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Medical Surgical Nursing Clinical Reasoning in Patient Care 6th Edition, LeMone Test Bank

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Test Bank For Medical Surgical Nursing Clinical Reasoning in Patient Care 6th Edition, LeMone. Note: This is not a text book. Description: ISBN-13: 978-0133139433, ISBN-10: 0133139433.

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Test Bank Medical Surgical Nursing Clinical Reasoning Patient Care 6th Edition, LeMone

CHAPTER 1

Question 1

Type: MCSA

The nurse is instructing a patient on the role of diet, exercise, and medication to control type 2 diabetes mellitus. Which core competency for healthcare professionals is the nurse implementing?

  1. Quality improvement
  2. Evidence-based practice
  3. Patient-centered care
  4. Teamwork and collaboration

Question 2

Type: MCSA

The nurse is planning to utilize the core competency use informatics when providing patient care. Which action should the nurse perform when using this core competency?

  1. Change the sharps container in a patient’s room.
  2. Document the effectiveness of pain medication for a patient.
  3. Discuss the effectiveness of bedside physical therapy with the therapist.
  4. Search through a database of articles to find current research on wound care.

Question 3

Type: MCMA

The nurse plans to implement evidence-based practice when providing patient care. Which activities should the nurse perform?

Standard Text: Select all that apply.

  1. Participate in education and research activities when possible.
  2. Integrate research findings with clinical care to maximize patient outcomes.
  3. Serve on the committee to create critical pathways for patient care.
  4. Reinforce hand hygiene techniques with unlicensed assistive personnel.
  5. Contact Environmental Services to report a malfunctioning infusion pump.

Question 4

Type: MCSA

The community health nurse is planning to meet with several community members during a health fair. Which nursing activity exemplifies the core competency patient-centered care?

  1. Provide smoking cessation classes and literature.
  2. Increase the hours for the physician to see patients.
  3. Attend a continuing education program on clean water initiatives.
  4. Evaluate the effectiveness of weight reduction strategies.

Question 5

Type: MCSA

The nurse is instructing a patient on weight reduction and smoking cessation. Which code of nursing practice is the nurse implementing?

  1. International Council of Nurses Code of Ethics for Nurses
  2. American Nurses Association Standards of Professional Practice
  3. American Nurses Association Code of Ethics for Nurses
  4. State Board of Nursing Code

Question 6

Type: MCSA

The nurse is providing patient care within the American Nurses Association Standards of Professional Performance. Which activity is the nurse implementing?

  1. Integrating research findings into practice
  2. Implementing a patient’s plan of care
  3. Evaluating patient progress toward identified outcomes
  4. Analyzing assessment data to determine issues

Question 7

Type: MCSA

The nurse prescribes strategies and alternatives to assist a patient achieve expected outcomes. Within which American Nurses Association standard is the nurse practicing?

  1. Planning
  2. Assessment
  3. Diagnosis
  4. Implementation

Question 8

Type: MCSA

A patient with a terminal illness is concerned about pain control. If the International Council of Nurses Code of Ethics for Nurses is followed, what should the nurse plan for the patient?

  1. Measures to alleviate suffering
  2. Modified activities of daily living
  3. Enforcement of strict bed rest
  4. Dietary interventions to maximize strength

Question 9

Type: MCSA

A patient is angry after waiting over an hour for pain medication. What should the nurse respond to the patient that demonstrates critical thinking?

  1. “I understand your anger and am sorry for the delay. I have your pain medication now.”
  2. “I had other patients who needed my attention first, so I did a few things before getting the pain medication.”
  3. “I needed to find out what your medication is and if you can have more when you asked.”
  4. “It seems that you always ask for pain medication when I am trying to do other things.”

Question 10

Type: MCSA

The nurse is reviewing data collected from a patient during an assessment. Which activity demonstrates that the nurse is using divergent thinking when analyzing this data?

  1. The nurse identifies abnormal data for further analyzing.
  2. The nurse focuses on normal data to rule out health problems.
  3. The nurse discriminates between facts and guesses.
  4. The nurse thinks about the information to determine solutions.

 

CHAPTER 2

Question 1

Type: MCSA

After purchasing a personal computer for use at home, the nurse enrolls in classes at the local community college to learn more about using the device. Which building block of informatics competencies is this nurse demonstrating?

  1. Computer literacy
  2. Information literacy
  3. Relationship analysis
  4. Computer integration

Question 2

Type: MCSA

While participating in the electronic communication committee, the nurse makes a recommendation to alter one aspect of the system to support nursing documentation. Which informatics competency is this nurse practicing?

  1. Implement policies relevant to best practice.
  2. Analyze and interpret information as part of planning care.
  3. Use informatics applications designed for nursing practice.
  4. Demonstrate expertise as a content expert in system design.

Question 3

Type: MCMA

The manager is evaluating a beginning nurse’s ability to use the computerized documentation system. Which observations indicate that the beginning nurse needs additional training on the computer?

Standard Text: Select all that apply.

  1. Documented care for one patient in 20 minutes
  2. Input patient safety data on the appropriate screen
  3. Stated laboratory results not available when they were entered 4 hours earlier
  4. Retrieved a recent peer-reviewed article supporting an aspect of one patient’s care
  5. Commented that a paper chart is the only legal and reliable form of documentation

Question 4

Type: MCMA

The staff development trainer is preparing a seminar for experienced nurses on the computerized clinical documentation system. What should the trainer include in this presentation?

Standard Text: Select all that apply.

  1. Strategies to locate information quickly
  2. Tips on using the computers and software efficiently
  3. Reasons the documentation system supports patient care
  4. Approaches to identify relationships among data elements
  5. Case studies to analyze data patterns to make clinical judgments

Question 5

Type: MCSA

A patient asks why the nurse is playing with an iPad in the midst of providing care. What should the nurse respond to this patient?

 

  1. “I’m just typing in notes to remember what care I provided to you.”
  2. “This is just a way for nurses to communicate instead of calling out to each other.”
  3. “I just needed to check and make sure I did everything that you needed at this time.”
  4. “This is a part of the computer system that is used to confidentially document your care.”

Question 6

Type: MCSA

The computerized clinical documentation system installed in a healthcare organization has a feature that alerts staff to potential safety hazards. Which computer message should the nurse interpret as a safety warning when providing patient care?

 

  1. Warning: Scan the bar code on the item before using for patient care
  2. Warning: Click on automatic calculation before leaving the graphic sheet section
  3. Warning: Leaving the computer unattended for 1 minute will result in data not being saved
  4. Warning: Administering this medication exceeds the maximum safe amount of acetaminophen

Question 7

Type: MCSA

While documenting care provided to a patient in the home, the nurse encounters a problem with the electronic medical record. Which action indicates that the nurse was able to troubleshoot and address the problem?

 

  1. Followed the steps in the technical difficulties guide and completed documentation
  2. Closed the electronic medical record and documented care in a traditional hard-copy note
  3. Telephoned the information technology department and reported a problem with the system
  4. Used the patient’s personal computer to access the electronic record to record documentation

Question 8

Type: MCMA

The nurse is a member of a committee charged with selecting a computerized clinical information system for an organization. Which features should the nurse recommend be included in this system to support patient care needs?

Standard Text: Select all that apply.

  1. Standards of care
  2. Quality improvement tracking database
  3. Conditions of participation for health plans
  4. Patient care policies and procedure manual
  5. Clinical competency information and schedule

Question 9

Type: MCMA

The manager is on a committee that is investigating the implementation of evidenced-based practice for the nursing staff. Which outcomes should the manager highlight as expected when this approach is implemented?

Standard Text: Select all that apply.

  1. Reduces costs
  2. Promotes the best patient outcomes
  3. Encourages healthcare worker retention
  4. Reduces the cost of healthcare worker salaries
  5. Reduces care variations between geographic locations

Question 10

Type: MCMA

The nurse is implementing evidence-based practice when caring for a patient with a chronic illness. Which actions indicate that the nurse is implementing this approach appropriately?

Standard Text: Select all that apply.

  1. Studies healthcare provider’s written orders
  2. Analyzes patient’s requests for care approaches
  3. Asks colleagues to identify best approaches to care
  4. Plans intervention based upon researched information
  5. Reviews findings from patient assessment and laboratory data

 

CHAPTER 3

Question 1

Type: MCSA

When planning holistic care for a patient admitted with heart failure, what should the nurse include?

  1. spiritual needs
  2. measuring intake and output
  3. daily weights
  4. ambulating with assistance

Question 2

Type: MCSA

A patient tells the nurse that he has been fortunate since he has never experienced any major illnesses and has enjoyed good health without much effort. How should the nurse realize this patient is defining “good health?”

  1. the absence of disease
  2. effortless
  3. fortunate
  4. an integrated method of functioning

Question 3

Type: MCSA

A patient tells the nurse that he often is concerned with his declining mobility status even though he continues to experience no major health issues. When planning care according to the wellness framework, what should the nurse include for this patient?

  1. interventions to restore the patient’s mobility status
  2. activities to promote the current level of functioning
  3. suggestions to maintain the patient’s current mobility status
  4. activities to help the patient cope with the decline in mobility status

Question 4

Type: MCSA

The nurse has provided care to a patient according to the concept of wellness. Which outcome indicates that care has been successful for this patient?

  1. The patient is returning home with adjustments in the home environment to support a temporary alteration in mobility status.
  2. The patient needs additional teaching to understand the reason for taking Coumadin at the same time every day.
  3. The patient is not independent with personal care and will need assistance when at home.
  4. The patient is easily fatigued and will need assistance with meal preparation and medication administration.

Question 5

Type: MCSA

During an assessment, the nurse learns that a patient has a genetic predisposition to the development of several disease processes. Which illness should the nurse realize is associated with genetic makeup?

  1. cancer
  2. hypertension
  3. osteoporosis
  4. myocardial infarction

Question 7

Type: MCSA

During an assessment, a patient tells the nurse that she is lactose intolerant. The nurse realizes that this food intolerance is common within which cultural groups?

  1. Mexican Americans
  2. Scandinavian Americans
  3. Indian Americans
  4. Mediterranean Americans

Question 9

Type: MCSA

The nurse is collecting data at the immunization clinic. Which disclosure by the patient would cause the nurse to withhold the administration of the varicella vaccine?

  1. a blood transfusion after undergoing surgery 3 months ago
  2. history of an allergic reaction to yeast bread
  3. itching and swelling on the face and hands after ingesting eggs
  4. a low-grade temperature within the past 2 days

Question 10

Type: MCMA

The nurse is reviewing the goals for Healthy People 2020 with a group of patients in an outpatient clinic. What should the nurse include in this presentation?

Standard Text: Select all that apply.

  1. Eliminating preventable disease, disability, injury, and premature death
  2. Achieving health equity, eliminating disparities, and improving the health of all groups
  3. Creating social and physical environments that promote good health for all
  4. Promoting healthy development and healthy behaviors across every stage of life
  5. Achieving a body weight 20% less than recommended in current standardized height/weight charts

 

CHAPTER 4

Question 1

Type: MCSA

A patient tells the nurse that he must be having minor surgery since it will be done as an outpatient. How should the nurse respond to this patient?

  1. “Every surgical procedure is serious, and I will make sure you have information to have a successful recovery.”
  2. “You are right.”
  3. “If it were more serious, you would be admitted to the hospital.”
  4. “Your insurance plan does not cover inpatient surgical procedures. That’s why your surgery is being done as an outpatient.”

Question 2

Type: MCSA

A patient scheduled for outpatient surgery asks the nurse why he will not be admitted to the hospital for the surgery. What should the nurse explain as an advantage of having outpatient surgery?

  1. reduced risk of healthcare-associated infections
  2. ability to use home care for postoperative care in the home
  3. reduced use of postoperative medications
  4. inadequate staffing on the surgical care areas

Question 3

Type: MCMA

The nurse is preparing to discharge a patient after having outpatient surgery. Which criteria should the nurse use to determine whether the patient is eligible to be discharged?

Standard Text: Select all that apply.

  1. stable vital signs
  2. no nausea or dizziness
  3. pain controlled
  4. adequate urine output
  5. patient’s expressed readiness to go home

Question 4

Type: MCSA

The nurse in the same-day surgical care area is preparing a patient for surgery. What should the nurse do to ensure that this patient has a successful recovery from the surgery?

  1. Provide teaching and additional resources to help the patient when at home.
  2. Measure intake and output.
  3. Assess vital signs.
  4. Limit pain control measures since the patient will need to ambulate when leaving after the surgery.

Question 5

Type: MCSA

The nurse is providing care to a patient during the preoperative phase of surgery. Which of the following interventions would be appropriate for the nurse to provide during this time?

  1. assisting with bathing
  2. patient safety
  3. assessing level of consciousness
  4. monitoring intake and output

Question 6

Type: MCSA

A patient was instructed on exercises to perform as part of preoperative teaching. While recovering from surgery, the patient experiences a deep vein thrombosis (DVT). Which preoperative exercise should the nurse identify as not having been effective for this patient?

  1. leg exercises
  2. deep breathing and coughing
  3. use of incentive spirometry
  4. splinting when coughing

Question 7

Type: MCSA

The nurse is assessing a patient who has returned to the care area after surgery. What should the nurse do to ensure the patient receives appropriate care?

  1. Check the physician’s orders to see if preoperative orders have been reordered.
  2. Schedule the patient for vital signs assessments every four hours.
  3. Orient the patient to person, place, and time.
  4. Assess the patient’s mental status.

Question 8

Type: MCSA

After providing a patient with a preoperative sedative, the nurse notes that the surgical consent form has not been signed by the patient. What should the nurse do?

  1. Contact the surgeon.
  2. Ask the patient to sign the consent form.
  3. Send the patient for surgery with an unsigned consent form.
  4. Phone the operating room suite to notify the nurse that the patient has not signed the consent form.

Question 9

Type: MCSA

A patient being prepared for surgery has been diagnosed with dehydration. Which laboratory values support the diagnosis for this patient?

  1. hemoglobin and hematocrit
  2. glucose
  3. white blood cell count
  4. platelet count

Question 10

Type: MCSA

A patient diagnosed with emphysema is being prepared for surgery. What laboratory value should the nurse review to obtain information about the patient’s respiratory status?

  1. carbon dioxide
  2. white blood cell count
  3. serum creatinine
  4. blood urea nitrogen

 

CHAPTER 5

Question 1

Type: MCSA

The brother of a terminally ill patient states, “I’ll donate a million dollars to the hospital if they cure my brother.” The nurse realizes this statement indicates which phase of Kübler-Ross’s stages of loss?

  1. bargaining
  2. denial
  3. anger
  4. acceptance

Question 2

Type: MCSA

A patient tells the nurse that her husband passed away a year ago and she is now beginning to realize that he is truly gone. The patient is planning to begin a new job and possibly move to a new community. The nurse realizes that this patient is in which stage of Bowlby’s theory of attachment?

  1. detachment
  2. protest
  3. despair
  4. anger

Question 3

Type: MCSA

A patient tells the nurse that since his wife died he has not been able to sleep and sees no reason to continue living. According to Freud’s theory on grief and loss, what should the nurse realize this patient is experiencing?

  1. depression
  2. grieving
  3. emancipation
  4. denial

Question 4

Type: MCSA

A patient has decided to join a support group for surviving spouses of victims of violent crime. According to Engel’s theory of grief and loss, the nurse identifies that this patient is in which stage?

  1. restitution
  2. acute grief
  3. shock and disbelief
  4. denial

Question 5

Type: MCSA

A 30-year-old terminally ill patient is concerned about how her 7-year-old child will perceive her death. What advice from the nurse would be most beneficial?

  1. Children this age recognize that death is permanent.
  2. Children this age emotionally distance themselves from the death.
  3. Because the child fears separation the patient can prepare the child by explaining that death is permanent.
  4. Children this age think death is sleeping.

Question 6

Type: MCSA

A patient of Native American descent is expected to die. The family arrives at the hospital and wants to observe their religious and cultural traditions. Which intervention by the nursing staff would be most appropriate?

  1. Offer the family a private room to sit together.
  2. Discourage the family from sitting with their loved one prior to death.
  3. Discuss the possibility of transferring the patient home for the death.
  4. Encourage the family to consider a DNR order.

Question 7

Type: MCSA

A patient tells the nurse that her estranged husband died a little over a year ago and states, “I am not sure why this is so difficult. I really couldn’t stand him near the end.” Which response by the nurse is most appropriate?

  1. “Sometimes a rocky relationship with someone at the time of their death can affect your ability to grieve.”
  2. “You seem angry.”
  3. “You should contact a therapist.”
  4. “You are just entering the grief process. Things will get better.”

Question 8

Type: MCSA

A terminally ill patient is demonstrating signs of spiritual distress. Which should the nurse do first to assist this patient?

  1. Use the FICA assessment.
  2. Help the patient with guided imagery.
  3. Offer to pray with the patient.
  4. Leave the patient alone with her thoughts.

Question 9

Type: MCSA

After an unsuccessful resuscitation attempt, a patient dies. What should the nurse do first?

  1. Document the time of death.
  2. Notify the funeral home.
  3. Contact the physician.
  4. Contact the orderly for transport to the morgue.

Question 10

Type: MCSA

A terminally ill patient is experiencing secretions pooling in the back of the throat. What can the nurse do to help this patient feel more comfortable?

  1. Raise the head of the bed.
  2. Gently massage the patient.
  3. Provide frequent small sips of fluids.
  4. Provide oral care.

 

CHAPTER 6

Question 1

Type: MCSA

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

  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.”

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. What should the nurse suspect about the patient?

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

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 to

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

Question 4

Type: MCSA

While analyzing data collected during an assessment, the nurse realizes that a patient’s risk for alcohol abuse is low. What information did the nurse use to come to this conclusion?

  1. The patient is Asian American.
  2. The patient is diagnosed with type 2 diabetes.
  3. The patient has two children.
  4. The patient is employed as an accountant.

Question 5

Type: MCSA

A nurse is concerned about potential substance abuse by a coworker. What 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.

Question 6

Type: MCSA

A nurse consistently arrives to work wearing a long-sleeved blouse despite the temperature being in the 90s and the air humid. When colleagues mention her attire, the nurse becomes defensive and isolates herself from others. What does the nurse’s behavior suggest?

  1. substance abuse
  2. a long-standing illness
  3. introverted behavior
  4. low self-esteem

Question 7

Type: MCMA

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

Standard Text: Select all that apply.

  1. calling for days off or illness before scheduled days off
  2. using the bathroom frequently
  3. excessive use of mouthwash
  4. volunteering to transfer a patient to the intensive care unit
  5. following up with nursing assistants on patient care needs

Question 8

Type: MCSA

The nurse is concerned that a colleague is experiencing depression from substance abuse. What does the nurse observe to make this assumption?

  1. The colleague leaves the unit and cannot be located for long periods of time.
  2. The colleague uses the visitor bathroom instead of employee bathroom.
  3. The colleague often eats lunch away from the hospital.
  4. The colleague complains of frequent headaches at work.

Question 9

Type: MCSA

A patient recovering from outpatient carpal tunnel surgery returns to the surgical center the next day and tells the nurse that she is having trouble attending to daily activities and the pain is “excruciating,” so she wants stronger pain medication immediately. What should this patient’s behavior suggest to the nurse?

  1. The patient could have a substance abuse problem.
  2. A nerve was cut during the procedure.
  3. The patient was not given strong enough postoperative pain medication.
  4. The patient is under stress to return to work.

Question 10

Type: MCSA

A patient complaining of back pain tells the nurse that he needs several refills on any prescription since he takes the medication more frequently than prescribed. What should this information suggest to the nurse?

  1. The patient has lost control over the consumption of the pain medication.
  2. The patient is impulsive.
  3. The patient uses the pain medication to fit in with a peer group.
  4. The patient uses the pain medication to overcome low self-esteem.

 

CHAPTER 7

Question 1

Type: MCSA

A school bus transporting a local university’s basketball team has just crashed in the rain on the side of the road. The bus was transporting approximately 60 people. Which classification should the nurse use to describe the situation?

  1. multiple-casualty incident
  2. natural disaster
  3. human-generated disaster
  4. mass-casualty incident

Question 2

Type: MCSA

The nurse is caring for a patient with injuries received in an earthquake. Which type of incident should the nurse identify as causing this patient’s injuries?

  1. natural disaster
  2. human-generated disaster
  3. emergency
  4. multiple-casualty incident

Question 3

Type: MCSA

A small commuter plane lost an engine and crashed into a shopping mall. The estimated number of injured people from this accident is 500. Which classification of incident should the nurse use when determining the care needed for these victims?

  1. mass-casualty incident
  2. multiple-casualty incident
  3. accidental natural disaster
  4. intentional human-generated disaster

Question 4

Type: MCSA

A train derailed in a local community. The contents of the train caused a hazardous spill, and noxious gasses are being released into the environment. All local and surrounding fire control and Hazmat teams have been mobilized and the event is considered under control. Which type of situation should the nurse prepare for?

  1. emergency
  2. disaster
  3. human-generated accidental disaster
  4. intentional emergency

Question 5

Type: MCSA

The nurse is caring for patients when a dirty bomb detonates at a nearby shopping mall. Which types of injuries should the nurse expect to see in the victims?

  1. radiation sickness
  2. fractured limbs and spinal injury
  3. thermal burns
  4. overexertion and exhaustion

Question 6

Type: MCSA

Several patients are admitted after being exposed to a substance that was released in their manufacturing plant. The patients are demonstrating flu-like symptoms, unproductive cough, and fever. These patients should be assessed for which type of exposure?

  1. anthrax
  2. smallpox
  3. dirty bomb
  4. nuclear detonation

Question 7

Type: MCSA

The nurse is caring for a patient who was brought into the emergency department after an explosion at a nuclear power plant. The patient is confused and keeps repeating that his skin is “on fire.” What does this information indicate to the nurse?

  1. The patient may not recover.
  2. The patient’s clothing is burning his skin.
  3. There is gastrointestinal system involvement and the patient will survive if he receives fluids.
  4. There is bone marrow damage and the patient needs oxygen for the confusion.

Question 8

Type: MCSA

A patient is brought into the emergency department complaining of blindness after an explosion at an atomic power plant. What should the nurse explain to this patient?

  1. “The effects of the blast will disappear with time.”
  2. “I’m afraid the blast has caused permanent blindness.”
  3. “I will contact Social Services so that resources can be identified to help you with your disability.”
  4. “There is a variety of resources available for those who are unable to see.”

Question 9

Type: MCSA

The nurse is caring for a patient who experienced a blast injury to the eye. Which intervention would be appropriate?

  1. Flush the eye with eyewash.
  2. Encourage the patient to rub the eye to get out specks of dust.
  3. Apply a warm compress to the eye.
  4. Remove debris lodged in the eye.

Question 10

Type: MCSA

The nurse is admitting the second patient in 2 days who is experiencing malaise, high fever, and headache. Both patients attended a local air show the previous weekend. What should the nurse do?

  1. Discuss the need to contact public health authorities regarding the similarity of the cases.
  2. Plan to place the patients in the same room.
  3. Ask the patients for permission to talk with family members regarding other symptoms.
  4. Assess the patients for what foods they ate while at the air show.

 

CHAPTER 8

Question 1

Type: MCSA

A female patient tells the nurse that she is genetically predisposed to type 2 diabetes. What is the most important information that the nurse should provide?

  1. the importance of maintaining a healthy weight and activity level
  2. the need to avoid carbohydrate intake
  3. the need to begin monitoring daily blood glucose levels
  4. the need to address active health problems and not those that have yet to manifest

Question 2

Type: MCSA

A patient tells the nurse that she does not want to pass on a disease that is genetic in origin to any future children. How should the nurse respond to this patient?

  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. “Are you sure that the disease is genetic in origin?”

Question 3

Type: MCSA

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

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

Question 4

Type: MCSA

At the completion of a genetic assessment, the nurse learns that a patient has three family members diagnosed with rectal cancer before the age of 40 years. What should the nurse discuss with the patient?

  1. importance of having screening for colorectal cancer at an earlier age
  2. importance of ingesting a diet high in protein and carbohydrates
  3. ways to maximize time spent in exercise
  4. reasons why having children would not be recommended for this patient

Question 5

Type: MCSA

While assessing a patient, the nurse notes an irregularity that has been observed in other patients, but on an inconsistent basis. What did the nurse most likely discover in this patient?

  1. a polymorphism
  2. a mutation
  3. a single-gene inheritance pattern
  4. an X-linked inheritance pattern

Question 6

Type: MCSA

A patient has been told that her unborn child will most likely have Down syndrome. The nurse realizes this diagnosis is consistent with which genetic finding?

  1. trisomy
  2. monosomy
  3. translocation
  4. deletions

Question 7

Type: MCSA

A nurse is planning to teach the parents of a child with cystic fibrosis about the disorder. Which statement should the nurse include in this explanation?

  1. “While all people carry the gene CFTR, which is responsible 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, then 25% of those children will develop the disease.”
  3. “One in four people carry the gene for cystic fibrosis. If two carriers have children, then 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.”

Question 8

Type: MCSA

A patient tells the nurse that many of her family members have a type of anemia that is genetic. What should the nurse realize will occur in this patient?

  1. The patient will develop the disease only if there is a mutation in the gene.
  2. The patient will develop the same type of anemia.
  3. The patient will die from the anemia.
  4. The patient will develop the disease only if the gene translocates.

Question 9

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 that 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.”

Question 10

Type: MCSA

The nurse is developing a teaching plan for parents who need genetic counseling. Which statement by a parent indicates the need for further education?

  1. “All the chromosomes are the same size in males and females alike.”
  2. “Half of the sets of chromosomes come from the mother and the other half comes 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 sex chromosome will produce a male child.”

 

CHAPTER 9

Question 1

Type: MCSA

The nurse is assessing a patient’s response to pain. Why should the nurse do this for every patient situation?

  1. Everyone has a unique tolerance to pain.
  2. Everyone has the same pain threshold.
  3. Everyone perceives painful stimuli at the same intensity.
  4. Most people have the same the pain response to surgery.

Question 2

Type: MCSA

After assessing a patient for pain, the nurse concludes that the pain is caused by a mechanical stimulus. What should the nurse consider as a possible cause of this patient’s pain?

  1. muscle tear
  2. burn
  3. frostbite
  4. myocardial infarction

Question 3

Type: MCSA

The nurse is using the neuromatrix theory when determining a patient’s pain. What should the nurse consider when assessing a patient’s pain?

  1. cultural and genetic factors
  2. specificity
  3. pattern
  4. previous sensitization

Question 4

Type: MCSA

A patient tells the nurse that he has had deep, burning muscle pain for most of his adult life. What does this information tell the nurse about how the patient’s pain is being transmitted in the body?

  1. C fibers
  2. A-delta fibers
  3. endorphins
  4. dynorphins

Question 5

Type: MCSA

A patient asks the nurse why he felt pain prior to a myocardial infarction primarily in his left arm. How should the nurse respond?

  1. “Pain in the arm related to cardiac tissue damage is a type of referred pain.”
  2. “Cardiac pain is generally unexplainable.”
  3. “Were you doing some physical activity with your arm just prior to the event?”
  4. “What you are describing relates to psychogenic pain.”

Question 6

Type: MCSA

A patient is being treated for chronic pain. What should the nurse keep in mind when assessing this patient’s level of pain?

  1. The pain rating may be inconsistent with the underlying pathology.
  2. There is usually a clear, physiologic cause.
  3. Pain typically lasts 2 months or less.
  4. The pain reported is usually less severe than acute pain.

Question 7

Type: MCSA

The nurse is managing care for a group of patients with pain. For which health problem should the nurse expect the patient to experience acute pain?

  1. cholecystectomy
  2. phantom limb pain
  3. complex regional pain syndrome
  4. degenerative joint disease

Question 8

Type: MCSA

The nurse is planning care for a patient with chronic pain. Which pain control goal would be most appropriate for this patient?

  1. Reduce the focus on pain.
  2. Reduce the sympathetic stress response.
  3. Be completely pain free.
  4. Improve patient outcomes.

Question 9

Type: MCSA

A patient scheduled for knee surgery tells the nurse, “I know I won’t feel as much pain with this knee surgery as I did with the other one when I was 20 years younger.” What should the nurse respond to this patient?

  1. “There might be more pain, because the pain response can get worse with aging.”
  2. “You are most likely correct.”
  3. “It should not be quite as bad with the newer technology.”
  4. “Pain responses diminish with age.”

Question 10

Type: MCSA

A female patient tells the nurse that at times the pain she has is so severe that she cannot move or get out of bed at home. What should the nurse realize is contributing to this patient’s pain?

  1. gender
  2. overuse of alcohol
  3. overuse of pain medication
  4. too much sleep and rest

 

CHAPTER 10

Question 1

Type: MCSA

The nurse is caring for an older patient who is occasionally confused. What should be the nurse’s primary concern regarding fluid and electrolytes when caring for this patient?

  1. risk of dehydration
  2. risk of kidney damage
  3. risk of stroke
  4. risk of bleeding

Question 2

Type: MCSA

The nurse is planning care for a patient with severe burns. What condition should the nurse realize that this patient could develop?

  1. intracellular fluid deficit
  2. intracellular fluid overload
  3. extracellular fluid deficit
  4. interstitial fluid deficit

Question 3

Type: MCSA

A patient experiencing multisystem fluid volume deficit has tachycardia; pale, cool skin; and decreased urine output. The nurse realizes these findings are most likely a direct result of which process?

  1. the body’s natural compensatory mechanisms
  2. pharmacological effects of a diuretic
  3. effects of rapidly infused intravenous fluids
  4. cardiac failure

Question 4

Type: MCSA

A pregnant patient is admitted with excessive thirst and increased urination. For which problem should the nurse focus the care of this patient?

  1. imbalanced fluid
  2. fluid overload
  3. nutritional deficiency
  4. insufficient blood flow

Question 5

Type: MCSA

A patient recovering from surgery has an indwelling urinary catheter. For which 24-hour urine output volumes should the nurse notify the patient’s healthcare provider?

  1. 600 milliliters
  2. 750 milliliters
  3. 1000 milliliters
  4. 1200 milliliters

Question 6

Type: MCSA

A patient is receiving intravenous fluids postoperatively following cardiac surgery. On which potential postoperative complication should the nurse focus the assessment of this patient?

  1. fluid volume excess
  2. fluid volume deficit
  3. seizure activity
  4. liver failure

Question 7

Type: MCSA

A patient is diagnosed with severe hyponatremia. The nurse realizes this patient will mostly likely need precautions implemented for what event?

  1. seizure
  2. infection
  3. neutropenia
  4. high-risk fall

Question 8

Type: MCSA

A patient is diagnosed with hypokalemia. After reviewing the patient’s current medications, which drug should the nurse consider that might have contributed to the patient’s health problem?

  1. corticosteroid
  2. thiazide diuretic
  3. narcotic
  4. muscle relaxer

Question 9

Type: MCSA

A patient prescribed spironolactone is demonstrating ECG changes and complaining of muscle weakness. The nurse realizes this patient is exhibiting signs of which electrolyte imbalance?

  1. hyperkalemia
  2. hypokalemia
  3. hypercalcemia
  4. hypocalcemia

Question 10

Type: MCSA

The nurse is planning care for a patient with fluid volume overload and hyponatremia. What should be included in this patient’s plan of care?

  1. Restrict fluids.
  2. Administer intravenous fluids.
  3. Provide Kayexalate.
  4. Administer intravenous normal saline with furosemide.

 

CHAPTER 11

Question 1

Type: MCSA

A patient is brought to the emergency department with injuries sustained in a motor vehicle crash. What should the nurse consider as the cause of this patient’s injuries?

  1. trauma
  2. not wearing a seat restraint
  3. a drunk driver
  4. not paying attention while driving

Question 2

Type: MCSA

The spouse of a patient admitted with a gunshot wound asks the nurse when her husband will be discharged so that they can resume their life together. How should the nurse respond?

  1. “Right now there is no way of knowing how soon your husband can return to his previous life.”
  2. “I would say in a few weeks.”
  3. “Probably never.”
  4. “As soon as the wound heals, your husband can return to work.”

Question 3

Type: MCMA

An older patient is admitted after falling on the steps at home. Which components of trauma should the nurse consider when planning care for the patient?

Standard Text: Select all that apply.

  1. host
  2. environment
  3. intention
  4. source
  5. transmission

Question 4

Type: MCSA

A patient comes into the emergency department with leg pain after falling on ice. For which classification of injuries should the nurse expect to plan care for this patient?

  1. Class 3 minor
  2. Class 1 minor
  3. Class 1 penetrating
  4. Class 3 penetrating

Question 5

Type: MCSA

A patient is brought to the emergency department with injuries sustained when a wall collapsed in the home. The nurse recognizes that this patient’s injuries were most likely caused by which mechanism of injury?

  1. crushing
  2. shearing
  3. deceleration
  4. blast

Question 6

Type: MCSA

A patient was admitted with a head injury caused by rapid acceleration and deceleration. How should the nurse expect this patient’s injuries to be classified?

  1. blunt
  2. shearing
  3. blast
  4. minor

Question 7

Type: MCSA

A patient is admitted with a thermal injury. Which mechanism of injury should the nurse consider as the most likely cause of this patient’s injuries?

  1. fire
  2. lightning
  3. ultraviolet radiation
  4. gunshot

Question 8

Type: MCSA

A pediatric patient is admitted after ingesting a household cleaning solution. The nurse should plan care for this patient’s injuries based on which energy source?

  1. chemical
  2. physical
  3. thermal
  4. mechanical

Question 9

Type: MCSA

A patient recovering from a motor vehicle accident tells the nurse that the other car “barely” hit him and asks why he has so many injuries. How should the nurse respond?

  1. “The car that hit you transferred a large amount of energy to your body, causing these injuries.”
  2. “You have other health problems that make the injuries worse.”
  3. “The driver of the other car intended to hit you.”
  4. “Because you are older, your injuries will be worse.”

Question 10

Type: MCSA

A construction worker was admitted after falling from the roof of a building. The nurse should plan care for this patient’s injuries based on which energy source?

  1. gravitational
  2. mechanical
  3. physical
  4. electrical

 

CHAPTER 12

Question 1

Type: MCSA

The nurse is reviewing the white blood cell count differential for a patient and notes that the basophil count is elevated. What should this laboratory value indicate to the nurse?

  1. The patient is experiencing an acute hypersensitivity reaction.
  2. The patient has a gastrointestinal infection.
  3. The patient is fighting a tuberculosis infection.
  4. The patient is fighting cancer.

Question 2

Type: MCSA

The nurse is caring for a patient recovering from a splenectomy. What should the nurse realize will occur regarding this patient’s immunity?

  1. The liver and bone marrow will take over the spleen’s functions.
  2. The patient will need to avoid infections every day of his life.
  3. The patient will have edematous lymph glands throughout his body.
  4. The thymus gland will take over the spleen’s functions.

Question 3

Type: MCSA

A patient’s white blood cell count is 11,000/mm3. What does the nurse understand this value to represent?

  1. the total number of circulating leukocytes
  2. the total number of circulating neutrophils
  3. the total number of circulating eosinophils
  4. the total number of circulating basophils

Question 4

Type: MCSA

A patient sustains fractures to the ribs, both femurs, and one humerus. When planning care for this patient’s immunologic status, what should the nurse include?

  1. Monitor complete blood count daily.
  2. Limit food rich in iron.
  3. Perform passive range of motion to unaffected extremities.
  4. Keep on bed rest.

Question 5

Type: MCSA

A patient is diagnosed with a positive tuberculosis skin test. The nurse understands that this response is due to what?

  1. performing a cell-mediated inflammatory response
  2. promoting phagocytosis of the antigen by neutrophils
  3. clumping antigens to form a noninvasive aggregate
  4. coating the antigen with antibodies

Question 6

Type: MCSA

A patient tells the nurse that he’s happy that his wife did not “catch” the same cold from which he has recently recovered. The nurse realizes that what most likely occurred in his wife?

  1. Helper T cells had a memory of a previous exposure to the same virus that caused the patient’s illness.
  2. Suppressor T cells killed the virus.
  3. The virus was eliminated via phagocytosis by neutrophils.
  4. Cytokines were released.

Question 7

Type: MCSA

The nurse is caring for a patient diagnosed with a lung infection. Which immunoglobulin level should the nurse expect to be elevated in this patient?

  1. immunoglobulin A
  2. immunoglobulin M
  3. immunoglobulin E
  4. immunoglobulin D

Question 8

Type: MCSA

A patient who just delivered a newborn baby is concerned that the baby will “catch” a cold from a healthcare provider who was coughing and sneezing in the delivery room. How should the nurse respond?

  1. “The baby has some protection from infections from the time of birth.”
  2. “The baby should be isolated.”
  3. “I will be sure to have everyone check the baby’s temperature for signs of an infection.”
  4. “The healthcare provider should not have been participating in your care.”

Question 9

Type: MCMA

The nurse is concerned that a patient is exhibiting signs and symptoms of inflammation. What did the nurse assess to come to this conclusion?

Standard Text: Select all that apply.

  1. leg edema
  2. severe pain from swelling
  3. severe erythema of leg
  4. leg cool to the touch
  5. decreased peripheral pulses

Question 10

Type: MCSA

An older patient has a small pressure ulcer on the coccyx. What should the nurse do to promote healing of the wound?

  1. encourage high-protein food choices in the diet
  2. limit carbohydrate intake
  3. encourage a high intake of vitamin E
  4. restrict caloric intake

 

CHAPTER 13

Question 1

Type: MCSA

A patient is admitted to receive a kidney transplant from a live sibling. The nurse realizes that what must have occurred for this surgery to be planned?

  1. The human leukocyte antigens between the patient and sibling must be very similar.
  2. The human leukocyte antigens between the patient and sibling must be very different.
  3. The patient has an overactive immune system.
  4. The donor has an overactive immune system.

Question 2

Type: MCSA

A patient in isolation for an incompetent immune system asks the nurse what “disease” he has that requires placement in isolation. How should the nurse respond?

  1. “Because your immune system is weak, you can develop a disease. The isolation is to protect you.”
  2. “I will have to find out from your doctor.”
  3. “It’s not a bad disease. The isolation is just to make sure it doesn’t spread.”
  4. “I am sure that once your medications start to work, you won’t have to remain in isolation.”

Question 3

Type: MCSA

A patient tells the nurse that she used to get the “common cold” at least three times a year but now can’t remember the last time she had one. What should the nurse realize this patient is describing?

  1. healthy B cell functioning
  2. healthy helper T cell functioning
  3. T cell secretion of antibodies
  4. healthy regulator T cell functioning

Question 4

Type: MCSA

An older patient tells the nurse that he develops pneumonia easily; however, his wife of the same age rarely “gets sick.” How should the nurse respond?

  1. “Not everyone’s immune system is the same, regardless of their age.”
  2. “Your wife must be doing something that you’re not doing.”
  3. “Maybe your wife just doesn’t tell you when she’s sick.”
  4. “It’s just a matter of time. Your wife will have the same illnesses you do.”

Question 5

Type: MCSA

A patient comes into the emergency department with itching, swelling, and slight shortness of breath after being stung by a bee. The nurse realizes this patient is experiencing which type of hypersensitivity reaction?

  1. type I IgE-mediated hypersensitivity
  2. type II cytotoxic hypersensitivity
  3. type III immune complex-mediated hypersensitivity
  4. type IV delayed hypersensitivity

Question 6

Type: MCSA

A patient is diagnosed with a type IV delayed hypersensitivity reaction. What is an example of this type of reaction?

  1. latex allergy
  2. reaction to a wasp sting
  3. serum sickness
  4. autoimmune hemolytic anemia

Question 7

Type: MCSA

A patient develops hemolytic anemia after receiving a dose of penicillin. What action should the nurse realize is indicated for this patient?

  1. Administer no further doses of penicillin.
  2. Administer a blood transfusion.
  3. Provide oxygen.
  4. Increase fluids.

Question 8

Type: MCSA

A patient develops a fever, rash, joint and muscle pain, and swollen lymph nodes after receiving a sulfonamide. What should these symptoms suggest to the nurse?

  1. serum sickness
  2. exacerbation of a disease process
  3. acute influenza
  4. subacute rheumatoid arthritis

Question 9

Type: MCSA

A patient who has received a bone marrow transplant develops a maculopapular rash on the palms of both hands and the soles of the feet. The patient complains of severe abdominal pain with bloody diarrhea. What should the nurse suspect this patient is experiencing?

  1. graft-versus-host disease
  2. chronic tissue rejection
  3. acute tissue rejection
  4. hyperacute tissue rejection

Question 10

Type: MCSA

A patient is diagnosed with valvular heart disease after experiencing rheumatic heart fever. The nurse understands this disorder is caused by what action?

  1. molecular mimicry
  2. release of hidden antigens into the circulation
  3. biologic changes that cause self-antigens to produce autoantibodies
  4. autoimmune response by slow-growing mycobacteria

 

CHAPTER 14

Question 1

Type: MCSA

A patient shows the nurse a new sore on the forearm that has been increasing in size and will not heal. The nurse knows that which sign could also point to a diagnosis of a malignant neoplasm?

  1. noncohesive, invasive, and invades and destroys surrounding tissues
  2. rapid growth, well-defined borders, and cohesiveness
  3. invasive, local, and does not stop at tissue border
  4. slow growth, well-defined borders, and encapsulated

Question 2

Type: MCSA

After learning that he has a benign tumor in his abdomen, the patient is overheard telling his wife that he has cancer. What should the nurse say to the patient and spouse?

  1. “There is a growth in the abdomen but it is encapsulated and after being removed, will not recur.”
  2. “This type of cancer is easily treated.”
  3. “This type of cancer will not spread to other tissues.”
  4. “Even though this growth has invaded other tissues, it can be contained.”

Question 3

Type: MCSA

A patient tells the nurse that he has a benign tumor that has spread into his lymph glands. How should the nurse respond to this patient?

  1. “What did your doctor tell you about the tumor?”
  2. “Benign tumors do not spread.”
  3. “That’s a good thing that the tumor is benign.”
  4. “Since it is benign, are you going to have surgery to remove it?”

Question 4

Type: MCSA

A patient with a history of cancer is surprised to learn that new cancer has been diagnosed in another body part. What should the nurse realize this patient is experiencing?

  1. metastasis
  2. contact inhibition
  3. destructive force from a benign neoplasm
  4. a solid mass

Question 5

Type: MCSA

A patient asks the nurse how his cancer developed. Which statement should the nurse avoid in responding to this patient?

  1. “The theory of cellular mutation suggests that carcinogens cause mutations in cellular RNA.”
  2. “Oncogenes are genes that promote cell proliferation and are capable of triggering cancerous characteristics.”
  3. “The majority of people do not have an inherited form of cancer.”
  4. “Known carcinogens include viruses, drugs, hormones, and chemical and physical agents.”

Question 6

Type: MCSA

A patient with a history of smoking is diagnosed with cancer. If applying the cellular mutation theory of cancer to this patient’s diagnosis, the nurse realizes that smoking impacted which stage?

  1. promotion
  2. initiation
  3. progression
  4. replication

Question 7

Type: MCSA

A female patient asks the nurse why she needs a procedure to remove part of her cervix that was infected with a virus. What should the nurse explain to this patient?

  1. Human papillomavirus can cause cervical cancer.
  2. The medication to treat this virus is toxic to the body.
  3. If left untreated, it could spread to the liver.
  4. If left untreated, it could spread to the breast.

Question 8

Type: MCSA

A patient with a history of using recreational cocaine tells the nurse that he would rather be addicted to cocaine than be diagnosed with cancer. What should the nurse respond with to this patient?

  1. “Cocaine has been linked to the development of cancer.”
  2. “I guess if that’s what you would prefer.”
  3. “People who use cocaine do have a lower risk of developing cancer.”
  4. “As long as the cocaine is pure and not mixed with toxic chemicals.”

Question 9

Type: MCMA

A college student is diagnosed with Epstein-Barr virus. The student has a history of smoking and recreational cocaine use and works for a floor refinishing company part-time. Which factors increase this student’s risk for developing cancer?

Standard Text: Select all that apply.

  1. drug use
  2. occupation
  3. smoking
  4. viral infection
  5. age

Question 10

Type: MCSA

The nurse is preparing to provide care to a group of assigned patients. Which patient should the nurse realize is at the highest risk for developing cancer?

  1. an African American man
  2. a Native American woman
  3. an Hispanic man
  4. an Hispanic woman

 

CHAPTER 15

Question 1

Type: MCSA

A patient is experiencing a problem with the eccrine sweat glands. Because of this structural problem, the nurse realizes that which function will be affected in this patient?

  1. regulation of body temperature
  2. regulation of body heat by excretion of perspiration
  3. sebum secretion
  4. sexual scent gland

Question 2

Type: MCSA

During a conversation with the nurse, a patient comments that he rarely goes outside when the sun is shining because he is afraid of developing skin cancer. Which health problem is this patient at risk for developing?

  1. vitamin D deficiency
  2. hypercholesterolemia
  3. hypokalemia
  4. hypernatremia

Question 3

Type: MCMA

A patient who has experienced a burn involving both the epidermis and the dermis asks if the area will heal and be as it was prior to the burn. What knowledge of skin structures should the nurse use to respond to this patient?

Standard Text: Select all that apply.

  1. Most hair follicles are in the dermis.
  2. Most sweat glands are in the dermis.
  3. Hair follicles are located in the subcutaneous tissue.
  4. Sebaceous glands are located in the dermis.
  5. Receptors for pain and touch are located in the dermis.

Question 4

Type: MCSA

The nurse is caring for an African American patient who has a serum bilirubin of 6 mg/100 mL. What is the best way of assessing skin color changes in this patient?

  1. Assess the sclera.
  2. Assess the palms of the hands.
  3. Assess the fingernails.
  4. Assess the skin of the inner arms.

Question 5

Type: MCSA

The nurse is caring for an African American patient who has an ashen cast to his normally black skin. Which laboratory test results should the nurse review to determine a possible cause of the skin color change?

  1. BUN
  2. hemoglobin and hematocrit
  3. bilirubin
  4. oxygen saturation

Question 6

Type: MCSA

A Caucasian patient is admitted with possible carbon monoxide poisoning. What skin color can the nurse expect to find that would support this diagnosis?

  1. bluish
  2. dusky red
  3. cherry red
  4. orange green

Question 7

Type: MCSA

While conducting a patient’s health history, the nurse learns that the patient has worked at a landfill for the last 35 years. Why should the nurse find this information significant?

  1. Explains possible exposure to environmental toxins
  2. Helps understand the patient’s lack of communication skills
  3. Validates that the patient is an older adult
  4. Confirms the patient’s level of education

Question 8

Type: MCMA

A patient is seen for an erythematous generalized rash. Which questions should the nurse ask regarding the rash?

Standard Text: Select all that apply.

  1. “Have you recently eaten any new foods?”
  2. “What medications do you take?”
  3. “Have you changed your soap?”
  4. “Have you changed skin care lotions?”
  5. “How often do you walk outside?”

Question 9

Type: MCSA

A patient being seen for an elevated, darkened area of excess scar tissue asks the nurse what caused it. How should the nurse respond?

  1. “This scar was caused by the wearing away of the superficial epidermis, which left a moist, shallow depression.”
  2. “This scar was caused by excessive collagen formation during healing.”
  3. “This scar was caused by skin loss extending into the dermis or subcutaneous tissue.”
  4. “This scar was caused by wasting of the skin due to loss of collagen.”

Question 10

Type: MCMA

The nurse is performing an assessment of a patient’s nails. What should be included in this examination?

Standard Text: Select all that apply.

  1. nail thickness
  2. nail color
  3. nail curvature
  4. nail length
  5. for grooves

 

CHAPTER 16

Question 1

Type: MCSA

The mother of a teenage girl voices concerns about her daughter’s acne. Which response by the nurse is best?

  1. “The skin needs to be washed at least twice a day with mild soap and water to remove surface oil.”
  2. “The greatest culprit for acne is dietary habits, not inadequate hygiene.”
  3. “Are you embarrassed by her appearance?”
  4. “What are your concerns about her hygiene practices?”

Question 2

Type: MCSA

A patient has a lesion in the left axilla that is deep, painful, and contains pus. It is 3 centimeters in diameter. After the assessment, what type of lesion should the nurse determine that the patient has?

  1. furuncle
  2. folliculitis
  3. carbuncle
  4. herpes varicella

Question 3

Type: MCSA

An African American patient has reoccurring folliculitis on the face. What should the nurse instruct the patient to do about this health problem?

  1. Practice good hygiene.
  2. Shave daily.
  3. Shave very closely.
  4. Shave in the opposite direction of hair growth.

Question 4

Type: MCSA

The nurse is counseling a patient who has atopic dermatitis (eczema) and has developed a secondary infection. What should the nurse emphasize so that the patient can prevent this type of infections in the future?

  1. methods to prevent itching
  2. continuous antibiotic treatment
  3. frequent bathing
  4. allergy testing

Question 5

Type: MCSA

A patient has a small, red, scaling lesion that is sitting on an elevated base on the forehead. The patient states that lesion began several weeks before and will not heal. What type of lesion does the nurse consider the patient is experiencing?

  1. squamous cell carcinoma
  2. melanoma
  3. psoriasis
  4. seborrheic keratosis

Question 6

Type: MCSA

A patient diagnosed with scabies asks the nurse how he “caught” the disorder. What information should be provided to the patient?

  1. The disorder is transmitted by contact with infected persons or their possessions.
  2. The disorder is transmitted by the feces of infected animals.
  3. Scabies is a bacterial infection transmitted by direct contact with infected persons.
  4. Scabies is a fungal infection transmitted by contact with infected respiratory secretions.

Question 7

Type: MCSA

The nurse is planning care for a patient with herpes zoster. Which problem should the nurse identify as being the priority for this patient?

  1. managing pain
  2. avoiding breakouts
  3. relieving itchiness
  4. improving hygiene

Question 8

Type: MCSA

The patient with herpes zoster has pruritus and reports difficulty resting at night. Which intervention will best aid the patient?

  1. Encourage the patient to take prescribed antipruritic agents approximately one hour before bedtime.
  2. Massage the irritated skin areas with lotion.
  3. Apply powder to the lesions.
  4. Use heavy bed linens to avoid chilling at night.

Question 9

Type: MCMA

A patient at risk for the development of skin cancer is discussing sun exposure prevention with the nurse. What information should be included in the discussion?

Standard Text: Select all that apply.

  1. A higher-rated sunscreen is needed between 10 a.m. and 3 p.m.
  2. Sunscreen is needed even on cloudy days.
  3. Apply a sunscreen with an SPF of 15 or more.
  4. The higher the sunscreen rating, the less the protection provided.
  5. When swimming, sunscreen should be reapplied every 4 hours.

Question 10

Type: MCMA

The nurse is planning care for a patient at risk for pressure ulcer development. What should the nurse include in this patient’s plan of care?

Standard Text: Select all that apply.

  1. Initiate a frequent toileting schedule.
  2. Turn the patient every 2 hours.
  3. Massage pressure areas with lotion every 4 hours.
  4. Use inflatable donut rings to reduce pressure on the sacrum.
  5. Use hot water to cleanse the skin immediately after incontinence.

 

CHAPTER 17

Question 1

Type: MCMA

A patient comes into the emergency department with a chemical burn from contact with lye. Which facts about this type of burn should guide the nurse when assessing and planning care for this patient?

Standard Text: Select all that apply.

  1. This is an alkali burn.
  2. This type of burn tends to be deeper.
  3. This is an acid burn.
  4. This type of burn is easier to neutralize.
  5. This type of burn tends to be more superficial.

Question 2

Type: MCMA

A patient arrives at the emergency department with an electrical burn. What assessment questions should the nurse ask when determining the possible severity of the burn injury?

Standard Text: Select all that apply.

  1. What type of current was involved?
  2. How long was the patient in contact with the current?
  3. How much voltage was involved?
  4. Where was the patient when the burn occurred?
  5. What was the point of contact with the current?

Question 3

Type: MCSA

A nurse sees a patient get struck by lightning during a thunderstorm on a golf course. What is the first action the nurse should perform?

  1. Check breathing and circulation.
  2. Look for entrance and exit wounds.
  3. Cover the victim to prevent heat loss.
  4. Move the victim indoors to a dry place.

Question 4

Type: MCMA

The nurse is teaching a class of older adults at a senior center about household cleaning agents that may cause burns. Which agents should be included in this discussion?

Standard Text: Select all that apply.

  1. drain cleaners
  2. household ammonia
  3. oven cleaner
  4. toiler bowl cleaner
  5. lemon oil furniture polish

Question 5

Type: MCSA

A patient with a burn that is pale, waxy, and with large flat blisters asks the nurse about the severity of the burn and how long it will take to heal. How should the nurse respond?

  1. The wound is a deep partial-thickness burn and will take more than 3 weeks to heal.
  2. The wound is a superficial partial-thickness burn and could take up to 2 weeks to heal.
  3. The wound is a superficial burn and will take up to 3 weeks to heal.
  4. The wound is a full-thickness burn and will take 1 to 2 weeks to heal.

Question 6

Type: MCMA

The nurse is classifying a patient’s burn injuries. What information should the nurse assess to ensure this classification is correct?

Standard Text: Select all that apply.

  1. depth of the burn
  2. extent of burns on the body
  3. causative agent and duration of exposure
  4. location of burns on the body
  5. time that the burns occurred

Question 7

Type: MCMA

A patient has a scald burn on the arm that is bright red, moist, and has several blisters. The nurse would classify this burn as which type?

Standard Text: Select all that apply.

  1. a superficial partial-thickness burn
  2. a thermal burn
  3. a superficial burn
  4. a deep partial-thickness burn
  5. a full-thickness burn

Question 8

Type: FIB

A patient is brought to the emergency department with the following burn injuries: a blistered and reddened anterior trunk, reddened lower back, and pale, waxy anterior right arm. Calculate the extent of the burn injury (TBSA) using the rule of nines.

_____ %

Standard Text: Record your answer rounding to the nearest whole number.

Question 9

Type: MCSA

A 25-year-old patient is admitted with partial-thickness burns on both lower legs, over 20% of the total body surface area. How should the nurse classify this burn?

  1. moderate burn injury
  2. minor burn injury
  3. major burn injury
  4. severe burn injury

Question 10

Type: MCSA

A patient has sustained a partial-thickness burn of 28% of total body surface area (TBSA) and full-thickness burn of 30% or greater of TBSA. How should the nurse classify this burn injury?

  1. major
  2. moderate
  3. minor
  4. superficial

 

CHAPTER 18

Question 1

Type: MCSA

The nurse is assessing a patient diagnosed with hypothyroidism. Which health assessment interview question should the nurse ask this patient?

  1. “Is your skin feeling rough and dry?”
  2. “Is your skin smooth or flushed?”
  3. “Does your skin feel clammy?”
  4. “Do you have brown, shiny patches on the lower extremities?”

Question 2

Type: MCSA

When measuring the blood pressure of a patient with hypoparathyroidism, the nurse notes spasms of the patient’s hand. How should the nurse document this finding?

  1. Trousseau sign
  2. Chvostek sign
  3. Turner sign
  4. Cullen sign

Question 3

Type: MCSA

A patient has a positive Trousseau sign. For which problem should the nurse plan care for this patient?

  1. pain
  2. excessive fluid
  3. difficulty breathing
  4. reduced blood flow

Question 4

Type: MCMA

During an endocrine assessment, the nurse asks a patient about changes in weight. For which organs is the nurse assessing function in the patient?

Standard Text: Select all that apply.

  1. adrenal
  2. thyroid
  3. pituitary
  4. parathyroid
  5. gonads

Question 5

Type: MCSA

The nurse is assessing a patient with a pituitary disorder. Which finding does the nurse assess for in this patient?

  1. enlargement of the hands and feet
  2. thin, soft hair
  3. excessive growth of facial hair
  4. purple striae over the trunk

Question 6

Type: MCSA

A patient is demonstrating signs of exophthalmos. What additional finding should the nurse expect to assess in this patient?

  1. enlarged thyroid gland
  2. dry, thick nails
  3. dry skin
  4. decreased reflexes

Question 7

Type: MCSA

The nurse is reviewing data collected during a patient’s health history. What information would indicate a disorder of the pituitary gland?

  1. dwarfism
  2. carpal spasms
  3. enlarged thyroid nodule
  4. hyperpigmentation of the skin

Question 8

Type: MCSA

The nurse is caring for a patient with Graves disease. On which laboratory value should the nurse focus for this patient?

  1. thyroxine
  2. urine-specific gravity
  3. cortisol
  4. calcium

Question 9

Type: MCSA

The nurse is conducting a physical assessment with a patient. Which assessment technique should the nurse use to assess the patient’s thyroid gland?

  1. Stand behind the patient and palpate the thyroid.
  2. Stand in front of the patient and palpate the thyroid.
  3. Place the patient supine and palpate one side of the neck at a time.
  4. Have the patient flex the neck forward and palpate the thyroid.

Question 10

Type: MCMA

The nurse is beginning the assessment of a patient with an endocrine disorder. What should the nurse include in this assessment?

Standard Text: Select all that apply.

  1. height and weight
  2. skin, hair, and nails
  3. deep tendon reflexes
  4. musculoskeletal system
  5. respiratory system

 

CHAPTER 19

Question 1

Type: MCSA

While assessing a patient with an alteration in thyroid function, the nurse notes smooth, fine hair and warm, dry skin. Which question should the nurse ask this patient?

  1. “Have you experienced any recent weight loss?”
  2. “Have you been feeling constipated?”
  3. “Have you noticed increased bruising?”
  4. “Have you noticed a change in your skin color?”

Question 2

Type: MCSA

The nurse is providing preoperative teaching to a patient scheduled for a subtotal thyroidectomy. What should the nurse include in these instructions?

  1. Report sensations of tingling in toes, fingers, or lips.
  2. Report signs of constipation.
  3. Report the improvement of hoarseness.
  4. Take aspirin before the surgery.

Question 3

Type: MCSA

The nurse is caring for a patient with elevated serum T3 and T4 levels who receives a new prescription for methimazole (Tapazole). Which patient statement indicates that additional teaching is needed about this medication?

  1. “This medication will increase my metabolism.”
  2. “I must contact my physician if I plan to become pregnant.”
  3. “It may take several weeks for this medication to take effect.”
  4. “I may take a beta-blocker along with this medication.”

Question 4

Type: MCSA

The nurse is reviewing postoperative care for a patient scheduled for a thyroidectomy. What information should the nurse include in this teaching?

  1. “Avoid the use of iodized salt after your procedure.”
  2. “Plastic surgery may be required to conceal the surgical scar.”
  3. “Use iodized salt when preparing foods.”
  4. “Perform neck flexion and extension exercises twice daily for several weeks postoperatively.”

Question 5

Type: MCSA

The nurse is caring for a patient with elevated serum thyroid hormones and new-onset proptosis. Which problem would be a priority for this patient?

  1. change in appearance
  2. altered immunity
  3. weight gain
  4. fluid retention

Question 6

Type: MCSA

A patient whose thyroid gland produces an insufficient amount of thyroid hormone is concerned about an elevated cholesterol level. What should the nurse explain to this patient?

  1. “The thyroid gland malfunction can affect your cholesterol level.”
  2. “Maybe you don’t realize how much fat is in the foods you eat.”
  3. “Elevated cholesterol is a normal part of aging.”
  4. “Describe your typical bedtime snack.”

Question 7

Type: MCSA

The family of an older patient with hypothyroidism is concerned about the open wounds on the patient’s legs and arms. How should the nurse respond to the family’s questions about bathing?

  1. “Use warm water to bathe the patient.”
  2. “Make sure she has a daily bath.”
  3. “Use firm, consistent strokes when bathing.”
  4. “Follow the bath with a rubbing-alcohol massage.”

Question 8

Type: MCMA

The nurse is assessing a female patient who has an abnormally high level of parathyroid hormone. Which assessment findings would be consistent with this diagnosis?

Standard Text: Select all that apply.

  1. muscle atrophy
  2. muscle weakness
  3. diarrhea
  4. weight gain
  5. hypotension

Question 9

Type: MCMA

The nurse is providing care to a patient with a low level of serum parathyroid hormone. What should the nurse expect to assess in this patient?

Standard Text: Select all that apply.

  1. facial grimacing
  2. abdominal cramps
  3. hair loss
  4. dysrhythmias
  5. smooth, soft skin

Question 10

Type: MCSA

A patient taking steroids for an autoimmune disorder asks when the weight loss in the legs is going to stop. What should the nurse realize the patient is experiencing?

  1. muscle wasting
  2. poor wound healing
  3. risk for compression fractures
  4. increased susceptibility to infections

 

CHAPTER 20

Question 1

Type: MCSA

A patient with diabetes mellitus and poor circulation has thick and ingrown toenails. What should the nurse instruct the patient to do?

  1. Soak feet in Epsom salts daily.
  2. Use a clean sharp razor blade to trim nails.
  3. Make an appointment with a podiatrist.
  4. Cut toenails immediately prior to bathing.

Question 2

Type: MCSA

A patient with diabetes asks what can be done to prevent the development of corns on the feet. How should the nurse respond to this patient?

  1. “Make sure that you select shoes that are appropriately fitted.”
  2. “Use corn pads to gradually remove the growths.”
  3. “Corns are best treated by shaving them off.”
  4. “A mild abrasive soap can be used to scrub the area to remove them.”

Question 3

Type: MCSA

A patient at risk for the development of type 2 diabetes mellitus asks why weight loss will reduce risk of the condition. Which response by the nurse is most accurate?

  1. “The amount of foods taken in require more insulin to adequately metabolize them, resulting in diabetes.”
  2. “Excess body weight impairs the body’s release of insulin.”
  3. “Thin people are less likely to become diabetic.”
  4. “The physical inactivity associated with obesity causes a reduced ability by the body to produce insulin.”

Question 4

Type: MCSA

A patient recently diagnosed with type 1 diabetes mellitus does not understand why the disease developed because the patient is thin and eats all of the time. What is the most appropriate response by the nurse?

  1. “Thin people can be diabetic, too.”
  2. “Your condition makes it impossible for you to gain weight.”
  3. “Diabetes makes it difficult for your body to obtain energy from the foods you eat.”
  4. “Your lab tests indicate the presence of diabetes.”

Question 5

Type: MCSA

A 78-year-old patient without polyuria, polydipsia, or polyphagia has a serum glucose level of 130 mg/dL. What should the nurse conclude about this patient?

  1. The patient might have eaten a meal with high sugar content prior to the testing.
  2. The laboratory results might be erroneous.
  3. The patient has type 1 diabetes mellitus.
  4. The patient will need to be assessed for other manifestations of diabetes.

Question 6

Type: MCSA

The nurse notes that a 41-year-old patient’s fasting blood glucose level is 125 mg/dL. What should the nurse suspect is occurring with the patient?

  1. severe hyperglycemia
  2. consistent with diabetes
  3. normal results
  4. consistent with prediabetes

Question 7

Type: MCSA

A patient recently diagnosed with diabetes wants to check the urine for glucose instead of using capillary blood because of the cost. Which response should the nurse make to the patient?

  1. “Urine testing is best when combined with serum testing.”
  2. “Urine testing is as reliable as finger stick testing.”
  3. “Yes, urine testing is cheaper than glucose test strips.”
  4. “Would you like to switch to this method of monitoring?”

Question 8

Type: MCSA

A patient with type 1 diabetes mellitus who had one episode of vomiting in the past 2 hours asks if the routine insulin injection should be taken. What action by the nurse is best at this time?

  1. Contact the physician.
  2. Explain the need to take the insulin.
  3. Document the refusal and continue on with the planned care.
  4. Check the patient’s fasting serum glucose level.

Question 9

Type: MCSA

A patient beginning insulin for type 2 diabetes is experiencing blurred vision and is concerned about becoming blind. What response by the nurse is most appropriate?

  1. “I will make an appointment for you to see an ophthalmologist.”
  2. “I will call the physician to report your symptoms.”
  3. “Blurry vision is very common. Do not worry.”
  4. “This is a normal response when insulin therapy is initiated.”

Question 10

Type: MCSA

A patient with diabetes is diaphoretic, has a heart rate of 112 beats per minute, and is feeling nervous and shaky. What action should the nurse take first?

  1. Provide the patient with a snack of milk and crackers.
  2. Administer insulin utilizing the prescribed sliding scale dosages.
  3. Contact the laboratory and order a serum glucose level.
  4. Obtain a capillary serum glucose level reading with a glucose meter.

AND MUCH MORE