic or Degenerative Neurologic Disorders - Page 2075 Question 19 See full question A male patient presents at the free clinic with complaints of impotency. Upon physical examination, the nurse practitioner notes the presence of hypogonadism. What diagnosis should the nurse suspect? You Selected: • Prolactinoma Correct response: • Prolactinoma Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 70: Management of Patients With Oncologic or Degenerative Neurologic Disorders, p. 2054. Chapter 70: Management of Patients With Oncologic or Degenerative Neurologic Disorders - Page 2054 Question 20 See full questionA gerontologic nurse is advocating for diagnostic testing of an 81-year-old patient who is experiencing personality changes. The nurse is aware of what factor that is known to affect the diagnosis and treatment of brain tumors in older adults? You Selected: • The effects of brain tumors are often attributed to the cognitive effects of aging. Correct response: • The effects of brain tumors are often attributed to the cognitive effects of aging. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 70: Management of Patients With Oncologic or Degenerative Neurologic Disorders, p. 2054. Chapter 70: Management of Patients With Oncologic or Degenerative Neurologic Disorders - Page 2054 Question 21 See full question A patient with amyotrophic lateral sclerosis (ALS) is being visited by the home health nurse who is creating a care plan. What nursing diagnosis is most likely for a patient with this condition? You Selected: • Impaired verbal communication Correct response: • Impaired verbal communication Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 70: Management of Patients With Oncologic or Degenerative Neurologic Disorders, p. 2070. Chapter 70: Management of Patients With Oncologic or Degenerative Neurologic Disorders - Page 2070 Question 22 See full question A 25-year-old female patient with brain metastases is considering her life expectancy after her most recent meeting with her oncologist. Based on the fact that the patient is not receiving treatment for her brain metastases, what is the nurse's most appropriate action? You Selected: • Ensuring that the patient receives adequate palliative care Correct response: • Ensuring that the patient receives adequate palliative care Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 70: Management of Patients With Oncologic or Degenerative Neurologic Disorders, p. 2058. Chapter 70: Management of Patients With Oncologic or Degenerative Neurologic Disorders - Page 2058 Question 23 See full question A patient with a brain tumor has begun to exhibit signs of cachexia. What subsequent assessment should the nurse prioritize? You Selected: • Assessment of nutritional status Correct response:• Assessment of nutritional status Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 70: Management of Patients With Oncologic or Degenerative Neurologic Disorders, p. 2059. Chapter 70: Management of Patients With Oncologic or Degenerative Neurologic Disorders - Page 2059 Question 24 See full question A patient diagnosed with a pituitary adenoma has arrived on the neurologic unit. When planning the patient's care, the nurse should be aware that the effects of the tumor will primarily depend on what variable? You Selected: • The specifc hormones secreted by the tumor Correct response: • The specifc hormones secreted by the tumor Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 70: Management of Patients With Oncologic or Degenerative Neurologic Disorders, p. 2054. Chapter 70: Management of Patients With Oncologic or Degenerative Neurologic Disorders - Page 2054 Question 25 See full question A patient who was diagnosed with Parkinson's disease several months ago recently began treatment with levodopa-carbidopa. The patient and his family are excited that he has experienced signifcant symptom relief. The nurse should be aware of what implication of the patient's medication regimen? You Selected: • Benefts of levodopa-carbidopa often diminish after 1 or 2 years of treatment. Correct response: • Benefts of levodopa-carbidopa often diminish after 1 or 2 years of treatment. Test Bank Questions for CHP 46 47 48 (NO quiz for these, but they were on Exam 2) Med Surge Test 2 – 66 67 68 69 70 46 47 48 Question 1 See full question A patient seeking care because of recurrent heartburn and regurgitation is subsequently diagnosed with a hiatal hernia. Which of the following should the nurse include in health education? You Selected: • “Instead of eating three meals a day, try eating smaller amounts more often.” Correct response: • “Instead of eating three meals a day, try eating smaller amounts more often.” Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1252. Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1252Question 2 See full question A nurse is providing oral care to a patient who is comatose. What action best addresses the patient's risk of tooth decay and plaque accumulation? You Selected: • Brushing the patient's teeth with a toothbrush and small amount of toothpaste Correct response: • Brushing the patient's teeth with a toothbrush and small amount of toothpaste Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1237. Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1237 Question 3 See full question A patient who underwent surgery for esophageal cancer is admitted to the critical care unit following postanesthetic recovery. Which of the following should be included in the patient's immediate postoperative plan of care? You Selected: • Positioning the patient to prevent gastric reflux Correct response: • Positioning the patient to prevent gastric reflux Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1257. Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1257 Question 4 See full question An elderly patient comes into the emergency department complaining of an earache. The patient and has an oral temperature of 100.2ºF and otoscopic assessment of the ear reveals a pearly gray tympanic membrane with no evidence of discharge or inflammation. Which action should the triage nurse take next? You Selected: • Palpate the patient's parotid glands to detect swelling and tenderness. Correct response: • Palpate the patient's parotid glands to detect swelling and tenderness. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1241. Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1241 Question 5 See full question A nurse is caring for a patient who has just had a rigid fxation of a mandibular fracture. When planning the discharge teaching for this patient, what would the nurse be sure to include? You Selected: • Avoiding chewing food for the specifed number of weeks after surgery Correct response: • Avoiding chewing food for the specifed number of weeks after surgery Explanation:Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1241. Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1241 Question 6 See full question A patient has received treatment for oral cancer. The combination of medications and radiotherapy has resulted in leukopenia. Which of the following is an appropriate response to this change in health status? You Selected: • Ensure that none of the patient's visitors has an infection. Correct response: • Ensure that none of the patient's visitors has an infection. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1244. Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1244 Question 7 See full question A nurse is addressing the prevention of esophageal cancer in response to a question posed by a participant in a health promotion workshop. What action has the greatest potential to prevent esophageal cancer? You Selected: • Early diagnosis and treatment of gastroesophageal reflux disease Correct response: • Early diagnosis and treatment of gastroesophageal reflux disease Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1256. Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1256 Question 8 See full question A staff educator is reviewing the causes of gastroesophageal reflux disease (GERD) with new staff nurses. What area of the GI tract should the educator identify as the cause of reduced pressure associated with GERD? You Selected: • Lower esophageal sphincter Correct response: • Lower esophageal sphincter Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1250. Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1250 Question 9 See full question The nurse is assessing a client with an ulcer for signs and symptoms of hemorrhage. The nurse interprets which condition as a sign/symptom of possible hemorrhage? You Selected:• Hypertension Correct response: • Hematemesis Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1270. Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1270 Question 10 See full question A patient who is obese is exploring bariatric surgery options and presented to a bariatric clinic for preliminary investigation. The nurse interviews the patient, analyzing and documenting the data. Which of the following nursing diagnoses may be a contraindication for bariatric surgery? You Selected: • Defcient Knowledge Related to Risks and Expectations of Surgery Correct response: • Defcient Knowledge Related to Risks and Expectations of Surgery Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1273. Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1273 Question 11 See full question Diagnostic imaging and physical assessment have revealed that a patient with peptic ulcer disease has suffered a perforated ulcer. The nurse recognizes that emergency interventions must be performed as soon as possible in order to prevent the development of what complication? You Selected: • Peritonitis Correct response: • Peritonitis Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1270. Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1270 Question 12 See full question A nurse is providing care for a patient who is postoperative day 2 following gastric surgery. The nurse's assessment should be planned in light of the possibility of what potential complications? Select all that apply. You Selected: • Atelectasis • Metabolic imbalances • Pneumonia Correct response: • Atelectasis • Pneumonia • Metabolic imbalancesExplanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1281. Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1281 Question 13 See full question A patient with a history of peptic ulcer disease has presented to the emergency department (ED) in distress. What assessment fnding would lead the ED nurse to suspect that the patient has a perforated ulcer? You Selected: • The patient has a rigid, “boardlike” abdomen that is tender. Correct response: • The patient has a rigid, “boardlike” abdomen that is tender. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1270. Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1270 Question 14 See full question A nurse is caring for a client who underwent a subtotal gastrectomy 24 hours ago. The client has a nasogastric (NG) tube. The nurse should: You Selected: • irrigate the NG tube gently with normal saline solution if ordered. Correct response: • irrigate the NG tube gently with normal saline solution if ordered. Explanation: Reference: [ Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 12th ed. Philadelphia: Lippincott Williams & Wilkins, 2010, Chapter 37: Management of Patients With Gastric and Duodenal Disorders, p. 1062. Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1062 Question 15 See full question A patient has recently received a diagnosis of gastric cancer; the nurse is aware of the importance of assessing the patient's level of anxiety. Which of the following actions is most likely to accomplish this? You Selected: • The patient is encouraged to express fears openly. Correct response: • The patient is encouraged to express fears openly. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1276. Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1276 Question 16 See full question A patient was treated in the emergency department and critical care unit after ingesting bleach. What possible complication of the resulting gastritis should the nurse recognize? You Selected:• Esophageal or pyloric obstruction related to scarring Correct response: • Esophageal or pyloric obstruction related to scarring Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1262. Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1262 Question 17 See full question A nurse is completing a health history on a patient whose diagnosis is chronic gastritis. Which of the data should the nurse consider most signifcantly related to the etiology of the patient's health problem? You Selected: • Smokes one pack of cigarettes daily. Correct response: • Smokes one pack of cigarettes daily. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1280. Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1280 Question 18 See full question A patient admitted with acute diverticulitis has experienced a sudden increase in temperature and complains of a sudden onset of exquisite abdominal tenderness. The nurse's rapid assessment reveals that the patient's abdomen is uncharacteristically rigid on palpation. What is the nurse's best response? You Selected: • Contact the primary care provider promptly and report these signs of perforation. Correct response: • Contact the primary care provider promptly and report these signs of perforation. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1299. Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1299 Question 19 See full question A patient with a diagnosis of colon cancer is 2 days postoperative following bowel resection and anastomosis. The nurse has planned the patient's care in the knowledge of potential complications. What assessment should the nurse prioritize? You Selected: • Frequent abdominal auscultation Correct response: • Frequent abdominal auscultation Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1323. Chapter 48:Management of Patients With Intestinal and Rectal Disorders - Page 1323 Question 20 See full question An elderly client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make? You Selected: • Take a stool softener such as docusate sodium (Colace) daily. Correct response: • Take a stool softener such as docusate sodium (Colace) daily. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1288. Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1288 Question 21 See full question A nurse is caring for a patient admitted with symptoms of an anorectal infection; cultures indicate that the patient has a viral infection. The nurse should anticipate the administration of what drug? You Selected: • Acyclovir (Zovirax) Correct response: • Acyclovir (Zovirax) Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1330. Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1330 Question 22 See full question A nurse is caring for a patient with constipation whose primary care provider has recommended senna (Senokot) for the management of this condition. The nurse should provide which of the following education points? You Selected: • “Avoid taking the drug on a long-term basis.” Correct response: • “Avoid taking the drug on a long-term basis.” Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1288. Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1288 Question 23 See full question A nurse caring for a patient with a newly created ileostomy assesses the patient and notes that the patient has had not ostomy output for the past 12 hours. The patient also complains of worsening nausea. What is the nurse's priority action? You Selected: • Report signs and symptoms of obstruction to the physician. Correct response: • Report signs and symptoms of obstruction to the physician. Explanation:Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1315. Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1315 Question 24 See full question A 16-year-old presents at the emergency department complaining of right lower quadrant pain and is subsequently diagnosed with appendicitis. When planning this patient's nursing care, the nurse should prioritize what nursing diagnosis? You Selected: • Risk for Infection Related to Possible Rupture of Appendix Correct response: • Risk for Infection Related to Possible Rupture of Appendix Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1296. Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1296 Question 25 See full question During a patient's scheduled home visit, an older adult patient has stated to the community health nurse that she has been experiencing hemorrhoids of increasing severity in recent months. The nurse should recommend which of the following? You Selected: • Increased fluid and fber intake Correct response: • Increased fluid and fber intake Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1359. Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1359 Question 26 See full question A patient with a brain tumor has begun to exhibit signs of cachexia. What subsequent assessment should the nurse prioritize? You Selected: • Assessment of nutritional status Correct response: • Assessment of nutritional status Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 70: Management of Patients With Oncologic or Degenerative Neurologic Disorders, p. 2059. Chapter 70: Management of Patients With Oncologic or Degenerative Neurologic Disorders - Page 2059 Question 27 See full question A patient diagnosed with a pituitary adenoma has arrived on the neurologic unit. When planning the patient's care, the nurse should be aware that the effects of the tumor will primarily depend on what variable?You Selected: • The specifc hormones secreted by the tumor Correct response: • The specifc hormones secreted by the tumor Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 70: Management of Patients With Oncologic or Degenerative Neurologic Disorders, p. 2054. Chapter 70: Management of Patients With Oncologic or Degenerative Neurologic Disorders - Page 2054 Question 28 See full question A patient who was diagnosed with Parkinson's disease several months ago recently began treatment with levodopa-carbidopa. The patient and his family are excited that he has experienced signifcant symptom relief. The nurse should be aware of what implication of the patient's medication regimen? You Selected: • Benefts of levodopa-carbidopa often diminish after 1 or 2 years of treatment. Correct response: • Benefts of levodopa-carbidopa often diminish after 1 or 2 years of treatment. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 70: Management of Patients With Oncologic or Degenerative Neurologic Disorders, p. 2064. Chapter 70: Management of Patients With Oncologic or Degenerative Neurologic Disorders - Page 2064 Question 29 See full question A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classifed as? You Selected: • An intracerebral hematoma Correct response: • An intracerebral hematoma Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 68: Management of Patients With Neurologic Trauma, p. 2000. Chapter 68: Management of Patients With Neurologic Trauma - Page 2000 Question 30 See full question The staff educator is precepting a nurse new to the critical care unit when a patient with a T2 spinal cord injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the patient closely, what would be the nurse's most appropriate action? You Selected: • Prepare for interventions to increase the patient's BP. Correct response: • Prepare for interventions to increase the patient's BP. Explanation: Reference:[ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 68: Management of Patients With Neurologic Trauma, p. 2014. Chapter 68: Management of Patients With Neurologic Trauma - Page 2014 Question 31 See full question A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient? You Selected: • Bradycardia and hypertension Correct response: • Bradycardia and hypertension Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 68: Management of Patients With Neurologic Trauma, p. 2010. Chapter 68: Management of Patients With Neurologic Trauma - Page 2010 Question 32 See full question The nurse recognizes that a patient with a SCI is at risk for muscle spasticity. How can the nurse best prevent this complication of an SCI? You Selected: • Perform passive ROM exercises as ordered. Correct response: • Perform passive ROM exercises as ordered. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 68: Management of Patients With Neurologic Trauma, p. 2022. Chapter 68: Management of Patients With Neurologic Trauma - Page 2022 Question 33 See full question A middle-aged woman has sought care from her primary care provider and undergone diagnostic testing that has resulted in a diagnosis of MS. What sign or symptom is most likely to have prompted the woman to seek care? You Selected: • Difculty in coordination Correct response: • Difculty in coordination Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies, p. 2035. Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies - Page 2035 Question 34 See full question A patient with suspected Creutzfeldt-Jakob disease (CJD) is being admitted to the unit. The nurse would expect what diagnostic test to be ordered for this patient? You Selected: • EEG Correct response:• EEG Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies, p. 2033. Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies - Page 2033 Question 35 See full question A patient diagnosed with Bell's palsy is being cared for on an outpatient basis. During health education, the nurse should promote which of the following actions? You Selected: • Applying a protective eye shield at night Correct response: • Applying a protective eye shield at night Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies, p. 2049. Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies - Page 2049 Question 36 See full question When preparing to discharge a patient home, the nurse has met with the family and warned them that the patient may exhibit unexpected emotional responses. The nurse should teach the family that these responses are typically a result of what cause? You Selected: • Frustration around changes in function and communication Correct response: • Frustration around changes in function and communication Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 1986. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 1986 Question 37 See full question A patient with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the patient's cardiac and neurologic status, the nurse monitors the patient for signs of what complication? You Selected: • Bleeding Correct response: • Bleeding Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 1979. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 1979Question 38 See full question The nurse is performing stroke risk screenings at a hospital open house. The nurse has identifed four patients who might be at risk for a stroke. Which patient is likely at the highest risk for a hemorrhagic stroke? You Selected: • White male, age 60, with history of uncontrolled hypertension Correct response: • White male, age 60, with history of uncontrolled hypertension Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 1988. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 1988 Question 39 See full question A patient who has experienced an ischemic stroke has been admitted to the medical unit. The patient's family in adamant that she remain on bed rest to hasten her recovery and to conserve energy. What principle of care should inform the nurse's response to the family? You Selected: • The patient should mobilize as soon as she is physically able. Correct response: • The patient should mobilize as soon as she is physically able. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 1982. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 1982 Question 40 See full question A patient diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse knows that teaching for the patient and family needs to begin as soon as the patient is settled on the unit and will continue until the patient is discharged. What will family education need to include? You Selected: • How to correctly modify the home environment Correct response: • How to correctly modify the home environment Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 1992. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 1992 Question 41 See full question A community health nurse is giving an educational presentation about stroke and heart disease at the local senior citizens center. What nonmodifable risk factor for stroke should the nurse cite? You Selected: • Advanced age Correct response:• Advanced age Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 1976. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 1976 Question 42 See full question The nurse is caring for a patient diagnosed with an ischemic stroke and knows that effective positioning of the patient is important. Which of the following should be integrated into the patient's plan of care? You Selected: • The patient should be placed in a prone position for 15 to 30 minutes several times a day. Correct response: • The patient should be placed in a prone position for 15 to 30 minutes several times a day. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 1982. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 1982 Question 43 See full question After a major ischemic stroke, a possible complication is cerebral edema. Nursing care during the immediate recovery period from an ischemic stroke should include which of the following? You Selected: • Positioning to avoid hypoxia Correct response: • Positioning to avoid hypoxia Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 1979. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 1979 Question 44 See full question A patient has been admitted to the ICU after being recently diagnosed with an aneurysm and the patient's admission orders include specifc aneurysm precautions. What nursing action will the nurse incorporate into the patient's plan of care? You Selected: • Maintain the patient on complete bed rest. Correct response: • Maintain the patient on complete bed rest. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 67: Management of Patients With Cerebrovascular Disorders, p. 1991. Chapter 67: Management of Patients With Cerebrovascular Disorders - Page 1991Question 45 See full question The neurologic ICU nurse is admitting a patient following a craniotomy using the supratentorial approach. How should the nurse best position the patient? You Selected: • Maintain head of bed (HOB) elevated at 30 to 45 degrees. Correct response: • Maintain head of bed (HOB) elevated at 30 to 45 degrees. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 66: Management of Patients With Neurologic Dysfunction, p. 1954. Chapter 66: Management of Patients With Neurologic Dysfunction - Page 1954 Question 46 See full question A hospital patient has experienced a seizure. In the immediate recovery period, what action best protects the patient's safety? You Selected: • Place the patient in a side-lying position. Correct response: • Place the patient in a side-lying position. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 66: Management of Patients With Neurologic Dysfunction, p. 1966. Chapter 66: Management of Patients With Neurologic Dysfunction - Page 1966 Question 47 See full question A nurse is working in the neurologic intensive care unit and admits from the emergency department a patient with an inoperable brain tumor. Upon entering the room, the nurse observes that the patient is positioned like the person in part B of the accompanying image. Which posturing is the patient exhibiting? You Selected: • Decerebrate Correct response: • Decerebrate Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 66: Management of Patients With Neurologic Dysfunction, pp. 1937-1938. Chapter 66: Management of Patients With Neurologic Dysfunction - Page 1937-1938 Question 48 See full question A clinic nurse is caring for a patient diagnosed with migraine headaches. During the patient teaching session, the patient questions the nurse regarding alcohol consumption. What would the nurse be correct in telling the patient about the effects of alcohol? You Selected: • Alcohol causes vasodilation of the blood vessels. Correct response: • Alcohol causes vasodilation of the blood vessels. Explanation: Reference:[ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 66: Management of Patients With Neurologic Dysfunction, p. 1970. Chapter 66: Management of Patients With Neurologic Dysfunction - Page 1970 Question 49 See full question A patient is recovering from intracranial surgery performed approximately 24 hours ago and is complaining of a headache that the patient rates at 8 on a 10-point pain scale. What nursing action is most appropriate? You Selected: • Administer morphine sulfate as ordered. Correct response: • Administer morphine sulfate as ordered. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 66: Management of Patients With Neurologic Dysfunction, p. 1955. Chapter 66: Management of Patients With Neurologic Dysfunction - Page 1955 Question 50 See full question A patient has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the patient's ICP increases and condition worsens, the nurse knows to assess for indications of approaching death. These indications include which of the following? You Selected: • Loss of brain stem reflexes Correct response: • Loss of brain stem reflexes Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 66: Management of Patients With Neurologic Dysfunction, p. 1952. Chapter 66: Management of Patients With Neurologic Dysfunction - Page 1952 Question 51 See full question A patient has been diagnosed with a hiatal hernia. The nurse explains the diagnosis to the patient and his family by telling them that a hernia is a (an): You Selected: • Involution of the esophagus, which causes a severe stricture. Correct response: • Protrusion of the upper stomach into the lower portion of the thorax. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, pp. 1251. Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1251 Question 52 See full question A medical nurse who is caring for a patient being discharged home after a radical neck dissection has collaborated with the home health nurse to develop a plan of care for this patient. What is a priority psychosocial outcome for a patient who has had a radical neck dissection?You Selected: • Freely expresses needs and concerns related to postoperative pain management Correct response: • Indicates acceptance of altered appearance and demonstrates positive self-image Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1247. Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1247 Question 53 See full question The nurse's comprehensive assessment of a patient includes inspection for signs of oral cancer. What assessment fnding is most characteristic of oral cancer in its early stages? You Selected: • Presence of a painless sore with raised edges Correct response: • Presence of a painless sore with raised edges Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1242. Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1242 Question 54 See full question A patient has been diagnosed with achalasia based on his history and diagnostic imaging results. The nurse should identify what risk diagnosis when planning the patient's care? You Selected: • Risk for Imbalanced Nutrition: Less than Body Requirements Related to Impaired Absorption Correct response: • Risk for Aspiration Related to Inhalation of Gastric Contents Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1250. Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1250 Question 55 See full question A patient with GERD has undergone diagnostic testing and it has been determined that increasing the pace of gastric emptying may help alleviate symptoms. The nurse should anticipate that the patient may be prescribed what drug? You Selected: • Metoclopramide (Reglan) Correct response: • Metoclopramide (Reglan) Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1254. Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1254Question 56 See full question A patient comes to the bariatric clinic to obtain information about bariatric surgery. The nurse assesses the obese patient knowing that in addition to meeting the criterion of morbid obesity, a candidate for bariatric surgery must also demonstrate what? You Selected: • Adequate understanding of required lifestyle changes Correct response: • Adequate understanding of required lifestyle changes Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1274. Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1274 Question 57 See full question A patient with a diagnosis of peptic ulcer disease has just been prescribed omeprazole (Prilosec). How should the nurse best describe this medication's therapeutic action? You Selected: • “This medication will reduce the amount of acid secreted in your stomach.” Correct response: • “This medication will reduce the amount of acid secreted in your stomach.” Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1267. Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1267 Question 58 See full question A patient comes to the clinic complaining of pain in the epigastric region. What assessment question during the health interview would most help the nurse determine if the patient has a peptic ulcer? You Selected: • “Does your pain resolve when you have something to eat?” Correct response: • “Does your pain resolve when you have something to eat?” Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1266. Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1266 Question 59 See full question A patient who underwent gastric banding 3 days ago is having her diet progressed on a daily basis. Following her latest meal, the patient complains of dizziness and palpitations. Inspection reveals that the patient is diaphoretic. What is the nurse's best action? You Selected: • Monitor the patient closely for further signs of dumping syndrome. Correct response: • Monitor the patient closely for further signs of dumping syndrome. Explanation: Reference:[ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1277. Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1277 Question 60 See full question A patient has been diagnosed with peptic ulcer disease and the nurse is reviewing his prescribed medication regimen with him. What is currently the most commonly used drug regimen for peptic ulcers? You Selected: • Antibiotics, proton pump inhibitors, and bismuth salts Correct response: • Antibiotics, proton pump inhibitors, and bismuth salts Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1267. Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1267 Question 61 See full question A patient has been admitted to the hospital after diagnostic imaging revealed the presence of a gastric outlet obstruction (GOO). What is the nurse's priority intervention? You Selected: • Insertion of an NG tube for decompression Correct response: • Insertion of an NG tube for decompression Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1271. Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1271 Question 62 See full question A community health nurse is preparing for an initial home visit to a patient discharged following a total gastrectomy for treatment of gastric cancer. What would the nurse anticipate that the plan of care is most likely to include? You Selected: • Monthly administration of injections of vitamin B12 Correct response: • Monthly administration of injections of vitamin B12 Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1276. Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1276 Question 63 See full question A nurse is providing patient education for a patient with peptic ulcer disease secondary to chronic nonsteroidal anti-inflammatory drug (NSAID) use. The patient has recently been prescribed misoprostol (Cytotec). What would the nurse be most accurate in informing the patient about the drug? You Selected:• It protects the stomach's lining Correct response: • It protects the stomach's lining Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1264. Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1264 Question 64 See full question An older adult who resides in an assisted living facility has sought care from the nurse because of recurrent episodes of constipation. Which of the following actions should the nurse frst perform? You Selected: • Assess the patient's food and fluid intake. Correct response: • Assess the patient's food and fluid intake. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1289. Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1289 Question 65 See full question A nurse is assessing a patient's stoma on postoperative day 3. The nurse notes that the stoma has a shiny appearance and a bright red color. How should the nurse best respond to this assessment fnding? You Selected: • Document that the stoma appears healthy and well perfused. Correct response: • Document that the stoma appears healthy and well perfused. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1323. Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1323 Question 66 See full question A nurse is planning discharge teaching for a 21-year-old patient with a new diagnosis of ulcerative colitis. When planning family assessment, the nurse should recognize that which of the following factors will likely have the greatest impact on the patient's coping after discharge? You Selected: • The family's ability to provide emotional support Correct response: • The family's ability to provide emotional support Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1307. Chapter 48:Management of Patients With Intestinal and Rectal Disorders - Page 1307 Question 67 See full question A patient's colorectal cancer has necessitated a hemicolectomy with the creation of a colostomy. In the 4 days since the surgery, the patient has been unwilling to look at the ostomy or participate in any aspects of ostomy care. What is the nurse's most appropriate response to this observation? You Selected: • Acknowledge the patient's reluctance and initiate discussion of the factors underlying it. Correct response: • Acknowledge the patient's reluctance and initiate discussion of the factors underlying it. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1324. Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1324 Question 68 See full question A nurse is preparing to provide care for a patient whose exacerbation of ulcerative colitis has required hospital admission. During an exacerbation of this health problem, the nurse would anticipate that the patient's stools will have what characteristics? You Selected: • Watery with blood and mucus Correct response: • Watery with blood and mucus Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1303. Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1303 Question 69 See full question A patient's screening colonoscopy revealed the presence of numerous polyps in the large bowel. What principle should guide the subsequent treatment of this patient's health problem? You Selected: • The patient's polyps constitute a risk factor for cancer. Correct response: • The patient's polyps constitute a risk factor for cancer. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1327. Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1327 Question 70 See full question A patient has been diagnosed with a small bowel obstruction and has been admitted to the medical unit. The nurse's care should prioritize which of the following outcomes? You Selected: • Maintaining fluid and electrolyte balance Correct response: • Maintaining fluid and electrolyte balanceExplanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1317. Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1317 Question 71 See full question The school nurse has been called to the football feld where player is immobile on the feld after landing awkwardly on his head during a play. While awaiting an ambulance, what action should the nurse perform? You Selected: • Ensure that the player is not moved. Correct response: • Ensure that the player is not moved. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 68: Management of Patients With Neurologic Trauma, p. 2013. Chapter 68: Management of Patients With Neurologic Trauma - Page 2013 Question 72 See full question A patient is admitted to the neurologic ICU with a spinal cord injury. When assessing the patient the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect? You Selected: • Spinal shock Correct response: • Spinal shock Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 68: Management of Patients With Neurologic Trauma, p. 2015. Chapter 68: Management of Patients With Neurologic Trauma - Page 2015 Question 73 See full question The nurse is planning the care of a patient with a T1 spinal cord injury. The nurse has identifed the diagnosis of “risk for impaired skin integrity.” How can the nurse best address this risk? You Selected: • Change the patient's position frequently. Correct response: • Change the patient's position frequently. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 68: Management of Patients With Neurologic Trauma, p. 2021. Chapter 68: Management of Patients With Neurologic Trauma - Page 2021 Question 74 See full question A patient with Parkinson's disease is experiencing episodes of constipation that are becoming increasingly frequent and severe. The patient states that he has beenachieving relief for the past few weeks by using OTC laxatives. How should the nurse respond? You Selected: • “Let's explore other options, because laxatives can have side effects and create dependency.” Correct response: • “Let's explore other options, because laxatives can have side effects and create dependency.” Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 70: Management of Patients With Oncologic or Degenerative Neurologic Disorders, p. 2067. Chapter 70: Management of Patients With Oncologic or Degenerative Neurologic Disorders - Page 2067 Question 75 See full question The nurse is caring for a patient newly diagnosed with a primary brain tumor. The patient asks the nurse where his tumor came from. What would be the nurse's best response? You Selected: • “Your tumor originated from cells within your brain itself.” Correct response: “Your tumor originated from cells within your brain itself.” ^^^**********END OF CONTENT FOR EXAM 2**********^^^ **********START OF CONTENT FOR EXAM 3********** MedSurg Quiz 5 - 54 55 Question 1 See full question The critical care nurse is monitoring the patient's urine output and drains following renal surgery. What should the nurse promptly report to the physician? You Selected: • Absence of drain output Correct response: • Absence of drain output Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1565. Chapter 54: Management of Patients With Kidney Disorders - Page 1565 Question 2 See full question The nurse has identifed the nursing diagnosis of “risk for infection” in a patient who undergoes peritoneal dialysis. What nursing action best addresses this risk? You Selected: • Maintain aseptic technique when administering dialysate. Correct response: • Maintain aseptic technique when administering dialysate. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-SurgicalNursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1556. Chapter 54: Management of Patients With Kidney Disorders - Page 1556 Question 3 See full question The nurse is assessing a patient suspected of having developed acute glomerulonephritis. The nurse should expect to address what clinical manifestation that is characteristic of this health problem? You Selected: • Hematuria Correct response: • Hematuria Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1527. Chapter 54: Management of Patients With Kidney Disorders - Page 1527 Question 4 See full question The nurse is caring for acutely ill patient. What assessment fnding should prompt the nurse to inform the physician that the patient may be exhibiting signs of acute kidney injury (AKI)? You Selected: • The patient's average urine output has been 10 mL/hr for several hours. Correct response: • The patient's average urine output has been 10 mL/hr for several hours. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1537. Chapter 54: Management of Patients With Kidney Disorders - Page 1537 Question 5 See full question The nurse is caring for a patient postoperative day 4 following a kidney transplant. When assessing for potential signs and symptoms of rejection, what assessment should the nurse prioritize? You Selected: • Assessment of the quantity of the patient's urine output Correct response: • Assessment of the quantity of the patient's urine output Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1569. Chapter 54: Management of Patients With Kidney Disorders - Page 1569 Question 6 See full question The nurse is providing a health education workshop to a group of adults focusing on cancer prevention. The nurse should emphasize what action in order to reduce participants' risks of renal carcinoma? You Selected: • Smoking cessationCorrect response: • Smoking cessation Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1534. Chapter 54: Management of Patients With Kidney Disorders - Page 1534 Question 7 See full question The nurse is caring for a patient with a history of systemic lupus erythematosus who has been recently diagnosed with end-stage kidney disease (ESKD). The patient has an elevated phosphorus level and has been prescribed calcium acetate to bind the phosphorus. The nurse should teach the patient to take the prescribed phosphorusbinding medication at what time? You Selected: • With each meal Correct response: • With each meal Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1542. Chapter 54: Management of Patients With Kidney Disorders - Page 1542 Question 8 See full question The nurse coming on shift on the medical unit is taking a report on four patients. What patient does the nurse know is at the greatest risk of developing ESKD? You Selected: • A patient with diabetes mellitus and poorly controlled hypertension Correct response: • A patient with diabetes mellitus and poorly controlled hypertension Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1528. Chapter 54: Management of Patients With Kidney Disorders - Page 1528 Question 9 See full question A patient with chronic kidney disease is completing an exchange during peritoneal dialysis. The nurse observes that the peritoneal fluid is draining slowly and that the patient's abdomen is increasing in girth. What is the nurse's most appropriate action? You Selected: • Reposition the patient to facilitate drainage. Correct response: • Reposition the patient to facilitate drainage. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1557. Chapter 54: Management of Patients With Kidney Disorders - Page 1557Question 10 See full question A patient is brought to the renal unit from the PACU status post resection of a renal tumor. Which of the following nursing actions should the nurse prioritize in the care of this patient? You Selected: • Managing postoperative pain Correct response: • Managing postoperative pain Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1535. Chapter 54: Management of Patients With Kidney Disorders - Page 1535 Question 11 See full question A football player is thought to have sustained an injury to his kidneys from being tackled from behind. The ER nurse caring for the patient reviews the initial orders written by the physician and notes that an order to collect all voided urine and send it to the laboratory for analysis. The nurse understands that this nursing intervention is important for what reason? You Selected: • Hematuria is the most common manifestation of renal trauma and blood losses may be microscopic, so laboratory analysis is essential. Correct response: • Hematuria is the most common manifestation of renal trauma and blood losses may be microscopic, so laboratory analysis is essential. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1571. Chapter 54: Management of Patients With Kidney Disorders - Page 1571 Question 12 See full question The nurse is caring for a patient after kidney surgery. The nurse is aware that bleeding is a major complication of kidney surgery and that if it goes undetected and untreated can result in hypovolemia and hemorrhagic shock in the patient. When assessing for bleeding, what assessment parameter should the nurse evaluate? You Selected: • Level of consciousness Correct response: • Level of consciousness Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1565. Chapter 54: Management of Patients With Kidney Disorders - Page 1565 Question 13 See full question A patient has a glomerular fltration rate (GFR) of 43 mL/min/1.73 m2. Based on this GFR, the nurse interprets that the patient's chronic kidney disease is at what stage? You Selected:• Stage 3 Correct response: • Stage 3 Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1528. Chapter 54: Management of Patients With Kidney Disorders - Page 1528 Question 14 See full question A nurse's colleague has applied an incontinence pad to an older adult patient who has experienced occasional episodes of functional incontinence. What principle should guide the nurse's management of urinary incontinence in older adults? You Selected: • Urinary incontinence is not considered a normal consequence of aging. Correct response: • Urinary incontinence is not considered a normal consequence of aging. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1583. Chapter 55: Management of Patients With Urinary Disorders - Page 1583 Question 15 See full question The nurse who is leading a wellness workshop has been asked about actions to reduce the risk of bladder cancer. What health promotion action most directly addresses a major risk factor for bladder cancer? You Selected: • Smoking cessation Correct response: • Smoking cessation Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1597. Chapter 55: Management of Patients With Urinary Disorders - Page 1597 Question 16 See full question A patient being treated in the hospital has been experiencing occasional urinary retention. What nursing action should the nurse take to encourage a patient who is having difculty voiding? You Selected: • Provide privacy for the patient. Correct response: • Provide privacy for the patient. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1586. Chapter 55: Management of Patients With Urinary Disorders - Page 1586Question 17 See full question A patient with a recent history of nephrolithiasis has presented to the ED. After determining that the patient's cardiopulmonary status is stable, what aspect of care should the nurse prioritize? You Selected: • Insertion of an indwelling urinary catheter Correct response: • Pain management Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1592. Chapter 55: Management of Patients With Urinary Disorders - Page 1592 Question 18 See full question A patient has undergone the creation of an Indiana pouch for the treatment of bladder cancer. The nurse identifed the nursing diagnosis of “disturbed body image.” How can the nurse best address the effects of this urinary diversion on the patient's body image? You Selected: • Encourage the patient to speak openly and frankly about the diversion. Correct response: • Encourage the patient to speak openly and frankly about the diversion. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1605. Chapter 55: Management of Patients With Urinary Disorders - Page 1605 Question 19 See full question A female patient has been experiencing recurrent urinary tract infections. What health education should the nurse provide to this patient? You Selected: • Drink liberal amounts of fluids. Correct response: • Drink liberal amounts of fluids. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1579. Chapter 55: Management of Patients With Urinary Disorders - Page 1579 Question 20 See full question The nurse is caring for a patient who underwent percutaneous lithotripsy earlier in the day. What instruction should the nurse give the patient? You Selected: • Notify the physician about cloudy or foul-smelling urine. Correct response: • Notify the physician about cloudy or foul-smelling urine. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-SurgicalNursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1595. Chapter 55: Management of Patients With Urinary Disorders - Page 1595 Question 21 See full question The nurse is working with a patient who has been experiencing episodes of urinary retention. What assessment fnding would suggest that the patient is experiencing retention? You Selected: • The patient's suprapubic region is dull on percussion. Correct response: • The patient's suprapubic region is dull on percussion. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1586. Chapter 55: Management of Patients With Urinary Disorders - Page 1586 Question 22 See full question A nurse on a busy medical unit provides care for many patients who require indwelling urinary catheters at some point during their hospital care. The nurse should recognize a heightened risk of injury associated with indwelling catheter use in which patient? You Selected: • A patient who has Alzheimer's disease and who is acutely agitated Correct response: • A patient who has Alzheimer's disease and who is acutely agitated Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1590. Chapter 55: Management of Patients With Urinary Disorders - Page 1590 Question 23 See full question An adult patient has been hospitalized with pyelonephritis. The nurse's review of the patient's intake and output records reveals that the patient has been consuming between 3 L and 3.5 L of oral fluid each day since admission. How should the nurse best respond to this fnding? You Selected: • Encourage the patient to continue this pattern of fluid intake. Correct response: • Encourage the patient to continue this pattern of fluid intake. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1581. Chapter 55: Management of Patients With Urinary Disorders - Page 1581 Question 24 See full question A female patient's most recent urinalysis results are suggestive of bacteriuria. When assessing this patient, the nurse's data analysis should be informed by what principle? You Selected: • Urine samples are frequently contaminated by bacteria normally present in the urethralarea. Correct response: • Urine samples are frequently contaminated by bacteria normally present in the urethral area. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1576. Chapter 55: Management of Patients With Urinary Disorders - Page 1576 Question 25 See full question A 52-year-old patient is scheduled to undergo ileal conduit surgery. When planning this patient's discharge education, what is the most plausible nursing diagnosis that the nurse should address? You Selected: • Defcient knowledge related to care of the ileal conduit Correct response: Defcient knowledge related to care of the ileal conduit MedSurge Quiz 6 - 49 50 Question 1 See full question A nurse is caring for a patient with hepatic encephalopathy. The nurse's assessment reveals that the patient exhibits episodes of confusion, is difcult to arouse from sleep and has rigid extremities. Based on these clinical fndings, the nurse should document what stage of hepatic encephalopathy? You Selected: • Stage 3 Correct response: • Stage 3 Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1355. Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1355 Question 2 See full question A group of nurses have attended an inservice on the prevention of occupationally acquired diseases that affect healthcare providers. What action has the greatest potential to reduce a nurse's risk of acquiring hepatitis C in the workplace? You Selected: • Disposing of sharps appropriately and not recapping needles Correct response: • Disposing of sharps appropriately and not recapping needles Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1364. Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1364 Question 3 See full question A nurse is caring for a patient with cirrhosis secondary to heavy alcohol use. The nurse'smost recent assessment reveals subtle changes in the patient's cognition and behavior. What is the nurse's most appropriate response? You Selected: • Report this fnding to the primary care provider due to the possibility of hepatic encephalopathy. Correct response: • Report this fnding to the primary care provider due to the possibility of hepatic encephalopathy. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1368. Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1368 Question 4 See full question A patient has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The patient's current medication regimen includes lactulose (Cephulac) four times daily. What desired outcome should the nurse relate to this pharmacologic intervention? You Selected: • Two to 3 soft bowel movements daily Correct response: • Two to 3 soft bowel movements daily Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1356. Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1356 Question 5 See full question A nurse is caring for a patient with a blocked bile duct from a tumor. What manifestation of obstructive jaundice should the nurse anticipate? You Selected: • Orange and foamy urine Correct response: • Orange and foamy urine Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1344. Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1344 Question 6 See full question A nurse educator is teaching a group of recent nursing graduates about their occupational risks for contracting hepatitis B. What preventative measures should the educator promote? Select all that apply. You Selected: • Use of standard precautions • Immunization Correct response: • Immunization• Use of standard precautions Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1362. Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1362 Question 7 See full question A patient with a liver mass is undergoing a percutaneous liver biopsy. What action should the nurse perform when assisting with this procedure? You Selected: • Position the patient on the right side with a pillow under the costal margin after the procedure. Correct response: • Position the patient on the right side with a pillow under the costal margin after the procedure. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1343. Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1343 Question 8 See full question A participant in a health fair has asked the nurse about the role of drugs in liver disease. What health promotion teaching has the most potential to prevent drug-induced hepatitis? You Selected: • Adhere to dosing recommendations of OTC analgesics. Correct response: • Adhere to dosing recommendations of OTC analgesics. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1365. Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1365 Question 9 See full question A nurse is caring for a patient with cancer of the liver whose condition has required the insertion of a percutaneous biliary drainage system. The nurse's most recent assessment reveals the presence of dark green fluid in the collection container. What is the nurse's best response to this assessment fnding? You Selected: • Document the presence of normal bile output. Correct response: • Document the presence of normal bile output. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1379. Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1379Question 10 See full question A nurse is performing an admission assessment of a patient with a diagnosis of cirrhosis. What technique should the nurse use to palpate the patient's liver? You Selected: • Place hand under right lower rib cage and press down lightly with the other hand. Correct response: • Place hand under right lower rib cage and press down lightly with the other hand. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1340. Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1340 Question 11 See full question A nurse is performing an admission assessment for an 81-year-old patient who generally enjoys good health. When considering normal, age-related changes to hepatic function, the nurse should anticipate what fnding? You Selected: • A slightly decreased size of the liver Correct response: • A slightly decreased size of the liver Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1338. Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1338 Question 12 See full question A patient with a history of injection drug use has been diagnosed with hepatitis C. When collaborating with the care team to plan this patient's treatment, the nurse should anticipate what intervention? You Selected: • A regimen of antiviral medications Correct response: • A regimen of antiviral medications Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1364. Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1364 Question 13 See full question A previously healthy adult's sudden and precipitous decline in health has been attributed to fulminant hepatic failure, and the patient has been admitted to the intensive care unit. The nurse should be aware that the treatment of choice for this patient is what? You Selected: • Liver transplantation Correct response: • Liver transplantation Explanation: Reference:[ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1366. Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1366 Question 14 See full question A patient with a cholelithiasis has been scheduled for a laparoscopic cholecystectomy. Why is laparoscopic cholecystectomy preferred by surgeons over an open procedure? You Selected: • Laparoscopic cholecystectomy poses fewer surgical risks than an open procedure. Correct response: • Laparoscopic cholecystectomy poses fewer surgical risks than an open procedure. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1395. Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1395 Question 15 See full question A patient has been diagnosed with acute pancreatitis. The nurse is addressing the diagnosis of Acute Pain Related to Pancreatitis. What pharmacologic intervention is most likely to be ordered for this patient? You Selected: • IV hydromorphone (Dilaudid) Correct response: • IV hydromorphone (Dilaudid) Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1403. Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1403 Question 16 See full question A patient with ongoing back pain, nausea, and abdominal bloating has been diagnosed with cholecystitis secondary to gallstones. The nurse should anticipate that the patient will undergo what intervention? You Selected: • Laparoscopic cholecystectomy Correct response: • Laparoscopic cholecystectomy Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1396. Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1396 Question 17 See full question A patient has been scheduled for an ultrasound of the gallbladder the following morning. What should the nurse do in preparation for this diagnostic study? You Selected: • Have the patient refrain from food and fluids after midnight. Correct response:• Have the patient refrain from food and fluids after midnight. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1393. Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1393 Question 18 See full question A patient who had surgery for gallbladder disease has just returned to the postsurgical unit from postanesthetic recovery. The nurse caring for this patient knows to immediately report what assessment fnding to the physician? You Selected: • Rigidity of the abdomen Correct response: • Rigidity of the abdomen Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1400. Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1400 Question 19 See full question A patient's abdominal ultrasound indicates cholelithiasis. When the nurse is reviewing the patient's laboratory studies, what fnding is most closely associated with this diagnosis? You Selected: • Increased bilirubin Correct response: • Increased bilirubin Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1389. Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1389 Question 20 See full question A nurse is preparing a plan of care for a patient with pancreatic cysts that have necessitated drainage through the abdominal wall. What nursing diagnosis should the nurse prioritize? You Selected: • Impaired Skin Integrity Correct response: • Impaired Skin Integrity Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1409. Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1409 Question 21 See full question The nurse is caring for a patient who has just returned from the ERCP removal ofgallstones. The nurse should monitor the patient for signs of what complications? You Selected: • Bleeding and perforation Correct response: • Bleeding and perforation Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1395. Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1395 Question 22 See full question A patient has been admitted to the hospital for the treatment of chronic pancreatitis. The patient has been stabilized and the nurse is now planning health promotion and educational interventions. Which of the following should the nurse prioritize? You Selected: • Educating the patient about postdischarge lifestyle modifcations Correct response: • Educating the patient about postdischarge lifestyle modifcations Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1409. Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1409 Question 23 See full question One difference between cholesterol stones (left) and the stones on the right are that the ones on the right account for only 10% to 25% of cases of stones in the United States. What is the name of the stones on the right? You Selected: • Pearl Correct response: • Pigment Explanation: Reference: [ Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical SurgicalNursing, 12th ed. Philadelphia: Lippincott Williams & Wilkins, 2010, Chapter 40: Assessment and Management of Patients With Biliary Disorders, p. 1172. Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1172 Question 24 See full question A 37-year-old male patient presents at the emergency department (ED) complaining of nausea and vomiting and severe abdominal pain. The patient's abdomen is rigid, and there is bruising to the patient's flank. The patient's wife states that he was on a drinking binge for the past 2 days. The ED nurse should assist in assessing the patient for what health problem? You Selected: • Severe pancreatitis with possible peritonitis Correct response: • Severe pancreatitis with possible peritonitis Explanation: Reference:[ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1402. Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1402 Question 25 See full question A client is diagnosed with gallstones in the bile ducts. The nurse knows to review the results of blood work for a You Selected: • Serum ammonia concentration of 90 mg/dL Correct response: Serum bilirubin level greater than 1.0 mg/dL Test Bank Questions for CHP 57 58 59 (NO quiz for these, but they were on Exam 3) MedSurge Exam 3 – 54 55 49 50 57 58 59 Question 1 See full question A patient with genital herpes is having an acute exacerbation. What medication would the nurse expect to be ordered to suppress the symptoms and shorten the course of the infection? You Selected: • Acyclovir (Zovirax) Correct response: • Acyclovir (Zovirax) Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1649. Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1649 Question 2 See full question A woman in her late 30s has been having unusually heavy menstrual periods combined with occasional urine and stool leakage over the past few weeks. Upon further enquiry, she reveals that she also has postcoital pain and bleeding. To which diagnosis will the investigation most likely lead? You Selected: • Cervical cancer Correct response: • Cervical cancer Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1667. Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1667 Question 3 See full question While taking a health history on a 20-year-old female patient, the nurse ascertains that this patient is taking miconazole (Monistat). The nurse is justifed in presuming that this patient has what medical condition? You Selected:• Candidiasis Correct response: • Candidiasis Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1649. Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1649 Question 4 See full question The nurse is caring for a patient with a diagnosis of vulvar cancer who has returned from the PACU after undergoing a wide excision of the vulva. How should this patient's analgesic regimen be best managed? You Selected: • Scheduled analgesia should be administered around-the-clock to prevent pain. Correct response: • Scheduled analgesia should be administered around-the-clock to prevent pain. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1671. Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1671 Question 5 See full question The nurse notes that a patient has a history of “fbroids” and is aware that this term refers to a benign tumor of the uterus. What is a more appropriate term for a fbroid? You Selected: • Leiomyoma Correct response: • Leiomyoma Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1664. Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1664 Question 6 See full question A patient diagnosed with cervical cancer will soon begin a round of radiation therapy. When planning the patient's subsequent care, the nurse should prioritize actions with what goal? You Selected: • Protecting the safety of the patient, family, and staff Correct response: • Protecting the safety of the patient, family, and staff Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1677. Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1677 Question 7 See full questionA patient has been diagnosed with polycystic ovary syndrome (PCOS). The nurse should encourage what health promotion activity to address the patient's hormone imbalance and infertility? You Selected: • Weight loss Correct response: • Weight loss Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1664. Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1664 Question 8 See full question A student nurse is doing clinical hours at an OB/GYN clinic. The student is helping to develop a plan of care for a patient with gonorrhea who has presented at the clinic. The student should include which of the following in the care plan for this patient? You Selected: • The patient should also be treated for chlamydia. Correct response: • The patient should also be treated for chlamydia. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1655. Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1655 Question 9 See full question A 42-year-old man has come to the clinic for an annual physical. The nurse notes in the patient's history that his father was treated for breast cancer. What should the nurse provide to the patient before he leaves the clinic? You Selected: • Instructions about breast self-examination (BSE) Correct response: • Instructions about breast self-examination (BSE) Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1684. Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1684 Question 10 See full question A nurse is explaining that each breast contains 12 to 20 cone-shaped lobes. The nurse should explain that each lobe consists of what elements? You Selected: • Lobules and ducts Correct response: • Lobules and ducts Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-SurgicalNursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1681. Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1681 Question 11 See full question When planning discharge teaching with a patient who has undergone a total mastectomy with axillary dissection, the nurse knows to instruct the patient that she should report what sign or symptom to the physician immediately? You Selected: • Sudden cessation of output from the drainage device Correct response: • Sudden cessation of output from the drainage device Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1699. Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1699 Question 12 See full question The nurse is caring for a 52-year-old woman whose aunt and mother died of breast cancer. The patient states, “My doctor and I talked about Tamoxifen to help prevent breast cancer. Do you think it will work?” What would be the nurse's best response? You Selected: • “Tamoxifen is known to be a highly effective protective measure.” Correct response: • “Tamoxifen is known to be a highly effective protective measure.” Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1704. Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1704 Question 13 See full question A nurse is examining a patient who has been diagnosed with a fbroadenoma. The nurse should recognize what implication of this patient's diagnosis? You Selected: • The patient might be referred for a biopsy. Correct response: • The patient might be referred for a biopsy. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1480. Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1480 Question 14 See full question A patient has had a total mastectomy with immediate reconstruction. The patient asks the nurse when she can take a shower. What should the nurse respond? You Selected: • “Not until the drain is removed” Correct response: • “Not until the drain is removed”Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1699. Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1699 Question 15 See full question A 52-year-old woman has just been told she has breast cancer and is scheduled for a modifed mastectomy the following week. The nurse caring for this patient knows that she is anxious and fearful about the upcoming procedure and the newly diagnosed malignancy. How can the nurse most likely alleviate this patient's fears? You Selected: • Provide the patient with relevant information about expected recovery. Correct response: • Provide the patient with relevant information about expected recovery. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1697. Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1697 Question 16 See full question A client with breast cancer is scheduled to undergo chemotherapy with aromatase inhibitors. Which of the following best reflects the rationale for using this group of drugs? You Selected: • They lower the level of estrogen in the body blocking the tumor's ability to use it. Correct response: • They lower the level of estrogen in the body blocking the tumor's ability to use it. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1704. Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1704 Question 17 See full question For which of the following population groups would an annual clinical breast examination be recommended? You Selected: • Women over age 40 Correct response: • Women over age 40 Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1682. Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1682 Question 18 See full question A public health nurse is teaching a health class for the male students at the local high school. The nurse is teaching the boys to perform monthly testicular self-examinations. What point would be appropriate to emphasize?You Selected: • Testicular cancer is a highly curable type of cancer. Correct response: • Testicular cancer is a highly curable type of cancer. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1741. Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1741 Question 19 See full question An uncircumcised 78-year-old male has presented at the clinic complaining that he cannot retract his foreskin over his glans. On examination, it is noted that the foreskin is very constricted. The nurse should recognize the presence of what health problem? You Selected: • Phimosis Correct response: • Phimosis Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1745. Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1745 Question 20 See full question An adolescent is identifed as having a collection of fluid in the tunica vaginalis of his testes. The nurse knows that this adolescent will receive what medical diagnosis? You Selected: • Hydrocele Correct response: • Hydrocele Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1744. Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1744 Question 21 See full question A nurse is assessing a patient who presented to the ED with priapism. The student nurse is aware that this condition is classifed as a urologic emergency because of the potential for what? You Selected: • Permanent vascular damage Correct response: • Permanent vascular damage Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-SurgicalNursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1746. Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1746 Question 22 See full question A nurse is performing an admission assessment on a 40-year-old man who has been admitted for outpatient surgery on his right knee. While taking the patient's family history, he states, “My father died of prostate cancer at age 48.” The nurse should instruct him on which of the following health promotion activities? You Selected: • The patient should have PSA levels drawn regularly. Correct response: • The patient should have PSA levels drawn regularly. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1717. Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1717 Question 23 See full question A patient is 24 hours postoperative following prostatectomy and the urologist has ordered continuous bladder irrigation. What color of output should the nurse expect to fnd in the drainage bag? You Selected: • Light pink Correct response: • Light pink Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1737. Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1737 Question 24 See full question A patient who is postoperative day 12 and recovering at home following a laparoscopic prostatectomy has reported that he is experiencing occasional “dribbling” of urine. How should the nurse best respond to this patient's concern? You Selected: • Inform the patient that urinary control is likely to return gradually. Correct response: • Inform the patient that urinary control is likely to return gradually. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1738. Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1738 Question 25 See full questionA 22-year-old male is being discharged home after surgery for testicular cancer. The patient is scheduled to begin chemotherapy in 2 weeks. The patient tells the nurse that he doesn't think he can take weeks or months of chemotherapy, stating that he has researched the adverse effects online. What is the most appropriate nursing action for this patient at this time? You Selected: • Provide empathy and encouragement in an effort to foster a positive outlook. Correct response: • Provide empathy and encouragement in an effort to foster a positive outlook. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1743. Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1743 Question 26 See full question A group of nurses have attended an inservice on the prevention of occupationally acquired diseases that affect healthcare providers. What action has the greatest potential to reduce a nurse's risk of acquiring hepatitis C in the workplace? You Selected: • Disposing of sharps appropriately and not recapping needles Correct response: • Disposing of sharps appropriately and not recapping needles Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1364. Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1364 Question 27 See full question A patient has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The patient's current medication regimen includes lactulose (Cephulac) four times daily. What desired outcome should the nurse relate to this pharmacologic intervention? You Selected: • Two to 3 soft bowel movements daily Correct response: • Two to 3 soft bowel movements daily Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1356. Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1356 Question 28 See full question A nurse is caring for a patient with a blocked bile duct from a tumor. What manifestation of obstructive jaundice should the nurse anticipate? You Selected: • Orange and foamy urine Correct response:• Orange and foamy urine Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1344. Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1344 Question 29 See full question A nurse educator is teaching a group of recent nursing graduates about their occupational risks for contracting hepatitis B. What preventative measures should the educator promote? Select all that apply. You Selected: • Immunization • Use of standard precautions Correct response: • Immunization • Use of standard precautions Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1362. Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1362 Question 30 See full question A participant in a health fair has asked the nurse about the role of drugs in liver disease. What health promotion teaching has the most potential to prevent drug-induced hepatitis? You Selected: • Adhere to dosing recommendations of OTC analgesics. Correct response: • Adhere to dosing recommendations of OTC analgesics. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1365. Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1365 Question 31 See full question A nurse is performing an admission assessment of a patient with a diagnosis of cirrhosis. What technique should the nurse use to palpate the patient's liver? You Selected: • Place hand under right lower rib cage and press down lightly with the other hand. Correct response: • Place hand under right lower rib cage and press down lightly with the other hand. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1340. Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1340 Question 32 See full questionA nurse is performing an admission assessment for an 81-year-old patient who generally enjoys good health. When considering normal, age-related changes to hepatic function, the nurse should anticipate what fnding? You Selected: • A slightly decreased size of the liver Correct response: • A slightly decreased size of the liver Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1338. Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1338 Question 33 See full question A patient with a history of injection drug use has been diagnosed with hepatitis C. When collaborating with the care team to plan this patient's treatment, the nurse should anticipate what intervention? You Selected: • A regimen of antiviral medications Correct response: • A regimen of antiviral medications Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1364. Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1364 Question 34 See full question A previously healthy adult's sudden and precipitous decline in health has been attributed to fulminant hepatic failure, and the patient has been admitted to the intensive care unit. The nurse should be aware that the treatment of choice for this patient is what? You Selected: • Liver transplantation Correct response: • Liver transplantation Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1366. Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1366 Question 35 See full question A patient with ongoing back pain, nausea, and abdominal bloating has been diagnosed with cholecystitis secondary to gallstones. The nurse should anticipate that the patient will undergo what intervention? You Selected: • Laparoscopic cholecystectomy Correct response: • Laparoscopic cholecystectomy Explanation: Reference:[ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1396. Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1396 Question 36 See full question A patient's abdominal ultrasound indicates cholelithiasis. When the nurse is reviewing the patient's laboratory studies, what fnding is most closely associated with this diagnosis? You Selected: • Increased bilirubin Correct response: • Increased bilirubin Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1389. Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1389 Question 37 See full question The critical care nurse is monitoring the patient's urine output and drains following renal surgery. What should the nurse promptly report to the physician? You Selected: • Absence of drain output Correct response: • Absence of drain output Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1565. Chapter 54: Management of Patients With Kidney Disorders - Page 1565 Question 38 See full question The nurse is assessing a patient suspected of having developed acute glomerulonephritis. The nurse should expect to address what clinical manifestation that is characteristic of this health problem? You Selected: • Hematuria Correct response: • Hematuria Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1527. Chapter 54: Management of Patients With Kidney Disorders - Page 1527 Question 39 See full question The nurse is caring for acutely ill patient. What assessment fnding should prompt the nurse to inform the physician that the patient may be exhibiting signs of acute kidney injury (AKI)? You Selected: • The patient's average urine output has been 10 mL/hr for several hours.Correct response: • The patient's average urine output has been 10 mL/hr for several hours. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1537. Chapter 54: Management of Patients With Kidney Disorders - Page 1537 Question 40 See full question The nurse is caring for a patient postoperative day 4 following a kidney transplant. When assessing for potential signs and symptoms of rejection, what assessment should the nurse prioritize? You Selected: • Assessment of the quantity of the patient's urine output Correct response: • Assessment of the quantity of the patient's urine output Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1569. Chapter 54: Management of Patients With Kidney Disorders - Page 1569 Question 41 See full question The nurse is providing a health education workshop to a group of adults focusing on cancer prevention. The nurse should emphasize what action in order to reduce participants' risks of renal carcinoma? You Selected: • Smoking cessation Correct response: • Smoking cessation Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1534. Chapter 54: Management of Patients With Kidney Disorders - Page 1534 Question 42 See full question The nurse is caring for a patient with a history of systemic lupus erythematosus who has been recently diagnosed with end-stage kidney disease (ESKD). The patient has an elevated phosphorus level and has been prescribed calcium acetate to bind the phosphorus. The nurse should teach the patient to take the prescribed phosphorusbinding medication at what time? You Selected: • With each meal Correct response: • With each meal Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1542. Chapter 54: Management ofPatients With Kidney Disorders - Page 1542 Question 43 See full question A patient is brought to the renal unit from the PACU status post resection of a renal tumor. Which of the following nursing actions should the nurse prioritize in the care of this patient? You Selected: • Managing postoperative pain Correct response: • Managing postoperative pain Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1535. Chapter 54: Management of Patients With Kidney Disorders - Page 1535 Question 44 See full question The nurse is caring for a patient after kidney surgery. The nurse is aware that bleeding is a major complication of kidney surgery and that if it goes undetected and untreated can result in hypovolemia and hemorrhagic shock in the patient. When assessing for bleeding, what assessment parameter should the nurse evaluate? You Selected: • Level of consciousness Correct response: • Level of consciousness Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1565. Chapter 54: Management of Patients With Kidney Disorders - Page 1565 Question 45 See full question A patient has a glomerular fltration rate (GFR) of 43 mL/min/1.73 m2. Based on this GFR, the nurse interprets that the patient's chronic kidney disease is at what stage? You Selected: • Stage 3 Correct response: • Stage 3 Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1528. Chapter 54: Management of Patients With Kidney Disorders - Page 1528 Question 46 See full question The nurse who is leading a wellness workshop has been asked about actions to reduce the risk of bladder cancer. What health promotion action most directly addresses a major risk factor for bladder cancer? You Selected: • Smoking cessation Correct response: • Smoking cessationExplanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1597. Chapter 55: Management of Patients With Urinary Disorders - Page 1597 Question 47 See full question A patient being treated in the hospital has been experiencing occasional urinary retention. What nursing action should the nurse take to encourage a patient who is having difculty voiding? You Selected: • Provide privacy for the patient. Correct response: • Provide privacy for the patient. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1586. Chapter 55: Management of Patients With Urinary Disorders - Page 1586 Question 48 See full question A patient has undergone the creation of an Indiana pouch for the treatment of bladder cancer. The nurse identifed the nursing diagnosis of “disturbed body image.” How can the nurse best address the effects of this urinary diversion on the patient's body image? You Selected: • Encourage the patient to speak openly and frankly about the diversion. Correct response: • Encourage the patient to speak openly and frankly about the diversion. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1605. Chapter 55: Management of Patients With Urinary Disorders - Page 1605 Question 49 See full question A female patient has been experiencing recurrent urinary tract infections. What health education should the nurse provide to this patient? You Selected: • Drink liberal amounts of fluids. Correct response: • Drink liberal amounts of fluids. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1579. Chapter 55: Management of Patients With Urinary Disorders - Page 1579 Question 50 See full question The nurse is caring for a patient who underwent percutaneous lithotripsy earlier in the day. What instruction should the nurse give the patient? You Selected:• Notify the physician about cloudy or foul-smelling urine. Correct response: • Notify the physician about cloudy or foul-smelling urine. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1595. Chapter 55: Management of Patients With Urinary Disorders - Page 1595 Question 51 See full question The nurse is working with a patient who has been experiencing episodes of urinary retention. What assessment fnding would suggest that the patient is experiencing retention? You Selected: • The patient's suprapubic region is dull on percussion. Correct response: • The patient's suprapubic region is dull on percussion. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1586. Chapter 55: Management of Patients With Urinary Disorders - Page 1586 Question 52 See full question A 31-year-old patient has returned to the post-surgical unit following a hysterectomy. The patient's care plan addresses the risk of hemorrhage. How should the nurse best monitor the patient's postoperative blood loss? You Selected: • Count and inspect each perineal pad that the patient uses. Correct response: • Count and inspect each perineal pad that the patient uses. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1676. Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1676 Question 53 See full question A 27-year-old female patient is diagnosed with invasive cervical cancer and is told she needs to have a hysterectomy. One of the nursing diagnoses for this patient is “disturbed body image related to perception of femininity.” What intervention would be most appropriate for this patient? You Selected: • Reassure the patient that she will still be able to have intercourse with sexual satisfaction and orgasm. Correct response: • Reassure the patient that she will still be able to have intercourse with sexual satisfaction and orgasm. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-SurgicalNursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1675. Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1675 Question 54 See full question A middle-aged female patient has been offered testing for HIV/AIDS upon admission to the hospital for an unrelated health problem. The nurse observes that the patient is visibly surprised and embarrassed by this offer. How should the nurse best respond? You Selected: • “This testing is offered to every adolescent and adult regardless of their lifestyle, appearance or history.” Correct response: • “This testing is offered to every adolescent and adult regardless of their lifestyle, appearance or history.” Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1657. Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1657 Question 55 See full question A female patient with HIV has just been diagnosed with condylomata acuminata (genital warts). What information is most appropriate for the nurse to tell this patient? You Selected: • This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) test annually. Correct response: • This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) test annually. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1657. Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1657 Question 56 See full question A patient is being discharged home after a hysterectomy. When providing discharge education for this patient, the nurse has cautioned the patient against sitting for long periods. This advice addresses the patient's risk of what surgical complication? You Selected: • Venous thromboembolism Correct response: • Venous thromboembolism Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1676. Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1676 Question 57 See full question A woman scheduled for a simple mastectomy in one week is having her preoperative education provided by the clinic nurse. What educational intervention will be of primaryimportance to prevent hemorrhage in the postoperative period? You Selected: • Stop taking aspirin. Correct response: • Stop taking aspirin. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1689. Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1689 Question 58 See full question A patient in her 30s has two young children and has just had a modifed radical mastectomy with immediate reconstruction. The patient shares with the nurse that she is somewhat worried about her future, but she appears to be adjusting well to her diagnosis and surgery. What nursing intervention is most appropriate to support this patient's coping? You Selected: • Arrange a referral to a community-based support program. Correct response: • Arrange a referral to a community-based support program. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1697. Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1697 Question 59 See full question The nurse is teaching breast self-examination (BSE) to a group of women. The nurse should recommend that the women perform BSE at what time? You Selected: • Between days 5 and 7 after menses Correct response: • Between days 5 and 7 after menses Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1684. Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1684 Question 60 See full question The nurse is caring for a patient who has just had a radical mastectomy and axillary node dissection. When providing patient education regarding rehabilitation, what should the nurse recommend? You Selected: • Avoid lifting objects heavier than 10 pounds. Correct response: • Avoid lifting objects heavier than 10 pounds. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-SurgicalNursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1699. Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1699 Question 61 See full question A patient has been referred to the breast clinic after her most recent mammogram revealed the presence of a lump. The lump is found to be a small, well-defned nodule in the right breast. The oncology nurse should recognize the likelihood of what treatment? You Selected: • Lumpectomy and radiation Correct response: • Lumpectomy and radiation Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1695. Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1695 Question 62 See full question A patient has experienced occasional urinary incontinence in the weeks since his prostatectomy. In order to promote continence, the nurse should encourage which of the following? You Selected: • Pelvic floor exercises Correct response: • Pelvic floor exercises Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1738. Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1738 Question 63 See full question A nurse is providing care for a patient who has recently been admitted to the postsurgical unit from PACU following a transuretheral resection of the prostate. The nurse is aware of the nursing diagnosis of Risk for Imbalanced Fluid Volume. In order to assess for this risk, the nurse should prioritize what action? You Selected: • Closely monitoring the input and output of the bladder irrigation system Correct response: • Closely monitoring the input and output of the bladder irrigation system Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1736. Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1736 Question 64 See full question A 29-year-old patient has just been told that he has testicular cancer and needs to have surgery. During a presurgical appointment, the patient admits to feeling devastated thathe requires surgery, stating that it will leave him “emasculated” and “a shell of a man.” The nurse should identify what nursing diagnosis when planning the patient's subsequent care? You Selected: • Disturbed Body Image Related to Effects of Surgery Correct response: • Disturbed Body Image Related to Effects of Surgery Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1743. Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1743 Question 65 See full question A man comes to the clinic complaining that he is having difculty obtaining an erection. When reviewing the patient's history, what might the nurse note that contributes to erectile dysfunction? You Selected: • The patient has a history of hypertension. Correct response: • The patient has a history of hypertension. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1717. Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1717 Question 66 See full question The nurse is preparing a discharge teaching plan for a client who has had a prostatectomy. Which of the following would be appropriate to include? You Selected: • Performing perineal exercises frequently throughout the day Correct response: • Performing perineal exercises frequently throughout the day Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1739. Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1739 Question 67 See full question The nurse is preparing a presentation for a men's community group about health promotion. Which of the following would the nurse include as a current recommendation for screening? You Selected: • Annual prostate-specifc antigen (PSA) testing after age 40 years Correct response: • Monthly testicular self-examination (TSE)Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1742. Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1742 Question 68 See full question The nurse is caring for a patient receiving hemodialysis three times weekly. The patient has had surgery to form an arteriovenous fstula. What is most important for the nurse to be aware of when providing care for this patient? You Selected: • Taking a BP reading on the affected arm can damage the fstula. Correct response: • Taking a BP reading on the affected arm can damage the fstula. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1560. Chapter 54: Management of Patients With Kidney Disorders - Page 1560 Question 69 See full question A 45-year-old man with diabetic nephropathy has ESKD and is starting dialysis. “What should the nurse teach the patient about hemodialysis? You Selected: • “Hemodialysis is a treatment option that is usually required three times a week.” Correct response: • “Hemodialysis is a treatment option that is usually required three times a week.” Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1548. Chapter 54: Management of Patients With Kidney Disorders - Page 1548 Question 70 See full question A patient with chronic kidney disease has been hospitalized and is receiving hemodialysis on a scheduled basis. The nurse should include which of the following actions in the plan of care? You Selected: • Ensure that the patient moves the extremity with the vascular access site as little as possible. Correct response: • Assess for a thrill or bruit over the vascular access site each shift. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1560. Chapter 54: Management of Patients With Kidney Disorders - Page 1560 Question 71 See full question The nurse is caring for a patient in acute kidney injury. Which of the followingcomplications would most clearly warrant the administration of polystyrene sulfonate (Kayexalate)? You Selected: • Hyperkalemia Correct response: • Hyperkalemia Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1539. Chapter 54: Management of Patients With Kidney Disorders - Page 1539 Question 72 See full question A 42-year-old woman comes to the clinic complaining of occasional urinary incontinence when she sneezes. The clinic nurse should recognize what type of incontinence? You Selected: • Stress incontinence Correct response: • Stress incontinence Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1582. Chapter 55: Management of Patients With Urinary Disorders - Page 1582 Question 73 See full question The nurse is caring for a patient who has undergone creation of a urinary diversion. Forty-eight hours postoperatively, the nurse's assessment reveals that the stoma is a dark purplish color. What is the nurse's most appropriate response? You Selected: • Inform the primary care provider that the vascular supply may be compromised. Correct response: • Inform the primary care provider that the vascular supply may be compromised. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1600. Chapter 55: Management of Patients With Urinary Disorders - Page 1600 Question 74 See full question A patient with kidney stones is scheduled for extracorporeal shock wave lithotripsy (ESWL). What should the nurse include in the patient's post-procedure care? You Selected: • Strain the patient's urine following the procedure. Correct response: • Strain the patient's urine following the procedure. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1593. Chapter 55: Management ofPatients With Urinary Disorders - Page 1593 Question 75 See full question A patient with cancer of the bladder has just returned to the unit from the PACU after surgery to create an ileal conduit. The nurse is monitoring the patient's urine output hourly and notifes the physician when the hourly output is less than what? You Selected: • 30 mL Correct response: • 30 mL ^^^**********END OF CONTENT FOR EXAM 3**********^^^ **********START OF NEW CONTENT – NOT TESTED ON YET********** MedSurg Quiz 7 – 63 64 Question 1 See full question A patient is being discharged home from the ambulatory surgical center after cataract surgery. In reviewing the discharge instructions with the patient, the nurse instructs the patient to immediately call the ofce if the patient experiences what? You Selected: • A new floater in vision Correct response: • A new floater in vision Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1860. Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1860 Question 2 See full question A nurse is teaching a patient with glaucoma how to administer eye drops to achieve maximum absorption. The nurse should teach the patient to perform what action? You Selected: • Instill the medication in the conjunctival sac. Correct response: • Instill the medication in the conjunctival sac. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1853. Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1853 Question 3 See full question A patient got a sliver of glass in his eye when a glass container at work fell and shattered. The glass had to be surgically removed and the patient is about to be discharged home. The patient asks the nurse for a topical anesthetic for the pain in his eye. What should the nurse respond? You Selected: • “Overuse of these drops could soften your cornea and damage your eye.”Correct response: • “Overuse of these drops could soften your cornea and damage your eye.” Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1850. Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1850 Question 4 See full question A 56-year-old patient has come to the clinic for a routine eye examination and informed bifocals will be prescribed. The patient asks the nurse what eyes changes has caused a need for bifocals. How should the nurse respond? You Selected: • “There is a gradual thickening of the lens of the eye and it can limit the eye's ability for accommodation.” Correct response: • “There is a gradual thickening of the lens of the eye and it can limit the eye's ability for accommodation.” Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1847. Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1847 Question 5 See full question A patient who presents for an eye examination is diagnosed as having a visual acuity of 20/40. The patient asks the nurse what these numbers specifcally mean. What is a correct response by the nurse? You Selected: • “A person whose vision is 20/40 can see an object from 20 feet away that a person with 20/20 vision can see from 40 feet away.” Correct response: • “A person whose vision is 20/40 can see an object from 20 feet away that a person with 20/20 vision can see from 40 feet away.” Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1842. Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1842 Question 6 See full question A patient with chronic open-angle glaucoma is being taught to self-administer pilocarpine. After the patient administers the pilocarpine, the patient states that her vision is blurred. Which nursing action is most appropriate? You Selected: • Explaining that this is an expected adverse effect Correct response: • Explaining that this is an expected adverse effectExplanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1856. Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1856 Question 7 See full question A patient has just returned to the surgical floor after undergoing a retinal detachment repair. The postoperative orders specify that the patient should be kept in a prone position until otherwise ordered. What should the nurse do? You Selected: • Follow the order because this position will help keep the retinal repair intact. Correct response: • Follow the order because this position will help keep the retinal repair intact. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1865. Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1865 Question 8 See full question When administering a patient's eye drops, the nurse recognizes the need to prevent absorption by the nasolacrimal duct. How can the nurse best achieve this goal? You Selected: • Occlude the puncta after applying the medication. Correct response: • Occlude the puncta after applying the medication. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1852. Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1852 Question 9 See full question During a routine eye examination, a patient complains that she is unable to read road signs at a distance when driving her car. What should the patient be assessed for? You Selected: • Myopia Correct response: • Myopia Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1846. Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1846 Question 10 See full questionA patient visits a clinic for an eye examination. He describes his visual changes and mentions a specifc diagnostic clinical sign of glaucoma. What is that clinical sign? You Selected: • The presence of halos around lights Correct response: • The presence of halos around lights Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1854. Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1854 Question 11 See full question The nurse is providing care to a client who has been admitted to the hospital for treatment of an infection. The client is visually impaired. Which of the following would be most appropriate for the nurse to do when interacting with the client? You Selected: • Face the client when speaking directly to him. Correct response: • Face the client when speaking directly to him. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1849. Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1849 Question 12 See full question The nurse is admitting a 55-year-old patient diagnosed with a left eye retinal detachment . While assessing this patient, what characteristic symptom would the nurse expect to fnd? You Selected: • Flashing lights in the visual feld Correct response: • Flashing lights in the visual feld Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1863. Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1863 Question 13 See full question The registered nurse taking shift report learns that an assigned patient is blind. How should the nurse best communicate with this patient? You Selected: • State her name and role immediately after entering the patient's room. Correct response: • State her name and role immediately after entering the patient's room. Explanation:Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1849. Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1849 Question 14 See full question Which symptoms may a client with Ménière disease report before an attack? You Selected: • Nystagmus Correct response: • A full feeling in the ear Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1897. Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1897 Question 15 See full question The advanced practice nurse is attempting to examine the patient's ear with an otoscope. Because of impacted cerumen, the tympanic membrane cannot be visualized. The nurse irrigates the patient's ear with a solution of hydrogen peroxide and water to remove the impacted cerumen. What nursing intervention is most important to minimize nausea and vertigo during the procedure? You Selected: • Maintain the irrigation fluid at a warm temperature. Correct response: • Maintain the irrigation fluid at a warm temperature. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1883. Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1883 Question 16 See full question A client complains of vertigo. The nurse anticipates that the client may have a problem with which portion of the ear? You Selected: • Tympanic membrane Correct response: • Inner ear Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1897. Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1897 Question 17 See full questionA patient has been diagnosed with hearing loss related to damage of the end organ for hearing or cranial nerve VIII. What term is used to describe this condition? You Selected: • Sensorineural hearing loss Correct response: • Sensorineural hearing loss Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1887. Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1887 Question 18 See full question A client comes to the emergency department, reporting that a bee has flown into his ear and is stuck. The client reports a signifcant amount of pain. Which of the following would be most appropriate to use to remove the bee? You Selected: • Mineral oil Correct response: • Mineral oil Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1890. Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1890 Question 19 See full question After mastoid surgery, an 81-year-old patient has been identifed as needing assistance in her home. What would be a primary focus of this patient's home care? You Selected: • Assisting the patient with ambulation as needed to avoid falling Correct response: • Assisting the patient with ambulation as needed to avoid falling Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1895. Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1895 Question 20 See full question A patient diagnosed with arthritis has been taking aspirin and now reports experiencing tinnitus and hearing loss. What should the nurse teach this patient? You Selected: • The hearing loss will likely resolve with time after the drug is discontinued. Correct response: • The hearing loss will likely resolve with time after the drug is discontinued. Explanation: Reference:[ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1901. Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1901 Question 21 See full question When discussing diseases of the middle ear, the nursing instructor distinguishes the different types of otitis media. What generally causes purulent otitis media? You Selected: • Upper respiratory infections Correct response: • Upper respiratory infections Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1892. Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1892 Question 22 See full question The nurse on a cruise ship is assessing clients for motion sickness. Which of the following is a common misconception? You Selected: • Once symptoms occur, they will always be present. Correct response: • Once symptoms occur, they will always be present. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1897. Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1897 Question 23 See full question Which of the following nursing interventions would most likely facilitate effective communication with a hearing-impaired patient? You Selected: • Reduce environmental noise and distractions before communicating. Correct response: • Reduce environmental noise and distractions before communicating. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1890. Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1890 Question 24 See full question The nurse is discharging a patient home after mastoid surgery. What should the nurse include in discharge teaching? You Selected:• “Don't blow your nose for 2 to 3 weeks.” Correct response: • “Don't blow your nose for 2 to 3 weeks.” Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1895. Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1895 Question 25 See full question The clinic nurse is assessing a child who has been brought to the clinic with signs and symptoms that are suggestive of otitis externa. What assessment fnding is characteristic of otitis externa? You Selected: • Pain on manipulation of the auricle Correct response: • Pain on manipulation of the auricle MedSurg Quiz 8 (online) - 17 18 19 Question 1 See full question The nurse is caring for a patient in the postoperative period following an abdominal hysterectomy. The patient states, “I don't want to use my pain meds because they'll make me dependent and I won't get better as fast.” Which response is most important when explaining the use of pain medication? You Selected: • “You will move more easily and heal more quickly with decreased pain. Dependence only occurs when it is administered for an extended period of time.” Correct response: • “You will move more easily and heal more quickly with decreased pain. Dependence only occurs when it is administered for an extended period of time.” Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 17: Preoperative Nursing Management, p. 415. Chapter 17: Preoperative Nursing Management - Page 415 Question 2 See full question One of the things a nurse has taught to a patient during preoperative teaching is to have nothing by mouth for the specifed time before surgery. The patient asks the nurse why this is important. What is the most appropriate response for the patient? You Selected: • “You will need to have food and fluid restricted before surgery so you are not at risk for choking.” Correct response: • “You will need to have food and fluid restricted before surgery so you are not at risk for choking.” Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 17:Preoperative Nursing Management, p. 416. Chapter 17: Preoperative Nursing Management - Page 416 Question 3 See full question A clinic nurse is conducting a preoperative interview with an adult patient who will soon be scheduled to undergo cardiac surgery. What interview question most directly addresses the patient's safety? You Selected: • “What prescription and nonprescription medications do you currently take?” Correct response: • “What prescription and nonprescription medications do you currently take?” Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 17: Preoperative Nursing Management, p. 407. Chapter 17: Preoperative Nursing Management - Page 407 Question 4 See full question The nurse is caring for a hospice patient who is scheduled for a surgical procedure to reduce the size of his spinal tumor in an effort to relieve his pain. The nurse should plan this patient care with the knowledge that his surgical procedure is classifed as which of the following? You Selected: • Palliative Correct response: • Palliative Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 17: Preoperative Nursing Management, p. 403. Chapter 17: Preoperative Nursing Management - Page 403 Question 5 See full question A patient is admitted to the ED complaining of severe abdominal pain, stating that he has been vomiting “coffee-ground” like emesis. The patient is diagnosed with a perforated gastric ulcer and is informed that he needs surgery. When can the patient most likely anticipate that the surgery will be scheduled? You Selected: • Without delay because the bleed is emergent Correct response: • Without delay because the bleed is emergent Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 17: Preoperative Nursing Management, p. 406. Chapter 17: Preoperative Nursing Management - Page 406 Question 6 See full question During the care of a preoperative patient, the nurse has given the patient a preoperative benzodiazepine. The patient is now requesting to void. What action should the nurse take? You Selected:• Offer the patient a bedpan or urinal. Correct response: • Offer the patient a bedpan or urinal. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 17: Preoperative Nursing Management, p. 417. Chapter 17: Preoperative Nursing Management - Page 417 Question 7 See full question The nurse is creating the care plan for a 70-year-old obese patient who has been admitted to the postsurgical unit following a colon resection. This patient's age and increased body mass index mean that she is at increased risk for what complication in the postoperative period? You Selected: • Infection Correct response: • Infection Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 17: Preoperative Nursing Management, p. 405. Chapter 17: Preoperative Nursing Management - Page 405 Question 8 See full question The ED nurse is caring for an 11-year-old brought in by ambulance after having been hit by a car. The child's parents are thought to be en route to the hospital but have not yet arrived. No other family members are present and attempts to contact the parents have been unsuccessful. The child needs emergency surgery to save her life. How should the need for informed consent be addressed? You Selected: • Surgery should be done without informed consent. Correct response: • Surgery should be done without informed consent. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 17: Preoperative Nursing Management, p. 406. Chapter 17: Preoperative Nursing Management - Page 406 Question 9 See full question A circulating nurse provides care in a surgical department that has multiple surgeries scheduled for the day. The nurse should know to monitor which patient most closely during the intraoperative period because of the increased risk for hypothermia? You Selected: • A 74-year-old woman with a low body mass index Correct response: • A 74-year-old woman with a low body mass index Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-SurgicalNursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 18: Intraoperative Nursing Management, p. 421. Chapter 18: Intraoperative Nursing Management - Page 421 Question 10 See full question The anesthetist is coming to the surgical admissions unit to see a patient prior to surgery scheduled for tomorrow morning. Which of the following is the priority information that the nurse should provide to the anesthetist during the visit? You Selected: • Latex allergy Correct response: • Latex allergy Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 18: Intraoperative Nursing Management, p. 434. Chapter 18: Intraoperative Nursing Management - Page 434 Question 11 See full question The OR nurse is taking the patient into the OR when the patient informs the operating nurse that his grandmother spiked a 104°F temperature in the OR and nearly died 15 years ago. What relevance does this information have regarding the patient? You Selected: • The patient may be at risk for malignant hyperthermia. Correct response: • The patient may be at risk for malignant hyperthermia. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 18: Intraoperative Nursing Management, p. 435. Chapter 18: Intraoperative Nursing Management - Page 435 Question 12 See full question You are caring for a male patient who has had spinal anesthesia. The patient is under a physician's order to lie flat postoperatively. When the patient asks to go to the bathroom, you encourage him to adhere to the physician's order. What rationale for complying with this order should the nurse explain to the patient? You Selected: • Preventing the onset of a headache Correct response: • Preventing the onset of a headache Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 18: Intraoperative Nursing Management, p. 429. Chapter 18: Intraoperative Nursing Management - Page 429 Question 13 See full question A 68-year-old patient is scheduled for a bilateral mastectomy. The OR nurse has come out to the holding area to meet the patient and quickly realizes that the patient is profoundly anxious. What is the most appropriate intervention for the nurse to apply? You Selected:• Clearly explain any information that the patient seeks. Correct response: • Clearly explain any information that the patient seeks. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 18: Intraoperative Nursing Management, p. 436. Chapter 18: Intraoperative Nursing Management - Page 436 Question 14 See full question A patient who underwent a bowel resection to correct diverticula suffered irreparable nerve damage. During the case review, the team is determining if incorrect positioning may have contributed to the patient's nerve damage. What surgical position places the patient at highest risk for nerve damage? You Selected: • Trendelenburg Correct response: • Trendelenburg Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 18: Intraoperative Nursing Management, p. 436. Chapter 18: Intraoperative Nursing Management - Page 436 Question 15 See full question A 59-year-old male patient is scheduled for a hemorrhoidectomy. The OR nurse should anticipate assisting the other team members with positioning the patient in what manner? You Selected: • Lithotomy position Correct response: • Lithotomy position Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 18: Intraoperative Nursing Management, p. 436. Chapter 18: Intraoperative Nursing Management - Page 436 Question 16 See full question As an intraoperative nurse, you are the advocate for each of the patients who receives care in the surgical setting. How can you best exemplify the principles of patient advocacy? You Selected: • By maintaining each of your patients' privacy Correct response: • By maintaining each of your patients' privacy Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 18: Intraoperative Nursing Management, p. 437. Chapter 18: Intraoperative NursingManagement - Page 437 Question 17 See full question The recovery room nurse is admitting a patient from the OR following the patient's successful splenectomy. What is the frst assessment that the nurse should perform on this newly admitted patient? You Selected: • Airway patency Correct response: • Airway patency Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 19: Postoperative Nursing Management, p. 441. Chapter 19: Postoperative Nursing Management - Page 441 Question 18 See full question The nurse is caring for a 79-year-old man who has returned to the postsurgical unit following abdominal surgery. The patient is unable to ambulate and is now refusing to wear an external pneumatic compression stocking. The nurse should explain that refusing to wear external pneumatic compression stockings increases his risk of what postsurgical complication? You Selected: • Pulmonary embolism Correct response: • Pulmonary embolism Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 19: Postoperative Nursing Management, p. 456. Chapter 19: Postoperative Nursing Management - Page 456 Question 19 See full question The nurse admits a patient to the PACU with a blood pressure of 132/90 mm Hg and a pulse of 68 beats per minute. After 30 minutes, the patient's blood pressure is 94/47 mm Hg, and the pulse is 110. The nurse documents that the patient's skin is cold, moist, and pale. Of what is the patient showing signs? You Selected: • Hypovolemic shock Correct response: • Hypovolemic shock Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 19: Postoperative Nursing Management, p. 442. Chapter 19: Postoperative Nursing Management - Page 442 Question 20 See full question The nurse is caring for a patient on the medical–surgical unit postoperative day 5. During each patient assessment, the nurse evaluates the patient for infection. Which of the following would be most indicative of infection? You Selected:• Red, warm, tender incision Correct response: • Red, warm, tender incision Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 19: Postoperative Nursing Management, p. 457. Chapter 19: Postoperative Nursing Management - Page 457 Question 21 See full question A surgical patient has just been admitted to the unit from PACU with patient-controlled analgesia (PCA). The nurse should know that the requirements for safe and effective use of PCA include what? You Selected: • A clear understanding of the need to self-dose Correct response: • A clear understanding of the need to self-dose Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 19: Postoperative Nursing Management, p. 449. Chapter 19: Postoperative Nursing Management - Page 449 Question 22 See full question A patient is 2 hours postoperative with a Foley catheter in situ. The last hourly urine output recorded for this patient was 10 mL. The tubing of the Foley is patent. What should the nurse do? You Selected: • Notify the physician and continue to monitor the hourly urine output closely. Correct response: • Notify the physician and continue to monitor the hourly urine output closely. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 19: Postoperative Nursing Management, p. 450. Chapter 19: Postoperative Nursing Management - Page 450 Question 23 See full question An adult patient is in the recovery room following a nephrectomy performed for the treatment of renal cell carcinoma. The patient's vital signs and level of consciousness stabilized, but the patient then complains of severe nausea and begins to retch. What should the nurse do next? You Selected: • Turn the patient completely to one side. Correct response: • Turn the patient completely to one side. Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 19: Postoperative Nursing Management, p. 441. Chapter 19: Postoperative NursingManagement - Page 441 Question 24 See full question The nurse is caring for an 88-year-old patient who is recovering from an ileac-femoral bypass graft. The patient is day 2 postoperative and has been mentally intact, as per baseline. When the nurse assesses the patient, it is clear that he is confused and has been experiencing disturbed sleep patterns and impaired psychomotor skills. What should the nurse suspect is the problem with the patient? You Selected: • Postoperative delirium Correct response: • Postoperative delirium Explanation: Reference: [ Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 19: Postoperative Nursing Management, p. 444. Chapter 19: Postoperative Nursing Management - Page 444 Question 25 See full question The nurse is preparing to change a patient's abdominal dressing. The nurse recognizes the frst step is to provide the patient with information regarding the procedure. Which of the following explanations should the nurse provide to the patient? You Selected: • “During the dressing change, I will provide privacy at a time of your choosing, it should not be painful, and you can look at the incision and help with the procedure if you want to.” Correct response: • “During the dressing change, I will provide privacy at a time of your choosing, it should not be painful, and you can look at the incision and help with the procedure if you want