Medical Surgical Nursing 2nd Edition By Osborn Wraa Watson  – Test Bank

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INSTANT DOWNLOAD COMPLETE TEST BANK WITH ANSWERS

 

Medical Surgical Nursing 2nd Edition By Osborn Wraa Watson  – Test Bank

 

Sample  Questions

 

Osborn, Medical-Surgical Nursing, 2e
Chapter 06

Question 1

Type: MCSA

While conducting a health assessment, the nurse documents a patient’s response under the heading “chief complaint.” Which part of the assessment is the nurse conducting?

  1. History of present illness
  2. Family history
  3. Psychosocial history
  4. Past medical history

Correct Answer: 1

Rationale 1: The history of the present illness includes information about what brought the patient to the health care provider. The reason is usually written verbatim in the health record and often becomes the chief complaint.

Rationale 2: The patient’s chief complaint is not part of the family history.

Rationale 3: The patient’s chief complaint is not part of the psychosocial history.

Rationale 4: The patient’s chief complaint is not part of the past medical history.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-1

 

Question 2

Type: MCSA

A patient comes to the emergency department and states, “I am having chest pain and I feel short of breath.” How is the data the patient has just given the nurse classified?

  1. Nonspecific
  2. Objective
  3. Factual
  4. Subjective

Correct Answer: 4

Rationale 1: Nonspecific is not a term used to describe types of assessment data.

Rationale 2: Objective data is information collected when the nurse uses the senses: observation, palpation, auscultation, percussion, and smell.

Rationale 3: Factual is not a term used to describe types of assessment data.

Rationale 4: Subjective data is information the patient provides to the nurse.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-3

 

Question 3

Type: MCSA

The nurse has completed the collection and analysis of data from a patient assessment. What is the nurse’s next action?

  1. Evaluate outcomes from care.
  2. Plan care.
  3. Determine patient care goals.
  4. Formulate nursing diagnoses.

Correct Answer: 4

Rationale 1: Evaluation occurs after care is implemented.

Rationale 2: Planning occurs later in the nursing process.

Rationale 3: Determining patient goals is a later step of the nursing process.

Rationale 4: Once data is collected, it is used to formulate nursing diagnoses, which is the next step of the nursing process.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-2

 

Question 4

Type: MCSA

The nurse asks the patient, “What brings you to the hospital today?” What is the nurse’s rationale for using this type of question?

  1. It acknowledges agreement between the patient and the nurse.
  2. It elicits specific information.
  3. It is useful for introducing a subject in general terms.
  4. It helps to clarify information.

Correct Answer: 3

Rationale 1: The question does not acknowledge agreement between the patient and the nurse. The nurse’s summary at the end of the interview acknowledges agreement.

Rationale 2: Direct questions are used to elicit specific information.

Rationale 3: The question is an open-ended question and asks for narrative information by stating the topic in general terms. It is used to introduce a topic.

Rationale 4: The question does not help to clarify information.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-3

 

Question 5

Type: MCSA

While conducting a health history, the nurse nods her head as the patient is talking. What is the nurse’s primary rationale for this action?

  1. It conveys acknowledgment of the patient’s feelings.
  2. It helps to reduce the patient’s anxiety level.
  3. It encourages the patient to continue talking.
  4. It allows the nurse time to observe the patient’s nonverbal cues.

Correct Answer: 3

Rationale 1: Empathy is used to acknowledge the patient’s feelings.

Rationale 2: Explanation will reduce the patient’s anxiety level.

Rationale 3: Nodding the head encourages the patient to tell the nurse more and is considered facilitation.

Rationale 4: The use of silence will allow the nurse time to observe the patient’s nonverbal cues.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-3

 

Question 6

Type: MCSA

A patient tells the nurse that he has a history of back pain that is controlled with yoga and herbal supplements. How would the nurse document this information?

  1. The patient does not believe in Western medicine.
  2. The patient has strong spiritual beliefs.
  3. The patient uses some alternative forms of medicine to treat illness.
  4. The patient uses stress reduction techniques to control back pain.

Correct Answer: 3

Rationale 1: Western medicine is the type of health care traditionally provided in the United States and includes diagnostic testing, treatments, and medications. There is no indication that the patient does not believe in Western medicine.

Rationale 2: The strength of the patient’s spiritual beliefs cannot be assessed by this information alone.

Rationale 3: The use of herbal supplements to relieve back pain is a form of complementary or alternative medicine. The nurse must assess this practice, as some “natural cures” are ineffective and some can interfere with prescribed medications.

Rationale 4: There is not enough information to make this statement. The patient may use yoga as a strengthening exercise for back muscles. The herbs may not be taken for stress reduction.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 06-01

 

Question 7

Type: MCSA

The nurse introduces herself and shakes the patient’s hand, then sits so as to maintain eye contact during the health interview. What do the nurse’s actions demonstrate?

  1. Facilitation
  2. Negative nonverbal messages
  3. Positive nonverbal messages
  4. Empathy

Correct Answer: 3

Rationale 1: Facilitation would occur if the nurse nodded the head to encourage the patient to continue talking.

Rationale 2: Negative nonverbal messages include tense posture, yawning, and avoiding eye contact. The nurse’s actions are not negative.

Rationale 3: Positive nonverbal messages enhance the relationship with the patient and include eye contact and equal-status seating.

Rationale 4: Empathy is acknowledging a patient’s feelings with a statement of understanding.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-3

 

Question 8

Type: MCSA

During the health history, a patient tells the nurse that she is in an abusive relationship and is fearful of getting hurt if her husband finds out that she told the nurse. Which response by the nurse is most appropriate for this patient?

  1. “Don’t worry. They only strike back when they are angry.”
  2. “Are you saying that you are in danger?”
  3. “I would get an attorney if I were you.”
  4. “Remember, what goes around comes around.”

Correct Answer: 2

Rationale 1: This answer does not promote the patient’s health.

Rationale 2: The nurse needs to clarify what the patient is explaining, and the best response would be to clarify if the patient is saying she is in danger.

Rationale 3: The nurse should not offer legal advice to the patient.

Rationale 4: This statement dismisses the patient’s concern for her safety and does not promote her health.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6-3

 

Question 9

Type: MCSA

During an assessment, the patient describes shoulder pain. The nurse responds, “So, you have this shoulder pain when you eat fried foods or ice cream, is that correct?” The nurse is using which interview technique?

  1. Facilitation
  2. Empathy
  3. Interpretation
  4. Summary

Correct Answer: 3

Rationale 1: Facilitation is a technique that would encourage the patient to continue talking.

Rationale 2: Empathy acknowledges the patient’s feelings with a statement of understanding to help the patient feel accepted.

Rationale 3: Interpretation links events or implies a cause, which is what the nurse is doing when responding to this patient.

Rationale 4: Summary occurs at the end of the interview, when the nurse summarizes the perception of the patient’s health problem from the information gained during the interview.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-3

 

Question 10

Type: MCSA

The nurse notices a patient has a strong, foul body odor. The patient tells the nurse he has trouble getting in and out of the bathtub. Which areas of the physical assessment does this information address?

  1. Behavior and pain
  2. Nutritional assessment, mental status, and behavior
  3. Physical appearance, height, and weight
  4. Functional assessment, physical appearance, and mobility

Correct Answer: 4

Rationale 1: The patient did not say that his inability to use the bathtub was associated with pain, and the nurse should be careful not to make this assumption.

Rationale 2: An inability to use the bathtub does not speak specifically to nutrition, mental status, or behavior.

Rationale 3: The inability to use the bathtub does affect physical appearance. The patient did not mention that the tub was too small or that his weight made using it difficult, so these issues cannot currently be considered a factor. The nurse must be careful not to make assumptions without data.

Rationale 4: The patient states difficulty with using a bathtub, which provides information relevant to functional assessment, physical appearance, and mobility.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-4

 

Question 11

Type: MCSA

Prior to palpating the abdomen of a patient with several skin lesions, the nurse puts on a pair of gloves. The patient asks, “What are the gloves for?” Which is the best response the nurse can give the patient?

  1. “Gloves are considered a standard precaution to provide protection to the health care provider during an exam.”
  2. “I don’t want to catch anything from you.”
  3. “I prefer to wear gloves when touching people.”
  4. “The gloves help me to grip my equipment better.”

Correct Answer: 1

Rationale 1: The nurse needs to use standard precautions throughout the entire physical examination and should explain this to the patient. Gloves are particularly important when skin lesions are present.

Rationale 2: The nurse should not make the patient feel “dirty” or “bad” when answering this question.

Rationale 3: This should not be the reason the nurse is wearing gloves and is not an appropriate answer.

Rationale 4: This statement is not accurate.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-4

 

Question 12

Type: MCMA

While performing percussion in a physical examination, the nurse elicits dullness. Which structure is the nurse likely percussing?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Intestines
  2. Lungs
  3. Pelvic bone
  4. Liver
  5. Kidney

Correct Answer: 4,5

Rationale 1: Tympany is the percussion sound heard over air-filled intestines.

Rationale 2: Resonance is the percussion sound heard over normal lungs.

Rationale 3: Flatness is the percussion sound heard over muscle and bone.

Rationale 4: Dullness is the percussion sound heard over large, solid organs such as the liver.

Rationale 5: Dullness is the percussion sound heard over large, solid organs such as the kidney.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-4

 

Question 13

Type: MCSA

A patient in the unit has a blood pressure of 55/30, is lethargic, has slurred speech, and is unable to get back to bed from the bathroom. The nurse calls for a rapid response team. Which component of critical thinking is the nurse exhibiting?

  1. Analysis of situation, distinguishing normal from abnormal
  2. Selection of alternative by developing outcomes and plans
  3. Collection of information, subjective and objective
  4. Evaluation of situation, determination of outcomes achieved

Correct Answer: 1

Rationale 1: Analysis of the situation is the second component of critical thinking. This component includes the ability to distinguish normal from abnormal.

Rationale 2: Selection of alternatives is the fourth step in the critical thinking process and is used when developing outcomes and plans.

Rationale 3: Collection of information is the first step in the critical thinking process and is used during the health assessment.

Rationale 4: Evaluation of the situation is the last step of the critical thinking process and is used to determine if the expected outcomes have been achieved.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6-5

 

Question 14

Type: MCSA

The nurse and a patient are discussing a variety of options that may help alleviate a health problem. The nurse and patient are involved in which step of the critical thinking process?

  1. Evaluation
  2. Collection of information
  3. Generation of alternatives
  4. Analysis of the situation

Correct Answer: 3

Rationale 1: Evaluation is the last step of the process and is done to determine whether the expected outcomes have been achieved.

Rationale 2: Collection of information begins with the interview and continues throughout the entire health assessment.

Rationale 3: Generation of alternatives occurs when options are identified and priorities are established. The nurse and patient work together to discuss the options so the patient can make an informed decision.

Rationale 4: Analysis of the situation follows the collection of information and helps distinguish normal from abnormal findings.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6-5

 

Question 15

Type: MCMA

The nurse is reviewing the outcomes of a patient’s plan of care. Which portions of the critical thinking process are used in this evaluation?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Revision of cues
  2. Generation of alternatives
  3. Analysis of the situation
  4. Selection of alternatives
  5. Collection of information

Correct Answer: 3,4,5

Rationale 1: Cues are bits of information that may hint at the possibility of a health problem. The cues are static and cannot be revised.

Rationale 2: Each step of the critical thinking process is used in evaluation. The nurse may need to generate new alternatives to address unmet or undesirable outcomes.

Rationale 3: Each step of the critical thinking process is used in evaluation. The nurse reanalyzes the situation to see if any omissions or misinterpretations have occurred.

Rationale 4: Each step of the critical thinking process is used in evaluation. The nurse uses critical thinking to determine if the alternatives selected were appropriate and if any omissions occurred.

Rationale 5: Each step of the critical thinking process is used in evaluation. The nurse uses critical thinking to determine if all pertinent information was collected and if any misinterpretation occurred.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 6-5

 

Question 16

Type: FIB

A 54-year-old patient reports that she smokes a pack and a half of cigarettes daily and has been smoking since she was 16 years old. The nurse would record a smoking history of ______ pack-years.

Standard Text:

Correct Answer: 57

Rationale : This patient has been smoking for 38 years (54-16). 38 × 1.5 = 57 pack-years.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-1

 

Question 17

Type: MCMA

The nurse is using the technique of inspection during a patient’s physical examination. Which findings are possible using this technique?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. The patient’s left leg is larger than the right leg.
  2. The patient’s abdomen is scaphoid.
  3. The patient has a strong radial pulse.
  4. The patient has difficulty extending the right arm above the head.
  5. The patient has periorbital edema.

Correct Answer: 1,2,4,5

Rationale 1: The nurse can see the differences in size using inspection.

Rationale 2: The nurse can see the contours of the abdomen using inspection.

Rationale 3: To assess the radial pulse, the nurse must use palpation.

Rationale 4: Difficulty in movement can be assessed through inspection.

Rationale 5: Edema can be assessed through inspection, although it must be graded through palpation.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-4

 

Question 18

Type: MCMA

The nurse is preparing to use auscultation as part of a patient’s physical examination. Which techniques should the nurse use?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Pressing the bell of the stethoscope firmly on the skin to hear muffled tones
  2. Using the diaphragm of the stethoscope to hear normal lung sounds
  3. Placing the diaphragm of the stethoscope firmly against the patient’s gown
  4. Focusing on one sound at a time
  5. Using the bell of the stethoscope to hear low-pitched sounds

Correct Answer: 2,4,5

Rationale 1: The bell of the stethoscope becomes a diaphragm when pressed firmly on the skin. The skin under the bell stretches, creating a surface that reduces audible vibratory sensations.

Rationale 2: The diaphragm of the stethoscope is best for hearing high-pitched sounds such as normal lung sounds.

Rationale 3: The stethoscope should be placed on bare skin. The patient’s gown or bed sheets will produce sounds that interfere with body sounds.

Rationale 4: A variety of sounds can be heard when the nurse listens at each auscultatory landmark. The nurse should focus on one sound at a time.

Rationale 5: The bell is the best side of the stethoscope for hearing low-pitched sounds such as heart murmurs.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 06-04

 

Question 19

Type: MCMA

The nurse is using blunt percussion to assess a patient who was involved in a motor vehicle accident. The nurse would use this technique to assess for injury to which organs?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Kidney
  2. Liver
  3. Lungs
  4. Bladder
  5. Heart

Correct Answer: 1,2

Rationale 1: Blunt percussion is often used as a quick screen for inflammation or damage to the kidney.

Rationale 2: Blunt percussion over the liver that elicits pain would indicate injury.

Rationale 3: Blunt percussion is not used to assess the lungs.

Rationale 4: Indirect percussion is used to assess the bladder.

Rationale 5: Blunt percussion is not used to assess the heart.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-4

 

Question 20

Type: MCSA

Using critical thinking, the nurse assesses that a patient is not a reliable historian. How should the nurse proceed?

  1. Stop the assessment because all data is invalid.
  2. Document that the patient is not answering questions truthfully.
  3. Ask different questions to assess the same information.
  4. Document the information just as the patient reports it.

Correct Answer: 3

Rationale 1: There are many parts of assessment that do not depend on the patient being an accurate historian.

Rationale 2: Being an unreliable historian does not mean that the patient is not truthful. In some cases it indicates that the patient has memory or hearing issues.

Rationale 3: The nurse can assess information in a variety of ways. Asking different questions to elicit information is a valid technique.

Rationale 4: The nurse should not taint the data set by recording obviously inaccurate data. Further attempts to verify data should be taken.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-5

Osborn, Medical-Surgical Nursing, 2e
Chapter 07

Question 1

Type: MCSA

A patient tells the nurse that she does not want to pass on a genetic disorder to any future children. What is the nurse’s most accurate response?

  1. “A complete genetic study could help guide you in your decision making.”
  2. “I suppose, then, that you are not going to have any children.”
  3. “Adoption is always a possibility.”
  4. “Just because the disease is genetic doesn’t mean your children will inherit it.”

Correct Answer: 1

Rationale 1: Findings from genetic research can be used by patients and family members to improve their own health and prevent illness.

Rationale 2: It is premature to suggest refraining from having children until a genetic study is completed.

Rationale 3: It is premature to suggest adoption until a genetic study is completed.

Rationale 4: This may be true, but it does not help to allay the patient’s concerns. Additional intervention is indicated.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7-1

 

Question 2

Type: MCSA

A patient tells the nurse that she is genetically predisposed to type 2 diabetes. The patient is hypertensive and smokes a pack of cigarettes daily. What information should the nurse provide for this patient?

  1. “Maintaining a healthy weight and activity level will help you avoid type 2 diabetes.”
  2. “Unfortunately, you are probably predestined to develop type 2 diabetes.”
  3. “You probably need to begin monitoring your blood glucose levels daily.”
  4. “The risk of developing diabetes is several years away, and you have other health problems to consider now.”

Correct Answer: 1

Rationale 1: The best way for this patient to avoid illness is to maintain a healthy weight and activity level.

Rationale 2: A genetic predisposition does not guarantee the disease will develop.

Rationale 3: Daily monitoring of blood glucose levels is not indicated for this patient.

Rationale 4: It is important to take action to prevent disease and not wait for the disease to manifest.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7-1

 

Question 3

Type: MCSA

The nurse is conducting a class for expectant parents who need genetic counseling. Which statement by a parent would indicate the need for further education?

  1. “The reason men and women are so different from one another is that none of their chromosomes are alike.”
  2. “Half of the sets of chromosomes come from the mother and the other half come from the father.”
  3. “The 23rd pair of chromosomes will determine if our child will be male or female.”
  4. “One Y chromosome and one X chromosome will produce a male child.”

Correct Answer: 1

Rationale 1: The first 22 pairs of chromosomes are alike in males and females.

Rationale 2: One copy, or half of the complete set of 46 chromosomes, is inherited from the mother, and the other copy is inherited from the father.

Rationale 3: The 23rd pair, the sex chromosomes, determines an individual’s gender.

Rationale 4: A female has two copies of the X chromosome and a male has one X chromosome and a Y chromosome. These X and Y chromosomes are known as sex chromosomes.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 7-2

 

Question 4

Type: MCSA

At the conclusion of genetic testing, a patient learns that he has a predisposition for developing cardiovascular disease at a young age. Which instruction should the nurse provide this patient?

  1. “This information can help guide you to make lifestyle changes to reduce your chances of developing cardiovascular disease.”
  2. “At least you know now that you will need cardiac bypass surgery.”
  3. “As you are likely to develop the disease early in life, enjoy your life as much as possible now.”
  4. “I would not place too much emphasis on these test results, as most of the time they are inconclusive.”

Correct Answer: 1

Rationale 1: One benefit of genetic testing is that it can help patients reduce their chances of developing particular diseases through preventive measures and lifestyle adaptations.

Rationale 2: The nurse has no way of knowing if the patient will need cardiac bypass surgery.

Rationale 3: Having a predisposition does not guarantee the patient will develop the disease.

Rationale 4: The nurse should not minimize the importance of the genetic testing results.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7-3

 

Question 5

Type: MCSA

A patient is concerned about transmitting genetic illnesses to any future children. What can the nurse do initially to help the patient determine which diseases might be transmitted?

  1. Work with the patient to complete a pedigree.
  2. Conduct a health promotion assessment.
  3. Schedule a complete genetic analysis.
  4. Refer the patient to a geneticist for diagnosis.

Correct Answer: 1

Rationale 1: A pedigree is a pictorial representation or diagram of the medical history of a family that typically includes three generations. The finished pedigree presents a family’s medical data and biologic relationships at a glance.

Rationale 2: A health promotion assessment will not provide information regarding the patient’s risk for passing on genetic illnesses to future children.

Rationale 3: There are steps the nurse should take before this analysis is scheduled.

Rationale 4: There are steps the nurse should complete before referring the patient to a geneticist.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-6

 

Question 6

Type: MCSA

A patient has been told that her unborn child has Down syndrome. Which information will the nurse include when teaching the patient about the etiology of this disorder?

  1. “Down syndrome is the most common type of trisomy, which occurs when there is an extra chromosome.”
  2. “Most Down syndrome is caused by monosomy.”
  3. “Down syndrome occurs as a result of breaks in chromosomes called translocations.”
  4. “Deletions or loss of part of a chromosome is a common cause of Down syndrome.”

Correct Answer: 1

Rationale 1: Trisomy refers to the presence of a third or extra chromosome instead of the normal pair of a particular chromosome. The most common type of trisomy in infants is trisomy 21 or Down syndrome.

Rationale 2: Monosomy refers to the presence of only one chromosome instead of the normal pair of chromosomes. It is not the cause of Down syndrome.

Rationale 3: Translocations occur when there are breaks in two or more chromosomes with reattachments in new combinations. This is not the etiology of Down syndrome.

Rationale 4: Structural rearrangements of chromosomes may result from deletions or loss of a chromosome segment or piece. This is not the etiology of Down syndrome.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 07-05

 

Question 7

Type: MCSA

The mother of a child with cystic fibrosis says, “No one in our family has ever had cystic fibrosis. Why did it suddenly appear in my child?” What information should the nurse offer this mother?

  1. “While all people carry the gene for cystic fibrosis, those who develop the disease have a mutation in that gene.”
  2. “A small percentage of the general population carries the gene for cystic fibrosis. If two carriers have children, 25% of those children will develop the disease.”
  3. “One in four people carries the gene for cystic fibrosis. If two carriers have children, 25% of those children will develop the disease.”
  4. “Some people carry the gene for cystic fibrosis. Of those carriers, one in four will develop the disease.”

Correct Answer: 1

Rationale 1: Every individual carries the cystic fibrosis transference regulator (CTFR) gene. Those who develop the disease have a mutation in that gene.

Rationale 2: Every individual carries the cystic fibrosis transference regulator (CTFR) gene.

Rationale 3: Every individual carries the cystic fibrosis transference regulator (CTFR) gene.

Rationale 4: Every individual carries the cystic fibrosis transference regulator (CTFR) gene. Those who develop the disease have a mutation in that gene.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 7-4

 

Question 8

Type: MCSA

At the completion of genetic testing, it has been determined that a patient’s baby will have Down syndrome. What should the nurse say to the patient after learning this information?

  1. “I realize that this news is difficult for you. Is there anything I can do to help you at this time?”
  2. “It’s not too late to consider ending the pregnancy.”
  3. “You are young enough to be able to handle the baby’s challenges.”
  4. “It does not matter if the baby has problems; all life is precious.”

Correct Answer: 1

Rationale 1: When supporting a pregnant patient who learns that her baby has Down syndrome, the best response by the nurse would be to acknowledge that the news is difficult and offer to help the patient.

Rationale 2: The nurse should not suggest that the patient terminate the pregnancy.

Rationale 3: The assumption that the patient will be able to handle the baby’s health condition just because she is young is dismissive of the very real challenges the baby will present.

Rationale 4: Stating that all life is precious is judgmental and should be avoided by the nurse.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7-6

 

Question 9

Type: MCSA

A patient planning to be married tells the nurse that she has a strong family history of Huntington’s chorea but does not plan to let her fiancé know. How should the nurse respond?

  1. “Is there any reason you do not want your fiancé to know about your genetic illness?”
  2. “It is probably best that he is not aware of the disease.”
  3. “Are you afraid he will not want to marry you if he knows?”
  4. “There are worse disease processes than Huntington’s chorea.”

Correct Answer: 1

Rationale 1: The nurse needs to support the patient in ethical and social issues. The best response would be to try to discover the patient’s reason for wanting to keep her genetic illness a secret.

Rationale 2: Agreeing that the fiancé should not be made aware would be an inappropriate response.

Rationale 3: Suggesting that the fiancé might not want to marry the patient if he was aware of the genetic disease is an inappropriate response.

Rationale 4: The nurse should not make this judgment about the patient’s illness.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7-6

 

Question 10

Type: MCSA

A patient planning to have genetic testing prior to having children tells the nurse that she is fearful that people will learn about the testing and the results. How should the nurse respond to this concern?

  1. “The results of the tests are confidential, and no one can see them without your permission.”
  2. “Most insurance companies will want the results before paying for the tests.”
  3. “The results will be available to anyone who reviews your medical record.”
  4. “The doctor will most likely use the results when planning care and treatment for other patients with the same genetic disorder.”

Correct Answer: 1

Rationale 1: The nurse should explain that the results of genetic testing are confidential.

Rationale 2: Insurance companies do not need the results before paying for the tests.

Rationale 3: The results are confidential and not accessible by anyone who reviews the patient’s medical record.

Rationale 4: The patient’s physician cannot use the test results for this purpose.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7-6

 

Question 11

Type: MCSA

A patient is having difficulty achieving adequate anticoagulation with prescribed doses of warfarin. What information should the nurse offer this patient?

  1. “Some people metabolize medications differently because of their genetic makeup.”
  2. “You are probably not taking the medication correctly.”
  3. “There must be something you are eating that is interfering with the drug.”
  4. “Something in your lifestyle is interfering with the action of the medication.”

Correct Answer: 1

Rationale 1: One use of genetic testing involves predicting or studying the patient’s response to particular medications.

Rationale 2: There is no evidence that the patient is not taking the medication correctly.

Rationale 3: There could be a dietary component influencing action of warfarin, but this would be unlikely to result in a total inability to achieve adequate anticoagulation.

Rationale 4: An analysis of the patient’s lifestyle will not help determine why successful anticoagulation has not been achieved.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-7

 

Question 12

Type: MCSA

A baby is born with a genetic disorder that did not affect either of the parents. What would the nurse deduce about this situation?

  1. The mother is the carrier of the disorder.
  2. The father is the carrier of the disorder.
  3. The father is not the biological father of the baby.
  4. Both parents are carriers of the disorder.

Correct Answer: 4

Rationale 1: If only one parent was affected, the child would not be born with the disorder but simply be a carrier as well.

Rationale 2: If only one parent was affected, the child would not be born with the disorder but simply be a carrier as well.

Rationale 3: There is no evidence to contradict the father’s paternity.

Rationale 4: A child born with a recessive condition has inherited one altered gene from the mother and one from the father. In most cases neither parent is affected; therefore, each parent must have a single gene alteration on one chromosome of a pair and the normal, wild-type, or unaltered form of the gene on the other chromosome. These parents are carriers and do not usually exhibit any signs and symptoms of the condition.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-5

 

Question 13

Type: MCSA

Upon the completion of genetic testing for breast cancer, a patient is happy to learn that the test results are negative. What information should the nurse provide?

  1. “You should be relieved to know you will never experience breast cancer.”
  2. “None of your children will be at risk for breast cancer either.”
  3. “Your children will be at risk for breast cancer only if there is a random change in a chromosome.”
  4. “There is no guarantee that you will never experience breast cancer.”

Correct Answer: 4

Rationale 1: A negative test result cannot guarantee that the disease will not develop in the future.

Rationale 2: The patient’s children may have random chromosomal abnormalities that are seen in the rest of the population.

Rationale 3: This is not necessarily true.

Rationale 4: A negative test result cannot guarantee that the disease will not develop in the future.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7-4

 

Question 14

Type: MCSA

A patient is upset to hear the nurse say that the results of genetic testing revealed “wild-type” genes. What information should the nurse provide?

  1. “This term means your genes are unaltered and are considered the normal type.”
  2. “Your genes are considered normal for the most part but do have some limitations.”
  3. “We detected some abnormalities in your genes.”
  4. “The results of your genetic test were unexpected.”

Correct Answer: 1

Rationale 1: Wild-type genes are unaltered and are considered normal.

Rationale 2: Wild-type genes are normal, not “normal with limitations.”

Rationale 3: Wild-type genes are normal, not defective.

Rationale 4: Wild-type genes are normal, not unexpected.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-3

 

Question 15

Type: MCMA

A pregnant woman reports a family history of cystic fibrosis. Which information should the nurse provide?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. The disorder will be transmitted to male children only.
  2. Each child will have a 25% chance of being affected.
  3. If the mother is does not have cystic fibrosis, her children will not have it either.
  4. The chances that children who do not manifest the disorder will be carriers are 2 out of 3.
  5. One of every four children will be affected by the disorder.

Correct Answer: 2,4

Rationale 1: Autosomal recessive disorders are not sex-linked.

Rationale 2: The chances that a specific child will be affected are 1 in 4.

Rationale 3: The mother could be a carrier for the disorder.

Rationale 4: Phenotypically normal children have a 2 out of 3 chance of being carriers.

Rationale 5: The risk applies equally to each child. If this mother has four children, each child carries equal risks of being affected, being a carrier, or not inheriting the mutant gene at all.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7-5

 

Question 16

Type: MCMA

A newborn has been diagnosed with cri du chat syndrome. The parents request information about this syndrome. Which information should the nurse provide?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. “Your baby’s chromosomal makeup is unbalanced.”
  2. “This condition occurred because your baby has too much material in a particular chromosome.”
  3. “This syndrome is genetically related to trisomy 21.”
  4. “Your baby’s syndrome is the result of a large amount of material missing from chromosome 5.”
  5. “We suspected this condition because of the sound of your child’s cry.”

Correct Answer: 1,4,5

Rationale 1: A chromosomal alteration that includes a missing or additional whole chromosome or segment of a chromosome is an unbalanced rearrangement.

Rationale 2: Cri du chat syndrome is caused by a gene deletion, not nondisjunction.

Rationale 3: Translocation between chromosomes 9 and 22 is responsible for trisomy 21 and is not associated with cri du chat syndrome.

Rationale 4: Cri du chat syndrome results from a large deletion on the short arm of chromosome 5.

Rationale 5: Patients with cri du chat syndrome have mental retardation, crying that sounds like a cat mewing, and low-set ears.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7-5

 

Question 17

Type: MCMA

The nurse works in a geneticist’s office and is educating a new employee about human cells. Which statement by the employee indicates an understanding of the information?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. “Every human cell has 23 pairs of chromosomes and a total of 46 chromosomes.”
  2. “Genes are found in the nucleus of all cells.”
  3. “Each human cell contains mitochondria.”
  4. “The 22nd pair of chromosomes determines the person’s gender.”
  5. “All human cells function in the same way regardless of their location.”

Correct Answer: 1,3

Rationale 1: Every human cell has 23 pairs of chromosomes. There are 46 chromosomes in each cell.

Rationale 2: Genes are found in the nucleus of all cells except red blood cells, which have no nucleus.

Rationale 3: Each human cell contains organelles such as mitochondria.

Rationale 4: The 23rd pair of chromosomes determines the person’s gender.

Rationale 5: Human cells function very differently based on their location.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7-2

 

Question 18

Type: MCMA

The patient has blue eyes. During the interview with the nurse at the geneticist’s office, the patient states that his mother has blue eyes and his father has brown eyes. Which statements by the nurse are accurate?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. “You have two identical alleles that are responsible for your eye color.”
  2. “The alleles responsible for your eye color are heterozygous.”
  3. “Your eye color is the result of an expressed gene.”
  4. “Alleles are forms of a gene.”
  5. “Your eye color is just one part of your phenotype.”

Correct Answer: 2,3,4,5

Rationale 1: This patient has a blue-eyed mother and a brown-eyed father, so the patient has two different forms of the gene responsible for his eye color.

Rationale 2: The patient’s alleles are heterozygous.

Rationale 3: The patient’s blue eyes are the result of an expressed gene. An expressed gene impacts the patient’s observable traits.

Rationale 4: Alleles are versions or forms of a gene. The patient’s eye color is part of his phenotype.

Rationale 5: The phenotype is the patient’s entire physical, biochemical, and physiologic makeup and is influenced by genetic and environmental factors.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7-4

 

Question 19

Type: MCMA

A fetus is found to have an autosomal recessive condition. After genetic testing is completed, both parents are found to have the same genetic alteration. Which statements by a parent indicate that further education is required?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. “This condition is related to a genetic alteration of the X chromosome.”
  2. “This condition is a Mendelian condition.”
  3. “So we are carriers of this condition because we don’t have any signs or symptoms of the condition.”
  4. “Our baby would have a better chance of living if we were both positive for an autosomal dominant condition.”
  5. “The problem is the result of an alteration of a single gene.”

Correct Answer: 1,4

Rationale 1: Genetic alterations of the X chromosome are referred to as X-lined recessive or X-linked dominant conditions, not autosomal recessive conditions.

Rationale 2: This is a Mendelian condition because it follows Mendel’s laws of inheritance.

Rationale 3: The parents deny having any clinical manifestations associated with the condition, so they are likely carriers of the condition.

Rationale 4: It is not necessarily true that the infant will die because of an autosomal recessive condition. The baby affected by a homozygous autosomal dominant condition is much more likely to die from problems associated with that type of condition.

Rationale 5: Autosomal recessive conditions are single-gene disorders.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7-5

 

Question 20

Type: MCSA

A patient who has been diagnosed with Parkinson’s disease expresses hopelessness regarding the future. The nurse would consider which genetic technology when formulating a response?

  1. Gene therapy
  2. Real-time PCR
  3. Stem cell therapy
  4. Microarray analysis

Correct Answer: 3

Rationale 1: Gene therapy is the correction of a genetic mutation by the introduction of DNA into a cell to improve the patient’s health. Complications and ethical considerations have limited the use of gene therapy in clinical settings.

Rationale 2: Real-time PCR is an emerging technology that allows for the detection and quantification of a small fragment of replicating DNA during the amplification process and offers rapid and sensitive quantification of the gene of interest. Its current application is in research.

Rationale 3: Stem cells are unspecialized cells that have the potential to divide without limit and to develop into specialized cells. Stem cell technology is promising in the treatment of such diseases as cancer and Parkinson’s disease.

Rationale 4: Microarray analysis is primarily used in the research setting, specifically in the area of cancer prognosis and treatment stratification.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7-7

 

Question 21

Type: MCSA

While reviewing a male patient’s history in the chart, the nurse becomes concerned. The patient states, “I haven’t been to see a physician in years and it’s time for me to get a thorough check-up.” Based on the nurse’s understanding of genetically related diseases, which diagnostic screening examination may be ordered for this patient?

  1. Mammogram
  2. Prostate exam
  3. Colonoscopy
  4. Cardiovascular assessment

Correct Answer: 4

Rationale 1: This patient does not necessarily have an increased risk of breast cancer because the mother was diagnosed with breast cancer after the age of 50.

Rationale 2: The patient does not have an increased risk of prostate cancer because the uncle was diagnosed with prostate cancer after the age of 60.

Rationale 3: The patient does not have an increased risk of developing colon cancer because the sister was diagnosed with colon cancer after the age of 50.

Rationale 4: The patient has an increased risk of being diagnosed with a cardiovascular disease because two family members were diagnosed with cardiovascular disorders that developed early.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-6

Osborn, Medical-Surgical Nursing, 2e
Chapter 11

Question 1

Type: MCSA

A terminally ill patient is experiencing dyspnea. What should the nurse do to help the patient feel more comfortable?

  1. Raise the head of the bed.
  2. Gently massage the patient.
  3. Replace the oxygen cannula with a face mask.
  4. Provide oral care.

Correct Answer: 1

Rationale 1: Elevating the head of the bed reduces choking sensations and promotes expansion of the lungs.

Rationale 2: Massage has not been shown to reduce dyspnea, but will help reduce discomfort from accumulating edema in the extremities.

Rationale 3: Face masks often make the patient more dyspneic.

Rationale 4: Providing oral care is not the best answer for reducing dyspnea.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-4

 

Question 2

Type: MCSA

A competent elderly patient has a living will that specifies avoiding resuscitation and heroic life support measures. The family members are not supportive of this directive. Which action by the nurse is most appropriate?

  1. Consider the document valid and document its existence in the medical record.
  2. Contact the Social Services department.
  3. Notify the hospital attorney.
  4. Explain to the patient that the conflict could invalidate the document.

Correct Answer: 1

Rationale 1: The patient is competent. The nurse should consider this document valid and should advocate for the patient’s wishes by including the information in the medical record.

Rationale 2: If there are concerns about the authenticity of the document, the Social Services department or the unit supervisor will need to be contacted.

Rationale 3: The nurse would not contact the hospital attorney but would make the situation known to the unit supervisor.

Rationale 4: A lack of support by the family does not invalidate the document.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-2

 

Question 3

Type: MCSA

While preparing for the discharge of an elderly, terminally ill patient, the family asks for information concerning the most appropriate time to become involved with a hospice agency. Which action by the nurse is most appropriate?

  1. Assist the family in making contact with a hospice agency at this time.
  2. Estimate the patient’s life expectancy to gauge when contact with hospice should be made.
  3. Encourage the family to “hold off” making the contact until death is very close.
  4. Determine what expectations the family has of the hospice agency.

Correct Answer: 1

Rationale 1: Hospice agencies provide vital services to patients who are facing death and to their families. Referrals should be prompt.

Rationale 2: Even though a hospice is generally considered appropriate in the last 6 months of life, it is not appropriate for the nurse to make that determination.

Rationale 3: Waiting until the time of death is at hand does not leave much time for the hospice agency to assist the family.

Rationale 4: Determining the family’s expectations is an action more appropriate for the hospice intake nurse.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-5

 

Question 4

Type: MCSA

A terminally ill patient is receiving palliative care. How would the nurse explain the purpose of this type of care to the family?

  1. “Palliative care is designed to alleviate suffering and promote quality of life.”
  2. “Palliative care reduces pain and prevents medical complications.”
  3. “Palliative care’s purpose is to control the side effects of illness while postponing death.”
  4. “Palliative care involves withdrawing all medical care to allow natural death.”

Correct Answer: 1

Rationale 1: The purpose of palliative care is to provide comprehensive care focused on alleviating suffering and promoting quality of life.

Rationale 2: Medical complications can be controlled by palliative care, but not prevented. Palliative care can also help control pain.

Rationale 3: The purpose of palliative care is not specifically to postpone death.

Rationale 4: Withdrawing all medical care would be inappropriate, as it would cause more suffering.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-6

 

Question 5

Type: MCSA

A patient asks the nurse what it means to have hospice care at home. What is the most accurate response to this patient?

  1. “Hospice makes sure that you are comfortable at home.”
  2. “Hospice care helps cure your illness.”
  3. “Hospice care is for patients who will be sick for longer than a year.”
  4. “Hospice care means all your needs will be met.”

Correct Answer: 1

Rationale 1: Hospice care focuses on comfort care versus curative care.

Rationale 2: Hospice care does not focus on cure.

Rationale 3: Patients receiving hospice care are generally defined as patients who have a prognosis of 6 months or less if their terminal disease runs a normal course.

Rationale 4: The nurse cannot guarantee that all needs will be met.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-5

 

Question 6

Type: MCSA

A patient with a chronic illness who is receiving palliative care asks the nurse if a newly prescribed medication will cure the disease. What is the nurse’s best response?

  1. “It will help you be more comfortable. I don’t think it’s going to cure the disease.”
  2. “Of course it’s going to cure the disease.”
  3. “If you believe it will cure the disease, then it will.”
  4. “I don’t think it’s going to help or hurt at this time.”

Correct Answer: 1

Rationale 1: In palliative care, the nurse should be honest with the patient and explain that the medication will help with comfort, but it will not cure.

Rationale 2: In palliative care, the nurse should be honest with the patient and explain that the medication will not cure the disease.

Rationale 3: The nurse should not approach palliative care as curative because this could rob the patient of time and closure at the end of life.

Rationale 4: The nurse has no way of knowing the effect of the medication as far as helping or hurting the illness progression.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-6

 

Question 7

Type: MCSA

Several visitors are in the room of a terminally ill patient. The nurse enters the room to discuss the plan of care for the patient. Which actions should be taken?

  1. Stand at the foot of the patient’s bed and tell all present the best course of action.
  2. Ask the patient which individuals he or she would like to have stay in the room.
  3. Ask the other patient in the room to raise the volume of the television.
  4. Sit down next to the patient and discuss the plan.

Correct Answer: 2

Rationale 1: The nurse should not assume that everyone in the room is supposed to hear the plan of care.

Rationale 2: Just because the patient is terminally ill does not mean that privacy is no longer an issue. The nurse should continue to honor the patient’s wishes.

Rationale 3: If the roommate cannot leave the room, the nurse should draw the curtain and speak in quiet tones.

Rationale 4: Sitting next to the patient does not necessarily ensure privacy.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-1

 

Question 8

Type: MCSA

A terminal patient with a fulminating leg wound needs surgery, yet it is unlikely the patient will survive the procedure. The nurse could ethically support which action by the health care team?

  1. Explaining that the surgery is needed and every effort will be done to keep the patient alive
  2. Deciding not to conduct the surgery and determining if there are other treatment approaches
  3. Telling the patient that offering surgery was an error and that treatment will be done with medications and therapy
  4. Conducting the surgery without telling the patient that survival is unlikely.

Correct Answer: 2

Rationale 1: The surgery should not be done with the promise of keeping the patient alive. If the patient is likely to die, this violates the ethical principle of veracity.

Rationale 2: Surgical intervention is stressful and painful. If the patient is not likely to survive the surgery, it should not be performed. The ethical action is to determine if other treatment approaches exist.

Rationale 3: Lying to the patient is not ethical and should not be supported by the nurse.

Rationale 4: This is unethical conduct. The patient should be taken to surgery only if informed consent is valid.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 11-1

 

Question 9

Type: MCSA

The family of an incapacitated patient desires one course of treatment that contradicts the decisions of the person with durable power of attorney. The disagreement is affecting the patient’s nursing care. What should the nurse do?

  1. Tell the person with durable power of attorney that he has to get the family’s consent.
  2. Follow the family’s desires.
  3. Provide care according to the decisions of the person with durable power of attorney.
  4. Ask the physician to talk with the family and the person with durable power of attorney.

Correct Answer: 3

Rationale 1: The person appointed to make medical decisions does not need consent from other family members or friends.

Rationale 2: Following the family’s desires is not advocating for the patient’s directions.

Rationale 3: A durable power of attorney for health care allows the patient to appoint a decision maker in case of future incapacity. The durable power of attorney specifically states which powers the patient gives to the surrogate decision maker, and those decisions are to be followed even when they conflict with family members’ desires.

Rationale 4: The nurse should make decisions about the nursing care of the patient. The physician makes decisions related to medical care and discusses them with the family.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 11-2

 

Question 10

Type: MCSA

The nurse is preparing an analgesic infusion for a cancer patient who is in pain and is nearing the end of life. What should the nurse do to ensure this patient’s comfort?

  1. Titrate the medication to help with pain relief and not hasten the dying process.
  2. Use meperidine in the infusion.
  3. Limit the amount of medication infused.
  4. Contact the pharmacy for the correct dose to provide the patient.

Correct Answer: 1

Rationale 1: The nurse should titrate the medication to reduce the patient’s pain but not hasten the dying process.

Rationale 2: Meperidine is not recommended for pain because it could cause seizures.

Rationale 3: The patient may have been receiving pain medication for cancer treatment and may have some tolerance to the medication. Limiting the amount of medication infused will result in inadequate pain control.

Rationale 4: There is no set dosage for pain medications at the end of life.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-3

 

Question 11

Type: MCSA

A patient is experiencing delirium. Which group of medications should the nurse consider administering to help reduce delirium?

  1. Neuroleptics
  2. Benzodiazapines
  3. NSAIDs (nonsteroidal anti-inflammatory drugs)
  4. Opioids

Correct Answer: 1

Rationale 1: Neuroleptics such as Haldol help reduce the symptoms of delirium.

Rationale 2: Benzodiazapines are used for sedation and to prevent seizures.

Rationale 3: NSAIDs are helpful for treating inflammation, pain, and fever rather than delirium.

Rationale 4: Opioids are used for relief of pain and dyspnea.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-3

 

Question 12

Type: MCSA

The nurse is planning palliative care for a patient with severe atherosclerotic disease. What is the highest priority for this patient?

  1. Tolerance of physical activity
  2. Use of available financial resources
  3. Redesigning the patient’s home to support assistive devices
  4. Pain and symptom management

Correct Answer: 4

Rationale 1: Tolerance of physical activity is a low priority for this patient.

Rationale 2: Using available financial resources is not the highest priority.

Rationale 3: Home environment redesign is not the highest priority for this patient.

Rationale 4: When providing care to patients in a palliative care program, targeted interventions are common and include pain and symptom management, end-of-life care planning, and interventions to support the patient’s psychosocial and spiritual needs.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 11-6

 

Question 13

Type: MCSA

Which nursing intervention follows the principles of palliative care?

  1. Encouraging physical therapy to restore prior level of functioning
  2. Talking to the patient about plans for funeral arrangements
  3. Talking to the patient about possibly becoming an organ donor
  4. Facilitating a consult to promote weight gain

Correct Answer: 2

Rationale 1: Attempting to return to a prior level of functioning is not the goal of palliative care.

Rationale 2: Palliative care focuses on pain and symptom management, end-of-life planning, and psychosocial as well as spiritual needs. Encouraging end-of-life planning such as funeral plans would be very appropriate.

Rationale 3: Organ donation is only possible when a patient experiences brain death on life support. This is not the goal of palliative care.

Rationale 4: Encouraging weight gain is not necessary for this patient.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 11-6

 

Question 14

Type: MCMA

The medical team has proposed a new therapy for a patient who is terminally ill. The nurse should ensure that the patient and family understand which aspects of the therapy before they make a decision about its implementation?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. The goals of the treatment
  2. The likelihood that the goals of therapy will be met
  3. The treatment burden
  4. Predicted quality of life after the treatment
  5. Implications for the health care community

Correct Answer: 1,2,3,4

Rationale 1: The patient and family should understand how the treatment is expected to benefit the patient.

Rationale 2: The patient and family should understand how the patient’s current condition affects the implementation of the therapy and the achievement of therapy goals.

Rationale 3: The patient and family should understand the physical and psychological costs of the treatment.

Rationale 4: The patient and family should consider the predicted quality of life so they can decide if the treatment is worthwhile.

Rationale 5: Agreeing to a new therapy to add to the health care community’s knowledge base would be altruistic, but the implications are not the primary information needed by this patient and family.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 11-1

 

Question 15

Type: MCMA

The health care team has just given the family of a terminally ill patient an update on the patient’s status. Thirty minutes later the patient’s sibling says, “The family does not understand the last update the physician gave us.” Which nursing actions are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Repeat the information the physician provided.
  2. Have the physician paged to talk to the family again.
  3. Explain the information in a different way.
  4. Offer to call the physician’s answering service to leave a message for the family.
  5. Have the unit supervisor talk with the family.

Correct Answer: 1,3

Rationale 1: Families under stress often need for information to be repeated.

Rationale 2: The nurse can clarify this information.

Rationale 3: The nurse can often facilitate understanding by explaining the information in a different way.

Rationale 4: The nurse can clarify this information without calling the physician.

Rationale 5: The patient’s primary nurse should be able to discuss this situation with the family and clarify any information.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-4

 

Question 16

Type: MCMA

A terminally ill patient has been transferred from acute care to palliative care. The health care team should review former orders for which characteristics?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Does the order comply with the patient’s wishes?
  2. Does this treatment provide symptom relief?
  3. Does the treatment make the best use of resources?
  4. Does the intervention support the patient’s emotional health?
  5. Does the intervention support the patient’s spiritual health?

Correct Answer: 1,2,4,5

Rationale 1: In palliative care, the patient is in command. All interventions should comply with the patient’s wishes about death and dying.

Rationale 2: If a treatment is not making the patient feel better, it is likely to be inappropriate in the palliative care setting.

Rationale 3: Resource utilization is always important in health care but takes on a lesser importance in palliative care.

Rationale 4: Any intervention that makes the patient anxious or uncomfortable should be revised or eliminated.

Rationale 5: Spiritual health does not imply religious dogma, but refers to the patient’s philosophy, values, and understanding of the meaning of life. Any intervention that does not support these essential components should be revised or eliminated.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 11-3

 

Question 17

Type: MCMA

A terminally ill patient is unconscious. Which nursing assessment findings would the nurse evaluate as possible pain responses?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. The patient’s breathing pattern changes.
  2. The patient becomes diaphoretic.
  3. It is unlikely that the unconscious patient will experience pain.
  4. Agitation will begin or will increase.
  5. Facial grimacing will occur with movement.

Correct Answer: 1,2,4,5

Rationale 1: Changes in breathing pattern such as guarding respirations may indicate pain. An increase or decrease in respiratory rate may also indicate pain.

Rationale 2: Diaphoresis may indicate pain.

Rationale 3: The unconscious patient may have severe pain and be unable to verbally communicate its presence to the nurse.

Rationale 4: Restlessness, agitation, and inability to lie still may all indicate pain.

Rationale 5: Facial grimacing is a common indicator of pain.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11-3

 

Question 18

Type: MCMA

A patient is very near the end of life. Which nursing interventions are indicated to assist the family during their grieving process?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Teach the family about the normal events that occur just prior to death.
  2. Remove as much monitoring equipment from the patient and the room as is possible.
  3. Support the family’s use of cultural and religious customs.
  4. Avoid using harsh terms such as “death” or “dying” when describing the situation.
  5. Limit the number of people at the bedside to no more than two or three.

Correct Answer: 1,2,3

Rationale 1: One source of anxiety for the family is their inexperience with the dying process. The family that is prepared for the experience is generally better able to cope with being present at the time of their loved one’s death.

Rationale 2: The nurse should evaluate whether monitoring equipment is serving a valid purpose as the patient is dying. If it is not, it should be removed from the patient and the room if possible.

Rationale 3: Assessment of and support for these customs will facilitate the family’s grieving process.

Rationale 4: Clear words such as “death” or “dying” should be used to facilitate understanding. Euphemisms should be avoided.

Rationale 5: The nurse should allow as many people as are desired and can be accommodated.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-4

 

Question 19

Type: FIB

A patient is prescribed an intravenous midazolam drip at a rate of 1–5 mg/hr, titrated to symptom relief. The nurse would start this drip at ______ mg/hr.

Standard Text:

Correct Answer: 1

Rationale : Titration is achieved by starting at the lowest drip rate ordered and increasing the rate based on patient response. The nurse closely evaluates patient response throughout therapy and adjusts the rate up or down according to need.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-3

 

Question 20

Type: MCSA

A woman is acting as primary caregiver for her husband, who is on hospice care. The wife needs to keep her own physician’s appointment. What advice should the nurse give?

  1. “Your husband should be okay for a couple of hours on his own.”
  2. “Can your daughter take off from work to stay with your husband?”
  3. “Hospice can provide a caregiver to be with your husband while you are at your appointment.”
  4. “Maybe you can delay your appointment until someone can stay with your husband.”

Correct Answer: 3

Rationale 1: This is not the best suggestion for this situation. The wife needs to be able to go to her physician’s appointment and not worry about her husband’s comfort.

Rationale 2: This may be a viable option in some situations, but another suggestion would be more appropriate.

Rationale 3: Hospice provides respite care for caregivers.

Rationale 4: The wife should not be made to feel as if her needs are not important and should be delayed.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 11-5

Osborn, Medical-Surgical Nursing, 2e
Chapter 13

Question 1

Type: MCSA

A patient tells the nurse that both his parents are alcoholics, and he wonders about the likelihood of becoming an alcoholic as well. How should the nurse respond?

  1. “There are studies that support a genetic link for developing alcoholism.”
  2. “Why are you concerned about becoming an alcoholic?”
  3. “You will likely become an alcoholic.”
  4. “Don’t worry about that.”

Correct Answer: 1

Rationale 1: Genetic studies suggest that heredity plays a role in the development of alcoholism.

Rationale 2: The nurse should not question the patient’s request for information about becoming an alcoholic like his parents.

Rationale 3: Although the patient does have an increased risk, stating that he will become an alcoholic is inappropriate.

Rationale 4: Telling the patient not to worry about becoming an alcoholic is an inappropriate response.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13-1

 

Question 2

Type: MCSA

The mother of a patient admitted with alcohol abuse tells the nurse that alcohol is not consumed at home and the patient is adopted. How would the nurse evaluate this information?

  1. The patient’s biological parents might have abused alcohol.
  2. The patient spends time drinking with friends.
  3. Consuming alcohol is a symptom of stress.
  4. Alcoholism is a learned behavior.

Correct Answer: 1

Rationale 1: Genetic studies suggest that heredity plays a role in the development of alcoholism. Because the patient was adopted, the patient’s biological parents may have abused alcohol.

Rationale 2: There is not enough information to conclude that the patient is drinking with friends.

Rationale 3: There is not enough information to conclude that the patient is consuming alcohol because of stress.

Rationale 4: There is not enough evidence to conclude that the patient’s alcohol use is learned behavior.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13-1

 

Question 3

Type: MCSA

A patient tells the nurse that she started to have a glass of wine every evening at home after work to “unwind” and then realized that she cannot continue with her day unless she has the wine. The nurse realizes that this patient uses wine for which reason?

  1. To cope with day-to-day problems
  2. To deal with difficulty expressing emotions
  3. To suppress a genetic need for alcohol
  4. To socialize with others

Correct Answer: 1

Rationale 1: Psychological factors in substance abuse include the use of the substance as self-medication to cope with day-to-day problems that over time becomes an addiction.

Rationale 2: There is no information to suggest that the patient is having difficulty expressing emotions.

Rationale 3: There is no information to suggest that the patient has a genetic need for alcohol.

Rationale 4: The patient is drinking at home after work.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13-1

 

Question 4

Type: MCSA

The nurse is concerned about possible substance abuse by a coworker. Which behavior warrants further investigation?

  1. The coworker frequently wastes medications.
  2. The coworker frequently requests the largest patient care assignment for the shift.
  3. The coworker prefers not to be the “medication nurse” on the shift.
  4. The coworker declines to take scheduled breaks.

Correct Answer: 1

Rationale 1: Excessive waste of medications could be a sign that a nurse is using or diverting drugs.

Rationale 2: Requesting a large patient care assignment would not be characteristic of a nurse who is abusing substances. The nurse who is unable or unwilling to manage a patient care assignment could be a substance abuser.

Rationale 3: Requesting not to be the medication nurse would reduce access to drugs subject to abuse.

Rationale 4: Taking frequent or lengthy breaks might signal substance abuse. Declining scheduled breaks is not consistent with substance abuse.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13-3

 

Question 5

Type: MCSA

A nurse frequently cannot be found on the unit when patients call for assistance. When colleagues mention these absences, the nurse becomes defensive and withdraws from the others. What does the nurse’s behavior suggest?

  1. Substance abuse
  2. A long-standing illness
  3. Introverted behavior
  4. Low self-esteem

Correct Answer: 1

Rationale 1: Signs of drug abuse include frequent disappearance from the work area. The defensive behavior and isolation are also signs of substance abuse.

Rationale 2: There is insufficient information to support long-standing illness as a reason for the nurse’s behavior.

Rationale 3: There is insufficient information to support introverted behavior as a reason for the nurse’s behavior.

Rationale 4: There is insufficient information to support low self-esteem as a reason for the nurse’s behavior.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13-3

 

Question 6

Type: MCMA

The nurse manager is concerned that a staff nurse is demonstrating signs of substance abuse. Which behaviors did the manager observe in the staff nurse?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Calling for days off or illness before scheduled days off
  2. Using the bathroom frequently
  3. Offering to give medication to patients not assigned to the nurse
  4. Volunteering to transfer a patient to the intensive care unit
  5. Following up with nursing assistants on patient care needs

Correct Answer: 1,2,3

Rationale 1: Observable warning signs of potential substance abuse include calling for days off before scheduled days off.

Rationale 2: Observable warning signs of potential substance abuse include frequent absence from the assigned work area.

Rationale 3: Observable warning signs of potential substance abuse include offering to give medications to patients not assigned to the nurse.

Rationale 4: Volunteering to transfer a patient to the intensive care unit is not an indication of substance abuse.

Rationale 5: Following up with nursing assistants on patient care needs is an expected part of the nurse’s job, not an indication of substance abuse.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13-3

 

Question 7

Type: MCSA

A community pharmacist calls the clinic and reports that a patient has asked for pain medication refills early for the last 2 months. What action should be taken by the nurse?

  1. Notify the health care provider that the patient has lost control of his or her consumption of medication.
  2. Tell the pharmacist to refill the prescriptions early.
  3. Ask the pharmacist if the patient has received medications early from any other provider.
  4. Notify the health care provider of the patient’s request.

Correct Answer: 4

Rationale 1: The nurse does not have sufficient information to make this assumption.

Rationale 2: This decision is not within the nurse’s scope of practice.

Rationale 3: This is not the best course of action for the nurse and may violate HIPAA regulations.

Rationale 4: There may be a valid reason the patient needs the medication earlier than is prescribed. The prescriber should make a decision according to the patient’s history.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13-1

 

Question 8

Type: MCSA

A patient is brought to the emergency department with a gunshot wound inflicted while attempting to steal beer from a convenience store. Which statement by the patient would reflect a sociocultural influence on the patient’s behavior?

  1. “My dad was killed while driving drunk before I was even born.”
  2. “I didn’t take anything out of that store. The manager is just trying to pin something on me.”
  3. “There was lots of beer in that store. I didn’t see how taking one six-pack would hurt anything.”
  4. “I can’t have fun at a party without beer.”

Correct Answer: 4

Rationale 1: The nurse could surmise from this information that the patient has a biological predisposition toward alcohol abuse.

Rationale 2: Inner dishonesty is a common trait among substance abusers. This is related to the psychological theory of substance abuse.

Rationale 3: Self-centeredness is a common trait among substance abusers. This is related to the psychological theory of substance abuse.

Rationale 4: Some abusers use substances to help cope with stressful situations or to fit in with a crowd. This behavior is consistent with sociocultural theory.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13-1

 

Question 9

Type: MCSA

A patient tells the nurse that he becomes very angry and abusive to his friends and family when he is unable to obtain an illegal substance. How should the nurse respond?

  1. “Have you considered seeking treatment for this behavior?”
  2. “You must not have many friends left.”
  3. “Have your actions caused problems for you at work?”
  4. “I don’t see how that kind of behavior helps get you what you want.”

Correct Answer: 1

Rationale 1: The patient’s description indicates a substance abuse problem. The best response is for the nurse to ask the patient if he has considered seeking treatment for this behavior.

Rationale 2: The nurse should not comment about the patient’s number of friends.

Rationale 3: The patient has reported that he is abusive to friends and family. Whether this behavior has caused problems at work is not the most important assessment question.

Rationale 4: Confronting the patient about how illogical his actions are is not the most therapeutic or safest course of action.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13-1

 

Question 10

Type: MCSA

A patient who is a recovering alcoholic says, “I haven’t had a drink in 10 days. I think I am over the hardest part and will be okay now.” The nurse formulates a response based on which information?

  1. Symptoms of postacute withdrawal syndrome begin about a month after the last drink.
  2. Symptoms of postacute withdrawal syndrome peak from 3 to 6 months after the last drink.
  3. The recovering alcoholic is never “okay” again.
  4. It is easier to recover from cocaine abuse than from alcohol abuse.

Correct Answer: 2

Rationale 1: Postacute withdrawal syndrome begins about 1 to 2 weeks after the last exposure to the substance.

Rationale 2: Postacute withdrawal syndrome symptoms peak at 3 to 56 months after the last exposure to the substance.

Rationale 3: Alcoholism is a long term illness, but people do recover from it and could be characterized as “okay.”

Rationale 4: Any type of abuse recovery takes work and it is not accurate to gauge the difficulty of one recovery against another.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 13-1

 

Question 11

Type: MCSA

A patient involved in a minor accident reports using “crank” an hour ago. The patient denies having used the drug before. Which manifestation can the nurse anticipate assessing in this patient?

  1. Feelings of increased energy and happiness
  2. Increased strength and coordination
  3. Drowsiness
  4. Delusional accusations

Correct Answer: 1

Rationale 1: Crank is a form of methamphetamine that gives rise to feelings of increased energy and euphoria. These are the patient’s impressions and are not based in reality.

Rationale 2: The patient will not display increased strength and coordination.

Rationale 3: Drowsiness is an uncommon finding in an individual who has used crank for the first time.

Rationale 4: Delusional accusations might be made by an individual who has been using crank for a long period.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13-2

 

Question 12

Type: MCSA

A patient admitted with seizures is diagnosed with a perforated nasal septum. The nurse realizes that this patient most likely has abused which substance?

  1. Cocaine
  2. Marijuana
  3. Alcohol
  4. Barbiturates

Correct Answer: 1

Rationale 1: Long-term intranasal use of cocaine is associated with a perforated nasal septum. Severe cocaine overdose can lead to a seizure disorder.

Rationale 2: Seizures and a perforated nasal septum are not associated with marijuana use.

Rationale 3: Seizures and a perforated nasal septum are not associated with alcohol abuse.

Rationale 4: Seizures and a perforated nasal septum are not associated with barbiturate abuse.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13-2

 

Question 13

Type: MCSA

A teenager who is brought to the emergency department by the parents is reported to have taken barbiturates with alcohol. What will be the greatest concern for this patient?

  1. Respiratory depression
  2. Seizure activity
  3. Signs of withdrawal
  4. Hallucinations

Correct Answer: 1

Rationale 1: Barbiturates are central nervous system depressants. Barbiturates and alcohol are a lethal combination. The patient who has ingested both is at risk for varying degrees of sedation, up to coma and death.

Rationale 2: Seizure activity is not the greatest risk for this patient.

Rationale 3: Signs of withdrawal are not the greatest risk for this patient.

Rationale 4: Hallucinations are not the greatest risk for this patient.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13-2

 

Question 14

Type: MCSA

A patient comes to the emergency department with a PCP overdose. Which intervention can the nurse anticipate the patient will require?

  1. Administering a benzodiazepine as prescribed
  2. Inducing vomiting
  3. Assisting with lavage
  4. Administering Narcan as prescribed

Correct Answer: 1

Rationale 1: PCP overdose is associated with possible hypertensive crisis, respiratory arrest, hyperthermia, and seizures. The nurse should anticipate administering a benzodiazepine as prescribed.

Rationale 2: Inducing vomiting is not appropriate treatment for PCP overdose.

Rationale 3: Lavage is not indicated for PCP overdose.

Rationale 4: Narcan is not used to treat PCP overdose.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 13-2

 

Question 15

Type: MCSA

A patient with a history of chronic alcohol abuse is underweight and malnourished. Which drug may be prescribed to manage the patient’s nutritional status?

  1. Vitamin B1
  2. Warfarin
  3. Methadone
  4. Narcan

Correct Answer: 1

Rationale 1: Vitamins, especially B vitamins, are not metabolized well in an alcoholic’s body and must be replenished.

Rationale 2: The administration of warfarin is not indicated for this patient.

Rationale 3: Methadone is prescribed to manage heroin cravings.

Rationale 4: Narcan is used to treat the effects of central nervous system depression.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 13-2

 

Question 16

Type: MCMA

A patient has been using amphetamines for the last 3 years and has been diagnosed with substance dependence. Which statements by the patient are associated with substance dependence?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. “I am so tired and I feel so confused about everything that is happening around me.”
  2. “I have really tried to cut down my use, but I fail miserably every time.”
  3. “The only thing I care about right now is getting my fix.”
  4. “I have to use a lot more right now to get the same high as before.”
  5. “I have a great job where I work full-time as a mechanical engineer, so that part of my life is very fulfilling.”

Correct Answer: 1,2,3,4

Rationale 1: Fatigue and confusion are withdrawal symptoms associated with the use of amphetamines.

Rationale 2: Unsuccessfully attempting to cut down on use of a substance is a behavior associated with substance dependence.

Rationale 3: A focus on obtaining the drug is a behavior associated with substance dependence.

Rationale 4: Persons with substance dependence are likely to develop tolerance to the drug.

Rationale 5: A patient with substance dependence is unlikely to keep a full-time job because of the time required to procure and use the drug. The patient invests less time in occupational activities.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13-3

 

Question 17

Type: MCMA

A patient has been admitted to an addiction detoxification unit. The nurse has educated the patient about the medications that have been prescribed to help with withdrawal symptoms. Which statements by the patient indicate that further education is required?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. “Naltrexone is an antidepressant.”
  2. “The Antabuse will help me with my cravings for heroin.”
  3. “Chlordiazepoxide is also called Librium, and it can help with my anxiety.”
  4. “The phenobarbital will help prevent seizures.”
  5. “I need folic acid and other vitamin supplements because I haven’t eaten well for so long.”

Correct Answer: 1,2

Rationale 1: Naltrexone (ReVia) helps diminish cravings for alcohol and opiates. It is not an antidepressant.

Rationale 2: Antabuse is given to patients to stop the breakdown of alcohol within the body and make the consequences of drinking alcohol more severe. Methadone helps to block heroin cravings.

Rationale 3: Librium can be used to help with anxiety and prevent seizure activity.

Rationale 4: Phenobarbital can help prevent seizure activity.

Rationale 5: Vitamin supplements can help the patient with alcoholism, who has likely developed vitamin deficiencies.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12-03

 

Question 18

Type: MCMA

A patient is exhibiting addictive behaviors and has admitted to using illegal drugs. Which statements by the patient are consistent with addictive behaviors?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. “I think even as a child I didn’t have much self-esteem.”
  2. “When I was in the hospital for appendicitis, they told me they had to give me more pain medication than normal because I was still in pain.”
  3. “Sometimes I steal things from stores just to see if I can get away with it.”
  4. “I like to play it safe. When my friends were bungee jumping off the bridge, I just watched.”
  5. “I have always been very slow to anger.”

Correct Answer: 1,2,3

Rationale 1: People may turn to substance abuse because of low self-esteem.

Rationale 2: Substance abusers are more likely to have a low tolerance for pain.

Rationale 3: Substance abusers are more likely to participate in risky behaviors such as stealing.

Rationale 4: Substance abusers are more likely to participate in risky behaviors such as bungee jumping without regard for social norms or their own safety.

Rationale 5: Substance abusers are more likely to have problems with anger control than others who do not abuse substances.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12-03

 

Question 19

Type: MCMA

The patient has been admitted to the hospital after a motor vehicle accident. The patient states that she frequently smokes “ice” and had smoked some as recently as 2 hours prior to the accident. Which assessment findings are consistent with this information?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. The apical heart rate is 112 beats per minute.
  2. Premature ventricular contractions are noted during electrocardiogram.
  3. The patient weighs 92 pounds and is 5’5” tall.
  4. The patient is complaining of chest pain.
  5. The patient’s blood pressure is 96/72.

Correct Answer: 1,2,3,4

Rationale 1: The patient is likely to exhibit tachycardia.

Rationale 2: The patient is likely to exhibit dysrhythmias.

Rationale 3: Because methamphetamine use suppresses appetite, the patient is likely to be thin.

Rationale 4: Angina is a common complaint among people who use methamphetamines.

Rationale 5: The patient’s blood pressure is likely to be elevated due to the vasoconstriction that is produced by this type of drug use.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12-02

 

Question 20

Type: MCMA

Which assessment findings would the nurse evaluate as indicating substance dependence?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. The patient is exhibiting tolerance.
  2. The patient spends significant amounts of time trying to obtain the substance.
  3. The patient continues to use the substance after acknowledging it is not good for his health.
  4. The patient describes several attempts to control substance use.
  5. The patient continues to use the substance in spite of serious relationship problems.

Correct Answer: 1,2,3,4

Rationale 1: Substance dependence is demonstrated by tolerance to the drug.

Rationale 2: A patient who is dependent on a substance spends a significant amount of time trying to obtain it.

Rationale 3: Substance dependence is demonstrated by continuing to use the substance despite recognition of the associated problems and difficulties.

Rationale 4: The patient has made unsuccessful attempts to cut down or control use of the substance.

Rationale 5: Substance abuse, not dependence, is characterized by continued use despite social and relationship problems.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13-3

 

Question 21

Type: MCMA

The nurse is assessing a patient who reports frequent use of marijuana during her current pregnancy. The nurse would teach the patient about which effects of this drug?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Poor pregnancy outcomes
  2. Bradycardia
  3. Lung damage with long-term use
  4. Diuresis
  5. Increased risk of respiratory cancer

Correct Answer: 1,3,5

Rationale 1: The use of cannabis during pregnancy can cause poor pregnancy outcomes.

Rationale 2: There is no evidence that marijuana use results in bradycardia.

Rationale 3: Lung damage can occur with long-term use.

Rationale 4: Diuresis is not caused by cannabis.

Rationale 5: Persons who use marijuana on a long-term basis have a higher risk of respiratory cancer.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13-2

 

Question 22

Type: FIB

A patient withdrawing from alcohol addiction has an order for diazepam (Valium), 10 mg every 4 hours for four doses, then 5 mg every 4 hours for four doses. The drug comes in a concentration of 5 mg/mL. The patient is given a total of ______ mL.

Standard Text:

Correct Answer: 12

Rationale : The drug comes in 5 mg/mL, and at 10 mg ordered, each dose is 2 mL. 2 mL x four doses = 8 mL. The four doses of 5 mg = 4 mL. 4 + 8 = 12.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13-3

 

Question 23

Type: FIB

A loading dose of magnesium sulfate 4 g is ordered for a patient. The concentration available is 4 g/250 mL to be given over 30 minutes. The IV pump rate will be set at _______ mL/h.

Standard Text:

Correct Answer: 500

Rationale : 4g/30 min = x mL/h. 250mL/30 min = x mL/h. 250 mL/30 min x 2/2 = 500 mL/60 min = 500 mL/h.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13-3

 

Question 24

Type: MCMA

The nurse should ask nonjudgmental questions when assessing a patient for substance abuse. Which questions would be appropriate?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. “On average, how many days a week do you drink or use drugs?”
  2. “How often and how much do you usually use?”
  3. “When you drink alcohol, do you usually drink a pint or a quart?”
  4. “You don’t drink hard liquor, do you?”
  5. “Why in the world did you ever start abusing prescription drugs?”

Correct Answer: 1,2,3

Rationale 1: This question does not make a judgment that the patient does or does not drink.

Rationale 2: This is an open-ended question that does not judge the wisdom of using.

Rationale 3: This statement does not judge the patient for drinking either quantity. It also allows the patient to correct an overstatement.

Rationale 4: This statement may be interpreted as judgmental against “hard liquor.”

Rationale 5: This statement implies a judgment about the patient’s intelligence or self-control.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13-3

 

Question 25

Type: MCSA

A patient tells the nurse that he does not want to attend his wife’s family events because he is expected to drink alcohol and he prefers not to. The nurse realizes this patient is describing behaviors found within which theory of substance disorders?

  1. Sociocultural
  2. Psychological
  3. Biological
  4. Metaphysical

Correct Answer: 1

Rationale 1: In the sociocultural framework, the roles different family members play and the importance of family rituals contribute to the problem of substance abuse and its treatment.

Rationale 2: The psychological theory explains how the psychological underpinnings of experiences and behaviors come together to form motivation to use drugs in a destructive manner.

Rationale 3: The biological theory supports a genetic explanation for substance abuse.

Rationale 4: There is no metaphysical theory for substance abuse.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13-1

 

Question 26

Type: MCSA

A young adult patient tells the nurse that he periodically uses “uppers” to keep awake while studying for college classes, so he does not understand why he has been feeling so depressed lately. How would the nurse interpret what the patient is experiencing?

  1. Expected effects of the drug
  2. Symptoms of a “crash”
  3. Cocaine abstinence syndrome
  4. Hallucinations

Correct Answer: 2

Rationale 1: Depression is not an expected effect of amphetamines when they are used appropriately.

Rationale 2: Tolerance for amphetamines develops rapidly, and withdrawing the substance can lead to a depressive episode or “crash.”

Rationale 3: Cocaine is not described as an “upper.”

Rationale 4: The feeling of depression is not a hallucination.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13-2

 

Question 27

Type: MCSA

The nurse realizes the patient is describing tolerance when the patient makes which statement?

  1. “I think I have the flu. My stomach is upset and my hands are shaking.”
  2. “If I have my drink before I go home, I don’t lose my patience so easily.”
  3. “I had a really good time at the party. At least my friends told me I did, but I don’t remember much of it.”
  4. “I seem to need more alcohol each evening just to unwind.”

Correct Answer: 4

Rationale 1: These symptoms reflect withdrawal from the drug.

Rationale 2: This statement reflects substance abuse.

Rationale 3: This statement reflects substance abuse.

Rationale 4: Tolerance is a cumulative state in which a particular dose of the chemical elicits a smaller response than before. With increasing tolerance, the individual needs higher and higher doses to obtain the desired effects.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13-3

 

Question 28

Type: MCSA

A patient is admitted with symptoms of alcohol withdrawal. Which intervention is the highest priority for this patient?

  1. Encourage verbalization of feelings.
  2. Support respiratory and cardiac status.
  3. Keep the room dimly lit.
  4. Encourage taking fluids by mouth.

Correct Answer: 2

Rationale 1: Encouraging verbalization of feelings is part of the care of patients in alcohol withdrawal but is not the highest priority.

Rationale 2: Substance abusers who are acutely ill are often treated in the medical-surgical unit of a general hospital. Life-threatening physiological symptoms are addressed first. Respiratory and cardiac status should be supported.

Rationale 3: Keeping the room dimly lit to reduce stimuli is important but is not the highest priority.

Rationale 4: Keeping the patient hydrated is important but is not the priority.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 13-2

 

Question 29

Type: MCSA

A patient tells the nurse that he gets off cocaine for a while and then in a few months finds himself “hanging out in the same places” where he knows he can easily get drugs. How should the nurse respond?

  1. “This will happen for the rest of your life. There isn’t anything you can do to change it.”
  2. “This is drug-seeking behavior and is a response to a craving. What can you do instead of going to the places where you can get drugs?”
  3. “This is because you are an addict and need the drugs.”
  4. “Have you considered using a less addictive type of drug instead of the kind you used to use?”

Correct Answer: 2

Rationale 1: The nurse has no way of knowing if this behavior will continue for the rest of the patient’s life. The patient can learn coping mechanisms to replace the drug-seeking behavior.

Rationale 2: The patient is describing drug-seeking behavior. The nurse should suggest ways to cope with the craving by asking what the patient can do instead of going to the places where he knows he can get drugs.

Rationale 3: The nurse should not confront the patient this way.

Rationale 4: The nurse should not suggest that the patient replace one addictive drug with another.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13-3

 

Question 30

Type: FIB

A patient has been admitted to withdraw from alcohol. The patient is agitated and restless and complains of having “the shakes.” The nurse anticipates this patient will experience these effects for at least _____ weeks.

Standard Text:

Correct Answer: 2

Rationale : During alcohol withdrawal, the duration of agitation, restlessness, tremulousness, and inner shakiness is about 2 weeks.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 13-2

 

Osborn, Medical-Surgical Nursing, 2e
Chapter 21

Question 1

Type: MCSA

A patient comes to the clinic complaining of repetitive episodes of sudden severe pain on the right side of the face. The nurse anticipates additional testing for which disorder?

  1. Trigeminal neuralgia
  2. Parkinson’s disease
  3. Bell’s palsy
  4. Myasthenia gravis

Correct Answer: 1

Rationale 1: The cause of trigeminal neuralgia is not known, but contributing factors are recent flulike illness, trauma or infection of the teeth or jaw, and arteriosclerotic changes of an artery close to the nerve. It is manifested by repetitive episodes of sudden severe pain on the affected side of the face.

Rationale 2: The facial symptom associated with Parkinson’s disease is decreased facial movement resulting in a masklike presentation. Severe facial pain is not associated with Parkinson’s disease.

Rationale 3: Bell’s palsy results in paralysis of one side of the face. Severe espisodic facial pain is not associated with Bell’s palsy.

Rationale 4: Myasthenia gravis results in drooping of the eyelid. Severe espisodic facial pain is not associated with myasthenia gravis.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-1

 

Question 2

Type: MCSA

A patient has just been diagnosed with trigeminal neuralgia. What would the nurse teach this patient about treatment for this disorder?

  1. Drugs used to treat seizure disorders are generally effective.
  2. Drug therapy will begin with a trial of antiviral drugs.
  3. The primary treatment focus will be on supporting respiratory function until the condition resolves.
  4. Gargling with hot salt water will help reduce pain and keep tissues moistened.

Correct Answer: 1

Rationale 1: Trigeminal neuralgia is treated by a pharmacologic approach to pain control with anticonvulsants such as carbamazepine (Tegretol).

Rationale 2: There is no evidence that trigeminal neuralgia is a viral illness or that antiviral drugs are indicated.

Rationale 3: Respiratory support is not necessary to treat this condition.

Rationale 4: Contact with hot or cold substances is often a trigger that induces pain and should be avoided.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 21-1

 

Question 3

Type: MCMA

A 25-year-old female is diagnosed with tic douloureux. How should the nurse describe this disorder to the patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. “This condition is also called Bell’s palsy.”
  2. “You are the typical age for onset of this condition.”
  3. “More women than men have this condition.”
  4. “More testing will be necessary.”
  5. “The treatment for this condition is to allow it to run its course, which is typically 5 to 7 days.”

Correct Answer: 3,4

Rationale 1: The other name for this condition is trigeminal neuralgia.

Rationale 2: The condition generally begins after age 40, with the typical onset at 60 to 70 years in approximately 90% of patients.

Rationale 3: This condition affects twice as many women as men.

Rationale 4: Occurrence of this condition in people 20 to 40 years of age may indicate other diseases such as multiple sclerosis.

Rationale 5: This condition does not abate untreated. Pharmacotherapy is necessary. If pharmacotherapy is not successful, surgical treatments are considered.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 21-1

 

Question 4

Type: MCSA

A patient is in the emergency department following a head injury. The nurse would assess for which sign indicating early increased intracranial pressure?

  1. Decreasing level of consciousness
  2. Elevated diastolic blood pressure
  3. Decreasing respiratory rate
  4. Tachycardia

Correct Answer: 1

Rationale 1: The brain is very sensitive to the level of oxygenation. As the pressure inside the skull increases, hypoxia develops, which negatively affects the level of consciousness.

Rationale 2: A change in blood pressure is generally a widening pulse pressure that would include increased systolic blood pressure.

Rationale 3: A change in respiratory rate is a late sign of increased ICP.

Rationale 4: Bradycardia is the most common indicator of increased ICP.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-2

 

Question 5

Type: MCMA

A patient with increased intracranial pressure (ICP) is being repositioned. The nurse would incorporate which actions into this intervention?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Inform the patient regarding what is going to occur during the intervention.
  2. Reposition the patient every 1 to 2 hours.
  3. Accompany each repositioning with passive range-of-motion exercises.
  4. Elevate the head of the bed to 30 degrees.
  5. Manage the repositioning with slow, smooth, and gentle movements.

Correct Answer: 1,4,5

Rationale 1: Patients should always be informed about what is going to occur.

Rationale 2: Position changes should be done less frequently for patients with ICP because turning, skin care, and passive ROM exercises can elicit involuntary posturing, which also causes increased ICP.

Rationale 3: Turning alone can cause an increase of ICP. Care should be spaced over time to avoid this complication.

Rationale 4: The head of the bed should be elevated. The degree depends on the reaction of the patient to the position; 30 degrees is usually appropriate, but this can vary by patient.

Rationale 5: It is especially important that patients with increased ICP be repositioned slowly and with smooth, gentle movements, because rapid changes can cause the pressure to increase.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 21-2

 

Question 6

Type: MCSA

The nurse is caring for a patient with an intracranial pressure monitoring device. What is the priority nursing diagnosis (NDX) for this patient?

  1. Risk for Infection
  2. Ineffective Thermoregulation
  3. Risk for Impaired Skin Integrity
  4. Impaired Physical Mobility

Correct Answer: 1

Rationale 1: The priority NDX for this patient is related to infection. In some cases, such as this one, a risk diagnosis takes priority over actual diagnoses. This patient has an invasive monitoring device in the skull. Infection would be devastating.

Rationale 2: Ineffective Thermoregulation is a very important NDX for this patient, but it is not as important as another NDX.

Rationale 3: The patient does have a break in skin integrity, but this is not the priority NDX.

Rationale 4: The patient is likely to have impairment in physical mobility, but this is not the highest-priority NDX.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 21-2

 

Question 7

Type: MCSA

Decerebrate posturing is present in an unconscious patient following a motor vehicle accident. The nurse expects to see which position?

  1. The arms and legs are hyperextended, and arms are hyperpronated.
  2. The arms are folded over the chest and spasms are rhythmic.
  3. The arms are pulled inward and the head is turned to the side.
  4. The arms and legs have tonic-clonic seizure activity.

Correct Answer: 1

Rationale 1: Decerebrate posture is displayed by hyperextension of the arms and legs and hyperpronation of the arms. Decerebration is considered a sign that the patient has a serious injury with a poor prognosis.

Rationale 2: In decerebrate posture, the arms are hyperextended.

Rationale 3: In decerebrate posture, the arms are hyperextended.

Rationale 4: Tonic-clonic movement is not present in decerebrate posturing.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-2

 

Question 8

Type: SEQ

A patient without a history of previous seizures experiences two tonic-clonic seizures in succession while the nurse is in the patient’s room. List in priority order the actions the nurse should take.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Turn the patient on his or her side.

Choice 2. Protect the patient from environmental harm.

Choice 3. Start oxygen via face mask.

Choice 4. Reorient the patient to time, person, and place.

Correct Answer: 1,2,3,4

Rationale 1: Nursing care of patients during a seizure should first focus on maintaining a patent airway. During a seizure, the tongue may fall back and obstruct the airway, the gag reflex may be depressed, and secretions may pool at the back of the throat. To open and maintain a patent airway, the patient should be turned on his or her side.

Rationale 2: After ensuring the airway is patent, the nurse should protect the patient from harm.

Rationale 3: After the clonic phase of seizure activity, if needed, oxygen can be administered by face mask.

Rationale 4: Consciousness returns gradually. It may take hours before the patient is fully aware and alert and reorientation to person, place, and time can be achieved.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 21-6

 

Question 9

Type: MCSA

Reviewing a patient’s report of laboratory test results (see accompanying box), the nurse realizes that which values are critical for the patient with a decreased level of consciousness?

  1. Glucose and serum osmolality
  2. Sodium and potassium levels
  3. Sodium and white blood cell count
  4. Glucose and white blood cell count

Correct Answer: 1

Rationale 1: Blood glucose is measured immediately when coma or decreased LOC is of unknown origin. When the glucose falls to less than 50 mg/dl, cerebral function declines rapidly and hypoglycemia should be suspected. Serum osmolality of less than 250 mOsm/kg H2O leads to cerebral edema and swelling, impairing consciousness.

Rationale 2: The sodium and potassium levels are normal.

Rationale 3: The sodium and white blood cell count are normal.

Rationale 4: The white blood cell count is normal.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-2

 

Question 10

Type: MCSA

The patient was an unrestrained front-seat passenger in a motor vehicle crash and struck his forehead on the inside of the windshield. Diagnostic testing in the emergency department reveals coup–contrecoup injury. The nurse identifies which area as the contrecoup injury?

  1. The frontal area of the brain
  2. The posterior or occipital part of the brain
  3. Both the anterior and posterior areas of the brain
  4. The midpoint of the brainstem

Correct Answer: 2

Rationale 1: The frontal area is the coup injury.

Rationale 2: The area directly opposite the original injury is where the contrecoup injury occurs.

Rationale 3: Only one of these areas is described as sustaining contrecoup injury.

Rationale 4: The brainstem may be injured due to shearing forces, but it would not be included in the coup-contrecoup designation.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-3

 

Question 11

Type: MCSA

The patient sustains a subdural hematoma after falling. How would the nurse explain this injury to the patient’s family?

  1. “Bleeding has occurred between the skull and the covering of the brain.”
  2. “Bleeding has occurred in the center of the brain.”
  3. “Bleeding has occurred between the layers of the scalp.”
  4. “Bleeding is occurring between the brain and its covering.”

Correct Answer: 4

Rationale 1: Bleeding between the skull and the covering of the brain (dura) is termed epidural.

Rationale 2: Subdural hematoma does not occur in the center of the brain.

Rationale 3: Bleeding between the layers of the scalp creates a hematoma but is not described as subdural.

Rationale 4: A subdural hematoma occurs between the brain and the covering or dura.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 21-3

 

Question 12

Type: MCSA

The nurse anticipates that which medication will be ordered to halt status epilepticus in a patient?

  1. Lorazepam (Ativan) IV
  2. Oral glucose
  3. Phenytoin (Dilantin) orally
  4. Gabapentin (Neurontin) and lamotrigine (Lamictal)

Correct Answer: 1

Rationale 1: Lorazepam (Ativan) can be used IV to stop the seizure and is an appropriate treatment order.

Rationale 2: No drug would be given orally during status epilepticus, although glucose IV might be appropriate.

Rationale 3: The drug must be given IV in this situation, and phenytoin (Dilantin) could be an option if ordered IV.

Rationale 4: The drug therapy used to treat this event uses only one drug at a time.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 21-6

 

Question 13

Type: MCSA

Which nursing diagnosis is most applicable to a patient with new-onset seizures?

  1. Anxiety
  2. Self-Care Deficit
  3. Activity Intolerance
  4. Impaired Mobility

Correct Answer: 1

Rationale 1: Anxiety is related to fear of the unknown in the future as well as to loss of control.

Rationale 2: There is no indication that the patient will not be able to care for him- or herself.

Rationale 3: There is no evidence that the patient will be intolerant of activity.

Rationale 4: There is no evidence that the patient with new-onset seizures will experience an alteration of mobility.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 21-6

 

Question 14

Type: MCSA

The patient was riding in a car that hit a tree. The head hit the windshield, and then the brain rebounded within the skull toward the opposite side. This injury represents which mechanism of injury?

  1. An acceleration-deceleration injury
  2. A penetrating head injury
  3. An acceleration injury
  4. A deceleration injury

Correct Answer: 1

Rationale 1: In an acceleration-deceleration injury, two or more areas of the brain can be injured.

Rationale 2: Penetrating injury occurs when an object disrupts the integrity of the head and skull.

Rationale 3: An acceleration injury occurs when the head is rapidly moved forward such as when a car stops abruptly.

Rationale 4: A deceleration injury occurs when the head hits a stationary object such as a windshield, dashboard, or other object in a car.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-3

 

Question 15

Type: MCSA

Following a fall, a patient is brought to the emergency department. There was a brief loss of consciousness; the patient complains of headache, has vomited twice, has a dilated pupil on the same side as a hematoma over the temporal area, and is currently having a seizure. The nurse prepares to care for this patient based on which evaluation of this assessment?

  1. This is an emergency situation likely involving an epidural hematoma and requires surgery.
  2. This is a controlled situation once the seizure stops.
  3. This is a serious situation in which a subdural hematoma is developing and requires surgery.
  4. This is a typical situation seen with most patients who fall, and symptoms will subside with observation.

Correct Answer: 1

Rationale 1: Classic signs of an epidural hematoma include a loss of consciousness followed by a brief lucid period before rapid deterioration.

Rationale 2: Because this injury involves a skull fracture that tears an artery, the patient is bleeding uncontrollably into the head. The bleeding may continue until herniation occurs. The situation is not controlled.

Rationale 3: A subdural hematoma would be manifested by drowsiness, confusion, and enlargement of the ipsilateral pupil within minutes of the injury. Hemiparesis and changes in respiratory pattern may soon follow.

Rationale 4: The assessments as stated indicate that the patient will require immediate intervention, not simply observation.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 21-3

 

Question 16

Type: MCSA

A patient is having a seizure that involves a blank stare, unresponsiveness to questions, and smacking of the lips. The seizure lasts less than a minute. How would the nurse categorize this seizure?

  1. Absence seizure
  2. Partial seizure
  3. Tonic-clonic seizure
  4. Status epilepticus seizure

Correct Answer: 1

Rationale 1: Absence (or petit mal) seizures involve a blank stare, unresponsiveness to questions, and abnormal behavior such as smacking of the lips.

Rationale 2: A partial seizure involves only one area of the brain. The symptoms displayed are reflective of the area affected and may be muscle contraction of a single body part if the motor cortex is affected. Sensory manifestations may be exhibited by hallucinations or abnormal sensations.

Rationale 3: Tonic-clonic seizures involve generalized contraction coupled with impairment of consciousness.

Rationale 4: Status epilepticus seizures are repetitive, with only very brief calm periods in between.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-6

 

Question 17

Type: MCSA

The patient is supine and the head is flexed to the chest without pain, resistance, or flexion of the hips or knees. The nurse is observing for which finding?

  1. Doll’s eyes reflex
  2. Brudzinski sign
  3. Babinski reflex
  4. Kernig’s sign

Correct Answer: 2

Rationale 1: In the doll’s eyes reflex, the eyes move in the opposite direction in which the head is turned.

Rationale 2: The Brudzinski sign is elicited by placing the patient in a supine position and flexing the neck toward the chest. A positive result would be noted if the patient has pain or flexes the hip or knees in response to the neck flexion. A positive response indicates meningeal irritation.

Rationale 3: The Babinski reflex is the extensor plantar response. An abnormal response is dorsiflexion of the big toe and often a fanning of the other toes.

Rationale 4: To assess for Kernig’s sign, the patient, in the supine position, flexes the hip and extends the leg. Bilateral pain in the hamstring area that prevents straightening of the leg is a positive sign of meningitis.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-4

 

Question 18

Type: MCSA

Which neurologic assessment is being performed in the exhibit?

  1. Kernig’s sign
  2. Babinski reflex
  3. Brudzinski sign
  4. Decorticate posturing

Correct Answer: 3

Rationale 1: To assess for Kernig’s sign, the patient, in the supine position, flexes the hip and extends the leg.

Rationale 2: The Babinski reflex occurs when the big toe moves toward the top of the foot and the other toes fan out after the sole of the foot has been firmly stroked. This reflex is normal in younger children, but abnormal after the age of 2.

Rationale 3: To test for Brudzinski sign, the nurse flexes the patient’s head to the chest with the patient supine. If pain, resistance, or flexion of the hips or knees occurs, this indicates meningeal irritation.

Rationale 4: Patients with decorticate posturing present with the arms flexed or bent inward on the chest, the hands clenched into fists, the legs extended, and the feet turned inward.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-4

 

Question 19

Type: MCSA

The nurse is assessing the patient using the technique shown. What is considered a normal finding using this technique?

  1. Pain only at the hip during flexion
  2. Resistance in the hip joint
  3. A clicking sound in the knee upon flexion
  4. No pain or resistance in either joint

Correct Answer: 4

Rationale 1: Pain in the hip is not normal.

Rationale 2: Resistance in the hip is not normal.

Rationale 3: A clicking sound in the knee is not normal.

Rationale 4: This technique tests for Kernig’s sign. There should be no pain or resistance when doing this maneuver.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-4

 

Question 20

Type: MCSA

A patient has experienced a subarachnoid hemorrhage and is at risk for increased intracranial pressure (ICP) due to the initiation of the vasodilatory cascade. The nurse plans care for this patient to avoid which primary initiating factor?

  1. Vasoconstriction of cerebral vessels
  2. Cerebral tissue ischemia
  3. Decreased cerebral perfusion pressure
  4. Cerebral edema

Correct Answer: 2

Rationale 1: Vasoconstriction of cerebral blood vessels is not a cause of ICP.

Rationale 2: The vasodilatory cascade is a series of events triggered by hypoxia, with the result being increased ICP.

Rationale 3: Depressed cerebral perfusion pressure (CPP) is a decrease in the pressure gradient that drives cerebral blood flow.

Rationale 4: Cerebral edema may be a result of the vasodilatory cascade but is not its cause.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-2

 

Question 21

Type: MCMA

A patient at risk for increased intracranial pressure (ICP) is likely to experience involuntary compensatory mechanisms. The nurse would monitor this patient for signs of which involuntary compensation?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Vasoconstriction of cardiac vessels
  2. Vasodilation of the cerebral vessels
  3. Decreased production of cerebral spinal fluid (CSF)
  4. Decreased metabolic energy needs
  5. Increased absorption of cerebral spinal fluid (CSF)

Correct Answer: 3,4,5

Rationale 1: Vasoconstriction of cardiac vessels is not a normal compensatory mechanism for ICP.

Rationale 2: Vasoconstriction of the cerebral blood vessels results as space becomes compressed.

Rationale 3: For the brain to maintain a normal ICP, attempts are made to compensate for changes in any of the three components within the brain. Initial mechanisms for ICP may include changing the volume of CSF by decreasing production.

Rationale 4: Autoregulation can help maintain adequate tissue perfusion by adjusting metabolic needs.

Rationale 5: For the brain to maintain a normal ICP, attempts are made to compensate for changes in any of the three components within the brain. Initial mechanisms for ICP may include changing the volume of CSF by increasing absorption.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-2

 

Question 22

Type: MCSA

A patient with a right temporal lobe hematoma is displaying Cheyne-Stokes respirations. How should this nurse interpret this assessment finding?

  1. The next sign will likely be sluggish pupil reaction ipsilaterally.
  2. This type of brain pathophysiology is usually self-limiting.
  3. This patient requires surgical decompression of the brain.
  4. There is no medical treatment appropriate for this symptomology.

Correct Answer: 3

Rationale 1: This patient is experiencing a symptom of uncal herniation. Cheyne-Stokes respiration is a late sign. Ipsilateral pupillary changes would have already occurred.

Rationale 2: Herniation syndromes are life-threatening neurologic emergencies that, left untreated, can progress rapidly to death.

Rationale 3: Urgent surgical intervention to decompress the brain is often the treatment of choice.

Rationale 4: Urgent medical treatment may correct the condition causing this symptomology.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-3

 

Question 23

Type: MCSA

A 2-year-old child fell and sustained a scalp laceration that will require suturing. The parents ask the nurse, “How serious an injury is this?” How should the nurse respond?

  1. “There is a lot of bleeding, but it is really a rather superficial injury.”
  2. “From the description of the fall it doesn’t appear serious, but the X-ray will tell us for sure.”
  3. “He’ll need a few stitches and a tetanus injection, but that should do it.”
  4. “Children this age are really resilient, but you never know until the X-rays are read.”

Correct Answer: 2

Rationale 1: Telling the parents that the wound is superficial without the benefit of radiological confirmation is inappropriate.

Rationale 2: Scalp lacerations account for a large number of emergency department visits and are usually not serious, but with any scalp laceration, the possibility of an underlying skull fracture must be addressed. An accurate history of the event surrounding the injury is very important. If there is any reason to suspect a skull fracture, a computerized tomography (CT) scan or a plain X-ray of the skull should be obtained.

Rationale 3: Stating that a few stitches and a tetanus injection are all that is needed is minimizing the potential extent of the injury.

Rationale 4: Stating that children are resilient is minimizing the parents’ concern.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 21-3

 

Question 24

Type: MCMA

Which observations by the nurse are representative of the symptomology of an epidural hematoma (EDH)?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. History of unconsciousness immediately after trauma
  2. Muscle weakness on the side opposite the head injury
  3. Rapid deterioration in level of consciousness
  4. Period of lucidity prior to onset of symptoms
  5. Dilated pupil on the same side as the injury

Correct Answer: 1,3,4,5

Rationale 1: The classic clinical presentation of EDH is characterized by an immediate posttraumatic period of unconsciousness, followed by a lucid interval, which can last from minutes to hours.

Rationale 2: Hemiparesis (muscle weakness) of the contralateral arm and leg (opposite side from the injury) may be present with an acute subdural hematoma.

Rationale 3: A rapid deterioration in the level of consciousness may occur unexpectedly.

Rationale 4: The classic clinical presentation of EDH is characterized by an immediate posttraumatic period of unconsciousness, followed by a lucid interval, which can last from minutes to hours.

Rationale 5: Possible signs and symptoms include an enlarging pupil on the same side as the injury (ipsilateral).

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-3

 

Question 25

Type: MCMA

A patient is recovering from a lumbar puncture, and the nurse is concerned that the patient may contract bacterial meningitis. The nurse should be alert for which common early symptoms?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Fever
  2. Seizures
  3. Rhinorrhea
  4. Headache
  5. Confusion

Correct Answer: 1,2,4,5

Rationale 1: Fever is a common and early symptom of meningitis.

Rationale 2: Seizures are a common and early symptom of meningitis.

Rationale 3: Patients with skull fractures may experience rhinorrhea, which is the leaking of cerebral spinal fluid via the nose.

Rationale 4: Headache is a common and early symptom of meningitis.

Rationale 5: Confusion is a common and early symptom of meningitis.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-4

 

Question 26

Type: MCSA

A patient is being admitted for possible early-stage viral meningitis. The nurse would assess for which significant findings to help confirm the diagnosis?

  1. A history of flulike symptoms resolving 5 days ago
  2. Sluggish pupils bilaterally
  3. Blood pressure of 100/62
  4. A cervical lymph node palpable on physical examination

Correct Answer: 1

Rationale 1: The presence of systemic viral infections such as a “flulike” illness is significant and may indicate the original source of the viral invasion.

Rationale 2: Sluggish pupils are not associated with viral meningitis.

Rationale 3: Decreased blood pressure is not an early finding of meningitis.

Rationale 4: The presence of a palpable cervical lymph node would not raise suspicion of viral meningitis.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-4

 

Question 27

Type: MCSA

A patient has been diagnosed with a grade 1 astrocytoma, an intra-axial brain tumor. The patient asks, “What are my chances of surviving this thing?” The nurse’s response is based on which information?

  1. A grade 1 astrocytoma is a very aggressive form of this type of tumor.
  2. It depends on whether the tumor metastasizes outside the brain.
  3. Age is the greatest predictor of patient survival.
  4. This type of tumor has a survival rate of 10 years.

Correct Answer: 3

Rationale 1: A grade 1 astrocytoma is not the most aggressive form of this cancer.

Rationale 2: Although astrocytomas may spread into surrounding normal brain tissue, it is rare for them to spread outside the brain and CSF system.

Rationale 3: The strongest predictor of survival with low-grade (grades 1 and 2) astrocytoma is age. One study reported a mean survival time of 8.5 years for adults less than 40 years of age; this contrasts with 4.9 years for adults 40 years of age and older.

Rationale 4: Approximately 75% of patients with this type of tumor die within 5 years.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 21-5

 

Question 28

Type: MCSA

A patient has had a surgical resection of an acoustic neuroma. The nurse would prioritize which postoperative assessment?

  1. Timing how long it takes for tinnitus to return
  2. Measuring urine output hourly
  3. Determining the degree of hearing loss
  4. Identifying damage to cranial nerves VII, IX, X, and XII

Correct Answer: 4

Rationale 1: Acoustic neuromas cause tinnitus. It is not expected to return after surgery.

Rationale 2: Decreased urine output is not an expected effect of this surgery. Hourly outputs may be ordered because the patient is being given intravenous fluids, but this measurement is not the highest priority.

Rationale 3: Acoustic neuromas usually are diagnosed when the patient experiences gradual hearing loss. Hearing loss would not continue to progress.

Rationale 4: Surgical resection of acoustic neuromas can cause damage to cranial nerves in proximity to the tumor. Damage to cranial nerves VII, IX, X, and XII is possible. Therefore, a thorough cranial nerve assessment is important, both preoperatively and postoperatively.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-5

 

Question 29

Type: MCSA

A patient has been diagnosed with a pituitary adenoma. Which assessment finding supports that it is a nonfunctioning form?

  1. 20/60 vision using a Snellen chart
  2. A round, moon-shaped face
  3. A protruding lower jaw
  4. Report of insomnia

Correct Answer: 1

Rationale 1: Nonfunctioning pituitary adenomas produce symptoms caused by pressure of the tumor on surrounding structures, such as the optic nerve. Frequently, visual loss is the presenting symptom, sometimes in the form of decreased acuity.

Rationale 2: Functioning pituitary adenomas produce endocrine symptoms such as a moon-shaped face.

Rationale 3: A protruding lower jaw is not associated with a nonfunctioning pituitary adenoma.

Rationale 4: Insomnia is not associated with a nonfunctioning pituitary adenoma.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-5

 

Question 30

Type: MCSA

A patient diagnosed with a benign brain tumor is scheduled for gamma knife surgery. How would the nurse explain this procedure?

  1. “A radioactive seed or capsule will be implanted into the tumor.”
  2. “A robotic arm device will deliver multiple beams of radiation to the tumor.”
  3. “This is the traditional method of delivering radiation to a tumor.”
  4. “The gamma knife is a method of delivering a focused dose of radiation at your tumor.”

Correct Answer: 4

Rationale 1: Brachytherapy is the surgical implantation of radioactive capsules, or “seeds,” directly into the tumor bed.

Rationale 2: Cyber knife radiosurgery is a radiosurgical system that consists of a robotic arm used to deliver multiple beams of radiation.

Rationale 3: The gamma knife is not the traditional method of delivering radiation to a tumor.

Rationale 4: Gamma knife radiosurgery is a system that uses focused radiation in a single dose.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 21-5

 

Question 31

Type: MCSA

A patient diagnosed with a brain tumor is reluctant to agree to a surgical excision of the lesion. How can the nurse best address the patient’s concerns?

  1. Notifying the neurosurgeon of the patient’s concerns
  2. Assuring the patient that the procedure is necessary
  3. Providing detailed written information on the benefits of the proposed procedure
  4. Asking the patient to be more specific about the concerns

Correct Answer: 4

Rationale 1: The neurosurgeon may be notified of the concern if it is outside the nurse’s scope of responsibility.

Rationale 2: Merely assuring the patient about the necessity of the procedure does not address the patient’s concerns.

Rationale 3: While written reinforcement of the information is appropriate, the patient needs personal involvement on the part of the nurse to address specific concerns.

Rationale 4: The nurse has a responsibility to help address the patient’s concerns, but this cannot be done until the nurse fully understands those concerns.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 21-5

 

Question 32

Type: MCSA

A patient has developed severe postsurgical muscle weakness in the lower extremities after the removal of a brain tumor. The nurse takes which initial intervention to minimize the patient’s risk of developing a deep vein thrombosis (DVT)?

  1. Ask the patient questions to determine if there is a history of DVT.
  2. Add regular leg massages to the patient’s care plan.
  3. Instruct the patient to perform leg exercises at least twice daily.
  4. Apply well-fitted antiembolism hose.

Correct Answer: 4

Rationale 1: Determining whether the patient has a history of DVT is not the priority intervention.

Rationale 2: Massaging the legs is not an appropriate nursing intervention and may result in serious injury to the patient.

Rationale 3: The patient with this level of muscle weakness is not capable of performing leg exercises.

Rationale 4: The use of antiembolism hose or pneumonic stockings is highly recommended, and they should be applied as soon as possible. The hose must fit correctly to be effective.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 21-5

 

Question 33

Type: FIB

A nurse is providing care to a patient with increased intracranial pressure following a closed head injury. The nurse would determine that adequate cerebral perfusion pressure exists if the CPP is at least ____.

Standard Text:

Correct Answer: 50

Rationale : A CPP of at least 50 is required for adequate cerebral perfusion. The preferred CPP is 60.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 21-6

 

Question 34

Type: MCMA

The nurse is planning a community education session regarding prevention of traumatic brain injury (TBI). The nurse would discuss which risk factors?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Age over 65
  2. Male gender
  3. Age under 18
  4. High alcohol intake
  5. Serving in the military

Correct Answer: 2,4,5

Rationale 1: The risk of TBI becomes higher at age 70.

Rationale 2: Males suffer twice as many TBIs as women.

Rationale 3: The age group with the highest risk is adults 18 to 25 years old.

Rationale 4: High alcohol intake is a risk factor for TBI.

Rationale 5: Military service increases the risk of TBI.

Global Rationale:

 

Cognitive Level:

Client Need:

Client Need Sub:

Nursing/Integrated Concepts:

Learning Outcome: 21-3

 

Question 35

Type: MCSA

A patient is being tested for bacterial meningitis. Which finding would the nurse evaluate as supporting that diagnosis?

  1. The CSF is negative for glucose.
  2. CSF is high in sodium.
  3. The CSF is turbid in appearance.
  4. The potassium level in the CSF is low.

Correct Answer: 3

Rationale 1: Glucose is present in the CSF in both viral and bacterial meningitis.

Rationale 2: The sodium level in CSF is not associated with meningitis.

Rationale 3: When bacteria are present in the CSF, the fluid is cloudy and turbid.

Rationale 4: The potassium level of the CSF is not associated with meningitis.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-4

Osborn, Medical-Surgical Nursing, 2e
Chapter 31

Question 1

Type: MCSA

The nurse is in orientation for a new job caring for patients in the intensive care area. Which statement indicates to the preceptor that the new nurse needs more information about hemodynamic monitoring?

  1. “Data from hemodynamic monitoring can be used to evaluate the patient’s progress.”
  2. “Hemodynamic monitoring data can help to guide fluid administration and prevent fluid overload.”
  3. “Hemodynamic monitoring data can be used to aid in the diagnosis of lung disorders.”
  4. “One drawback of hemodynamic monitoring is that the catheter must go through the heart and into the pulmonary artery.”

Correct Answer: 4

Rationale 1: One of the purposes of hemodynamic monitoring is evaluating patient response to therapy.

Rationale 2: One of the purposes of hemodynamic monitoring is guiding therapy to minimize or correct dysfunction.

Rationale 3: Hemodynamic monitoring can help to diagnose and treat a number of disorders, including disorders of the lung.

Rationale 4: The pulmonary artery catheter does go through the heart and into the pulmonary artery; however, hemodynamic monitoring can also be accomplished through a peripheral arterial line.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 31-1

 

Question 2

Type: MCSA

A family member of a critically ill patient is verbalizing the purpose of hemodynamic monitoring. Which statement indicates that the family member needs more education?

  1. “The hemodynamic monitor can measure how much blood is in the arteries and veins.”
  2. “The hemodynamic monitor can measure how much blood comes out of the heart each minute.”
  3. “The hemodynamic monitor can measure how much oxygen is left in the blood after it circulates through the body.”
  4. “The hemodynamic monitor can measure how much pressure is in the heart.”

Correct Answer: 1

Rationale 1: The pressure monitoring can see trends in pressure, which may indirectly be related to volume or to decreased vascular resistance. The nurse and physician would need to interpret this data to determine the cause of the change.

Rationale 2: An example of such a measurement is thermodilution cardiac output.

Rationale 3: An example of such a measurement is continuous mixed venous oxygen saturation.

Rationale 4: An example of such a measurement is pulmonary artery occlusion pressure (PAOP), an indirect measurement of left ventricular end-diastolic pressure.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 31-1

 

Question 3

Type: MCSA

A patient is concerned about the arterial line waveform pattern because there is a break in the downward slope of the pattern and “something must be wrong” because it is not a smooth line. What is the nurse’s best response?

  1. “What you are seeing is called a dicrotic notch, and it means the beginning of the resting phase of your heart.”
  2. “It is nothing for you to be concerned about. It is just a measurement of your blood pressure.”
  3. “You are right. I will see if you are prescribed any medication for that problem.”
  4. “You are seeing the strongest part of your heart muscle, which is the first number of a blood pressure reading.”

Correct Answer: 1

Rationale 1: The dicrotic notch represents closure of the aortic valve and distinguishes the beginning of diastole or the resting phase of the heart ventricles.

Rationale 2: The nurse should not minimize the patient’s concern.

Rationale 3: The nurse should not agree with the patient or suggest that the patient might need medication.

Rationale 4: The dicrotic notch does not signify the first number of a blood pressure reading.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-1

 

Question 4

Type: MCSA

The role of the nurse who is caring for a patient with invasive hemodynamic monitoring includes which important interventions?

  1. Keeping IV solutions at atmospheric pressure so the monitor obtains accurate patient pressures
  2. Frequent reassessment and evaluation of data in order to tailor therapies to the patient
  3. Using the hemodynamic line for monitoring pressures and not for infusing IV fluids
  4. Zero referencing the transducer to the level of the radial artery

Correct Answer: 2

Rationale 1: IV solutions are kept at 300 mmHg.

Rationale 2: An important nursing intervention is the frequent reassessment and evaluation of data in order to tailor therapies to the patient. Fluids and medications are often changed when the nurse reports changes in hemodynamic data to the health care provider.

Rationale 3: Fluids are infused constantly through the system to prevent clotting of the line.

Rationale 4: The hemodynamic transducer is zeroed using the phlebostatic axis as a reference.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-2

 

Question 5

Type: MCSA

A patient with an arterial line has just been turned and repositioned. After leveling the transducer, what should the nurse do next?

  1. Turn the stopcock closest to the patient to the neutral position.
  2. Zero the transducer.
  3. Increase the arterial line infusion to 5 mL/hour.
  4. Prime the transducer system.

Correct Answer: 2

Rationale 1: The stopcock is turned to the neutral position after the transducer has been zeroed.

Rationale 2: The transducer should be zeroed after turning the patient, once the transducer has been leveled.

Rationale 3: The arterial line infusion should be set at 1 to 3 mL/hour.

Rationale 4: Priming the transducer system ensures that air bubbles are removed from the system. This is done prior to leveling the transducer.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-4

 

Question 6

Type: MCSA

When comparing arterial, central venous, and pulmonary arterial pressures, the nurse keeps which factor in mind?

  1. It is not a good idea to measure the patient’s blood pressure from the arterial waveform tracing.
  2. The pressures in the superior and inferior vena cava are lower than the pressure in the right atrium of the heart.
  3. The normal pressure in the right atrium of the heart is very low, 4 to 6 mmHg.
  4. The small vessels of the pulmonary arteries are under more pressure than systemic arterial blood pressure.

Correct Answer: 3

Rationale 1: The arterial waveform tracing is an accurate way to measure blood pressure.

Rationale 2: The normal pressure in the right atrium of the heart is equal to the pressures in the superior and inferior vena cava because there is no valve between the vena cava and the right atrium.

Rationale 3: The normal pressure in the right atrium of the heart is very low, 4 to 6 mmHg.

Rationale 4: Pulmonary arterial pressure is normally lower than systemic arterial blood pressure.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-2

 

Question 7

Type: MCSA

A critically ill patient is admitted for the treatment of sepsis. The right arterial BP is 90/60, the central venous pressure is 2, and the pulmonary arterial pressure is 20/8. What assessment can the nurse make from this data?

  1. The patient may require additional fluids because all pressures are low.
  2. The pressure in the lungs is high even though the other pressures are low. The doctor should be notified and stat X-ray expected.
  3. The patient is stable and should continue to be monitored hourly because of the sepsis.
  4. The line should be flushed and rezeroed before an evaluation can be made.

Correct Answer: 1

Rationale 1: The arterial, central venous, and pulmonary arterial pressures are all low. Sepsis is a type of distributive shock. The nurse would expect to give a fluid bolus in this situation as well as initiate or continue other therapies for sepsis.

Rationale 2: The pressure in the lungs is not high.

Rationale 3: These pressures do not reflect stability. An intervention is indicated.

Rationale 4: The assessment does not indicate a need to flush and rezero the equipment.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-3

 

Question 8

Type: MCSA

Which information is essential for the nurse to keep in mind when monitoring a patient’s central venous pressure?

  1. It is better to look at current numbers for central venous pressure monitoring rather than trends.
  2. Central venous pressure is a direct measurement of systemic vascular resistance.
  3. A decreasing trend in central venous pressure may indicate right heart failure.
  4. An increasing trend in central venous pressure may result from fluid building in the lungs.

Correct Answer: 4

Rationale 1: It is more accurate to look at trends than at one CVP reading.

Rationale 2: CVP is not a direct measurement of systemic vascular resistance.

Rationale 3: Right heart failure would cause an increasing CVP.

Rationale 4: As pressure in the lungs increases, volume in the right heart will increase, which will increase the CVP.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 31-5

 

Question 9

Type: MCSA

The nurse is preparing to inflate a pulmonary artery catheter (PAC) balloon while it is located in the pulmonary artery. What assessment is possible from this action?

  1. When inflated, the catheter indirectly measures pressures in the left side of the heart.
  2. When inflated, the catheter measures the pressure in the right side of the heart.
  3. When inflated, the catheter indirectly measures the cardiac index.
  4. When inflated, the catheter measures cardiac output through thermodilution.

Correct Answer: 1

Rationale 1: Inflating the balloon in the pulmonary artery catheter indirectly measures pressures in the left side of the heart.

Rationale 2: Inflating the balloon in the pulmonary artery catheter measures other pressures.

Rationale 3: The cardiac index is the cardiac output divided by the body surface area.

Rationale 4: Cardiac output is measured though a thermistor within the catheter.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-4

 

Question 10

Type: MCSA

A patient’s central venous pressure reading is 8 mmHg. The nurse understands this reading reflects which physiological parameter?

  1. The blood pressure within the right atrium
  2. The blood pressure within the pulmonary artery
  3. The blood pressure within the left ventricle
  4. The blood pressure within the left atrium

Correct Answer: 1

Rationale 1: The central venous pressure reflects the blood pressure of the vena cava and the right atrium.

Rationale 2: The central venous pressure does not reflect pressures with the pulmonary artery.

Rationale 3: The central venous pressure is not the same as left ventricular pressure.

Rationale 4: The central venous pressure is not the same as left atrial pressure.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-3

 

Question 11

Type: MCSA

The nurse caring for a patient with hemodynamic monitoring would collaborate with a physician colleague to implement which intervention?

  1. Changing the dosages (titrating) of medications based on changes in hemodynamic pressures
  2. Using sterile technique to clean the site of insertion of the catheter and changing the dressing
  3. Inflating the balloon in the pulmonary artery to obtain pulmonary artery occlusion pressures
  4. Advancing the catheter if the radiologist determines it is not in the pulmonary artery

Correct Answer: 4

Rationale 1: It is within the nurse’s scope of practice to titrate medications based on patient response to therapy.

Rationale 2: Cleaning and dressing the insertion site of a hemodynamic catheter is within the nurse’s scope of practice.

Rationale 3: Inflating the pulmonary artery catheter balloon to obtain pressure readings is within the nurse’s scope of practice.

Rationale 4: The nurse does not advance the catheter through the heart.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-4

 

Question 12

Type: MCSA

While caring for a patient with a right radial arterial line, the nurse assesses that the fingers of the right hand are cool, pale, and dusky. Which intervention would be important to do first?

  1. Obtain a blood pressure in the left arm.
  2. Try to obtain a pulse using Doppler ultrasound.
  3. Notify the physician stat.
  4. Flush the arterial catheter and zero the line.

Correct Answer: 3

Rationale 1: Obtaining a blood pressure will not affect the outcome of this emergency situation.

Rationale 2: The patient is exhibiting symptoms of arterial compromise. Even if a pulse is obtainable with Doppler, it is obvious that emergency action must be taken.

Rationale 3: The health care provider must be notified stat, and the line needs to be discontinued. Symptoms including cool, pale, and dusky skin indicate arterial occlusion, and this is a medical emergency. Loss of arterial circulation will cause loss of the limb distal to the occlusion unless circulation can be restored.

Rationale 4: Flushing the arterial catheter and zeroing the line will not be sufficient intervention in this situation.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-4

 

Question 13

Type: MCSA

While caring for a patient with a pulmonary arterial catheter, the nurse notes that the number of centimeters of exposed catheter has decreased. What nursing action is indicated?

  1. Report this finding immediately; the patient may need another chest X-ray to check for placement.
  2. Flush the ports.
  3. Obtain a pulmonary artery occlusion pressure.
  4. Zero balance the system.

Correct Answer: 1

Rationale 1: The distance the catheter is inserted should be documented and serves as a reference to other care providers. If the length changes, the change should be reported immediately because it could mean that the catheter has advanced and could puncture a structure within the vasculature.

Rationale 2: If the catheter is not in correct position, flushing the ports is contraindicated.

Rationale 3: If the catheter is not in the correct position, readings are inaccurate. This is not the priority intervention.

Rationale 4: There is no reason to zero balance the system at this time.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-4

 

Question 14

Type: MCSA

The nurse has noted increasing afterload in a patient in the ICU. How would the nurse expect this increase to affect the patient’s cardiac output?

  1. If afterload is high, cardiac output will be increased because the heart rate increases during afterload.
  2. If afterload is high, cardiac output will be increased due to the increased volume in the heart.
  3. If afterload is high, cardiac output will be decreased due to high systemic vascular resistance.
  4. If afterload is high, cardiac output will be decreased due to decreased contractility.

Correct Answer: 3

Rationale 1: Afterload is a measure of pressure, not a cardiac event, so to say that heart rate increases during afterload is incorrect.

Rationale 2: If the increased volume in the heart has to overcome additional systemic vascular resistance (afterload), the cardiac output will not increase.

Rationale 3: Afterload measures the pressure that is needed to eject blood out of the heart. Systemic vascular resistance is the main factor that affects afterload. High resistance impedes flow and decreases cardiac output.

Rationale 4: Contractility may increase with high afterload to compensate for low stroke volume, or it may decrease if the patient decompensates. Either way, decreased contractility does not cause high afterload.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-5

 

Question 15

Type: MCSA

The nurse is attempting to increase contractility to improve cardiac output in a patient with acute exacerbation of heart failure. Which measure would be helpful to improve cardiac contractility?

  1. Administering magnesium sulfate
  2. Encouraging the patient to exercise
  3. Giving the patient a beta-adrenergic blocking medication
  4. Correcting oxygenation and mild respiratory acidosis

Correct Answer: 4

Rationale 1: Magnesium sulfate is a smooth muscle relaxer and would not increase cardiac contractility.

Rationale 2: Encouraging exercise in a patient with acute exacerbation of heart failure is an unsafe intervention.

Rationale 3: Beta-adrenergic blocking medication would decrease cardiac contractility.

Rationale 4: Achieving normal oxygenation and correcting acidosis would improve cardiac contractility.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-5

 

Question 16

Type: MCSA

A patient has been diagnosed with an increase in afterload and a CVP reading of 7 mmHg. What should the nurse include in this patient’s plan of care?

  1. Provide plasma.
  2. Provide intravenous fluids.
  3. Provide diuretic therapy as prescribed.
  4. Encourage an increase in fluids by mouth.

Correct Answer: 3

Rationale 1: Plasma might be indicated for a patient who is diagnosed with a decrease in preload and hypovolemia.

Rationale 2: Intravenous fluids might be indicated for a patient who is diagnosed with a decrease in preload and hypovolemia.

Rationale 3: Excessive preload is evidenced by a CVP reading of greater than 6 mmHg. The patient has excessive circulation, which strains the heart, increases the workload of the heart, and increases myocardial oxygen demands. Diuretic therapy would be indicated for this patient.

Rationale 4: Oral fluids might be indicated for a patient who is diagnosed with a decrease in preload and hypovolemia.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 31-5

 

Question 17

Type: MCSA

The nurse is caring for a patient who has invasive hemodynamic monitoring. What is the nurse’s highest priority of care for this patient?

  1. Prevent infection at the catheter site by changing the dressing as prescribed.
  2. Set alarm limits and turn monitor alarms on.
  3. Explain to family members why the monitoring is in use.
  4. Coil IV tubing on the bed.

Correct Answer: 2

Rationale 1: Prevention of infection by changing dressings is important but not the priority of care.

Rationale 2: Alarms should never be turned off as they are safety devices that warn of a disconnected line or hemodynamic instability. When an alarm sounds, the nurse should always investigate the cause.

Rationale 3: Keeping family members informed about monitoring is important, but not the priority of care.

Rationale 4: Coiling the IV tubing on the bed is contraindicated.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-4

 

Question 18

Type: MCSA

The patient in the critical care area has an invasive hemodynamic pressure monitoring line. Where would the nurse mark the patient’s phlebostatic axis?

  1. Fourth intercostal space, halfway between the left anterior and posterior chest walls
  2. Fifth intercostal space, midclavicular line
  3. Second intercostal space at the anterior chest wall
  4. Right side of sternum just below the sternal notch

Correct Answer: 1

Rationale 1: The phlebostatis axis is marked halfway between the left anterior and posterior chest walls (midaxillary line) at the fourth intercostal space.

Rationale 2: The fifth intercostal space, midclavicular line, is the position of the apex of the heart and is where auscultation for the apical pulse should be performed.

Rationale 3: The second intercostal space is too high to use as a landmark for the atrium.

Rationale 4: The right side of the sternum just below the sternal notch is the location of the second intercostal space.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-4

 

Question 19

Type: MCSA

The nurse is caring for a patient in the critical care area whose fluid volume status needs to be assessed closely. The nurse would expect which type of monitoring to be used?

  1. Arterial pressure monitoring
  2. Pulmonary artery pressure monitoring
  3. Central venous pressure monitoring
  4. Intra-aortic balloon pump monitoring

Correct Answer: 3

Rationale 1: Arterial pressure monitoring would not measure central venous pressure, which is essential for monitoring fluid volume status.

Rationale 2: Fluid volume can be monitored effectively with equipment that is less invasive than a pulmonary artery pressure monitor.

Rationale 3: Central venous pressure (CVP) monitoring can be accomplished with a central IV line and an IV pump or a monitoring system. It would be the least complicated method to monitor fluid status.

Rationale 4: An intra-aortic balloon pump would not be used for pressure monitoring.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 31-1

 

Question 20

Type: MCSA

The intensive care unit nurse would expect pulmonary artery (PA) catheter monitoring to be used with a patient in which situation?

  1. Cannot tolerate hemodynamic monitoring
  2. Requires a peripheral intravenous catheter for vasoactive medication administration
  3. Needs a central catheter for total parenteral nutrition
  4. Requires evaluation of left ventricular pressures each shift

Correct Answer: 4

Rationale 1: PA catheters are a form of hemodynamic monitoring.

Rationale 2: The PA would not be used to administer vasoactive medications because it is a central arterial catheter, not a peripheral line.

Rationale 3: A PA catheter is not necessary to infuse total parenteral nutrition.

Rationale 4: Pulmonary artery (PA) catheters can be used to evaluate pulmonary artery and left ventricular pressures, measure cardiac output, and manipulate fluid volume status in acutely ill patients.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-1

 

Question 21

Type: FIB

A patient’s vital signs are heart rate 82, respirations 22, and blood pressure 90/52. If hemodynamic monitoring reveals the patient’s cardiac output to be 5330 mL/min, the nurse would calculate that stroke volume is _____ mL.

Standard Text:

Correct Answer: 65

Rationale : Cardiac output is equal to heart rate times stroke volume: 82x = 5330; x = 65.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-3

 

Question 22

Type: MCMA

The nurse wishes to calculate a patient’s cardiac index. Which patient information will the nurse require for this calculation?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Age
  2. Weight
  3. Temperature
  4. Height
  5. Cardiac output

Correct Answer: 2,4,5

Rationale 1: Age is not a determinant of cardiac index.

Rationale 2: Weight is used to determine body surface area, which is used to calculate cardiac index.

Rationale 3: Temperature is not a determinant of cardiac index.

Rationale 4: Height is used to determine body surface area, which is used to calculate cardiac index.

Rationale 5: Cardiac output is used to calculate cardiac index.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-3

 

Question 23

Type: MCSA

Which finding would suggest to the nurse that the patient has a good cardiac reserve?

  1. The patient is able to tolerate a gradual increase of pace during a treadmill exam.
  2. The patient breathes in through the nose and out through the mouth when sitting quietly.
  3. After cardiac rehabilitation exercises the patient sits in a chair to cool down.
  4. The patient complains of pain in the legs after walking 100 yards.

Correct Answer: 1

Rationale 1: The heart’s ability to respond to the body’s changing need for cardiac output is called cardiac reserve. Increasing the pace of walking would place demand on the heart to increase blood flow.

Rationale 2: This action does not represent a physical demand on the heart and therefore does not test cardiac reserve.

Rationale 3: This action takes place after exercise so it does not represent a demand on the heart and does not test cardiac reserve.

Rationale 4: This physical demand results in intermittent claudication, but is not associated with cardiac reserve.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-3

 

Question 24

Type: MCMA

The nurse educator is discussing hemodynamic monitoring with newly hired intensive care unit nurses. Which information regarding the importance of leveling the hemodynamic transducer should the educator provide?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. The level of the transducer is set when the central venous catheter is initiated and should not be moved.
  2. If the transducer is too high, pressure readings will be decreased.
  3. The physician must be called in to level the transducer.
  4. The transducer should be leveled with the phlebostatic axis point.
  5. It the transducer is too low, the readings will be increased.

Correct Answer: 2,4,5

Rationale 1: The transducer should be leveled each time the patient is repositioned.

Rationale 2: A transducer that is set above the phlebostatic axis will result in pressure readings that are lower than actual readings.

Rationale 3: Leveling the transducer is a nursing responsibility.

Rationale 4: The phlebostatic axis point serves as a reference for the level of the transducer.

Rationale 5: A transducer that is set below the phlebostatic axis will result in pressure readings that are higher than actual readings.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-5

 

Question 25

Type: MCMA

Which actions are correct when the nurse is performing the Allen’s test?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Occlude the radial artery and, after 15 seconds, occlude the ulnar artery.
  2. Ask the patient to hold the hand below waist level for 30 seconds before beginning the test.
  3. Release pressure over the ulnar artery first.
  4. Hold pressure on the radial artery for 30 seconds before assessing the hand.
  5. Consider color return to the hand in 20 seconds as a negative test.

Correct Answer: 3,5

Rationale 1: The arteries are occluded at the same time.

Rationale 2: The patient should be asked to hold the hand above the head.

Rationale 3: After the patient releases the fist, the nurse releases pressure on the ulnar artery.

Rationale 4: Holding pressure on the radial artery for 30 seconds is not part of the Allen’s test.

Rationale 5: In this case a negative result indicates the superficial palmar arch is not intact. Color return that takes over 15 seconds is considered a negative result.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-4

 

Question 26

Type: MCMA

Which actions would the nurse take when removing a radial artery catheter?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Don a sterile gown, sterile gloves, and eye protection.
  2. Send the tip of the catheter to the laboratory for culture and sensitivity.
  3. Remove the dressing.
  4. Apply direct pressure to the insertion site after the catheter is removed.
  5. Plan frequent observation of the site after removal of the catheter.

Correct Answer: 3,4,5

Rationale 1: The nurse should wear clean gloves and eye protection. A gown may be worn, but it does not have to be sterile.

Rationale 2: Routine cultures of catheter tips are no longer recommended.

Rationale 3: The nurse must remove the dressing to have adequate visualization of the insertion site.

Rationale 4: Direct pressure is required to support hemostasis.

Rationale 5: The nurse must continue to assess the site for hematoma formation or for frank bleeding after the catheter has been removed.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-4

 

Question 27

Type: MCMA

The nurse is assisting with the insertion of a subclavian central venous catheter. Which actions are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Place the patient in a prone position.
  2. Ask the patient to turn the head away from the insertion site.
  3. Alert the patient that the face may be covered temporarily with sterile drapes.
  4. Place the bed in Trendelenburg position.
  5. Ask the patient to cough when feeling the insertion catheter touch the skin.

Correct Answer: 2,3,4

Rationale 1: Prone positioning will not allow access to the subclavian vein.

Rationale 2: Having the patient turn the head away from the insertion site helps make it easier to visualize the site and also decreases the potential for contamination.

Rationale 3: To create a sterile field, the patient’s upper torso, including the face, is covered with sterile drapes.

Rationale 4: The Trendelenburg position facilitates dilation of the central veins and reduces the risk of an air embolus.

Rationale 5: The patient should be asked to lie very still during this procedure. Coughing is not indicated.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-4

 

Question 28

Type: MCMA

During insertion of a subclavian central venous catheter, the patient reports chest pain. Vital signs reveal hypotension and tachypnea. Upon inspection, the patient appears dyspneic and cyanotic. The nurse would assess for which conditions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Pneumothorax
  2. Air embolism
  3. Perforation of the left ventricle
  4. Stroke
  5. Fluid volume overload

Correct Answer: 1,2

Rationale 1: These assessment findings support the development of a pneumothorax, which is a risk associated with central venous catheter placement.

Rationale 2: These assessment findings support the development of an air embolism, which is a risk associated with central venous catheter placement.

Rationale 3: Perforation of the left ventricle would be an unlikely complication of this procedure.

Rationale 4: These assessment findings would not raise immediate suspicion of stroke. Stroke is not commonly associated with central line placement.

Rationale 5: The patient who has fluid volume overload may not tolerate the positioning necessary for central line placement, but the health care provider would be aware of this issue prior to the procedure. Fluid volume overload is not caused by the placement of a central line.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-4

 

Question 29

Type: MCSA

Which nursing instruction is given to the patient whose central venous catheter will be removed?

  1. “Take a deep breath.”
  2. “Roll over to your left side.”
  3. “Use this gauze to apply pressure over the insertion site.”
  4. “Place your hand over your head as I remove this line.”

Correct Answer: 1

Rationale 1: The nurse removes the catheter when the patient takes a deep breath to decrease the chances of air embolism.

Rationale 2: There is no reason for the patient to roll to the left side.

Rationale 3: It is the nurse’s responsibility to apply pressure over the insertion site.

Rationale 4: There is no benefit in the patient placing the hand over the head during removal of a central line.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-4

 

Question 30

Type: MCSA

The patient is experiencing premature ventricular contractions (PVCs) every other beat of the cardiac rhythm. The nurse would expect which effect on the patient’s cardiac output?

  1. The cardiac output will be doubled.
  2. There will be little if any effect on cardiac output.
  3. Cardiac output will be markedly reduced.
  4. Cardiac output will be reduced with normal beats and increased with PVCs.

Correct Answer: 3

Rationale 1: The cardiac output is adversely affected by PVCs.

Rationale 2: Frequent PVCs will affect cardiac output.

Rationale 3: The presence of so many PVCs will markedly reduce cardiac output.

Rationale 4: The cardiac output is a measurement over time and is not figured beat by beat. PVCs will reduce cardiac output.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-5

 

Question 31

Type: MCMA

The patient has been X-rayed after insertion of a pulmonary artery catheter (PAC). Which components of this system would the nurse expect to see in the right atrium?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. The proximal port
  2. The thermistor
  3. The proximal injectate port
  4. The transducer
  5. The balloon

Correct Answer: 1,3

Rationale 1: The proximal port of the PAC sits in the right atrium and is used to infuse IV fluids and nonvasoactive medications.

Rationale 2: The thermistor is on the tip of the PAC and should be in the pulmonary artery.

Rationale 3: The proximal injectate port is located in the right atrium and is used for measuring cardiac output.

Rationale 4: The transducer is located outside the patient’s body.

Rationale 5: The balloon is located on the distal end of the PAC, which will be located in the pulmonary artery.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-2

 

Question 32

Type: MCSA

A critically ill patient is admitted for the treatment of pneumonia and is receiving mechanical ventilation. The central venous pressure (CVP) is 15, and the pulmonary arterial pressure (PAP) is 55/35. What evaluation can the nurse make from this data?

  1. Both pressures are low because the patient has increased fluid volume and may be septic from the pneumonia.
  2. The CVP is low because the patient has increased fluid volume, and the high PAP indicates increased pressure in the lungs.
  3. Both pressures are high, indicating that the patient has increased pressure in the lungs and a high fluid volume.
  4. The CVP is high, indicating increased fluid volume, and the low PAP indicates impending heart failure.

Correct Answer: 3

Rationale 1: Both the CVP and the PAP are extremely high.

Rationale 2: Both the CVP and the PAP are extremely high.

Rationale 3: Both the CVP and the PAP are extremely high. The high PAP indicates pressure in the lungs and is partially caused by mechanical ventilation as well as the pneumonia. The high CVP indicates increased fluid volume. The nurse would evaluate for signs of heart failure and renal failure in this critically ill patient.

Rationale 4: Both the CVP and the PAP are extremely high.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-3

 

Question 33

Type: MCMA

The nurse is obtaining a thermodilution cardiac output measurement from a pulmonary artery catheter (PAC). Which techniques should the nurse use?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. Keep the injectate at least 10°F below room temperature.
  2. Inject the injectate over 30–45 seconds.
  3. Inject the injectate smoothly.
  4. Inject the standard amount of injectate for the brand of catheter.
  5. Perform three measurements 1 to 2 minutes apart.

Correct Answer: 3,4,5

Rationale 1: The injectate is kept at room temperature.

Rationale 2: The injectate should be injected in less than 4 seconds.

Rationale 3: The injectate should be injected smoothly.

Rationale 4: Using more or less than the standard amount of injectate will invalidate the measurement.

Rationale 5: The average of three measurements obtained 1 to 2 minutes apart is considered the cardiac output.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-4

 

Question 34

Type: FIB

The nurse would discard any cardiac output measurement obtained from a pulmonary artery catheter if the measurement was questionable based on the curve or if two measurements differed by _____ %.

Standard Text:

Correct Answer: 10

Rationale : Operator variability is an inherent risk of pulmonary artery catheter calculation of cardiac output. The nurse should assess the shape of the cardiac output curve and discard results with a questionable curve. The nurse should also discard any two measurements that vary by 10%.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-4

 

Question 35

Type: MCMA

Which findings would suggest to the nurse that the balloon of a pulmonary artery catheter (PAC) has ruptured?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

  1. No pulmonary artery occlusion pressure tracing appears when the balloon is inflated.
  2. Blood is noted in the air inflation port.
  3. It is not possible to pull air back out of the balloon with the syringe.
  4. A right bundle branch block appears on the electrocardiogram tracing.
  5. The normal pulmonary artery waveform does not return after obtaining the pulmonary artery occlusion pressure.

Correct Answer: 1,2

Rationale 1: If the balloon has ruptured, it will not occlude the artery and no tracing will appear.

Rationale 2: Blood in the inflation port indicates that the balloon has allowed leakage back into the catheter. This would occur if the balloon was not intact.

Rationale 3: The balloon should be allowed to deflate passively. Using the syringe to remove air may cause balloon rupture.

Rationale 4: This conduction defect is more likely to occur if the catheter tip has advanced through the right ventricle.

Rationale 5: If the normal pulmonary artery waveform does not return, it is more likely that the balloon is wedged despite deflation.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-4