Med surg 2 Final Review

ANS: A To detect an apical-radial pulse deficit, the rates should be counted simultaneously and compared for differences. If a difference exists between the apical rate and the radial rate, then a pulse deficit is present. For example, in atrial fibrillation, a pulse deficit exists. DIF: Cognitive Level: Analysis REF: p. 687 OBJ: 8 TOP: Vital Sign Assessment: Pulse Deficit KEY: Nursing Process Step: Assessment MSC:

1. A nurse performs an apical-radial pulse evaluation, with the result of 100/88. What is the pulse deficit? a. 12 b. 24 c. 76 d. 88

ANS: B The plaque surface acts as a trap to which fibrous plaques can adhere, causing more narrowing of the vessel. The enlarging plaque can become a thrombus but not an embolus because emboli are usually considered to be traveling aggregations that lodge in a small arteriole. DIF: Cognitive Level: Comprehension REF: p. 709 OBJ: 7 TOP: Atherosclerosis KEY: Nursing Process Step: Implementation MSC:

10. What do fibrous plaques of atherosclerosis serve as when they are laid down in the vessels? a. Stent to keep the vessel open b. Trap to which other substances adhere c. Threat to the integrity of the vessel wall d. Embolus

ANS: A The code is A (chamber-paced) atria, A (sense impulse) atria only, I (inhibit) inhibit firing from the pacemaker, O (rate modification) no rate modification, and O (multichamber) no other chambers to be stimulated by the pacemaker. If the SA fires on its own, the pacemaker does nothing until it fails to sense an impulse. DIF: Cognitive Level: Application REF: p. 615 OBJ: 7 | 9 TOP: Permanent Pacemaker Care KEY: Nursing Process Step: Implementation MSC:

11. A patient with an irregular sinoatrial (SA) node conduction has a permanent pacemaker with the code AAIOO and is now going home. The patient asks, "What happens when my real SA node fires on its own?" How should the nurse respond regarding what the pacemaker should do? a. Not fire b. Fire only the ventricles c. Change the rate of firing d. Fire both the atria and the ventricles.

ANS: B A patient with angina who has pain at rest that is not relieved with one NTG pill is considered to have unstable angina, a precursor to an acute MI. DIF: Cognitive Level: Comprehension REF: p. 688 OBJ: 7 TOP: Unstable Angina KEY: Nursing Process Step: Assessment MSC:

12. A patient with angina pectoris complains of chest pain at rest and needs to take three nitroglycerin (NTG) pills to relieve the pain. Of what should the nurse assess this as a major symptom? a. Stable angina b. Unstable angina c. Full-blown acute myocardial infarction (MI) d. Pulmonary embolus

ANS: C Cardiac rehabilitation programs are supervised by a team of experts who arrange for telemetry-supervised exercise and other modalities, such as diet and medical protocol management. The focus is on the family, as well as the patient. Although some patients reject the program, they are rarely rejected by the rehabilitation center. DIF: Cognitive Level: Comprehension REF: p. 727 OBJ: 7 TOP: Cardiac Rehabilitation KEY: Nursing Process Step: Assessment MSC:

13. A nurse explains that cardiac rehabilitation lasts from the end of acute care to the return to home and beyond. What does this service include? a. One-on-one individualized care b. Focus on the patient rather than the family c. Telemetry-monitored exercise d. Rejection from the program for noncompliance

ANS: A Heart murmurs indicate turbulent blood flow and can be caused by valves that are stiff and do not shut correctly; consequently, blood flows back into the chamber. DIF: Cognitive Level: Comprehension REF: p. 688 OBJ: 7 TOP: Heart Murmur KEY: Nursing Process Step: Assessment MSC:

14. On auscultation, a nurse detects a heart murmur. What should the nurse know that a heart murmur indicates? a. Valves that do not close correctly b. Pericardium that is inflamed c. Decrease in pacemaker cells d. Loud ventricular gallop

ANS: B Patients with mitral stenosis need to balance their activity with their oxygen supply and avoid overhydration. DIF: Cognitive Level: Application REF: p. 727 OBJ: 7 TOP: Mitral Stenosis KEY: Nursing Process Step: Implementation MSC:

15. What is an important teaching point for a patient with mitral stenosis? a. Obtain a place on the heart transplant list. b. Balance activity with oxygen supply. c. Increase daily fluid intake to over 2000 mL. d. Have an annual electrocardiogram.

ANS: B Pulse oximetry measures arterial oxygen saturation noninvasively by attaching a clip to a digit, an ear, or a nose. DIF: Cognitive Level: Comprehension REF: p. 694 OBJ: 6 TOP: Pulse Oximetry KEY: Nursing Process Step: Implementation MSC:

16. A physician has ordered continuous pulse oximetry. What should the nurse explain to the patient about this procedure? a. Involves a single prick b. Measures the amount of oxygen in the blood c. Is applied to the wrist d. Identifies damaged cells in the myocardium

ANS: A A stress test is a noninvasive test that consists of a patient walking on a treadmill while an electrocardiogram records the activity. A consent form is required. DIF: Cognitive Level: Application REF: p. 692 OBJ: 6 TOP: Stress Test KEY: Nursing Process Step: Implementation MSC:

17. A stress test is scheduled for a 41-year-old patient. What action should the nurse implement to prepare the patient for the examination? a. Have the patient sign a consent form. b. Give the patient a special heart diet. c. Prepare the patient for sedation. d. Remove all metal objects.

ANS: B Cardiac catheterizations are invasive procedures during which a catheter is threaded through an artery. Postprocedure care requires bedrest and monitoring the puncture site. DIF: Cognitive Level: Application REF: p. 690 OBJ: 6 TOP: Cardiac Catheterization KEY: Nursing Process Step: Implementation MSC:

18. What action should a nurse expect to implement when a patient returns from a cardiac catheterization? a. Ambulate the patient in the hall. b. Check the puncture site. c. Monitor the gag reflex. d. Remove the gel from all sites on the skin.

ANS: C The abnormal wave form of the inverted T wave is an indicator that tissue death has occurred in part of the cardiac wall. The cardiac wall now has no ability to conduct or to contract and sends that message to the ECG via the inverted T. The tissue will take 6 weeks to regenerate. DIF: Cognitive Level: Analysis REF: p. 711 OBJ: 8 TOP: Significance of Inverted T Wave KEY: Nursing Process Step: Evaluation MSC:

19. A nurse assesses an inverted T wave on the ECG of a patient who had an acute MI two days earlier. How should the nurse interpret this finding? a. Normal recovery b. New MI c. Abnormal wave form d. Congestive heart failure

ANS: D An increase blood pressure creates an increase in afterload because the heart must work harder to push the blood out of the left ventricle into the circulating volume. DIF: Cognitive Level: Comprehension REF: p. 685-686 OBJ: 7 TOP: Hypertension Effect on Afterload KEY: Nursing Process Step: Implementation MSC:

2. What is increased in hypertension that in turn causes an increase in the work of the heart? a. Preload b. Stroke volume c. Contractility d. Afterload

ANS: D Troponin is elevated within 3 to 6 hours and is often measured in the emergency department. CPK-MB is elevated in 12 to 24 hours. Three serial samples are drawn. The LDH increases with heart damage within 3 to 6 days. The lipid profile is not elevated with heart damage. DIF: Cognitive Level: Knowledge REF: p. 690 | p. 712 OBJ: 8 TOP: Cardiac Enzymes KEY: Nursing Process Step: Implementation MSC:

20. Laboratory tests are performed to identify damage to the heart muscle. Which test is elevated the earliest with heart damage? a. Creatine phosphokinase-MB (CPK-MB) b. Lactate dehydrogenase (LDH) c. Lipid profile d. Troponin

ANS: A The dye injected during the cardiac catheterization is iodine based. An allergy to seafood is correlated with a reaction to this dye as well. DIF: Cognitive Level: Application REF: p. 693 OBJ: 5 TOP: Cardiac Catheterization KEY: Nursing Process Step: Implementation MSC:

21. A patient is scheduled for a heart catheterization. What action should the nurse implement in preparation for this examination? a. Ask the patient about allergies to seafood or iodine. b. Remove all metal objects. c. Give the patient a special heart diet. d. Test arterial blood gases (ABGs).

ANS: B Atropine increases the heart rate. The nurse should watch for tachycardia, which increases the workload of the heart. This medication causes urinary retention. DIF: Cognitive Level: Application REF: p. 701 OBJ: 7 TOP: Drugs for Dysrhythmias KEY: Nursing Process Step: Assessment MSC:

22. A patient has had atropine sulfate that has been administered intravenously to treat a dysrhythmia. What should the nurse assess this patient for after administration? a. Weight gain b. Tachycardia c. Muscle twitching d. Incontinence of urine

ANS: A Dopamine has a direct effect by elevating the blood pressure. The criterion is to titrate to the target blood pressure. Urinary output should also be monitored for a decreased amount because a heightened blood pressure may slow urine filtration and reduce urine output. DIF: Cognitive Level: Application REF: p. 701 OBJ: 7 TOP: Dopamine KEY: Nursing Process Step: Assessment MSC:

23. A dopamine infusion is being administered to a patient with shock. For what should the nurse be alert? a. Sharp spike in blood pressure b. Tremor of the hands c. Increasing urinary output d. Hyperirritability of the patient

ANS: A The drug amiodarone is meant to quiet atrial activity and modify rapid pulse rate, high blood pressure, and decreased cardiac output caused by the dysrhythmia. The drug interferes with the thyroid and causes an ataxic gait and trembling of hands as adverse effects. DIF: Cognitive Level: Application REF: p. 699 OBJ: 7 TOP: Atrial Fibrillation with Amiodarone KEY: Nursing Process Step: Assessment MSC:

24. A patient with atrial fibrillation is prescribed amiodarone for the dysrhythmia. Which potential adverse reaction should the nurse report? a. Ataxia b. Decreasing pulse rate c. Decreasing blood pressure d. Increase in cardiac output

ANS: D The reading that has both an HDL level above 40 mg/dL and an LDL level below 100 mg/dL is in the therapeutic target range. DIF: Cognitive Level: Knowledge REF: p. 695 OBJ: 7 TOP: Drug Therapy KEY: Nursing Process Step: Implementation MSC:

25. A medication, simvastatin (Zocor), is administered to lower a patient's cholesterol level. Follow-up lipid levels are reviewed by the nurse. Which level indicates the desired therapeutic range? a. High-density lipoprotein (HDL), 29 mg/dL; low-density lipoprotein (LDL), 160 mg/dL b. HDL, 38 mg/dL; LDL, 120 mg/dL c. HDL, 56 mg/dL; LDL, 106 mg/dL d. HDL, 42 mg/dL; LDL, 98 mg/dL

ANS: C The patient needs written instructions for diet, follow-up appointments, and exercise protocols. Giving detailed information about symptoms is not necessary other than to remind the patient about reporting chest pain and shortness of breath. A high-energy exercise program is not appropriate. Morphine is not part of the home care after an MI. DIF: Cognitive Level: Application REF: p. 716 OBJ: 7 TOP: Myocardial Infarction KEY: Nursing Process Step: Implementation MSC:

26. What information should a nurse include in a patient's discharge instruction after an acute myocardial infarction (MI)? a. Cautions about the use of morphine b. Detailed symptoms that indicate impending MI c. Written instructions on diet and follow-up appointments d. High-energy exercise program directions

ANS: B Fluid volume excess increases the workload of the heart and interferes with breathing. DIF: Cognitive Level: Application REF: p. 687 | p. 720 OBJ: 7 TOP: Congestive Heart Failure KEY: Nursing Process Step: Nursing Diagnosis MSC:

27. A patient with acute congestive heart failure has jugular vein distention, crackles bilaterally, and dyspnea. Which nursing diagnosis should have the highest priority? a. Activity intolerance b. Excess fluid volume c. Anxiety d. Ineffective coping

ANS: A This pattern is NSR because it has one P wave for every QRS and one T wave. DIF: Cognitive Level: Analysis REF: p. 731 OBJ: 7 TOP: Recognition of NSR KEY: Nursing Process Step: Assessment MSC:

28. A nurse is assessing the cardiac complex above. What pattern should the nurse recognize in this rhythm strip? a. NSR b. Premature ventricular contractions (PVCs) c. Ventricular tachycardia (VT) d. AF

ANS: D Increased urinary output, weight loss, and thirst are all anticipated consequences of the therapy. Muscle weakness is a sign of hypokalemia. DIF: Cognitive Level: Comprehension REF: p. 696 OBJ: 7 TOP: Diuretic Therapy KEY: Nursing Process Step: Assessment MSC:

29. A diuretic medication, furosemide (Lasix), is being administered for congestive heart failure. Which assessment is not an anticipated consequence of the therapy? a. Increased urinary output b. Weight loss c. Thirst d. Muscle weakness

ANS: A Ventricular gallops are considered normal in individuals younger than 30 years of age. All other options are pathologic abnormalities. DIF: Cognitive Level: Application REF: p. 688 OBJ: 7 TOP: Heart Sound Assessment KEY: Nursing Process Step: Assessment MSC:

3. Which heart sound should the nurse record as normal? a. Ventricular gallop in a 20-year-old patient b. Atrial gallop in a 25-year-old patient c. Friction rub in a 45-year-old patient d. Medium diastolic murmur in a 50-year-old patient

ANS: B The dose should be held if the apical rate is less than 60 beats/min for 1 minute. DIF: Cognitive Level: Application REF: p. 679 OBJ: 7 TOP: Drug Therapy KEY: Nursing Process Step: Implementation MSC:

30. A patient is receiving digoxin 0.25 mg/day. What should the nurse do prior to administering this medication? a. Count an apical pulse for 15 seconds. b. Hold the dose if the apical rate is 57 beats/min. c. Give the dose if the apical rate is 59 beats/min. d. Double the dose if the rate is 62 beats/min.

ANS: D Beta-blockers should never be stopped abruptly because they can cause angina or MI. Patients are gradually weaned off these medications. DIF: Cognitive Level: Comprehension REF: p. 698 OBJ: 7 TOP: Drug Therapy KEY: Nursing Process Step: Implementation MSC:

31. A 46-year-old patient is receiving propranolol (Inderal), a nonselective beta-adrenergic blocker, for a heart condition. What patient teaching is most appropriate? a. Sit or lie down when taking the drug. b. Limit caffeine intake. c. Double the dose if symptoms occur. d. Never stop taking the drug abruptly.

ANS: C A temperature that goes up drastically indicates an adverse reaction to lidocaine, malignant hyperthermia. The slowed ventricular rate, even with occasional PVCs, is an expected outcome of lidocaine infusion. Nausea and vomiting are adverse effects. DIF: Cognitive Level: Application REF: p. 699 OBJ: 7 TOP: Drug Therapy KEY: Nursing Process Step: Assessment MSC:

32. Which assessment should be immediately addressed in a patient on lidocaine? a. Slowed ventricular rate b. Occasional PVCs c. Increase in temperature to 102° F d. Nausea and vomiting

ANS: B This is an arrhythmia of a PVC with an extra premature QRS complex (inverted) before the P wave. DIF: Cognitive Level: Analysis REF: p. 732 OBJ: 7 TOP: Recognition of PVC KEY: Nursing Process Step: Assessment MSC:

33. How should a nurse interpret the arrhythmia in the above strip? a. NSR b. PVC c. VT d. AF

ANS: C A "1" in a pulse evaluation indicates a thready pulse that is easily obliterated by pressure. DIF: Cognitive Level: Application REF: p. 687 OBJ: 8 TOP: Pulse Quality KEY: Nursing Process Step: Assessment MSC:

34. A nurse records a "1" for the pulse quality of the pedal pulse. What interpretation is correct regarding the pulse? a. Absent b. Normal c. Thready d. Forceful

ANS: A, D, E Stroke volume is dependent on contractility, preload, and afterload. Age may affect all three, but the stroke volume, regardless of age, is dependent on these three factors. DIF: Cognitive Level: Knowledge REF: p. 685 OBJ: 2 TOP: Stroke Volume KEY: Nursing Process Step: Implementation MSC:

35. Which factors affect stroke volume? (Select all that apply.) a. Contractility b. Climate c. Age d. Preload e. Afterload

ANS: A, B, C, D Aging thickens and stiffens the valves and reduces the cells in the SA node. Age decreases the nerve fibers in the ventricles. DIF: Cognitive Level: Knowledge REF: p. 686 OBJ: 9 TOP: Age-Related Cardiac Changes KEY: Nursing Process Step: Planning MSC:

36. Which age-related changes in the heart should a nurse take into consideration? (Select all that apply.) a. Decrease in contractility b. Thickened valves c. Stiffened valves d. Decreased SA node cells e. Increased nerve fibers in ventricles

ANS: A, C, E To minimize the workload of the heart, the nurse would adjust nursing care to eliminate all unnecessary activities, assist in position changes, and give a minimal bath. Ambulation and active range-of-motion exercises are unnecessary activities at this time. DIF: Cognitive Level: Application REF: p. 720 OBJ: 7 TOP: Nursing Care of Congestive Failure KEY: Nursing Process Step: Planning MSC:

37. What actions should a nurse implement to decrease the workload of the heart in a patient with acute congestive failure? (Select all that apply.) a. Eliminate unnecessary activities. b. Direct the patient in active range-of-motion exercises. c. Help the patient change positions every 2 hours. d. Assist the patient to ambulate to the bathroom. e. Give a partial bed bath rather than full bed bath.

ANS: A, B, C, D Conditioning exercises performed daily for 30 minutes can reduce weight, improve the cardiac output of the left ventricle, decrease arterial stiffening, and decrease LDLs. Exercise does not affect dysrhythmias. DIF: Cognitive Level: Comprehension REF: p. 715-716 OBJ: 7 TOP: Effects of Conditioning Exercises KEY: Nursing Process Step: Implementation MSC:

38. A nurse urges a 50-year-old overweight executive who had a myocardial infarction (MI) 3 months earlier to take up some conditioning exercises for 30 minutes a day. What rationale supports this suggestion? (Select all that apply.) a. Lose weight. b. Improve function of the left ventricle. c. Decrease arterial stiffening. d. Decrease cholesterol levels. e. Improve cardiac dysrhythmia.

ANS: negative When the heart is at rest, the inside of the cell is negatively charged. DIF: Cognitive Level: Comprehension REF: p. 685 OBJ: 3 TOP: Polarization of Myocardium KEY: Nursing Process Step: Assessment MSC:

39. At rest, the cardiac cells in the myocardium are electrically polarized, with the inside of the cell being more _____ than the outside of the cell.

ANS: C Smoking, a high-fat diet, hypertension, sedentary lifestyle, and stress are considered modifiable risk factors. DIF: Cognitive Level: Comprehension REF: p. 708 OBJ: 7 TOP: Coronary Artery Disease Risk Factors KEY: Nursing Process Step: Assessment MSC:

4. A 49-year-old patient has multiple risk factors for coronary artery disease. Which risk factor is considered modifiable? a. Family history b. Age c. Smoking d. Male gender

ANS: C TEE evaluates the efficiency of the valves. DIF: Cognitive Level: Application REF: p. 689 OBJ: 6 TOP: TEE KEY: Nursing Process Step: Implementation MSC:

5. A patient asks what a transesophageal echocardiogram (TEE) is and what it is expected to do? What is the best explanation by the nurse? a. Measures conductivity b. Records the force of contraction c. Evaluates the efficiency of the valves d. Checks the volume of the preload

ANS: A NSR requires the presence of P, Q, R, S, and T waves, in that order, and all pointing in the same direction, with a rate of 60 to 100 seconds. Normal intervals are a PR interval of 0.12 to 0.20 seconds and a QRS complex less than 0.10 second. DIF: Cognitive Level: Application REF: p. 730-731 OBJ: 5 TOP: Normal Sinus Rhythm KEY: Nursing Process Step: Assessment MSC:

6. A nurse records the finding of a normal sinus rhythm (NSR) when the P, Q, R, S, and T are all present in the electrocardiographic complex. What additional information should the nurse document? a. Rate of 82 seconds b. PR interval of 0.36 second c. QRS complex of 0.16 second d. Inverted T

ANS: B ACE inhibitors suppress the excretion of angiotensin, which lowers the blood pressure, reduces fluid retention, and leads to increased urine output. DIF: Cognitive Level: Application REF: p. 696 OBJ: 6 TOP: ACE Inhibitors KEY: Nursing Process Step: Planning MSC:

7. A nurse should anticipate that a patient taking Vasotec, an angiotensin-converting enzyme (ACE) inhibitor, should have which positive outcome to this drug? a. Increased fluid retention b. Decreased blood pressure c. Decreased urine output d. Increased appetite

ANS: A A cardioversion has risks, such as ventricular fibrillation. Emergency equipment should be available. The digoxin dose is held before a cardioversion, and the patient is given a short-acting sedative such as Versed or Valium, which will require recovery. The electrocardiogram R wave is synchronized via the computer, and no pacemaker is involved. DIF: Cognitive Level: Comprehension REF: p. 705 OBJ: 6 | 7 TOP: Cardioversion KEY: Nursing Process Step: Implementation MSC:

8. A 29-year-old patient is to receive cardioversion for a dysrhythmia. What should the nurse instruct the patient to expect? a. Administration of a short-acting sedative b. Digoxin dose to be taken as scheduled c. Procedure to be completely safe d. Pacemaker spikes to be carefully monitored

ANS: C Therapeutic implementations identify and acknowledge feelings. Do not assume that you know how the patient feels and do not give false assurances. DIF: Cognitive Level: Application REF: p. 707 OBJ: 7 | 9 TOP: Open Heart Surgery KEY: Nursing Process Step: Implementation MSC:

9. A 68-year-old patient is scheduled for open heart surgery in the morning and is crying. What is the most appropriate response by the nurse? a. "Everything will go great! Dr. C. is the best!" b. "I know how you feel, so do not cry." c. "Tell me what concerns you the most." d. "I will call the physician for a sedative. You are too upset."

30. A nurse computes the number of "pack years" of a 24-year-old man who has smoked packs of cigarettes every day since he was 15 years old. This patient has _____ pack years.

ANS: 13.5 Pack years are calculated by multiplying the number of years of smoking by the number of packs smoked each day. A 24-year-old patient who has smoked since he was 15 years of age = 9 years multiplied by 1.5 = 13.5. DIF: Cognitive Level: Application REF: p. 560 OBJ: 1 TOP: Pack Years KEY: Nursing Process Step: Assessment

28. A patient who is using imiquimod (Aldara) for genital warts asks the outpatient clinic nurse how long she must use the medication. The nurse replies that she must apply the medication for _____ weeks.

ANS: 16 The protocol for Aldara is application three times a day for 16 weeks. DIF: Cognitive Level: Knowledge REF: p. 1168 OBJ: 6 TOP: Genital Warts KEY: Nursing Process Step: Implementation

33. A nurse checks the oxygen in the circulating volume for adequate concentration to support the brain's need of _____% of the oxygen supply of the body.

ANS: 20 The brain requires 20% of the available oxygen to function and to avoid hypoxic damage. DIF: Cognitive Level: Knowledge REF: p. 482 OBJ: 7 TOP: Oxygen Needs of the Brain KEY: Nursing Process Step: Implementation

30. To meet the nutritional needs of a patient with Graves disease, the nurse recommends a diet of _____ to _____ calories.

ANS: 4000; 5000 The patient with Graves disease has a high metabolism, which requires a large caloric intake. These patients need 4000 to 5000 calories a day. DIF: Cognitive Level: Knowledge REF: p. 1042 OBJ: 4 TOP: Nutritional Needs of the Patient with Graves Disease KEY: Nursing Process Step: Planning

28. A nurse reminds a patient, who is to have a partial laryngectomy, that the temporary tracheostomy that he will have after the original surgery will be closed within _____ days.

ANS: 5 five The temporary tracheostomy, which is done as part of the partial laryngectomy surgery, is usually closed 5 days after the original surgery. DIF: Cognitive Level: Comprehension REF: p. 555 OBJ: 4 TOP: Tracheostomy in Partial Laryngectomy KEY: Nursing Process Step: Implementation

30. A nurse explains that growth hormone will be given to the child with hypopituitarism on a scheduled basis until the child reaches the height of _____.

ANS: 5 feet Growth hormone is given to children with hypopituitarism until they reach a height of 5 feet. DIF: Cognitive Level: Comprehension REF: p. 1017 OBJ: 3 TOP: Growth Hormone in a Child with Hypopituitarism KEY: Nursing Process Step: Implementation

27. A nurse explains that the minimal acceptable hourly urine output for a patient in shock who weighs 220 lb is _____.

ANS: 5 mL 220 lb ÷ 2.2 lb = 10 kg; 0.5 mL/kg/hr 10 = 5 mL. DIF: Cognitive Level: Analysis REF: p. 309 OBJ: 7 TOP: Minimum Urine Output KEY: Nursing Process Step: Implementation

29. The nurse recommends that an annual mammogram be performed for women older than _____ years of age.

ANS: 50 Annual mammography is recommended for women age 50 years and older. DIF: Cognitive Level: Knowledge REF: p. 1096 OBJ: 2 TOP: Mammograms KEY: Nursing Process Step: Assessment

30. A nurse explains to a pregnant patient with AIDS that her baby will be treated with antiretroviral drugs for _____ weeks after birth.

ANS: 6 six The usual antiretroviral protocol for an infant born to a mother with AIDS is for 6 weeks. DIF: Cognitive Level: Knowledge REF: p. 674 OBJ: 7 TOP: Treatment of Newborns of AIDS Patients KEY: Nursing Process Step: Implementation

30. A nurse uses a diagram to show the physiologic sequence of hearing. After entering the external ear, the sound is then conducted through the (Arrange the options in sequence. Separate letters by a comma and space as follows: A, B, C, D.) A. tympanic membrane B. sensory receptors C. oval window D. acoustic nerve to the brain E. malleus, incus, and stapes

ANS: A, E, C, B, D The sound impulse, after entering the external ear, is conducted through the tympanic membrane; into the malleus, incus, and stapes; through the oval window; into the sensory receptors in the inner ear; and then through the acoustic nerve to the brain. DIF: Cognitive Level: Comprehension REF: p. 1252 OBJ: 1 TOP: Physiology of Hearing KEY: Nursing Process Step: Implementation MSC:

30. A nurse instructs a patient about how insulin affects blood glucose. (Arrange the events in sequence. Separate letters by a comma and space as follows: A, B, C, D.) A. Beta cells are stimulated to release insulin. B. Glucose enters the bloodstream. C. Glycogen is converted to glucose by alpha cells (glycogenesis). D. Glycogen is stored in the liver. E. Insulin transports glucose to muscle cells.

ANS: B, A, E, D, C Insulin transports the glucose to muscle cells or converts it to glycogen, which is stored in the liver to be accessed when hypoglycemia occurs. DIF: Cognitive Level: Analysis REF: p. 1059 OBJ: 3 TOP: Insulin's Effect on Glucose KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

32. The nurse conducting a Romberg test will ask the patient to do what? (Arrange in the correct sequence. Separate letters by a comma and space as follows: A, B, C, D.) A. Touch his or her nose with the index finger with the eyes open. B. Stand with eyes closed. C. Touch his or her nose with the index finger with the eyes closed. D. Touch his or her fingertip to nurse's fingertip. E. Pat the knees with the palms and then the back of the hands rapidly.

ANS: B, E, D, A, C These simple exercises used to assess balance and perception should be performed in order from least to most difficult. DIF: Cognitive Level: Application REF: p. 445 OBJ: 3 TOP: Romberg Test for Balance KEY: Nursing Process Step: Assessment

31. What instructions should a nurse give to a patient when teaching deep breathing and coughing techniques? (Place the options in the appropriate sequence. Separate letters by a comma and space as follows: A, B, C, D.) A. Place the hand on the abdomen to check the rise and fall. B. Inhale through the nose, pause 1 to 3 seconds, and then exhale through the mouth. C. Assume a semi-Fowler position. D. Take 4 to 6 deep breaths. E. Cough deeply.

ANS: C, A, B, D, E The exercise is performed in a sequence to ensure open bronchioles and a good deep cough. DIF: Cognitive Level: Application REF: p. 570 OBJ: 3 TOP: Deep Breathing and Coughing KEY: Nursing Process Step: Implementation

29. What should a nurse do when taking a specimen for a throat culture? (Place the appropriate actions in the correct sequence. Separate letters by a comma and space as follows: A, B, C, D.) A. Depress the tongue with a tongue blade. B. Place the applicator in a culture tube. C. Ask the patient to tilt the head back. D. Swab the back of the throat and tonsils.

ANS: C, A, D, B When collecting a specimen for throat culture the patient is asked to tilt the head back, the tongue is depressed with tongue blade, the back of the throat and tonsils are swabbed, and an applicator is placed in a culture tube. DIF: Cognitive Level: Comprehension REF: p. 533 OBJ: 2 TOP: Throat Culture Specimen KEY: Nursing Process Step: Implementation

31. A nurse explains to a family how the asthma attack progresses by using a progressive list of pathologic events. (Place the options in the correct sequence. Separate letters by a comma and space as follows: A, B, C, D.) A. Bronchoconstriction B. Ventilation-perfusion mismatch C. Production of mucous plugs D. Hypoxemia with compensatory hyperventilation E. Triggering of inflammatory process

ANS: E, A, C, B, D After the allergen has triggered the inflammatory response, bronchoconstriction occurs, which leads to the formation of mucous plugs in the bronchioles that block O2 from entering the alveoli, causing a ventilation-perfusion mismatch and resulting in hypoxemia and hyperventilation. DIF: Cognitive Level: Analysis REF: p. 599 OBJ: 2 TOP: Progression of Asthma Attack KEY: Nursing Process Step: Implementation

OTHER 29. A nurse plans the interventions to prepare a patient for a bone marrow aspiration. (Place the options in the correct sequence. Separate letters by a comma and space as follows: A, B, C, D.) a. Assist the patient to lie on his or her abdomen and drape the hip and lower limbs. b. Confirm the presence of laboratory personnel to stain the specimen. c. Apply a pressure dressing and help the patient lie on his or her back. d. Ensure that a signed permission form is obtained. e. Explain that the procedure will take about 30 minutes.

ANS: E, D, A, B, C The appropriate sequence is the following: (1) explain the procedure; (2) when the patient indicates an understanding, obtain a signed permission form; (3) assist the patient to lie on his or her abdomen and drape the hip and lower extremities; (4) confirm the presence of laboratory personnel to stain the specimen; and (5) apply a pressure dressing and help the patient lie on his or her back. DIF: Cognitive Level: Application REF: p. 628 OBJ: 3 TOP: Bone Marrow Aspiration Preparation KEY: Nursing Process Step: Implementation MSC:

31. The nurse assessing the level of consciousness in a patient will perform the following: (Arrange in order from the simplest to the most complex. Separate letters by a comma and space as follows: A, B, C, D.) A. Apply pressure to the nail bed. B. Shake the patient. C. Touch the patient. D. Call the patient's name. E. Approach the patient.

ANS: E, D, C, B, A The assessment begins with simply approaching the patient and progresses to imposing painful stimuli. DIF: Cognitive Level: Application REF: p. 443 OBJ: 3 TOP: Assessing Level of Consciousness KEY: Nursing Process Step: Implementation

29. When planning care for a patient who cannot perceive or interpret sounds, a nurse takes into consideration that the patient may have a(n) _____ hearing loss.

ANS: central The inability to perceive or interpret sounds is referred to as a central hearing loss. DIF: Cognitive Level: Comprehension REF: p. 1261 OBJ: 5 TOP: Central Hearing Loss KEY: Nursing Process Step: Planning MSC:

31. Congenital hypothyroidism, if left untreated, will result in _____.

ANS: cretinism Cretinism is the result of untreated congenital hypothyroidism. DIF: Cognitive Level: Knowledge REF: p. 1045 OBJ: 3 TOP: Cretinism KEY: Nursing Process Step: N/A

33. A nurse refers to the _____ to assess the extent of sensory loss and specific nerve root enervation.

ANS: dermatome chart The assessment of the level and extent of sensory loss and, consequently, the affected nerve roots involved can be performed with the assistance of a dermatome chart. DIF: Cognitive Level: Knowledge REF: p. 521 OBJ: 6 TOP: Dermatome Chart KEY: Nursing Process Step: Assessment

26. A nurse is aware that a tumor determined to be ER positive indicates that the tumor needs _____ for growth.

ANS: estrogen A tumor that is classified as ER positive requires estrogen to grow. DIF: Cognitive Level: Knowledge REF: p. 1122 OBJ: 4 TOP: ER+ Tumors KEY: Nursing Process Step: Assessment

29. Assessment of 24-year-old driver after an automobile accident, who is complaining of right-sided chest pain and is dyspneic, reveals the following: • Respirations: 26 breaths/min • Significant pain on inspiration • Hand is pressed to the rib area; large bruise is forming on the right chest • Blood pressure: 182/98 mm Hg Based on these assessments, the nurse suspects _____.

ANS: fractured ribs The placement of the bruise and the pain on inspiration are the main clues to the rib fracture. DIF: Cognitive Level: Analysis REF: p. 592 OBJ: 5 TOP: Rib Fracture KEY: Nursing Process Step: Assessment

31. A nurse explains that when a patient history reveals a recent episode of vomiting and diarrhea, the nurse anticipates that this fluid loss will cause _____ and increased blood viscosity.

ANS: hemoconcentration Hemoconcentration occurs when fluid is lost through dehydration, which makes the blood more viscous and shows an inaccurately high value of hemoglobin. DIF: Cognitive Level: Comprehension REF: p. 740 OBJ: 1 TOP: Hemoconcentration KEY: Nursing Process Step: Intervention MSC:

32. A nurse is aware that if a ureter is blocked by a kidney stone, the urine backs up into the kidney, causing _____.

ANS: hydronephrosis Hydronephrosis results when a ureter is obstructed and urine backs up into the pelvis of the kidney. If unrelieved, this condition will require the removal of the kidney. DIF: Cognitive Level: Comprehension REF: p. 917 OBJ: 5 TOP: Topic: Hydronephrosis KEY: Nursing Process Step: Assessment

31. A nurse noting a peaked T wave on the electrocardiogram (ECG) of a patient with Addison disease recognizes this complex as suggestive of _____.

ANS: hyperkalemia Hyperkalemia will cause an elevated, peaked T wave. DIF: Cognitive Level: Comprehension REF: p. 1026 OBJ: 3 TOP: Hyperkalemia KEY: Nursing Process Step: Assessment

30. A nurse cautions a group of individuals with COPD that using O2 at levels greater than 1 to 3 L/min can cause the loss of their _____.

ANS: hypoxic drive The hypoxic drive is the stimulus of CO2 in the system that drives respiration. If the CO2 level is reduced by excessive administration of O2, then the patient will cease to breathe. DIF: Cognitive Level: Comprehension REF: p. 606 OBJ: 2 TOP: Hypoxic Drive KEY: Nursing Process Step: Implementation

28. A nurse is aware that immobility and insertion of urinary catheters, although therapeutic, also places the patient at risk for _____.

ANS: infection The insertion of a Foley catheter and long-term immobility can cause infections. DIF: Cognitive Level: Comprehension REF: p. 309 OBJ: 6 TOP: Infection KEY: Nursing Process Step: Planning

30. A nurse explains that the lining of a vessel that allows for smooth blood flow and also reduced resistance in the vessel is the _____ of the vessel.

ANS: intima The interior lining of a blood vessel is referred to as the intima. DIF: Cognitive Level: Knowledge REF: p. 737 OBJ: 1 TOP: Intima KEY: Nursing Process Step: Implementation MSC:

26. A nurse explains that when shock forces the body into anaerobic metabolism, organ damage is caused by a product of that metabolism, which is _____.

ANS: lactic acid Lactic acid, a by-product of anaerobic metabolism, can cause organ damage in the patient who is in shock. DIF: Cognitive Level: Knowledge REF: p. 304 OBJ: 2 TOP: Lactic Acid KEY: Nursing Process Step: Implementation

29. A nurse reminds a patient with type I diabetes to rotate the insulin injection sites to prevent _____.

ANS: lipohypertrophy Using the same area for insulin injections causes swollen lumpy areas that interfere with the ab-sorption of insulin. DIF: Cognitive Level: Comprehension REF: p. 1071 OBJ: 5 TOP: Lipohypertrophy KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

29. A nurse explains that HIV is introduced to the systemic circulation by the _____, which is found in the mucous membranes.

ANS: macrophage The macrophage introduces HIV into the system. DIF: Cognitive Level: Knowledge REF: p. 667 OBJ: 2 TOP: Macrophage KEY: Nursing Process Step: Implementation

25. A nurse explains that pericardial tamponade and pulmonary embolus can place the patient at risk for _____ shock.

ANS: obstructive Obstructive shock can result from pericardial tamponade or pulmonary embolus. DIF: Cognitive Level: Knowledge REF: p. 301-302 OBJ: 1 | 2 TOP: Obstructive Shock KEY: Nursing Process Step: Implementation

29. A patient with a spinal cord injury complains to a nurse of the inability to experience an erection. The nurse explains, "The _____ component of the nervous system has been affected by your injury."

ANS: parasympathetic Parasympathetic nerves release neurotransmitters, which cause the cavernosal arteriole walls to relax. DIF: Cognitive Level: Knowledge REF: p. 1139 OBJ: 1 TOP: Erection with Spinal Cord Injury KEY: Nursing Process Step: Assessment

31. The major risk of peritoneal dialysis is _____.

ANS: peritonitis Peritonitis is the major risk of peritoneal dialysis. DIF: Cognitive Level: Comprehension REF: p. 930 OBJ: 5 TOP: Risk of Peritoneal Dialysis KEY: Nursing Process Step: N/A

28. Because small non-nodal metastases may be present, _____ is recommended after a lumpectomy.

ANS: radiation Radiation is recommended after a lumpectomy even when no indication of metastasis is evident because of the threat of small metastases without nodal involvement. DIF: Cognitive Level: Comprehension REF: p. 1122 OBJ: 2 TOP: Radiation KEY: Nursing Process Step: N/A

31. Cells in the bone marrow that are capable of developing into RBCs, WBCs, or platelets are the _____ cells.

ANS: stem Adult stem (progenitor) cells can evolve into WBCs, RBCs, or platelets. Stem cells from an embryo can mature into any specialized cell. Adult stem cells are limited to cells of their origin. DIF: Cognitive Level: Comprehension REF: p. 642 OBJ: 1 TOP: Adult Stem Cells KEY: Nursing Process Step: N/A

32. A nurse prepares a family for the altered appearance of the patient returning from stereotactic radiosurgery to see a(n) _____ in place.

ANS: stereotactic frame The stereotactic frame, which helps direct the radiation, is attached to the patient's head with pins. DIF: Cognitive Level: Comprehension REF: p. 1016 OBJ: 4 TOP: Stereotactic Radiosurgery KEY: Nursing Process Step: Implementation

27. A nurse points out to a group of young women who are being treated for PID that because of the effect of this disease on their reproductive organs, they may become _____.

ANS: sterile infertile Persons who have had repeated episodes of PID are at risk for becoming sterile or infertile. DIF: Cognitive Level: Comprehension REF: p. 1130 OBJ: 4 TOP: PID and Infertility KEY: Nursing Process Step: Implementation

28. When a significant elevation in the human chorionic gonadotropin (hCG) level is noted on a laboratory report, the nurse is aware that this is a marker for _____ cancer.

ANS: testicular An elevation in the hCG is a marker for testicular cancer. DIF: Cognitive Level: Knowledge REF: p. 1144 OBJ: 3 TOP: Human Chorionic Gonadotropin Report KEY: Nursing Process Step: Assessment

30. A nurse explains that early in life, lymphocytes migrate from the marrow of the bones to the _____, in which they mature into T cells.

ANS: thymus The lymphocytes migrate and mature to T cells in the thymus. DIF: Cognitive Level: Comprehension REF: p. 644 OBJ: 1 TOP: Thymus KEY: Nursing Process Step: Implementation

18. Which intervention by a nurse is effective in the prevention of autonomic dysreflexia in the patient with an SCI? a. Ensure patency of the urinary catheter. b. Give warm baths to the patient to stimulate vasodilation. c. Keep lighting at a minimum to reduce stimulation. d. Offer the patient four or five small meals daily.

ANS: A A distended bladder, constipation, and sudden jarring can all set off autonomic dysreflexia. Vagal stimulation retards vasodilation. The number and size of meals have no affect on preventing this syndrome. DIF: Cognitive Level: Application REF: p. 523 OBJ: 6 TOP: Autonomic Dysreflexia KEY: Nursing Process Step: Planning

29. A nurse is caring for a patient with diabetes insipidus (DI). Which signs should the nurse report that indicate a change in condition? (Select all that apply.) a. Dropping blood pressure b. Light clear urine c. Moist mucous membranes d. Excessive thirst e. Large urine output

ANS: A A dropping blood pressure is an indication that the hypovolemia with DI has reached a significant point and will require medical implementation. All other options are the expected signs of this disorder or an indication that therapy is effective. DIF: Cognitive Level: Comprehension REF: p. 1020 OBJ: 3 TOP: Diabetes Insipidus KEY: Nursing Process Step: Assessment

7. A worried patient asks the nurse to explain the advantage of a fluoroscopy. What is the nurse's best response regarding fluoroscopy? a. Shows respiratory function in motion b. Helps the physician evaluate ventilation-perfusion ratio c. Allows the physician to take tissue samples d. Facilitates the removal of fluid from the bronchi

ANS: A A fluoroscopy allows the visualization of both lungs while the patient is in the process of ventilation. DIF: Cognitive Level: Comprehension REF: p. 563 OBJ: 3 TOP: Diagnostic Tests KEY: Nursing Process Step: Implementation

21. A patient with cystic fibrosis (CF) furiously refuses any more manual chest physiotherapeutic treatment. Which alternative is appropriate for the nurse to suggest? a. Flutter mucus device b. Increase ambulation to 1 to 2 hours a day c. Steam inhalator several times a day d. Drink 3 quarts of fluid per day

ANS: A A flutter mucus clearance device is a handheld vibrating tool that helps loosen and evacuate secretions in the lung. DIF: Cognitive Level: Application REF: p. 612 OBJ: 3 TOP: Cystic Fibrosis KEY: Nursing Process Step: Planning

8. A patient comes into the clinic complaining of waking up with a dry mouth and nose and asks if the dryness has caused the colds she has had in the past few months. What is the most appropriate suggestion for the nurse to suggest? a. Use a humidifier at home. b. Get a throat culture. c. Get a nose culture. d. Request an antibiotic.

ANS: A A humidifier would be helpful in keeping the nasal mucous membranes moist, which can decrease nasal infections. DIF: Cognitive Level: Analysis REF: p. 535 OBJ: 3 TOP: Humidification KEY: Nursing Process Step: Implementation

8. What should a nurse include when developing a plan of care for a patient with human immunodeficiency virus (HIV)? a. Careful aseptic technique to prevent infection b. Instruction to limit fluids to prevent congestive heart failure c. Oral alcohol rinses to control mouth infections d. Selections of high-fat foods in the daily diet

ANS: A A major complication of HIV is opportunistic infections. DIF: Cognitive Level: Application REF: p. 652 OBJ: 6 TOP: Prevention of Infection in Patients with Human Immunodeficiency Virus (HIV) KEY: Nursing Process Step: Implementation

24. Which posthospital option should the nurse encourage a patient to do when recovering from a CVA to provide the most comprehensive assistance? a. Transfer to a rehabilitation center. b. Discharge to home with scheduled visits from home health care nurses. c. Discharge to home with scheduled visits from a physical therapist. d. Discharge to home with scheduled visits from an occupational therapist.

ANS: A A rehabilitation center with all modalities of support (e.g., physical therapy, occupational therapy, speech therapy, simulated home environments) is obviously the best option. DIF: Cognitive Level: Comprehension REF: p. 506 OBJ: 10 TOP: Postdischarge Planning KEY: Nursing Process Step: Planning

10. Conjugated estrogen (Premarin) is indicated for treatment of menopause. Which side effects should a nurse explain before administering the medication to a woman who has just had a hysterectomy? a. Breast tenderness b. Hypotension c. Arthralgia d. Skin rash

ANS: A A side effect of conjugated estrogen (Premarin) is breast tenderness. DIF: Cognitive Level: Comprehension REF: p. 1100 OBJ: 5 TOP: Drugs Used to Treat Menopause KEY: Nursing Process Step: Assessment

4. When making an initial assessment on a patient with a hearing deficit, the patient reports that he often feels off balance and is dizzy when he stands up. Which diagnosis might explain these symptoms? a. Sinus infection b. Rubella c. Otalgia d. Presbycusis

ANS: A A sinus infection can be an acute cause of hearing deficits and can create problems with balance. DIF: Cognitive Level: Comprehension REF: p. 1252 OBJ: 5 TOP: Hearing Assessment: Medical History KEY: Nursing Process Step: Assessment MSC:

18. What is characteristic of the primary stage syphilis? a. Chancre b. Alopecia c. Pruritus d. Dry skin

ANS: A A typical lesion, a chancre, is the first sign of syphilis. DIF: Cognitive Level: Knowledge REF: p. 1170-1171 OBJ: 4 TOP: Syphilis KEY: Nursing Process Step: Assessment

13. A family member of a patient who is in adrenal crisis asks why the IV cortisone is continued after the initial IV push of Solu-Cortef, which seemed to stop the symptoms. What is the best explanation by the nurse? a. Solu-Cortef has a very brief therapeutic period and needs a maintenance IV infusion to keep up the level. b. IV infusions guarantee that Solu-Cortef will be absorbed. c. Long-term IV infusions maintain adequate urine output. d. IV cortisone supports peripheral perfusion and elevates the blood pressure.

ANS: A Administering IV push Solu-Cortef will dramatically relieve the symptoms, but the therapeutic period is only approximately 5 hours; consequently, a slower IV infusion is needed to keep up the level of cortisol. DIF: Cognitive Level: Application REF: p. 1027-1028 OBJ: 3 TOP: Adrenal Crisis KEY: Nursing Process Step: Assessment

20. A patient is in the compensatory stage of shock. What symptoms displayed by the patient would indicate the need to implement immediate nursing action? a. Irritable and restless b. Listless and confused c. Unconscious d. Anxious and fearful

ANS: A An irritable and restless patient is at definite risk for falling or hurting him- or herself. DIF: Cognitive Level: Comprehension REF: p. 303 OBJ: 3 TOP: Compensatory Stage Symptoms KEY: Nursing Process Step: Implementation

26. A nurse is careful about limb position in caring for an unconscious patient who sustained a head injury 10 days ago. What is the nurse trying to prevent? a. Flexion deformities b. Atrophy c. Paralysis d. Pathologic fracture

ANS: A An unconscious patient should be positioned in anatomic alignment to prevent flexion deformities. Passive range of motion and frequent position changes are essential to maintain the limbs in a functional position. DIF: Cognitive Level: Comprehension REF: p. 461 OBJ: 7 TOP: Flexion Deformities KEY: Nursing Process Step: Implementation

14. A patient complains that he wants an antibiotic medication for his cold. What is the best response by the nurse? a. "Antibiotics are not effective with viral infections." b. "You will get better faster without the antibiotics." c. "You might try echinacea or vitamin C." d. "A cold is not that serious. Try forcing fluids."

ANS: A Antibiotics are not appropriate with colds because colds are caused by viruses. Overuse of antibiotics can promote resistant strains of bacteria to develop. DIF: Cognitive Level: Comprehension REF: p. 541 OBJ: 4 TOP: Acute Viral Coryza KEY: Nursing Process Step: Implementation

9. A patient in the acute phase of a CVA who has been speaking distinctly begins to speak indistinctly and only with great effort but still coherent. What should this nurse determine when assessing this patient? a. Stroke in evolution with dysarthria b. Lacunar stroke with fluent aphasia c. Complete stroke with global aphasia d. Stroke in evolution with dyspraxia

ANS: A As symptoms worsen, the CVA is still evolving. Speech that is coherent but difficult is dysarthria rather than any type of aphasia. Dyspraxia is a motor impairment, not a speech impairment. DIF: Cognitive Level: Analysis REF: p. 490 OBJ: 4 TOP: CVA Deficits KEY: Nursing Process Step: Assessment

17. A nurse removes a potted plant from the room of a patient with HIV. What is the nurse trying to prevent? a. Aspergillosis b. Candidiasis c. Coccidioidomycosis d. Cytomegalovirus (CMV)

ANS: A Aspergillosis can be contracted from the potting soil in and around the plant in the pot. DIF: Cognitive Level: Comprehension REF: p. 671 OBJ: 4 TOP: Aspergillosis KEY: Nursing Process Step: Implementation

16. A nurse is formulating a teaching plan for a 22-year-old woman taking rosiglitazone (Avandia). What should the nurse include information about in this plan to caution this patient? a. Decreased effectiveness of her birth control pills b. Excessive exposure to the sun c. Sudden drop in blood pressure with dizzi-ness d. Possible severe diarrhea

ANS: A Avandia causes some birth control pills to be less effective. DIF: Cognitive Level: Application REF: p. 1073 OBJ: 10 TOP: Side Effects of Avandia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

17. What is true regarding bacterial pharyngitis that is untrue for viral pharyngitis? a. Has an abrupt onset b. Presents a normal complete blood count (CBC) c. Presents a negative culture d. Has no serious complications

ANS: A Bacterial pharyngitis has an abrupt onset, an elevated white count on the CBC, and a positive culture and can lead to glomerulonephritis, rheumatic fever, and mastoiditis. DIF: Cognitive Level: Comprehension REF: p. 544 OBJ: 4 TOP: Bacterial Pharyngitis KEY: Nursing Process Step: N/A

18. A patient with glaucoma is taking a beta-adrenergic blocking agent, timolol (Timoptic). For which potential side effect should the nurse assess the patient? a. Wheezing b. Hypertension c. Sudden eye pain d. Blurred vision

ANS: A Beta-adrenergic blocking agents cause bronchospasm and tachycardia. DIF: Cognitive Level: Comprehension REF: p. 1243 OBJ: 3 TOP: Beta-Adrenergic Blocking Agents KEY: Nursing Process Step: Assessment MSC:

7. A nurse is taking the history of a patient who has come in for evaluation of large areas of purpura on her limbs. The patient reports using alternative therapy for her menopausal symptoms. What alternative therapy is most likely responsible for the patient's symptoms? a. Black cohosh b. Valerian c. Lavender d. Rosemary

ANS: A Black cohosh interferes with blood clotting. DIF: Cognitive Level: Comprehension REF: p. 627 OBJ: 5 TOP: Alternative Remedies KEY: Nursing Process Step: Assessment MSC:

25. At 1000 a nurse receives 2 units of blood for a patient to be transfused. What is the most appropriate nursing action? a. Set up 1 unit for the infusion to start by 1030 and send the other unit back until the first one has infused b. Set up both units to infuse at the same time and to start at 1100. c. Set up one unit for infusion and place the other in the refrigerator for the later infusion. d. Send both units back and ask for a reissue of 1 unit only.

ANS: A Blood must be started within 30 minutes of its receipt after it has been checked by two licensed staff members. In many settings, licensed practical nurses do not start the blood but can set up the infusion. The best option is to send the second unit back immediately, with an explanation that it will be called for later. One unit of blood usually takes about 2 to 4 hours to infuse. DIF: Cognitive Level: Application REF: p. 631 OBJ: 4 TOP: Transfusion Protocol KEY: Nursing Process Step: Implementation MSC:

16. A nurse asks a patient to repeat the instructions to evaluate her knowledge about safe sex practices. Which statement indicates an understanding? a. "Body massage would be considered safe." b. "Mutual open-mouth kissing is safe." c. "Vaginal intercourse with a properly used condom is safe." d. "Anal sex with a condom made of latex is a safe sex practice."

ANS: A Body massage is considered a safe sex practice. DIF: Cognitive Level: Comprehension REF: p. 1179 OBJ: 9 TOP: Safety of Various Sexual Practices KEY: Nursing Process Step: Evaluation

20. A nurse explains that laser-assisted in situ keratomileusis (Lasik) and photorefractive keratectomy (PRK) are methods to correct refractive errors surgically. What do these procedures reshape? a. Cornea b. Lens c. Iris d. Pupil

ANS: A Both surgical procedures are used to reshape the cornea. The clinician will need to determine which structure of the eye will need surgery to correct the vision. DIF: Cognitive Level: Knowledge REF: p. 1238 OBJ: 5 TOP: Surgical Treatment for Refractive Errors KEY: Nursing Process Step: Implementation MSC:

13. In treating a person outside of a medical facility, a nurse knows that immediate circulatory support for the vital organs must begin as quickly as possible because, without oxygen, the brain cells will begin to die in how many minutes? a. 4 b. 6 c. 14 d. 24

ANS: A Brain cells must have oxygen to live; they are very sensitive to lack of oxygen and begin to die in 4 minutes. DIF: Cognitive Level: Knowledge REF: N/A OBJ: 2 TOP: Brain Death without Oxygen KEY: Nursing Process Step: Assessment

14. What is contraindicated for a patient performing Buerger-Allen exercises? a. Lying on the stomach b. Raising legs for 2 minutes until they blanch c. Lowering the legs until the color returns d. Keeping legs flat for 5 minutes and then repeat the exercise

ANS: A Buerger-Allen exercises promote emptying of the blood vessels by gravity. Initially, lying on the back and elevating the legs will result in pallor, and then lowering the legs will allow color to return. DIF: Cognitive Level: Comprehension REF: p. 745-746 OBJ: 5 TOP: Buerger-Allen Exercises KEY: Nursing Process Step: N/A MSC:

17. A patient with COPD has a nursing diagnosis of "Activity intolerance, related to inability to meet O2 needs." Which intervention is inappropriate for this diagnosis? a. Bunch all nursing activities and treatments close together. b. Schedule rest periods during the day. c. Assist the patient only when needed to encourage independence. d. Provide daily ambulation to build tolerance.

ANS: A Bunching nursing activities is tiring to the patient with COPD. Assisting only when needed saves patient energy, as well as enhancing independence. Activities should be spread out to allow for uninterrupted rest periods. Progressive ambulation is an acceptable way to build tolerance. DIF: Cognitive Level: Application REF: p. 611 OBJ: 3 TOP: Activity Intolerance in COPD KEY: Nursing Process Step: Implementation

18. Which nursing interventions will best assist a patient cope with decreased cardiac output? a. Dovetailing nursing care tasks allows rest periods for the patient. b. Maintaining enough cover prevents the patient from shivering. c. Turning, coughing, deep breathing, and ambulating the patient every 2 hours reduce the risk of embolism. d. Analgesics should be administered cautiously.

ANS: A Care should be designed to reduce the metabolic demands on the failing heart. Shivering and physical activity increase the demands; analgesics may reduce output more. DIF: Cognitive Level: Comprehension REF: p. 308 OBJ: 6 TOP: Nursing Patients with Decreased Cardiac Output KEY: Nursing Process Step: Implementation

21. A patient reports to a home health care nurse of having cloudy vision and seeing spots and halos around lights. What should the nurse suspect based on these patient symptoms? a. Cataracts b. Glaucoma c. Detached retina d. Macular degeneration

ANS: A Cataracts are the cause of cloudy vision and seeing spots or halos. DIF: Cognitive Level: Comprehension REF: p. 1238 OBJ: 5 TOP: Internal Eye Disorders KEY: Nursing Process Step: Implementation MSC:

20. What should a patient with HIV avoid to prevent bacillary angiomatosis (BA)? a. Cats b. Large crowds of people c. Consuming unwashed fruits d. Exposure to mosquito bites

ANS: A Cats and their fleas are thought to transmit BA. DIF: Cognitive Level: Comprehension REF: p. 672 OBJ: 4 TOP: Prevention KEY: Nursing Process Step: Implementation

22. How does closed-angle glaucoma differ from open-angle glaucoma? a. The onset is acute. b. Trabeculectomy is the initial treatment. c. Treatment can be conservative. d. Intraocular pressure drops suddenly.

ANS: A Closed-angle glaucoma has an acute onset with eye pain and other systemic symptoms, such as nausea and vomiting. Reducing the intraocular pressure is an ocular emergency. DIF: Cognitive Level: Knowledge REF: p. 1240-1242 OBJ: 5 TOP: Open-Angle versus Closed-Angle Glaucoma KEY: Nursing Process Step: Implementation MSC:

6. What should the nurse suspect regarding the bronchus when auscultating coarse crackles in the lower right lobe? a. Partially filled with fluid b. Narrowed by spasm c. Partially filled with thick mucus d. Completely obstructed

ANS: A Coarse crackles are indicative of fluid in the bronchi. Many times these sounds can be cleared by coughing. DIF: Cognitive Level: Application REF: p. 561 OBJ: 1 TOP: Breath Sounds KEY: Nursing Process Step: Assessment

7. A patient at the outpatient clinic is reluctant to identify her sexual contacts. Why is the reporting of contacts essential? a. Slows transmission and spread of infections b. Increases public awareness c. Increases state funding for treatment d. Collects data for research

ANS: A Confirmed cases are reported to the health department. The purpose is to identify and treat infected individuals so that transmission can be slowed. DIF: Cognitive Level: Comprehension REF: p. 1166 OBJ: 2 TOP: Reporting STIs KEY: Nursing Process Step: Implementation

23. What action should the nurse implement when a patient falls to the floor in a generalized seizure? a. Cradle the head to prevent injury. b. Insert an object between the teeth to prevent the patient from biting the tongue. c. Manually restrain the limbs. d. Keep the patient on his or her back to prevent aspiration.

ANS: A Cradling the head and turning it to the side prevents injury and aspiration; restraint of limbs and insertion of an object into a patient's mouth often result in injury. DIF: Cognitive Level: Application REF: p. 455 OBJ: 7 TOP: Seizure Implementations KEY: Nursing Process Step: Implementation

9. A nurse assigned to care for a patient with diabetic ketoacidosis (DKA) is aware that this is a life-threatening condition. What will DKA result in? a. Disorder of carbohydrates, fats, and pro-teins metabolism b. Storage of glycogen, resulting in a severe shortage of glucose in the bloodstream c. Dangerously elevated pH and bicarbonate levels in the blood d. Severe hypoglycemia, which can result in coma and convulsions

ANS: A DKA is mainly related to the use of fat as an energy source because of an inability of the body to use glucose. The metabolism of fat produces ketones. DIF: Cognitive Level: Knowledge REF: p. 1064 OBJ: 6 TOP: Diabetic Ketoacidosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

4. A nurse is updating a teaching plan for a patient who sustained a TIA. What should the nurse be sure to include? a. Daily aspirin dose b. Long rest periods daily c. Reduction of fluid intake to 800 mL/day d. High-carbohydrate diet

ANS: A Daily aspirin reduces platelet aggregation and may prevent another attack. Reductions of fluid and long rest periods encourage clot formation. DIF: Cognitive Level: Application REF: p. 485 OBJ: 3 TOP: Post-TIA Teaching KEY: Nursing Process Step: Planning

18. Which instruction is most appropriate for a patient with arterial insufficiency? a. Frequently allow the legs to dangle dependently. b. Rub the legs vigorously. c. Stand often to keep blood flow in the legs. d. Walk barefoot.

ANS: A Dangling legs can use gravity to help with arterial circulation. Vigorous rubbing of the legs is contraindicated, and prolonged standing strains the vascular system. The patient should never walk barefoot. DIF: Cognitive Level: Comprehension REF: p. 745-746 OBJ: 4 TOP: Home Instruction for the Patient with a Vascular Disorder KEY: Nursing Process Step: Implementation MSC:

14. Which assessment by the nurse at the bedside of a patient with a chest tube attached to a water seal drainage device should require intervention? a. Dependent loops in the chest tube b. Patient in a semi-Fowler position c. Changing level of water in the water seal chamber d. Increased level of drainage to 20 mL in 8 hours

ANS: A Dependent loops in the chest tube can collect drainage and occlude the system. DIF: Cognitive Level: Application REF: p. 575-576 OBJ: 4 TOP: Water Seal Drainage KEY: Nursing Process Step: Assessment

11. A patient with generalized convulsive disorder has a nursing diagnosis of "Deficient knowledge, related to lack of information about the side effects of phenytoin (Dilantin)." Which goal and outcome criteria would be most appropriate? a. Absence of gastrointestinal (GI) complaint; takes medication with food b. Stimulation of gingiva; brushes teeth vigorously to encourage gingival growth c. Maintenance of normal pattern of elimination; limits fluids and eats foods that reduce diarrhea d. Maintenance of normal sleep pattern; reduces stimuli and takes warm baths to induce drowsiness

ANS: A Dilantin is irritating to GI tissues. Dilantin causes gingival hyperplasia, constipation, and drowsiness. DIF: Cognitive Level: Application REF: p. 456 OBJ: 7 TOP: Dilantin KEY: Nursing Process Step: Planning

3. A patient asks a nurse, "Will the laparoscopy be painful?" What is the best reply by the nurse? a. "You will probably have some pain below the rib cage and around the shoulder." b. "Most patients state that the procedure is painless during and afterward." c. "You may have some mild to moderate pain around the umbilicus and in the back." d. "Every person is different. It's difficult to say whether you'll have pain."

ANS: A During the immediate postoperative period, the patient tends to experience pain below the rib cage and in the shoulder area from the air injected into the abdominal cavity. The air is absorbed in 24 hours, and the pain disappears. DIF: Cognitive Level: Application REF: p. 1096 OBJ: 2 TOP: Laparoscopy KEY: Nursing Process Step: Implementation

14. A nurse is caring for a patient with thrombotic thrombocytopenic purpura who is having plasmapheresis every day. Which assessment alerts the nurse of a complication? a. Hypotension b. Seizure activity c. Diarrhea d. Intense headache

ANS: A During the period of treatment by plasmapheresis, the patient can become hemodynamically unstable and have a reduced cardiac output with the attendant hypotension. This is a serious complication and can lead to renal failure. DIF: Cognitive Level: Application REF: p. 657-658 OBJ: 2 TOP: Thrombotic Thrombocytopenic Purpura KEY: Nursing Process Step: Assessment

22. What is an appropriate nursing diagnosis for a patient with hyperparathyroidism? a. Impaired urinary elimination, related to urinary calculi b. Decreased cardiac output, related to heart failure secondary to hypocalcemia c. Risk for injury, related to hypocalcemia leading to muscle spasms and convulsions d. Imbalanced nutrition: Greater than body requirements, related to increased appetite

ANS: A Excessive calcium in the bloodstream leads to the formation of calcium stones in the urinary system. DIF: Cognitive Level: Application REF: p. 1052 | p. 1054 OBJ: 4 TOP: Hyperparathyroidism: Nursing Diagnosis KEY: Nursing Process Step: Planning

20. What should a nurse include when drawing up a patient's diabetes teaching plan? a. Develop an exercise plan because regular exercise helps control blood glucose levels. b. Monitor blood sugar levels only if not feeling well to ensure that the fingertips are not pricked too much. c. If nervousness, palpitations, or hunger is experienced, take a small dose (1 to 2 U) of regular insulin and call the physician. d. Use over-the-counter measures for any foot blisters, calluses, or wounds before seeking medical help.

ANS: A Exercise is an integral part of the patient's ability to take charge of his or her diabetes and needs to be included in the teaching plan. DIF: Cognitive Level: Application REF: p. 1068 OBJ: 8 TOP: Diabetes Teaching Plan KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

12. What information should a nurse relay to a patient when providing education about protecting vision? a. After 40 years of age, eye examinations should be performed every 2 years. b. Crusted eyelids on awakening are caused by decreased tear production. c. Floaters are a sign of eye infection. d. Blurred vision without pain is temporary eye strain.

ANS: A Eye examinations every 2 years are recommended for persons older than 40 years of age. All the other options are indications that the person should consult a physician for an eye disorder. DIF: Cognitive Level: Comprehension REF: p. 1231 OBJ: 4 TOP: Protection of the Eye and Vision KEY: Nursing Process Step: Implementation MSC:

16. Which nursing diagnosis should take priority in the care of an outpatient with AIDS? a. Ineffective therapeutic regimen management b. Impaired physical mobility c. Impaired skin integrity d. Social isolation

ANS: A Failure to take anti-HIV drugs as scheduled can encourage resistant strains of HIV. DIF: Cognitive Level: Analysis REF: p. 676 OBJ: 7 TOP: Nursing Diagnosis: AIDS KEY: Nursing Process Step: Nursing Diagnosis

23. Which instruction is most helpful in teaching the family and patient who is in the rehabilitation phase after a CVA about altered sensation? a. Make frequent assessments for signs of pressure or injury. b. Use the affected side in supporting the patient in ambulation and transfer to stimulate better sensation. c. Apply ice packs to the affected limbs to encourage a return of sensation. d. Apply a heating pad to the affected limbs to increase circulation.

ANS: A Frequent assessment using the National Institutes of Health Stroke Scale will allow early detection. The use of hot or cold applications and using the affected limbs in transfer or ambulation may cause injury. DIF: Cognitive Level: Application REF: p. 503 OBJ: 8 TOP: Altered Sensation KEY: Nursing Process Step: Planning

14. A newly diagnosed patient with macular degeneration flings her book at the television set and furiously says, "I can't read this blasted book, and I can't see what is on the stupid TV!" How should the nurse define this behavior? a. Anger stage of grieving b. Poor impulse control c. Ineffective management of a therapeutic regimen d. Psychotic reaction to loss

ANS: A Frequently, a grieving process accompanies the realization that deteriorating vision and ultimate blindness are inevitable with macular degeneration. DIF: Cognitive Level: Application REF: p. 1233 | p. 1246 OBJ: 6 TOP: Impact of Visual Impairment KEY: Nursing Process Step: Assessment MSC:

23. A nurse is assessing a patient 20 minutes after a bone marrow biopsy. Which statement by the patient is cause for the most concern? a. "There is fresh blood on my dressing." b. "I am thirsty." c. "My hip feels bruised where they stuck the needle." d. "I had a sharp pain in my leg when they pulled the needle out."

ANS: A Fresh blood on the pressure dressing 20 minutes after the aspiration needs to be addressed. Usually, redressing with a pressure dressing and an ice pack is sufficient. Feelings of bruising and pain on extraction are to be expected. Thirst is of no clinical significance. DIF: Cognitive Level: Application REF: p. 628 OBJ: 3 TOP: Diagnostic Tests KEY: Nursing Process Step: Implementation MSC:

3. What is true concerning passive-acquired immunity? a. Antibodies are acquired from outside the host and instilled in the host. b. Antibodies are manufactured in response to a disease in the host. c. Antibodies are innately acquired because of being born a human being. d. Antibodies are cell mediated inside the host.

ANS: A Gamma globulin injections provide passive-acquired immunity. The antibodies that are injected have been produced by another host, collected, fused in the mixture, and injected into a separate host. This gives the host a passive-acquired immunity that lasts for only 2 to 3 months. DIF: Cognitive Level: Knowledge REF: p. 646 OBJ: 1 TOP: Functions of the Immune System KEY: Nursing Process Step: Implementation

7. A patient is placed on diethylstilbestrol (DES) for prostate cancer. What should the nurse explain as a possible side effect of the medication? a. Gynecomastia b. Pruritus c. Constipation d. Tinnitus

ANS: A Gynecomastia is a side effect of DES. DIF: Cognitive Level: Knowledge REF: p. 1152-1153 OBJ: 4 TOP: Drug Therapy for Male Reproductive System KEY: Nursing Process Step: Planning

2. Which is considered an approximate normal hematocrit value? a. Three times the hemoglobin value b. The same as the hemoglobin value c. Four times lower than the red blood cell count d. Same as the red blood cell count

ANS: A Hematocrit is approximately three times the hemoglobin value. DIF: Cognitive Level: Knowledge REF: p. 627 OBJ: 3 TOP: Normal Laboratory Values KEY: Nursing Process Step: Assessment MSC:

26. Which human immunity is an example of innate immunity? a. Hoof-and-mouth disease b. Measles c. Rabies d. Mange

ANS: A Humans, by nature of their innate properties at birth, have an innate immunity to hoof-and-mouth disease. Cows also have an innate immunity to measles. DIF: Cognitive Level: Comprehension REF: p. 644 OBJ: 1 TOP: Innate Immunity KEY: Nursing Process Step: Implementation

11. A nurse is explaining the rationale behind the use of Hypothermic devices to a patient's family. When relaying information what explanation should the nurse provide when asked why this garment provides compression to the legs and abdomen? a. To help restore cellular perfusion b. Decreases internal hemorrhage c. Cools the patient to create less metabolic demand d. Applies pressure during the systole phase and relax pressure during the diastole phase

ANS: A Hypothermic devices compress the vessels in the legs and abdomen to increase both blood pressure and cardiac output. DIF: Cognitive Level: Comprehension REF: p. 308 OBJ: 6 TOP: Hypothermic devices KEY: Nursing Process Step: Implementation

4. What is true about the urine osmolality when the kidney is adequately functioning? a. Equal to the osmolality of the serum b. Approximately half of the serum c. In a ratio of 10:1 with the serum d. Equal to the excretion of urea

ANS: A If the blood osmolality is high, the kidneys need to dilute the blood and excrete more concentrated urine, and the reverse is true. The osmolality of the serum and the urine should be equal. DIF: Cognitive Level: Comprehension REF: p. 885 OBJ: 2 TOP: Kidney Function Tests KEY: Nursing Process Step: Assessment

1. A patient has weakness on the right side and impaired reasoning after having a cerebrovascular accident (CVA). What part of the brain is affected? a. Left hemisphere of the cerebrum b. Right hemisphere of the cerebrum c. Left cerebellum d. Right cerebellum

ANS: A Impaired motor strength on the right side in conjunction with impaired reasoning indicates a lesion in the left hemisphere of the cerebrum. The cerebellum controls balance and is not contralateral. DIF: Cognitive Level: Comprehension REF: p. 481-482 OBJ: 3 TOP: Symptoms of a CVA KEY: Nursing Process Step: Assessment

2. What laboratory value change should indicate to a nurse that a patient with renal failure has entered the oliguric stage? a. Blood urea nitrogen (BUN) level rises. b. Serum calcium increases. c. Blood volume decreases. d. Urine osmolality increases.

ANS: A In the oliguric stage of renal failure, the urine output decreases to less than 400 mL/day; the BUN, creatinine, and potassium increase; and the serum calcium decreases. The patient becomes hypervolemic as the urine osmolality increases. DIF: Cognitive Level: Comprehension REF: p. 896 OBJ: 1 TOP: Oliguric Stage of Renal Failure KEY: Nursing Process Step: Assessment

11. What indicates that a patient has entered the third stage of HIV infection? a. T-helper CD4 cell count of 500 b. Rise in antibody count c. Drop in viral load d. Increase in T4 helper cells

ANS: A In the third stage of HIV infection, T-helper CD4 cells drop to approximately 500. Antibodies are always high throughout the infection but are ineffective. The viral count is high. DIF: Cognitive Level: Comprehension REF: p. 668 OBJ: 5 TOP: Third Stage of HIV Infection KEY: Nursing Process Step: Assessment

24. A nurse is caring for a patient with HIV infection who has been prescribed highly active antiretroviral therapy (HAART). What should the nurse warn the patient that inconsistent administration of the drug can result in? a. HIV strain becoming resistant to the drug b. Decrease in antibodies in the circulating volume c. Addition of another antiretroviral agent to the protocol d. Rapid increase in the symptoms of AIDS

ANS: A Inconsistent administration of HAART drugs can cause the HIV strain to become resistant to the drug. DIF: Cognitive Level: Knowledge REF: p. 674 OBJ: 6 TOP: HAART KEY: Nursing Process Step: Implementation

21. A patient in the progressive stage of shock is receiving medication to manage the symptoms. What is the desired effect of the medication? a. Increase in cardiac output b. Decrease in blood pressure c. Decrease in urine output d. Lower temperature

ANS: A Increasing cardiac output requires aggressive action to prevent MODS. Dopamine increases heart contractibility and rate. DIF: Cognitive Level: Comprehension REF: p. 304-307 OBJ: 6 TOP: Treatment of Progressive Shock KEY: Nursing Process Step: Planning

9. A patient with a severe head injury begins to assume a posture of flexed upper extremities, with plantarflexed lower extremities. What do these assessments indicate? a. Increasing intracranial pressure (ICP) with decorticate posturing b. Decreasing ICP with decerebrate posturing c. Decreasing ICP with decorticate posturing d. Increasing ICP with decerebrate posturing

ANS: A Increasing pressure on the tissue above the midbrain results in abnormal flexion (decorticate posturing). DIF: Cognitive Level: Analysis REF: p. 451 OBJ: 5 TOP: Symptoms of Intracranial Pressure KEY: Nursing Process Step: Assessment

12. A nurse is caring for a patient with meningitis who has a positive Brudzinski sign. Which assessment led to this conclusion? a. Flexed hips when the neck is flexed by the nurse b. Inability to extend the flexed leg fully because of hamstring pain c. Resisting efforts of the nurse to flex his or her neck d. Flexing the big toe upward and fan out the other toes

ANS: A Inflamed meninges will stimulate hip flexion to reduce meningeal discomfort. DIF: Cognitive Level: Comprehension REF: p. 463 OBJ: 6 TOP: Symptoms of Meningitis KEY: Nursing Process Step: Assessment

26. What should a patient that had the BCG (Bacillus Calmette-Guérin) vaccine 2 years ago anticipate? a. False-positive result from TB skin tests b. Being at risk for contracting TB c. 3-week prophylactic protocol of rifampin or isoniazid (isonicotinic acid hydrazide [INH]) d. Needing a booster every 2 years

ANS: A Inoculation with BCG causes a false-positive result on TB skin tests that may be administered afterward. BCG is not used very much in the United States, but it is administered in most other countries. DIF: Cognitive Level: Comprehension REF: p. 613 OBJ: 3 TOP: Bacillus Calmette-Guérin (BCG) Vaccine KEY: Nursing Process Step: Implementation

24. Why should a nurse recommend the use of salt that is iodized when providing dietary education to patients? a. It prevents the development of goiter in adults and cretinism in infants. b. It can help prevent hypothyroidism. c. It is instrumental in preventing tumors of the parathyroid gland. d. It works as an important component of thyroid replacement therapy.

ANS: A Iodine is needed to convert thyroid hormones. Without it, the TSH continues to send the message to the thyroid gland to increase production of thyroid hormones. DIF: Cognitive Level: Knowledge REF: p. 1042 OBJ: 3 TOP: Nutrition Concepts KEY: Nursing Process Step: Assessment

10. Which foods should a nurse include in a nutrition teaching plan for a patient with iron-deficiency anemia? a. Beans and dried fruit b. Apples and white rice c. Yogurt and cooked carrots d. Yellow squash and tortillas

ANS: A Iron-rich foods include beans, dried fruit, liver, red meat, fish, and whole-grain breads. DIF: Cognitive Level: Comprehension REF: p. 635 OBJ: 6 TOP: Iron-Deficiency Anemia KEY: Nursing Process Step: Implementation MSC:

15. A patient with long-term asthma develops Cushing syndrome. What is the cause of this condition? a. Taking corticosteroids for many years b. Abruptly withdrawing cortisone therapy c. Lacking ACTH, related to the pituitary gland d. Poorly functioning adrenal glands

ANS: A Long-term corticosteroid use is a prime cause of Cushing syndrome. DIF: Cognitive Level: Comprehension REF: p. 1030 OBJ: 3 TOP: Cushing Syndrome KEY: Nursing Process Step: Evaluation

25. Why are patients diagnosed with chronic renal failure and on dialysis prone to injury? a. Bone demineralization and peripheral neuropathy b. Fatigue and drug side effects c. Impaired immune response and malnutrition d. Multiple life changes and hormone deficiencies

ANS: A Loss of calcium from the bones leaves them weak, and the lack of sensation in the hands and feet leaves patients with a lack of proprioception. Realizing these factors, the nurse can draw up implementations to help prevent injuries. DIF: Cognitive Level: Knowledge REF: p. 928 OBJ: 6 TOP: Chronic Renal Failure KEY: Nursing Process Step: Nursing Diagnosis

12. A patient who is severely dyspneic and cyanotic enters the emergency department. What rate should a nurse administer oxygen to the patient? a. 2 L to preserve the hypoxic drive b. 6 L to relieve the dyspnea c. 8 L, humidified, to liquefy secretions d. 10 L, humidified aerosol, to dilate the bronchi

ANS: A Low-dose oxygen is a safe initial dose to ensure that the hypoxic drive be preserved, especially for a patient whose history is unknown. DIF: Cognitive Level: Application REF: p. 572 OBJ: 4 TOP: Oxygen Administration KEY: Nursing Process Step: Implementation

14. What should a nurse instruct a patient after a lumbar puncture to prevent a headache? a. Lie flat. b. Lie on left side. c. Stay in semi-Fowler position. d. Ambulate in the room with assistance.

ANS: A Lying flat for a prescribed period will allow the loss of cerebrospinal fluid during the procedure to replenish. DIF: Cognitive Level: Application REF: p. 441 OBJ: 3 TOP: Lumbar Puncture Care KEY: Nursing Process Step: Implementation

12. A nurse is speaking to the family of a 65-year-old Latino woman. To whom should the nurse address most of the conversation to keeping in mind cultural considerations? a. 66-year-old husband b. Entire family, in general c. 42-year-old daughter (oldest child) d. 40-year-old son (only son)

ANS: A Many older Latino families recognize the older men in the family, the father or husband, as the decision makers. DIF: Cognitive Level: Comprehension REF: p. 310 OBJ: 7 TOP: Cultural Considerations KEY: Nursing Process Step: Planning

15. A patient is receiving methylprednisolone. What purpose should the nurse explain this drug has in treating a patient with an SCI? a. Reduces spinal cord cellular damage b. Counteracts spinal shock c. Increases blood supply to the injured cord d. Enhances sexual function

ANS: A Methylprednisolone, if given within the first 8 hours of the injury, can significantly reduce cellular damage to the cord. DIF: Cognitive Level: Knowledge REF: p. 519 OBJ: 4 TOP: Methylprednisolone KEY: Nursing Process Step: Implementation

5. A woman diagnosed with gonorrhea is astounded and states that she had no idea that she had an STI. What should the nurse explain about gonorrhea? a. It produces no symptoms in half of those in the early stages of the infection. b. It always produces a foul vaginal discharge. c. It causes a vaginal chancre that is not easily detected. d. It may appear to be an upper respiratory infection in the early stages of the infection.

ANS: A More than half of those in the early stages of gonorrhea have no symptoms at all. Symptoms of gonorrhea typically occur 3 days to 3 weeks after exposure and are more apparent in men than in women. No chancre is exhibited, as with syphilis, and gonorrhea does not produce a foul discharge. DIF: Cognitive Level: Application REF: p. 1170 OBJ: 4 TOP: Gonorrhea KEY: Nursing Process Step: Assessment

20. A nurse is assessing a young man who is being treated for sterility and inquires whether the young man had any common childhood disease that may be the cause of sterility. What childhood disease might result in sterility? a. Mumps b. Chicken pox c. Measles d. Scarlet fever

ANS: A Mumps in a man or pubescent boy may result in acute orchitis or epididymitis. Infections that ascend to the epididymis may result in decreased fertility. DIF: Cognitive Level: Knowledge REF: p. 1159 OBJ: 2 TOP: Mumps KEY: Nursing Process Step: Assessment

6. Which describes the Babinski reflex? a. Downward curl of the toes b. Big toe bending upward c. Spreading out of the toes d. Pain in the big toe

ANS: A Normal cortical function causes the toes to curl downward. Abnormal findings would be the toes turning up and spreading. DIF: Cognitive Level: Knowledge REF: p. 447-448 OBJ: 3 TOP: Neurologic Assessment KEY: Nursing Process Step: Assessment

22. A patient who has cancer of the larynx has been told that he needs a total laryngectomy. What action should this nurse consider to help the patient cope with the loss of his voice? a. Offer to have a volunteer from a local laryngectomy organization visit the patient. b. Explain in detail the available vocalization aids and techniques. c. Explain to the patient what will happen directly after the surgery. d. Notify the hospital chaplain of the patient's needs.

ANS: A Offering to request a volunteer from the laryngectomy organization is a recommended implementation to reduce the stress of losing the ability to speak. You should consult the patient before making the referral. DIF: Cognitive Level: Application REF: p. 551 OBJ: 5 TOP: Cancer of the Larynx KEY: Nursing Process Step: Planning

22. A young woman being admitted to the clinic service states that all the members of her family have been hard of hearing. She says her hearing loss became more pronounced when she was pregnant. What term explains this type of hearing loss? a. Otosclerosis b. Ototoxicity c. Otalgia d. Otitis media

ANS: A Otosclerosis is hereditary, develops in young women, and worsens with pregnancy. DIF: Cognitive Level: Comprehension REF: p. 1265 OBJ: 5 TOP: Otosclerosis KEY: Nursing Process Step: Assessment MSC:

21. A patient has an elevation in the prostatic-specific antigen (PSA) level from 4 to 6 ng/L. What should the nurse suspect to be the cause? a. Possibility of prostatic cancer b. ED c. Probability of orchiditis d. Significant indication of Peyronie disease

ANS: A PSA levels over 4 ng/L may indicate cancer of the prostate; further studies are needed. DIF: Cognitive Level: Comprehension REF: p. 1152 OBJ: 3 TOP: PSA KEY: Nursing Process Step: Implementation

12. A patient diagnosed with leukemia has had a bone marrow transplant and has completed chemotherapy. What is the greatest risk for this patient while healthy bone marrow is growing back? a. Infection and bleeding b. Hypertension and headache c. Oliguria and urinary retention d. Dyspnea and wheezing

ANS: A Patients are at greater risk for infection and bleeding while their healthy bone marrow is growing back. DIF: Cognitive Level: Comprehension REF: p. 655 OBJ: 4 TOP: Bone Marrow Complications KEY: Nursing Process Step: Planning

21. What does chlamydial infection place a person at greater risk for? a. HIV if exposed to it b. Urinary infections c. Hepatitis B if exposed to it d. Opportunistic bacterial infections

ANS: A Patients who have a chlamydial infection are five times more likely to contract HIV if exposed to it. DIF: Cognitive Level: Knowledge REF: p. 1166 OBJ: 8 TOP: Chlamydia KEY: Nursing Process Step: Implementation

11. Based on a nursing assessment, what is an appropriate nursing diagnosis for a patient with hemophilia? a. Acute pain related to bleeding into closed spaces b. Impaired gas exchange related to decreased oxygen to the cells c. Excess fluid volume related to increased fluid within the cells d. Hypothermia related to inability to produce heat

ANS: A Patients with hemophilia have severe pain caused by bleeding into the joints. DIF: Cognitive Level: Application REF: p. 640 OBJ: 4 TOP: Hemophilia KEY: Nursing Process Step: Nursing Diagnosis MSC:

21. What is the most significant topic for a nurse to include in a teaching plan for a patient with frequent episodes of laryngitis? a. Observing voice rest b. Reducing smoking c. Eating warm foods d. Maintaining a consistent environmental temperature

ANS: A Patients with laryngitis are advised to rest their voices. DIF: Cognitive Level: Comprehension REF: p. 549 OBJ: 5 TOP: Implementations for Laryngitis KEY: Nursing Process Step: Planning

15. To what level should the platelet count rise when the patient with a platelet count of 20,000/mm3 receives 1 unit of platelets? a. 25,000 to 30,000/mm3 b. 35,000 to 40,000/mm3 c. 45,000 to 50,000/mm3 d. 55,000 to 100,000/mm3

ANS: A Platelet transfusions are given when the platelet count falls below 20,000/mm3. One unit is expected to raise the count by 5000 to 10,000/mm3. DIF: Cognitive Level: Knowledge REF: p. 630 OBJ: 3 TOP: Platelet Transfusion KEY: Nursing Process Step: Assessment MSC:

13. What action should a nurse implement when assessing for abnormal bleeding in a patient following a hysterectomy? a. Record the number of perineal pads used. b. Assess vital signs every 8 hours. c. Place the patient's bed in a high Fowler position. d. Apply an abdominal binder.

ANS: A Recording the number of pads used and the appearance of the discharge is primary in posthysterectomy care. The abdominal dressing and perineal pad are checked every hour for the first 12 hours. Any excess bleeding is reported. The patient should be placed on her side in a semi-Fowler position. An abdominal binder, if used, has no effect on hemorrhage. DIF: Cognitive Level: Application REF: p. 1114 OBJ: 5 TOP: Hysterectomy KEY: Nursing Process Step: Implementation

11. A paraplegic patient excitedly reports seeing his foot move when he was being turned. How is this phenomenon best explained? a. Reflexive movement b. Return of motor function c. Early symptom of autonomic dysreflexia d. Result of hypertonicity of the muscle

ANS: A Reflexive action is a movement that does not require communication to the brain via the spinal cord. DIF: Cognitive Level: Comprehension REF: p. 511 OBJ: 5 TOP: Reflexive Motion KEY: Nursing Process Step: Assessment

7. What should a nurse focus on when assessing for major sources of infection in a patient with COPD? a. Stasis of respiratory secretions b. Low body weight c. Episodes of postural hypotension d. Delayed antigen-antibody response

ANS: A Retained static secretions in the lungs are major sources of bacterial infiltration and infection. DIF: Cognitive Level: Application REF: p. 607 OBJ: 2 TOP: COPD: Infection KEY: Nursing Process Step: Assessment

2. Which instruction should a nurse provide when a patient starts taking a saturated solution of potassium iodide (SSKI)? a. Sip medication through a straw to prevent tooth staining. b. Double the dose if a dose is missed. c. Expect excessive salivation. d. Take before meals.

ANS: A SSKI can discolor teeth if not sipped through a straw; no iodide drug should be doubled; excessive salivation is a sign of toxicity; and the medication should be taken after meals. DIF: Cognitive Level: Comprehension REF: p. 1040 OBJ: 1 TOP: SSKI KEY: Nursing Process Step: Implementation

11. A patient inquires about the purpose of the laboratory test to measure the serum level of adrenocorticotropic hormone (ACTH). What should a nurse respond that the laboratory test will determine? a. The pituitary gland is sending the correct message to the adrenal glands. b. The thyroid gland is not stimulating the production of ACTH. c. The adrenal glands are not responding to produce cortisol. d. Androgen metabolites are low or borderline.

ANS: A Serum levels are measured to detect elevations or deficiencies of pituitary hormone levels. If plasma ACTH is low, then the pituitary is not producing enough ACTH. If the plasma ACTH is high, then the adrenal glands are unable to respond to produce corticoids. DIF: Cognitive Level: Comprehension REF: p. 1007 OBJ: 2 TOP: Pituitary Laboratory Value KEY: Nursing Process Step: Implementation

4. Which nursing intervention enhances the nutritional status of a patient with COPD? a. Offer small, frequent meals. b. Encourage extra liquids with meals. c. Assist the patient to exercise before meals. d. Supply information about nutrition.

ANS: A Small meals are not as tiring for the patient and are more appealing. DIF: Cognitive Level: Application REF: p. 610 OBJ: 3 TOP: COPD: Nutrition KEY: Nursing Process Step: Implementation

13. Which method is used to identify organisms of gonorrhea? a. Smears and cultures b. Serologic tests c. Antibody screening d. Sensitivity testing

ANS: A Smears from genital discharge can be studied on a smear. DIF: Cognitive Level: Knowledge REF: p. 1170 OBJ: 1 TOP: Tests Used to Diagnose STIs KEY: Nursing Process Step: Assessment

4. A nurse records the assessment of stasis dermatitis on an intake assessment for a patient with peripheral vascular disease (PVD). What is the best way to describe this finding? a. Brownish skin discoloration on the lower legs b. Ulceration on medial surface of the lower legs c. Edema in the lower legs d. Purple rash on medial surface of the lower legs

ANS: A Stasis dermatitis is a brownish skin discoloration on the lower legs, which is indicative of venous stasis. DIF: Cognitive Level: Application REF: p. 742 OBJ: 2 TOP: Vascular Disorders KEY: Nursing Process Step: Assessment MSC:

6. What is the result of status asthmaticus that is not corrected? a. Pneumothorax, severe hypoxemia, and respiratory arrest b. Hypertension, cerebrovascular accident (CVA), and cardiac arrest c. Respiratory alkalosis, pneumonia, and death d. Lung abscess, cor pulmonale, and respiratory failure

ANS: A Status asthmaticus, because of severe bronchospasms, can result in hypoxemia, which could lead to pneumothorax and arrest. DIF: Cognitive Level: Comprehension REF: p. 599 OBJ: 2 TOP: Status Asthmaticus KEY: Nursing Process Step: Implementation

24. A patient has undergone bone marrow transplant. Which injection should the nurse anticipate this patient will receive to help stabilize the immune response and prevent rejection? a. Dexamethasone (Decadron) b. Filgrastim (Neupogen) c. Zidovudine (Retrovir) d. Nevirapine (Viramune)

ANS: A Steroids (e.g., dexamethasone [Decadron]) are drugs used in the treatment of patients with transplanted organs to prevent rejection. DIF: Cognitive Level: Knowledge REF: p. 660 OBJ: 5 TOP: Drugs to Prevent Rejection of Transplanted Organs KEY: Nursing Process Step: Implementation

24. A newly diagnosed patient with non-small cell lung carcinoma (NSCLC) is anxious about upcoming surgery. Which intervention by the nurse would be most helpful? a. Support the patient in preparation for surgery. b. Educate the patient regarding the high survival rate with this type of carcinoma. c. Assure the patient that chemotherapy and radiation can be used in this sort of cancer. d. Refer the patient to the American Cancer Society for postdischarge follow-up.

ANS: A Surgery is the treatment of choice of NSCLC carcinomas. The survival rate is only approximately 14%. Although referral may be in the long-range plan, the patient's need is immediate for information that is within the scope of nursing. DIF: Cognitive Level: Comprehension REF: p. 618 OBJ: 3 TOP: NSCLC KEY: Nursing Process Step: Implementation

11. A couple comes to the emergency department for the treatment of an STI. The man's presenting symptoms include a creamy penile discharge and frequent urination. The woman has lower abdominal pain and a vaginal discharge. What should the nurse recognize these symptoms to characterize? a. Chlamydial infection b. Gonorrhea infection c. HSV type B d. Trichomoniasis

ANS: A Symptoms in men are penile discharge, thin at first and then creamy, and frequent urination. Symptoms in women are a vaginal discharge and lower abdominal pain. DIF: Cognitive Level: Comprehension REF: p. 1166-1167 OBJ: 4 TOP: Chlamydia KEY: Nursing Process Step: Assessment

26. A nurse assesses a Grey Turner sign in a patient who was admitted 2 days earlier after an automobile accident. What does this finding indicate? a. Retroperitoneal bleeding and bruising over the flank b. Hematuria with abdominal bruising c. Distended bladder with painful urination d. Bladder spasms on palpation of abdomen

ANS: A The Grey Turner sign is bruising over the flank and retroperitoneal bleeding. This is observed in blunt trauma to the kidney. DIF: Cognitive Level: Comprehension REF: p. 918 OBJ: 1 TOP: Grey Turner Sign KEY: Nursing Process Step: Assessment

6. When asked about his vision, a patient says that the last time he had it tested, his vision was recorded as 20/50. What does this mean? a. He can read at 20 feet what a person with normal vision can read at 50 feet. b. He can read at 50 feet what a person with normal vision can read at 20 feet. c. He needs to be 50 feet from objects to see them. d. He can see objects the best between 20 and 50 feet.

ANS: A The Snellen eye chart is read at 20 feet. The last line the patient can read with no more than two errors is recorded. This patient was able to read the 50-foot line at 20 feet, which means that he is reading at 20 feet what a person with normal vision can read at 50 feet. DIF: Cognitive Level: Comprehension REF: p. 1223 OBJ: 1 TOP: Physical Examination: Eyes KEY: Nursing Process Step: Assessment MSC:

23. A nurse suspects that a patient with type 1 diabetes may be experiencing the Somogyi phenome-non. What symptom supports this suspicion? a. Headache on awakening and enuresis b. 6 AM blood sugar of 58 mg/dL and nausea c. Abdominal pain and elevated blood pres-sure d. Drowsiness and disorientation after eating

ANS: A The Somogyi phenomenon occurs because of a rebound hyperglycemia after a period of hypogly-cemia during the early morning. The patient wakes with a headache, enuresis, nausea and vomiting, nightmares, and a high level of blood sugar. DIF: Cognitive Level: Comprehension REF: p. 1077 OBJ: 8 TOP: Somogyi Phenomenon KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

19. A patient with Parkinson disease is depressed because his drug protocol of L-dopa and Sinemet is no longer controlling his symptoms. What is the best response by the nurse? a. Other drugs can be combined with L-dopa to increase its effectiveness. b. The effect of these drugs has an uneven course; symptoms will begin to subside again soon. c. The two drugs can be given in higher doses to control the symptoms. d. Surgical interventions have been very effective in the control of parkinsonian symptoms.

ANS: A The addition of other drugs to L-dopa may improve the conversion of L-dopa to dopamine. Palliative surgical implementations all have had little effect on controlling the symptoms. DIF: Cognitive Level: Comprehension REF: p. 468 OBJ: 6 TOP: Treatment of Parkinson Disease KEY: Nursing Process Step: Implementation

3. A patient comes into the clinic complaining of a runny nose and facial pain. What should the nurse's initial assessment include? a. Assessment for nasal drainage and sinus tenderness b. Transillumination and nasal speculum examination c. Palpation of the frontal and maxillary sinuses and tonsillar inspection d. Turbinate assessment and assessment for patency of the nares

ANS: A The assessment of the characteristics of the nasal drainage and location of the facial pain would be the first evaluation for sinusitis. DIF: Cognitive Level: Application REF: p. 533 OBJ: 2 TOP: Physical Examination of the Nose KEY: Nursing Process Step: Assessment

8. A 14-year-old adolescent male patient has been diagnosed with Addison disease. Which effect of Addison disease should this patient be aware of? a. He will not develop pubic hair. b. He will grow a heavy beard. c. He will become bald at an early age. d. He will have enlarged joints.

ANS: A The boy with Addison disease will not grow facial, axillary, or pubic hair. Balding and enlarged joints are not associated with Addison disease. DIF: Cognitive Level: Comprehension REF: p. 1027 OBJ: 1 TOP: Addison Disease KEY: Nursing Process Step: Assessment

7. Which statement by a woman with Addison disease would indicate a disturbance in body image? a. "Will I look like a zebra for the rest of my life?" b. "I have found makeup to cover my rash." c. "With this red face, I sure can't wear pink anymore." d. "At last! I look like I have a suntan."

ANS: A The brown hyperpigmentation of Addison disease appears on the face and in body creases, joints, and pressure points, and it is obvious. The skin changes are not a rash nor are they red. DIF: Cognitive Level: Comprehension REF: p. 1029-1030 OBJ: 2 TOP: Addison Disease KEY: Nursing Process Step: Assessment

5. Which symptom should a nurse recognize as being pertinent to a possible diagnosis of systemic lupus erythematosus (SLE)? a. Butterfly rash of the face b. Protruding abdomen c. Thinning hair d. Bloody diarrhea

ANS: A The classic butterfly rash of the face is one of the most recognizable signs. Because the symptoms come and go, SLE is extremely hard to diagnose quickly. DIF: Cognitive Level: Comprehension REF: p. 658 OBJ: 5 TOP: Systemic Lupus Erythematosus KEY: Nursing Process Step: Assessment

12. A patient who has sustained a hemorrhagic stroke is placed on a protocol of 60 mg of calcium channel blocker (nimodipine) every 4 hours. The patient's pulse is 82 beats/min before the administration of the prescribed dose. Which action should the nurse implement? a. Give the full dose as prescribed without further assessment. b. Omit the dose, recording the pulse rate as the rationale. c. Delay the dose until the pulse is below 60 beats/min. d. Give half of the prescribed dose (30 mg).

ANS: A The dose should be given; it would be held only if the pulse is below 60 beats/min. Assessments should be made regarding BP, urine output, and edema. DIF: Cognitive Level: Application REF: p. 487 OBJ: 3 TOP: CVA Medical Protocol KEY: Nursing Process Step: Implementation

12. A nurse is educating a patient regarding a stress test on a treadmill. Teaching includes that this test is a noninvasive procedure. What additional information is appropriate for the nurse to include? a. Is monitored continuously by blood pressure and an electrocardiogram b. Will last about 1 hour c. Is meant to stimulate claudication and dyspnea d. Will require a period of bedrest afterward

ANS: A The examination requires the patient to walk at a rate of approximately 1.5 miles per hour. The exercise is continually monitored and is terminated if the patient experiences pain or dyspnea. DIF: Cognitive Level: Comprehension REF: p. 744-745 OBJ: 3 TOP: Treadmill Stress Test KEY: Nursing Process Step: Implementation MSC:

7. A nurse is performing frequent catheterizations for residual urine. What causes the greatest concern for the nurse? a. Introduction of pathogens into the bladder b. Frequent genital exposure of the patient c. Presence of the indwelling catheter d. Causing urethral erosion

ANS: A The frequency of introducing a catheter into the bladder offers a very real risk of infection. DIF: Cognitive Level: Application REF: p. 902 OBJ: 3 TOP: Urinary Catheterization KEY: Nursing Process Step: Implementation

11. Which instruction should a nurse include when providing patient teaching information for a patient who will be self-administering ear drops for an ear infection? a. Tip the affected ear up and keep it in that position for several minutes after instilling the medication. b. Keep the medication in the refrigerator to preserve it. Instill the medication with the affected ear tilted upward. c. Touch the dropper to the opening of the ear canal to ensure that the drops are correctly instilled. d. Warm the ear drops and then tilt the head downward.

ANS: A The head is kept in an upward position to ensure that the drops penetrate deep into the external ear. DIF: Cognitive Level: Application REF: p. 1256-1257 OBJ: 4 TOP: Ear Drops KEY: Nursing Process Step: Implementation MSC:

19. A patient is admitted with possible cancer of the ovary. What fact should a nurse know about malignant tumors of the ovary? a. They are frequently advanced and inoperable by the time they are diagnosed. b. The respond well to radiation and chemotherapy because of early detection. c. They are easily detected because symptoms appear early in a woman's life. d. They are directly related to PID and other infections.

ANS: A The high mortality rate for women with ovarian cancer is due to the fact that a malignant tumor of the ovary is asymptomatic until it is advanced. DIF: Cognitive Level: Knowledge REF: p. 1127 OBJ: 4 TOP: Ovarian Cancer KEY: Nursing Process Step: Assessment

13. On returning from surgery after undergoing a thyroidectomy, a patient is alarmed about the large tracheostomy tray on the bedside table. What is the nurse's most reassuring response when the patient asks why it is there? a. "We have it there as a precautionary measure in the unlikely event that you have difficulty breathing." b. "If you start bleeding, we'll be able to take care of it right here at the bedside." c. "We have to keep it there in case of an emergency and the physician needs it." d. "It's hospital policy to have it available for persons who are likely to have respiratory arrest."

ANS: A The honest answers without any embellishments are best. Suggesting that any emergency is imminent will alarm the patient further. The presence of the tray is an item that should be covered in preoperative teaching. DIF: Cognitive Level: Comprehension REF: p. 1044 OBJ: 3 TOP: Postoperative Care: Thyroidectomy KEY: Nursing Process Step: Implementation

4. What are the classic symptoms of diabetes insipidus (DI)? a. Diuresis, tachycardia, and weakness b. Dizziness, hypertension, and excitability c. Stress incontinence, vomiting, and edema d. Bradycardia, insomnia, and muscle cramps

ANS: A The hypovolemia from massive diuresis leads to decreased blood pressure, tachycardia, and weakness. DIF: Cognitive Level: Knowledge REF: p. 1019 OBJ: 1 TOP: Diabetes Insipidus KEY: Nursing Process Step: Assessment

14. A nurse is caring for a patient with acute glomerulonephritis. What should the nurse be aware that the inflammation of the capillary loops in the glomeruli will lead to? a. Moderate to high blood pressure b. Low blood volume with polyuria c. Irritability and hyperactivity d. Low levels of BUN and creatinine

ANS: A The inflammatory process in the glomeruli decreases the filtration rate, and the blood volume increases, raising the patient's blood pressure. DIF: Cognitive Level: Comprehension REF: p. 911-912 OBJ: 5 TOP: Acute Glomerulonephritis KEY: Nursing Process Step: Assessment

7. Which intraocular pressure reading obtained by tonometry indicates a patient being evaluated for a visual impairment does not have glaucoma? a. 18 mm Hg b. 28 mm Hg c. 45 mm Hg d. 52 mm Hg

ANS: A The normal intraocular pressure is between 12 and 21 mm Hg. If the patient had glaucoma, the intraocular pressure would be abnormally high. DIF: Cognitive Level: Comprehension REF: p. 1224 OBJ: 3 TOP: Tonometry KEY: Nursing Process Step: Assessment MSC:

21. A nurse notes that no urinary output has occurred in a patient who underwent a laminectomy 2 hours earlier. What action should the nurse implement? a. Continue to monitor. b. Inform the charge nurse. c. Perform intermittent catheterizations. d. Turn the patient to the right side.

ANS: A The nurse should continue to monitor the patient for urine output. Two hours is too soon to expect a continent patient to void. Informing the charge nurse and catheterization are not necessary. Turning this patient to the side is contraindicated. DIF: Cognitive Level: Application REF: p. 527 OBJ: 8 TOP: Postoperative Care for Laminectomy KEY: Nursing Process Step: Implementation

20. A patient with COPD asks a nurse if nicotine patches are very effective for smoking cessation. What is the best response by the nurse? a. "No. Only about 25% are successful." b. "Yes. The success rate is between 50% and 60%." c. "No. Prescriptions such as Wellbutrin are 90% effective." d. "Yes. Individual success has been obtained with combination of patches and gum."

ANS: A The patches have a lower than 25% success rate. Smoking addiction is too strong to be overcome by medication or gum without a very unusual commitment from the patient. Successful smoking cessation is measured by 1 year of no smoking. DIF: Cognitive Level: Comprehension REF: p. 609 OBJ: 3 | 4 TOP: COPD: Smoking Cessation KEY: Nursing Process Step: Planning

2. What should preoperative teaching for a patient scheduled for a transsphenoidal hypophysectomy include that the patient should do postoperatively? a. Avoid sneezing. b. Drink through a straw. c. Cough forcefully. d. Wash mouth out with peroxide.

ANS: A The patient should be taught to avoid sneezing, coughing, drinking through a straw, and using a stringent mouthwash that might dislodge the graft. DIF: Cognitive Level: Comprehension REF: p. 1016 OBJ: 4 TOP: Pituitary Surgery KEY: Nursing Process Step: Implementation

9. Which assessment should indicate the necessity for a nurse to suction a patient with a tracheostomy? a. Becomes restless and has increases in vital signs b. Has decreased peak airway pressure c. Shows diaphoresis d. Is coughing frothy mucus

ANS: A The patient signals the need for suctioning by increased restlessness and an increase in vital signs. Peak airway pressures increase when suctioning is necessary. Frothy mucus is an expectation. DIF: Cognitive Level: Application REF: p. 535 OBJ: 3 TOP: Suctioning KEY: Nursing Process Step: Assessment

9. What is the cardinal indication of a pheochromocytoma? a. Significant hypertension b. Extreme nausea c. Abdominal pain d. Edema in the legs

ANS: A The patient with a pheochromocytoma exhibits dangerously high hypertension. Hypertension and its attendant symptoms are what bring the patient to the physician. The tumor is found incidentally. DIF: Cognitive Level: Knowledge REF: p. 1033 OBJ: 4 TOP: Adrenal Tumor KEY: Nursing Process Step: Assessment

12. A nurse is preparing a teaching plan for a patient with HIV who has been diagnosed with microsporidiosis. Which implementation should be included? a. Drink 3 quarts of fluid a day to combat dehydration. b. Include milk products with every meal. c. Consume liberal amounts of fat for increased energy. d. Limit protein intake to reduce serum ammonia levels.

ANS: A The patients need plenty of fluids to combat the diarrhea and proteins for calories. They should avoid milk products and fat. DIF: Cognitive Level: Application REF: p. 670 OBJ: 7 TOP: Microsporidiosis KEY: Nursing Process Step: Implementation

25. How does the ventilator function of positive end-expiratory pressure assist the patient? a. Keeps pressure in the lungs after expiration b. Delivers 100% oxygen on inspiration c. Allows the patient to control expiratory pressure d. Delivers an inhalant medication under positive pressure

ANS: A The positive end-expiratory pressure setting keeps the pressure in the lungs above the atmospheric pressure, which prevents atelectasis. DIF: Cognitive Level: Knowledge REF: p. 574-575 OBJ: 3 TOP: Mechanical Ventilators KEY: Nursing Process Step: Implementation

19. What is the primary function in the immune process of the spleen? a. Filter microorganisms from the blood. b. Store lymphocytes used to fight infections. c. Produce additional RBCs (red blood cells). d. Stimulate WBC production.

ANS: A The spleen filters microorganisms from the blood. DIF: Cognitive Level: Knowledge REF: p. 644 OBJ: 1 TOP: Functions of the Spleen KEY: Nursing Process Step: Assessment

17. A 35-year-old man is examined in an urgent care clinic. His presenting symptoms suggest polycythemia vera. Which extreme laboratory value would confirm this possible diagnosis? a. High hemoglobin level b. Low white cell count c. Low platelet count d. High iron level

ANS: A The symptoms of polycythemia vera are extremely high hemoglobin and hematocrit values because of the excessive production of red blood cells. Patients with polycythemia vera have 1 pint of blood taken from them until the blood values become more normal. The blood is collected as it would be for a blood donation, but it cannot be used for transfusion purposes. DIF: Cognitive Level: Comprehension REF: p. 632-633 OBJ: 5 TOP: Polycythemia Vera KEY: Nursing Process Step: Assessment MSC:

20. What symptoms should a nurse expect to see in a patient with hypoxemia? a. Restlessness, tachycardia, and tachypnea b. Bradycardia, cyanosis, and restlessness c. Dyspnea, flushed face, and tachycardia d. Cyanosis, nausea, and bradycardia

ANS: A The universal symptoms of hypoxemia, regardless of cause, are restlessness, tachycardia, and tachypnea. DIF: Cognitive Level: Comprehension REF: p. 571 | p. 592 OBJ: 6 TOP: Hypoxemia KEY: Nursing Process Step: Assessment

10. What should be immediately reported by the nurse caring for a 90-year-old patient with a closed head injury? a. Blood pressure change from 147/72 to 176/70 mm Hg b. Respiration rate increase from 14 to 18 breaths/min c. Slow pupillary reaction bilaterally d. Temperature decrease from 100.2° F to 97.6° F

ANS: A The widening pulse pressure is an indicator of increased ICP. Respirations and temperature are returning to more normal levels. Older adults have a slowed pupillary response as they age. DIF: Cognitive Level: Analysis REF: p. 451-452 OBJ: 5 TOP: Nursing Care of Patient with Closed Head Injury KEY: Nursing Process Step: Implementation

1. A physician ordered T3 and T4 tests for a young woman complaining of fatigue, weight gain, muscle aches and pains, and constipation. Which laboratory test results will help confirm the diagnosis of hypothyroidism? a. Both tests show decreases. b. Both tests show increases. c. The T3 test elevates, and the T4 test decreases. d. The level of thyroxin rises and then falls back to subnormal levels.

ANS: A These complaints are strongly suggestive of thyroid disorder; T3 and T4 laboratory diagnostic tests are the most useful. DIF: Cognitive Level: Knowledge REF: p. 1038 | p. 1047 OBJ: 2 TOP: Thyroid Diagnostic Tests KEY: Nursing Process Step: Assessment

18. What must be true for a woman to be diagnosed with primary infertility? a. She has been unable to conceive after 1 year of regular, unprotected sex. b. She conceived once but did not deliver a viable infant. c. She conceived once but was unable to conceive again. d. She conceived three times in 1 year without a viable birth.

ANS: A To be diagnosed with primary infertility, the patient must have been unable to conceive after 1 year of regular, unprotected sex. All other options are definitions of secondary infertility. DIF: Cognitive Level: Comprehension REF: p. 1130 OBJ: 5 TOP: Infertility KEY: Nursing Process Step: Assessment

6. After a mastectomy, many patients experience lymphedema. What action can the patient take to minimize this problem? a. Keep the arm elevated as much as possible. b. Take Lasix, 20 mg twice daily as ordered. c. Use a sling during the day to rest the arm. d. Avoid exercising the arm for several weeks.

ANS: A To manage lymphedema, the patient should elevate the arm to a height above the level of the heart. DIF: Cognitive Level: Comprehension REF: p. 1124 OBJ: 5 TOP: Postoperative Care for Mastectomy KEY: Nursing Process Step: Implementation

23. A woman calls the clinic office and asks the nurse why she is having spotting between her monthly periods when she is taking birth control pills to control the menorrhagia. What is the nurse's most appropriate response? a. "It is important to take the pill at the same time each day." b. "Irregular spotting is to be expected with oral contraceptives." c. "The pills are still safe. Continue to take them, regardless." d. "Physicians are still uncertain as to how oral contraceptives function."

ANS: A Treatment for menorrhagia consists of taking the birth control pill at the same time each day. DIF: Cognitive Level: Comprehension REF: p. 1104 OBJ: 5 TOP: Menorrhagia KEY: Nursing Process Step: Implementation

15. How do foods such as soybeans, turnips, and rutabagas affect people with thyroid disorders? a. Suppress thyroid hormone. b. Decrease the hypothermia of the person with hypothyroidism. c. Supplement the diet of a person with hypothyroidism. d. Counteract the effect of iodide therapy.

ANS: A Turnips, rutabagas, and soybeans are goitrogen substances and suppress the thyroid hormone. Such foods would synergize iodides and increase the symptoms of the patient with hypothyroidism. DIF: Cognitive Level: Comprehension REF: p. 1046 OBJ: 3 TOP: Goitrogen Substances KEY: Nursing Process Step: Evaluation

27. What patient teaching should be included for a patient with varicose veins? a. Weight reduction b. Decreasing exercise c. Wearing a panty girdle d. Standing rather than sitting

ANS: A Varicose veins are caused by a dilation of incompetent valves. Obesity, pregnancy, restrictive clothing, and prolonged standing aggravate the condition. DIF: Cognitive Level: Application REF: p. 760-761 OBJ: 4 TOP: Varicose Veins KEY: Nursing Process Step: Implementation MSC:

1. A nurse is reviewing the drugs taken by a 50-year-old male patient. What medication should the nurse recognize as the most probable cause of erectile dysfunction (ED)? a. Vasodilator for hypertension b. Antibiotic for an upper respiratory infection c. Antihistamine for allergies d. Glucophage for type 2 diabetes

ANS: A Vasodilators taken for the control of hypertension frequently cause ED. DIF: Cognitive Level: Knowledge REF: p. 1156 OBJ: 2 TOP: Male Sexual Dysfunction KEY: Nursing Process Step: Assessment

10. What is a characteristic of a venous stasis ulcer? a. Painlessness b. Poikilothermy c. Pale color d. Location near the groin

ANS: A Venous ulcers are painless ulcers near the ankle that are warm and have a ruddy color. DIF: Cognitive Level: Knowledge REF: p. 742 OBJ: 3 TOP: Venous Stasis Ulcer KEY: Nursing Process Step: Implementation MSC:

23. Which statement by a patient diagnosed with AIDS should lead a nurse to suspect an infection by CMV? a. "I need to get glasses; I can't see as well as I did a few months ago." b. "I need to drink more water. This diarrhea has really dehydrated me." c. "I need to get smaller clothes. I have lost 10 lb in the past 6 weeks." d. "I need to take some pep pills. I don't have any energy."

ANS: A Visual changes indicate the presence of CMV retinitis, which will eventually lead to blindness. Diarrhea is indicative of a fungal infection, and decreases in weight and energy are expected manifestations of AIDS. DIF: Cognitive Level: Comprehension REF: p. 672 OBJ: 4 TOP: Assessing CMV KEY: Nursing Process Step: Assessment

5. Which walking program would be the most effective for the nurse to recommend as part of a progressive walking program for an obese patient with COPD? a. 10 to 15 minutes a day b. 20 to 30 minutes a day c. 45 to 60 minutes a day d. Up to 2 hours a day

ANS: A Walking for as little as 10 to 15 minutes a day and progressing up to 45 minutes a day has proven beneficial for persons with COPD because it improves oxygenation and helps with weight loss. DIF: Cognitive Level: Application REF: p. 611 OBJ: 3 TOP: Exercise for the Patient with COPD KEY: Nursing Process Step: Planning

15. What causes the cool, damp skin of patients in compensatory shock? a. Constriction of peripheral blood vessels because of the shunting of blood to the vital organs b. Action of the antidiuretic hormone released in shock by the adrenal glands c. Decreasing levels of arterial carbon dioxide, which are pooling in the arms and legs d. Activation of the baroreceptors in the renal arteries

ANS: A When overall blood volume is reduced in shock, the remaining blood volume is shunted to vital organs. DIF: Cognitive Level: Comprehension REF: p. 303-304 OBJ: 2 TOP: Rationale for Skin Changes in Compensatory Shock KEY: Nursing Process Step: Assessment

9. A nurse assessing the results of a Rinne test sees the notation of BC > AC. How should the nurse translate this result? a. Conductive hearing loss b. Sensorineural hearing loss c. Normal hearing d. Cochlear defect

ANS: A When the bone conduction (BC) is greater than the air conduction (AC), the results of the Rinne test will read, BC > AC, which means the patient has a conductive hearing loss. The normal finding for the Rinne test is that AC is greater than BC (AC > BC). DIF: Cognitive Level: Analysis REF: p. 1255 OBJ: 2 TOP: Rinne Test KEY: Nursing Process Step: Assessment MSC:

2. Although several life-supporting systems of the body are involved in the pathophysiologic characteristics of shock, shock itself results from failure of which system? a. Circulatory b. Endocrine c. Neurologic d. Respiratory

ANS: A When the heart fails as a pump, the lack of tissue perfusion follows and deprives all the body's cells of oxygen and the removal of wastes. DIF: Cognitive Level: Knowledge REF: p. 301 OBJ: 2 TOP: Definition of Shock KEY: Nursing Process Step: N/A

19. One of the most important assessments that a nurse makes is to check urine output. Which value objectively validates minimal acceptable renal perfusion for the average-size person? a. 0.5 mL/kg/hr b. 0.5 mL/lb/hr c. 1 mL/lb/hr d. 0.2 mL/kg/hr

ANS: A When the kidneys produce at least 0.5 mL/kg/hr of urine, the indication is that the vital organs are also being perfused. DIF: Cognitive Level: Knowledge REF: p. 308 OBJ: 5 TOP: Urine Output As Measure of Tissue Perfusion KEY: Nursing Process Step: Implementation

20. What should a nurse include when caring for a patient after a hypophysectomy, during which the entire pituitary was removed? a. Maintaining strict intake and output fluids b. Keeping the patient flat in bed for the first 24 hours c. Withholding analgesics to assess the level of consciousness d. Providing mouth care with thorough cleansing of the oral cavity

ANS: A With the removal of the entire pituitary gland, the patient will have no effective ADH and will excrete large amounts of urine. The patient is usually kept in a semi-Fowler position and is medicated as needed for pain. Because of the graft, mouth care is minimal, if provided at all. DIF: Cognitive Level: Application REF: p. 1015 OBJ: 4 TOP: Hypophysectomy KEY: Nursing Process Step: Evaluation

20. At the end of a shift, a nurse documents the effectiveness of parent teaching concerning the transmission of hemophilia. Which statement by the mother would best indicate an accurate parental perception? a. "Hemophilia is a genetic disorder, and I am a carrier, although I do not have the disease." b. "My son developed hemophilia because I had measles while I was pregnant." c. "Because my husband isn't affected by the disease, our daughter will not be a carrier." d. "I know it is not necessary to have my two daughters tested for the disease."

ANS: A Women carry the trait and pass it on to their sons. DIF: Cognitive Level: Comprehension REF: p. 639 OBJ: 5 TOP: Hemophilia KEY: Nursing Process Step: Evaluation MSC:

16. After a physician has left the room of a 30-year-old man who has been diagnosed with testicular cancer, the patient covers his face with both hands and sighs. What is the nurse's most therapeutic intervention at this time? a. Ask the patient, "Do you want to talk about your cancer?" b. Leave the room and pull the door closed. c. Go to the nurse's station and call the patient's wife. d. Complete the patient care as quickly as possible.

ANS: A You can help the patient through active listening, providing information, and referring him for counseling as needed. DIF: Cognitive Level: Application REF: p. 1162-1163 OBJ: 6 TOP: Patient with Testicular Cancer KEY: Nursing Process Step: Implementation

10. Several days after a CVA, a patient's family asks a nurse if tissue plasminogen activator (tPA) is a drug therapy option now. The nurse's response is based on the knowledge that this drug must be used within how many hours after the onset of symptoms? a. 3 b. 5 c. 10 d. 24

ANS: A tPA is to be given within 3 hours of the onset of symptoms per the U.S. Food and Drug Administration's guidelines. In some special treatment centers this drug is given intravenously up to 6 hours after the stroke. DIF: Cognitive Level: Knowledge REF: p. 492 OBJ: 6 TOP: CVA Medication Implementation KEY: Nursing Process Step: Implementation

28. Which opportunistic fungal diseases threaten patients with HIV? (Select all that apply.) a. Aspergillosis b. Pneumocystis jiroveci c. Herpes simplex d. Oral hairy leukoplakia e. Tuberculosis

ANS: A, B Aspergillosis and P. jiroveci are caused by fungi. Herpes simplex and leukoplakia are caused by viruses. Tuberculosis is caused by bacteria. DIF: Cognitive Level: Knowledge REF: p. 670 OBJ: 7 TOP: Fungal Infections KEY: Nursing Process Step: Implementation

27. A teaching plan for a patient with diabetes is focused on smoking cessation and the control of hypertension for the avoidance of microvascular complications. What are examples of microvascu-lar complications? (Select all that apply.) a. Macular degeneration b. End-stage renal disease (ESRD) c. Coronary artery disease (CAD) d. Peripheral vascular disease (PVD) e. Cerebrovascular accident (CVA)

ANS: A, B Macular degeneration and ESRD are both microvascular complications. CAD, PVD, and CVA are all macrovascular complications. DIF: Cognitive Level: Comprehension REF: p. 1061 OBJ: 5 TOP: Microvascular Complications KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

28. Which instructions should a nurse provide to a patient just before a scheduled spirometry test? (Select all that apply.) a. Avoid smoking 4 to 6 hours before test. b. Do not use bronchodilator medications for at least 4 hours. c. Exercise for a few minutes. d. Drink 2 glasses of fluid. e. Avoid eating.

ANS: A, B Patients should not smoke, use bronchodilators, or exercise just before the test. Normal-sized meals and drinking fluids do not adversely affect the test. DIF: Cognitive Level: Comprehension REF: p. 567 OBJ: 3 TOP: Spirometry KEY: Nursing Process Step: Implementation

30. A nurse reads the serum calcium laboratory report of a patient as 4.2 mEq/L. Which symptoms should the nurse anticipate that the patient might exhibit? (Select all that apply.) a. Irritability b. Tingling sensations in limbs c. Tetany d. Nausea e. Visual disturbances

ANS: A, B, C Symptoms of hypocalcemia include irritability, tingling sensations, tetany, muscle twitching, and muscle contractions. DIF: Cognitive Level: Comprehension REF: p. 927 OBJ: 5 TOP: Hypocalcemia KEY: Nursing Process Step: Assessment

29. A nurse explains that in autoimmune diseases, the body identifies its own proteins as foreign matter and sets out to destroy itself. Which are examples of autoimmune diseases? (Select all that apply.) a. SLE b. Type 1 diabetes mellitus (DM) c. Rheumatoid arthritis (RA) d. Osteoarthritis e. Pancreatitis

ANS: A, B, C The autoimmune diseases are SLE, type 1 DM, and RA. DIF: Cognitive Level: Knowledge REF: p. 646 OBJ: 5 TOP: Autoimmune Diseases KEY: Nursing Process Step: Implementation

25. What do the causes for menorrhagia include? (Select all that apply.) a. Hormonal dysfunction b. Tumors c. Coagulation disorders d. Endometrial hyperplasia e. Excessive exercising

ANS: A, B, C, D Common causes for menorrhagia include hormonal dysfunction, tumors (both benign and malignant), coagulation disorders, and endometrial hyperplasia. Excessive exercise is far more likely to cause amenorrhea than menorrhagia. DIF: Cognitive Level: Knowledge REF: p. 1103 OBJ: 4 TOP: Menorrhagia KEY: Nursing Process Step: Implementation

27. Which actions should the nurse include in a care plan to effectively assist the patient with a total laryngectomy to maintain airway clearance? (Select all that apply.) a. Turning, coughing, and deep breathing b. Placing the patient in a semi-Fowler position c. Maintaining hydration d. Attaching a tracheostomy collar e. Providing a method to communicate

ANS: A, B, C, D Providing a communication method has high priority, but it is not related to airway clearance. DIF: Cognitive Level: Comprehension REF: p. 550-554 OBJ: 4 TOP: Maintaining Airway Clearance KEY: Nursing Process Step: Planning

26. Why are antithyroid medications provided presurgically to a patient with hyperthyroidism? (Select all that apply.) a. To decrease the level of hormone in the blood before surgery b. To help reduce the risk of hemorrhage during surgery c. To decrease the threat of a thyroid storm d. To reduce exophthalmia e. To increase weight

ANS: A, B, C, D The antithyroid medication will do all of the above except for increasing weight in a patient with hyperthyroidism. DIF: Cognitive Level: Comprehension REF: p. 1039-1040 OBJ: 3 TOP: Presurgical Use of Antithyroid Drugs KEY: Nursing Process Step: Implementation

28. What are the four distinct stages of the inflammatory process? a. Dolor b. Rubor c. Tumor d. Calor e. Rumor

ANS: A, B, C, D The four processes are rubor (red), tumor (swelling), calor (heat), and dolor (pain). DIF: Cognitive Level: Knowledge REF: p. 645 OBJ: 1 TOP: Stages of Inflammatory Process KEY: Nursing Process Step: Implementation

28. A nurse makes a list of symptoms that a patient who is taking methimazole (Tapazole), a thionamide drug, should report. What should this list include? (Select all that apply.) a. Becoming pregnant b. Jaundice c. Blood in the stool d. Rash e. Urine retention

ANS: A, B, C, D Urine retention is not a side effect of methimazole (Tapazole). DIF: Cognitive Level: Knowledge REF: p. 1041 OBJ: 4 TOP: Patient Education for Thionamides KEY: Nursing Process Step: Planning

30. Which are normal brain alterations associated with age? (Select all that apply.) a. Decrease in brain weight b. Pigmentation of brain with lipofuscin c. Present of amyloid d. Tiny clot formation e. Tangled nerve fibers

ANS: A, B, C, E All brain alterations listed are expected changes that affect the older adult's neurologic function except for tiny clot formations, which are a pathologic change. DIF: Cognitive Level: Knowledge REF: p. 439 OBJ: 1 TOP: Age-Related Cerebral Changes KEY: Nursing Process Step: Planning

25. A nurse explains that STIs must be reported to the local public health department. Which are considered reportable diseases? (Select all that apply.) a. HIV b. Acquired immunodeficiency syndrome (AIDS) c. Gonorrhea d. Chlamydia e. Viral hepatitis

ANS: A, B, C, E All confirmed cases of HIV, AIDS, gonorrhea, syphilis, and viral hepatitis are reportable. Chlamydia is not reportable. DIF: Cognitive Level: Knowledge REF: p. 1166 OBJ: 2 TOP: Reportable Diseases KEY: Nursing Process Step: Implementation

28. What actions should a nurse implement when assessing a patient's accommodation? (Select all that apply.) a. Hold his or her finger approximately 20 inches in front of the patient's eyes. b. Observe for pupillary constriction. c. Assess for convergence. d. Note blinking. e. Move his or her finger slowly toward the patient's nose.

ANS: A, B, C, E Assessment for blinking is not part of the accommodation assessment. All of the other options are part of the accommodation assessment. The nurse holds his or her finger approximately 20 inches in front of the patient's eyes and slowly moves the finger toward the patient's nose, assessing for pupillary constriction and convergence. DIF: Cognitive Level: Application REF: p. 1223 OBJ: 2 TOP: Testing for Accommodation KEY: Nursing Process Step: Implementation MSC:

26. A nurse assesses an 80-year-old patient for age-related changes to the eye. What potential changes should the nurse anticipate? (Select all that apply.) a. Decreased tear production b. Eyeball sunk deep in orbit c. Hyperopia d. Eye lashes diminished e. Arcus senilis

ANS: A, B, C, E Eyelash diminution is not a consistent finding in older adults. All of the other options are common eye changes related to advancing age. DIF: Cognitive Level: Comprehension REF: p. 1222 OBJ: 1 TOP: Age-Related Changes in the Eye KEY: Nursing Process Step: Assessment MSC:

27. A nurse recognizes that a patient with an STI may not cooperate in reporting sexual contacts. What fears might prevent reporting? (Select all that apply.) a. Judgment by health care workers b. Identifying self as infected c. Rejection by contacts d. Infecting others e. Reprisal from identified contacts

ANS: A, B, C, E Infection of others has already occurred. DIF: Cognitive Level: Comprehension REF: p. 1165 OBJ: 2 TOP: Impediments to Reporting STIs KEY: Nursing Process Step: Assessment

29. Why is hypothyroidism frequently overlooked in older adults? (Select all that apply.) a. Signs and symptoms are subtle. b. Signs and symptoms are discounted as age-related changes. c. Weight changes in the older adult are not pronounced. d. Older adults are not susceptible to thyroid disorders. e. Decrease in mental function is attributed to dementia.

ANS: A, B, C, E Older persons, especially women, are quite prone to hypothyroidism. Other major symptoms are overlooked or discounted as related to advancing age. Many of the symptoms of hypothyroidism are subtle and discounted as age-related changes or dementia. Weight changes are not pronounced as they are in younger people. DIF: Cognitive Level: Comprehension REF: p. 1036 OBJ: 3 TOP: Hypothyroidism KEY: Nursing Process Step: Assessment

24. A nurse teaching a seminar on breast cancer lists the signs that would alert a woman to the possibility of a tumor. What should those signs include? (Select all that apply.) a. Dimpling b. Nipple discharge c. Thickening of tissue d. Red bruise e. Dry rash around nipple

ANS: A, B, C, E Signs of breast cancer that should be investigated are dimpling of the skin of the breast, any discharge from the nipple, any thickening of breast tissue, or a dry rash in the areola. Although it should be investigated, bruising is not a classic sign of breast cancer. DIF: Cognitive Level: Knowledge REF: p. 1121 OBJ: 4 TOP: Signs of Breast Cancer KEY: Nursing Process Step: Implementation

28. An 18-year-old girl is diagnosed with adenoma of the anterior pituitary gland. What classic signs of this diagnosis should the nurse assess? (Select all that apply.) a. Cessation of menses b. Milk production c. Changing facial features d. Excessive urine output e. Weight gain

ANS: A, B, C, E The anterior pituitary gland controls the endocrine glands and excretes growth hormone. The signs of an adenoma of the anterior pituitary glands are amenorrhea, galactorrhea, and weight gain. The posterior pituitary controls diuresis. DIF: Cognitive Level: Comprehension REF: p. 1010 OBJ: 3 TOP: Signs of Adenoma of Anterior Pituitary KEY: Nursing Process Step: Assessment

31. Which home modifications will support rehabilitation for a patient who had a stroke? (Select all that apply.) a. Raised commode seat b. Provision of a seat in the shower c. Availability of soft, low chairs d. Bathtub hand rails e. Bright-colored scatter rugs

ANS: A, B, D A raised commode seat, a seat in the shower, and bathtub rails assist the patient who is recovering from a stroke with self-care. Low chairs are difficult to manage, and scatter rugs pose a hazard for falls. DIF: Cognitive Level: Comprehension REF: p. 503 OBJ: 8 TOP: Home Modification KEY: Nursing Process Step: Planning

28. A nurse is caring for a patient with a Foley catheter. What actions should the nurse implement to decrease this patient's risk for infection? (Select all that apply.) a. Keep the bag below the level of the bed. b. Provide perineal care twice a day. c. Flushing the tubing as needed. d. Using standard precautions when handling urine and tubing. e. Keep the drainage system open.

ANS: A, B, D Keeping the bag below the level of the bed, providing perineal care twice daily, and using standard precautions will assist in decreasing infection risk. Tubing is only flushed with a physician's order if required. The drainage system should be closed. DIF: Cognitive Level: Application REF: p. 902-903 OBJ: 4 TOP: Foley Catheter KEY: Nursing Process Step: Implementation

28. Why do older persons adapt more slowly to changes in the peripheral vascular system? (Select all that apply.) a. Slowing heart rate b. Decreasing cardiac output c. Increasing stroke volume d. Stiffening of blood vessels e. Thickening of aorta

ANS: A, B, D, E Age-related changes include a slowing of the heart rate, a decrease in both cardiac output and stroke volume, and a stiffening and thickening of blood vessels. DIF: Cognitive Level: Comprehension REF: p. 740 OBJ: 4 TOP: Age-Related Changes to the Cardiovascular System KEY: Nursing Process Step: Implementation MSC:

26. What should instructions relate to for a discharge teaching plan for a patient after undergoing a prostatectomy? (Select all that apply.) a. Remedy for bladder spasm b. Catheter care c. Delay of sexual activity for 3 months d. Perineal exercises e. Avoidance of heavy lifting

ANS: A, B, D, E Instruction relative to relieving bladder spasms, catheter care, perineal exercises to help reduce incontinence, and the avoidance of heavy lifting are appropriate. Sexual activity is usually resumed in 6 weeks. DIF: Cognitive Level: Comprehension REF: p. 1152 OBJ: 6 TOP: Discharge Instructions for Prostatectomy KEY: Nursing Process Step: Implementation

29. A nurse suspects a circulatory disorder in one leg. Which assessments should the nurse include when comparing both legs? (Select all that apply.) a. Color b. Warmth c. Muscle strength d. Pulse quality e. Hair loss on extremity

ANS: A, B, D, E Muscle strength is not a circulatory assessment. Color, warmth, pulse quality, and loss of superficial hair are indicators of decreased arterial perfusion. DIF: Cognitive Level: Application REF: p. 740-741 OBJ: 2 TOP: Circulatory Assessment KEY: Nursing Process Step: Assessment MSC:

26. Which patient behaviors should alert a nurse to a possible hearing deficit? (Select all that apply.) a. Watches the speaker's mouth b. Gives inappropriate answers to questions c. Pulls at the ears d. Fails to respond when spoken to e. Turns the good ear to the speaker

ANS: A, B, D, E Pulling at the ear is not a signal for hearing loss; all of the other options are. DIF: Cognitive Level: Comprehension REF: p. 1261 OBJ: 1 TOP: Behavioral Cues to Hearing Deficit KEY: Nursing Process Step: Assessment MSC:

25. Which populations are at the highest risks of contracting HIV? (Select all that apply.) a. Health care workers who mishandle infected sharps b. Breastfed infants of HIV-infected mothers c. Persons sharing living quarters with an HIV-infected person d. Heterosexual partners of an HIV-infected person e. Newborns of an HIV-infected mother

ANS: A, B, D, E Sharing living quarters without intimate contact does not expose a person to HIV infection. DIF: Cognitive Level: Comprehension REF: p. 664 OBJ: 2 TOP: Prevalence of HIV KEY: Nursing Process Step: Implementation

29. What signs and symptoms are characteristic of a patient with chronic blue bloater bronchitis? (Select all that apply.) a. Productive cough b. Peripheral edema c. Discolored teeth d. Exertional dyspnea e. Elevated red blood cell count

ANS: A, B, D, E The blue bloater has a productive cough, peripheral edema, dyspnea, elevated RBCs, and cyanosis. DIF: Cognitive Level: Knowledge REF: p. 604-605 OBJ: 2 TOP: Chronic Bronchitis KEY: Nursing Process Step: Planning

28. A patient complains that his hearing aid is not working. What actions should a nurse implement to assess the device? (Select all that apply.) a. Check to see if the device is turned on. b. Clean the earpiece and remove cerumen clogged in the vent. c. Open the earpiece to see if the microphone wire is connected. d. Examine the interior of the earpiece for water. e. Validate that the battery is correctly placed.

ANS: A, B, E Cleaning the earpiece to remove clogged cerumen and checking the device to see if it is turned on and if the battery is placed correctly are all good options. The earpiece should not be opened. If the hearing aid is still not working, it should be evaluated by the dealer. DIF: Cognitive Level: Application REF: p. 1258 OBJ: 4 TOP: Hearing Aids KEY: Nursing Process Step: Implementation MSC:

28. How is the Whipple triad described? (Select all that apply.) a. Symptoms of hypoglycemia are present. b. Low blood glucose levels are documented when symptoms are present. c. Symptoms can be reproduced with an in-jection of regular insulin, 10 units. d. Muscular activity does not have any effect on blood glucose. e. Symptoms improved when the blood glu-cose level rises.

ANS: A, B, E Whipple triad is the presence of the symptoms of hypoglycemia (e.g., diaphoresis, pallor, tachycar-dia), the documentation of low blood glucose levels when symptoms are present, and the im-provement of symptoms as the blood glucose level rises. DIF: Cognitive Level: Comprehension REF: p. 1084 OBJ: 9 TOP: Whipple Triad KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

27. A nurse is performing the initial assessment on a man with a reproductive disorder. What type of interview techniques should be used to demonstrate a sensitive approach? (Select all that apply.) a. Use open-ended questions. b. Pin the patient down for truthful and specific information. c. Leave sensitive questions until later in the interview. d. Share her or his professional opinion. e. Start most questions with "why."

ANS: A, C The use of open-ended questions encourages the patient to explain his problem in greater detail, especially if sensitive issues are left until later in the interview. Pinning the patient down, sharing professional opinion, and asking why are not therapeutic. DIF: Cognitive Level: Application REF: p. 1140 OBJ: 6 TOP: Initial Assessment KEY: Nursing Process Step: Assessment

25. What are functional causes of hypoglycemia? (Select all that apply.) a. Dumping syndrome b. Overdose of insulin c. Addison disease d. Prolonged muscular exercise e. Chronic alcoholism

ANS: A, C, D Dumping syndrome, Addison disease, and prolonged exercise are functional causes of hypogly-cemia. Overdose of insulin and chronic alcoholism are exogenous causes. DIF: Cognitive Level: Knowledge REF: p. 1084 OBJ: 1 TOP: Functional Causes of Hypoglycemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

27. Which factors explain the increase in HIV infections in persons over the age of 50 years? (Select all that apply.) a. Older persons are usually not questioned by health professionals about sex or drug abuse. b. Older persons are more promiscuous in earlier years. c. Older persons are less likely to seek HIV screening. d. Older persons mistake HIV symptoms as part of the discomforts of increased age. e. Older persons tend to use hormonal forms of contraception.

ANS: A, C, D Individuals older than 50 years of age are less likely to be questioned by health care professionals relative to sex activities or illicit drug use. Older adults are less likely to seek HIV screening and frequently accept the symptoms of HIV as part of increasing age. DIF: Cognitive Level: Comprehension REF: p. 674 OBJ: 7 TOP: Older Persons with HIV KEY: Nursing Process Step: N/A

32. What causes the 3% of strokes known to occur in persons younger than 45 years of age? (Select all that apply.) a. Drug abuse b. Alcohol abuse c. Birth control pills d. Sickle cell anemia e. Hemophilia

ANS: A, C, D Strokes in younger people are caused by drug abuse, birth control pills, sickle cell anemia, leukemia, atrial fibrillation, and rheumatic fever. Alcohol abuse and hemophilia do not have a causative role in stroke. DIF: Cognitive Level: Knowledge REF: p. 483 OBJ: 3 TOP: Stroke in Young Persons KEY: Nursing Process Step: Planning

27. What symptoms should a nurse expect a patient with the diagnosis of SIADH to report during an intake interview? (Select all that apply.) a. Headache b. Hypotension c. Weight gain d. Muscle cramps e. Weakness

ANS: A, C, D, E Retained fluid and hyponatremia cause weight gain and elevated blood pressure with an attendant headache. The hyperkalemia causes the patient to feel weak and have muscle cramps. DIF: Cognitive Level: Comprehension REF: p. 1021 OBJ: 3 TOP: Signs of SIADH KEY: Nursing Process Step: Assessment

26. What body areas might systemic (disseminated) gonorrhea involve? (Select all that apply.) a. Heart b. Eyes c. Meninges d. Skin e. Joints

ANS: A, C, D, E Systemic gonorrhea may damage all of the body areas mentioned except the eyes. DIF: Cognitive Level: Knowledge REF: p. 1169-1170 OBJ: 4 TOP: Systemic Gonorrhea KEY: Nursing Process Step: Implementation

27. What makes up the refractive media of the eye? (Select all that apply.) a. Aqueous humor b. Retina c. Vitreous humor d. Cornea e. Lens

ANS: A, C, D, E The retina is not part of the refractive media. All of the other options are components of the refractive media. DIF: Cognitive Level: Knowledge REF: p. 1221 OBJ: 1 TOP: Refractive Media KEY: Nursing Process Step: Assessment MSC:

28. Which neurotransmitters support smooth neural transmission? (Select all that apply.) a. Acetylcholine b. CSF c. Dopamine d. Dendrite e. Epinephrine

ANS: A, C, E Acetylcholine, dopamine, and epinephrine are neurotransmitters. CSF bathes the brain and spinal cord but has no transmission activity; the dendrite is the locus of the synapse. DIF: Cognitive Level: Knowledge REF: p. 436 OBJ: N/A TOP: Neurotransmitters KEY: Nursing Process Step: Implementation

28. What has occurred in the past 10 years to enhance rehabilitation of individuals with SCIs? (Select all that apply.) a. Technologically advanced assistive aids b. Rehabilitation personnel c. Development of trauma centers d. Health insurance e. Rapid transport of victims

ANS: A, C, E New assistive aids, the development of decentralized trauma centers, and the rapid transport of victims have all increased the potential for rehabilitation. Rehabilitation personnel and health insurance are not new. DIF: Cognitive Level: Knowledge REF: p. 509 OBJ: 7 TOP: Enhanced Rehabilitation Potential KEY: Nursing Process Step: Implementation

27. Which common characteristics might a patient with conductive hearing loss display? (Select all that apply.) a. Hears adequately in noisy settings b. Hears sounds but has difficulty understanding speech c. Has improved hearing with hearing aids d. Has a history of diabetes mellitus e. Speaks in a normal volume

ANS: A, C, E Persons with conductive hearing loss can hear in a noisy setting and can have improved hearing with the use of hearing aids. Persons with conductive hearing loss speak at a normal or soft volume because they can hear themselves. Muffled sounds and a history of diabetes would be associated with sensorineural hearing loss. DIF: Cognitive Level: Comprehension REF: p. 1260-1261 OBJ: 5 TOP: Common Characteristics in Persons with Conductive Hearing Loss KEY: Nursing Process Step: Assessment MSC:

26. What should a teaching plan about foot care include for a patient with diabetes? (Select all that apply.) a. Wash and carefully dry the feet every day. b. Apply lotion between the toes. c. Protect the feet from extreme temperatures. d. Walk barefoot only indoors. e. Buy shoes that are comfortable and sup-portive.

ANS: A, C, E Washing, inspecting, and drying the feet, especially between the toes, is essential. Protecting the feet from heat and cold and wearing supportive shoes is important to good foot health. Lotion can be applied to the soles and tops of the feet but not between the toes. Walking barefoot is contrain-dicated for a person with diabetes. DIF: Cognitive Level: Knowledge REF: p. 1063 OBJ: 5 TOP: Foot Care KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

29. A nurse caring for an immobilized patient with a brain tumor stimulates the patient several times a day with range-of-motion exercises and changes his position every 2 hours to try to prevent a disuse syndrome. What signs and symptoms does disuse syndrome include? (Select all that apply.) a. Pooling of pulmonary secretions b. Paralysis c. Muscle tremor d. Pressure ulcers e. Altered visual perceptions

ANS: A, D A disuse syndrome includes pooling of pulmonary secretions, pressure ulcers, weakness, and stiff joints. DIF: Cognitive Level: Knowledge REF: p. 462-463 OBJ: 6 TOP: Disuse Syndrome KEY: Nursing Process Step: Implementation

29. A female patient reports very painful urethritis. What should the home health care nurse question the patient about the use of? (Select all that apply.) a. Bubble bath b. Vitamin preparations c. Herbal remedies d. Vaginal sprays e. Exercise machines

ANS: A, D Bath additives and vaginal sprays are causative for urethritis. Vitamins, herbal preparations, and exercise machinery are noncontributory. DIF: Cognitive Level: Comprehension REF: p. 908 OBJ: 1 TOP: Urethritis KEY: Nursing Process Step: Implementation

30. Which patients with CVAs are considered candidates for treatment with tPA? (Select all that apply.) a. A 62-year-old construction worker who had a subdural hematoma 6 months earlier b. A 58-year-old executive with a bleeding ulcer c. A 44-year-old individual who had a seizure at the onset of a stroke d. A 40-year-old individual who is taking warfarin (Coumadin) and has an INR of 2.5 e. A 19-year-old young adult with leukemia with a platelet count of 200,000

ANS: A, E The criteria for exclusion are a head injury within the last 3 months, a platelet count less than 100,000, active gastrointestinal bleeding, current treatment with an anticoagulant, and a seizure noted at the time of the CVA. DIF: Cognitive Level: Application REF: p. 492 OBJ: 6 TOP: Drugs to Treat CVA KEY: Nursing Process Step: Assessment

26. A nurse is designing a teaching plan for a patient with AIDS. What should be included relative to food preparation precautions? (Select all that apply.) a. Check expiration dates on frozen foods. b. Leave produce unwashed to preserve protective spray. c. Drink a small glass of red wine before each meal to stimulate the appetite. d. Eat three large, well-balanced meals daily. e. Avoid leftovers.

ANS: A, E Using food before the expiration date and avoiding leftovers reduce the risk of food contamination. Individuals with AIDS should wash all fresh produce to get rid of contaminants, eat several small meals daily, and avoid alcohol and caffeine. DIF: Cognitive Level: Application REF: p. 678 OBJ: 7 TOP: Nutritional Precautions KEY: Nursing Process Step: Implementation

10. A patient who has cystitis has been told to drink at least 30 mL for each kilogram of body weight. Her weight is 154 lb. How many mL/day should the nurse instruct the patient to drink? a. 1500 b. 2100 c. 2700 d. 3100

ANS: B 154 lb ÷ 2.2 lb/kg = 70 kg; 70 kg 30 mL = 2100 mL. DIF: Cognitive Level: Analysis REF: p. 909 OBJ: 4 TOP: Cystitis KEY: Nursing Process Step: Implementation

19. A nurse making a care plan for a 10-year-old boy with hyperpituitarism identifies a disturbed self-image. What should the nurse relate this nursing diagnosis to? a. Lack of facial hair b. Excessive height c. Small genitalia d. Skin eruptions on the face

ANS: B A 10-year-old boy will be excessively tall for his age. Hair is not lacking, and skin eruptions associated with giantism are observed. Most 10-year-old boys have small genitalia. DIF: Cognitive Level: Application REF: p. 1010-1011 OBJ: 4 TOP: Hyperpituitarism KEY: Nursing Process Step: Planning

7. When recording the findings of muscle strength, a nurse records a 2 for the right arm. How should his score be interpreted? a. Weak contraction b. Muscle movement when supported c. Active muscle movement without support d. Full, active range-of-motion exercises against resistance

ANS: B A 2 on the muscle-grading scale means that muscular movement is observed when the limb is supported. DIF: Cognitive Level: Comprehension REF: p. 520 OBJ: 2 TOP: Neurologic Examination KEY: Nursing Process Step: Assessment

5. A nurse is teaching patients with endometriosis. What signs and symptoms of common complications should be included? a. Pelvic inflammatory disease b. Obstruction of the bowel and ureters c. Cancer of the endometrium d. Ovarian cancer

ANS: B A common complication of endometriosis is obstruction of bowel, ureters, or both, from the endometrial deposits, creating a medical emergency. DIF: Cognitive Level: Knowledge REF: p. 1112 OBJ: 4 TOP: Endometriosis KEY: Nursing Process Step: Implementation

23. What is the nurse aware is happening when the patient with hypoparathyroidism complains of fatigue and a lack of energy? a. Hypertension is the cause of the fatigue. b. Hypocalcemia has caused decreased cardiac output. c. Dyspnea has sapped the patient's energy. d. Poor muscle tone makes any activity tiring.

ANS: B A decreased amount of calcium in the bloodstream decreases the contractility of the heart and, consequently, reduces cardiac output. DIF: Cognitive Level: Comprehension REF: p. 1055 OBJ: 4 TOP: Hypoparathyroidism KEY: Nursing Process Step: Nursing Diagnosis

24. Which postoperative sign should a nurse report immediately when caring for a patient with an endarterectomy with a synthetic graft? a. Headache b. Fever c. Edema d. Pain

ANS: B A fever in a patient with a synthetic graft is a serious postoperative event. The infection may lead to an amputation. DIF: Cognitive Level: Comprehension REF: p. 755 OBJ: 4 TOP: Surgical Repair with Synthetic Graft KEY: Nursing Process Step: Implementation MSC:

10. When conducting an initial assessment on a 65-year-old male patient, a nurse assesses a mass in the left testicle that on transillumination glows red. What should the nurse note this indicates the presence of? a. Phimosis b. A hydrocele c. Smegma d. A hematocele

ANS: B A hydrocele will glow red on transillumination, but a hematocele will not. Phimosis is a foreskin that will not retract over the glans, and smegma is a cheeselike substance found under the foreskin. DIF: Cognitive Level: Comprehension REF: p. 1142 OBJ: 2 TOP: Health Assessment KEY: Nursing Process Step: Assessment

20. Which laboratory result for a patient with acute leukemia should alert the nurse to the fact that the drug protocols are not effective? a. Decreased prothrombin time b. Platelet count lower than 50,000/mm3 c. Negative Western blot result d. Neutrophils 50% to 62%

ANS: B A low platelet count predisposes a patient to bleeding. A count less than 50,000/mm3 is cause for concern. DIF: Cognitive Level: Comprehension REF: p. 654-657 OBJ: 3 TOP: Platelet Count KEY: Nursing Process Step: Implementation

23. What should a nurse include when educating a patient with Ménière disease? a. "When you feel dizzy, just stay in bed and take your medications." b. "Decrease your sodium intake and take your diuretic medication between attacks." c. "Vestibular rehabilitation might help, and you can still drink your morning coffee." d. "Your vertigo will get better if you take your medications. You won't need any relaxation techniques."

ANS: B A low-sodium diet and diuretic medications between attacks will prevent edema, which could cause an attack. DIF: Cognitive Level: Application REF: p. 1267 OBJ: 7 TOP: Inner Ear KEY: Nursing Process Step: Implementation MSC:

22. What should a nurse prepare when assessing paradoxical movement in a patient with a flail chest who has significant dyspnea? a. Thoracotomy b. Intubation c. Thoracentesis d. Body cast

ANS: B A patient with an unstable chest usually requires intubation and mechanical ventilation. DIF: Cognitive Level: Application REF: p. 592-293 OBJ: 6 TOP: Flail Chest KEY: Nursing Process Step: Planning

10. Which nursing assessment indicates a positive reading of a tuberculin (TB) skin test? a. 1 day after injection with a 10-mm area of redness and swelling b. 2 days after injection with a 5-mm area of redness and swelling c. 4 days after injection with a 3-mm area of redness and swelling d. 5 days after injection with a 2-mm area of redness and swelling

ANS: B A positive reading of a TB skin test is an area of redness and swelling of 5 mm or larger 24 to 48 hours after injection. DIF: Cognitive Level: Comprehension REF: p. 564 OBJ: 3 TOP: Diagnostic Tests KEY: Nursing Process Step: Assessment

9. What is the importance of the nurse closely monitoring bilateral breath sounds and chest movement after a thoracentesis? a. Fluid may quickly accumulate as a result of inflammation. b. The lung may have been punctured during the procedure. c. Severe bronchospasm may cause atelectasis. d. Asthma may result after the procedure.

ANS: B A possibility exists that the lung could have been punctured during the procedure. Bronchospasm, fluid collection, and asthma are not concerns related to a thoracentesis. DIF: Cognitive Level: Comprehension REF: p. 564 | p. 569 OBJ: 3 TOP: Diagnostic Tests KEY: Nursing Process Step: Assessment

19. What action should a nurse implement to reduce the risk of aspiration in a patient receiving continuous enteral feedings at a rate of 70 mL/hr? a. Check the position of the tube during every shift. b. Notify the charge nurse or physician about a residual volume of 20 mL. c. Elevate the patient's head during and for 10 minutes after feeding. d. Position the patient on the left side after the feeding.

ANS: B A residual of more than 20% of the hourly rate should be reported so that the rate can be reduced (70 mL multiplied by 0.20 = 14). DIF: Cognitive Level: Application REF: p. 588 OBJ: 5 TOP: Aspiration Pneumonia KEY: Nursing Process Step: Implementation

22. A nurse reads that a patient's breast tumor is a stage II. What should the nurse realize about this tumor? a. It is smaller than 2 cm, with no positive lymph node involvement and no metastasis evident. b. It measures between 2 and 5 cm, with no or one positive lymph node involvement and no metastasis evident. c. It is larger than 5 cm, with no positive lymph node involvement and no metastasis evident. d. It measures between 2 and 5 cm, with positive axillary lymph node involvement and metastasis evident.

ANS: B A stage II tumor is between 2 and 5 cm with no or one lymph nodes positive for cancer and no metastases present. All other options are for different stages of tumors. DIF: Cognitive Level: Comprehension REF: p. 1124 OBJ: 4 TOP: Staging of a Breast Tumor KEY: Nursing Process Step: Assessment

6. What is the purpose of the urethral smear? a. Screens for human immunodeficiency viral (HIV) infection b. Detects sexually transmitted infections c. Verifies fertility through a sperm count d. Eliminates concerns of prostate problems

ANS: B A sterile swab is inserted into the urethra to obtain a specimen to detect sexually transmitted infections. DIF: Cognitive Level: Knowledge REF: p. 1145 OBJ: 3 TOP: Diagnostic Tests KEY: Nursing Process Step: Implementation

4. When being interviewed, a 50-year-old patient says that he cannot see the newspaper as well as he used to. What is the reason this patient vision has changed from near to far? a. The ciliary muscle changes the pupil size. b. The lens of the eye changes shape as the ciliary muscle contracts and relaxes. c. Nearsightedness has set in. d. Clouding of the vitreous humor has occurred.

ANS: B Accommodation or adjustment of the lens by contraction and expansion of the ciliary muscle allows an individual to see far or near. DIF: Cognitive Level: Comprehension REF: p. 1221 OBJ: 1 TOP: Lens Adjustment KEY: Nursing Process Step: Assessment MSC:

17. A nurse is formulating a teaching plan for a patient with acute prostatitis. What information should be included regarding treatment? a. There will be a 2-week period with a temporary catheter and the instillation of antibiotics in the bladder. b. There will be a 4-week course of antibiotics and anti-inflammatory drugs. c. There will be a 6-week course of broad spectrum antibiotics followed by a prostatectomy. d. There will be a 16-week protocol of Sitz baths and the use of a sturdy scrotal support.

ANS: B Acute bacterial prostatitis is treated with antibiotics, analgesics, anti-inflammatory drugs, and Sitz baths for a period of 4 weeks. Chronic prostatitis requires a 16-week period of antibiotic therapy. DIF: Cognitive Level: Comprehension REF: p. 1146-1147 OBJ: 4 TOP: Prostatitis KEY: Nursing Process Step: Planning

7. What should a nurse ensure as a priority for a patient immediately after a CVA? a. Preservation of motor function b. Airway maintenance c. Adequate hydration d. Control of elimination

ANS: B Adequate oxygenation prevents hypoxemia, which can extend and worsen effects of the CVA. DIF: Cognitive Level: Application REF: p. 491 OBJ: 7 TOP: Nursing Care of Acute CVA KEY: Nursing Process Step: Planning

1. A 60-year-old patient who has had an enucleation asks when he can get his prosthesis fitted. In approximately how many weeks should this patient expect to be fitted? a. 2 b. 4 c. 8 d. 12

ANS: B After an enucleation, the patient is fitted with a prosthesis in 1 month. DIF: Cognitive Level: Knowledge REF: p. 1246 OBJ: 6 TOP: Enucleation KEY: Nursing Process Step: Implementation MSC:

12. After spinal shock has been resolved, an indwelling catheter is removed. What way should the nurse expect this patient to empty the bladder? a. Manual expression (Credé method) b. Spontaneous reflexive action c. Normal voluntary control d. Self-catheterization

ANS: B After spinal shock resolves, spasticity of the bladder causes spontaneous emptying. DIF: Cognitive Level: Comprehension REF: p. 516-517 OBJ: 6 TOP: Bladder Control KEY: Nursing Process Step: Planning

18. A patient is recovering after surgery to correct a testicular torsion. Which possibility should the nurse caution the young patient about? a. Reoccurrence b. Infertility c. Orchiditis d. Significant risk of prostatic hypertrophy

ANS: B After testicular torsion is corrected, lower sperm counts and infertility may follow. DIF: Cognitive Level: Knowledge REF: p. 1159 OBJ: 6 TOP: Testicular Torsion KEY: Nursing Process Step: Planning

10. A nurse is preparing a patient for a liver and spleen scan. Which intervention is most important to implement before the procedure? a. Prepare the biopsy site with a clean field. b. Check for any allergies to contrast media. c. Explain the procedure to the patient's family. d. Have the patient eat a complete regular diet.

ANS: B Allergies should always be checked before any diagnostic test. DIF: Cognitive Level: Application REF: p. 650 OBJ: 3 TOP: Preparation for Diagnostic Tests KEY: Nursing Process Step: Implementation

7. What should the nurse assess for the when a patient is scheduled for an angiogram? a. Dizziness b. Allergy to shrimp c. Increased BP d. Irregular heartbeat

ANS: B Allergy to shrimp and other shellfish also indicates a probable allergy to contrast medium. DIF: Cognitive Level: Application REF: p. 442 | p. 449 OBJ: 3 TOP: Angiogram Preassessment KEY: Nursing Process Step: Assessment

9. What should a patient's home instructions following a vasectomy include? a. Postoperative care consists of warm Sitz baths. b. Vasectomies should be seen as usually permanent but are sometimes reversible. c. Sexual intercourse should be delayed for up to 3 months. d. The surgical procedure may interfere with ejaculation.

ANS: B Although a vasectomy can sometimes be successfully reversed, it should be considered permanent. DIF: Cognitive Level: Comprehension REF: p. 1160 OBJ: 6 TOP: Vasectomy KEY: Nursing Process Step: Implementation

19. A patient on dialysis asks why he is receiving aluminum hydroxide gel (Amphojel), a phosphate binder, for his renal disorder. What should the nurse explain regarding the action of that Amphojel? a. Calms the frequent upset stomach experienced by patients on dialysis b. Binds with phosphorus to increase the serum calcium level c. Increases the appetite d. Corrects the pH of the bowel

ANS: B Amphojel binds phosphorus, which increases the serum calcium level and decreases hypocalcemia. DIF: Cognitive Level: Comprehension REF: p. 905 | p. 927 OBJ: 4 TOP: Use of Aluminum Hydroxide Gel in Patients on Dialysis KEY: Nursing Process Step: Implementation

1. Which potential side effect should a nurse caution a patient who is taking danazol (Danocrine), an androgenic steroid, for the treatment of menorrhagia to be prepared for? a. Heavy menses b. Masculinizing c. Acnelike skin eruptions d. Anemia

ANS: B Androgenic steroids cause masculinizing. The distressing signs are a deepening voice, development of chest hair, coarsening of the skin, clitoral enlargement, and hot flashes. Many patients reject the drug on the basis of these side effects. DIF: Cognitive Level: Knowledge REF: p. 1101 OBJ: 4 TOP: Androgenic Steroid Therapy KEY: Nursing Process Step: Implementation

3. A 69-year-old patient reports a burning, aching pain in the legs when walking to the mailbox. These symptoms are relieved with rest. What should the nurse suspect? a. Venous insufficiency b. Claudication c. Phlebitis d. Rest pain

ANS: B Arterial vascular disorders that produce pain with activity are defined as claudication, which is the result of ischemia of the tissues caused by a lack of adequate perfusion. DIF: Cognitive Level: Application REF: p. 741 OBJ: 4 TOP: Claudication KEY: Nursing Process Step: Assessment MSC:

20. An 85-year-old patient has had age-related changes in the cochlea. What is the most appropriate nursing action for the nurse to implement? a. Speak slowly. b. Provide assistance with ambulation. c. Speak in a lower tone. d. Communicate with the patient in writing.

ANS: B Assisting the patient when ambulating will diminish the risk of a fall. Changes in the cochlea will cause dizziness and ataxia. DIF: Cognitive Level: Application REF: p. 1252 OBJ: 5 TOP: Age-Related Changes KEY: Nursing Process Step: Assessment MSC:

25. Why is a patient with amyotrophic lateral sclerosis (ALS) uniquely prone to depression? a. Nutritional intake is poor. b. Intellectual capacity is not affected. c. Mobility is limited. d. Communication is altered.

ANS: B Because of their unimpaired intellect, patients with ALS are able to assess their deterioration, which increases their risk for depression. Altered mobility, nutrition, and communication are common to many disorders. DIF: Cognitive Level: Comprehension REF: p. 472 OBJ: 6 TOP: Symptoms of Amyotrophic Lateral Sclerosis (ALS) KEY: Nursing Process Step: Assessment

3. A patient with a hyperthyroid complains of fatigue but still cannot get to sleep. What is the best suggestion by the nurse? a. Taking "cat naps" during the day b. Adhering to a bedtime ritual c. Drinking a cup of cocoa before bedtime d. Performing mild prebedtime exercises

ANS: B Bedtime rituals such as a warm bath, reading, and listening to music cue the body for sleep. Naps during the day may make nighttime sleep difficult; exercising and drinking caffeine-filled drinks are stimulating and should be avoided by the person with insomnia. DIF: Cognitive Level: Comprehension REF: p. 1042 OBJ: 3 TOP: Hyperthyroidism Insomnia KEY: Nursing Process Step: Implementation

19. A nurse is completing an initial assessment on a new patient being seen in the hospital clinic. The presentation of this female patient includes vague symptoms of tiredness and large areas of ecchymosis. Which question is most important for the nurse to ask? a. "Are you allergic to anything?" b. "Do your gums easily bleed?" c. "How many hours do you sleep?" d. "How frequent are your periods?"

ANS: B Bleeding gums are indicative of general bleeding tendencies. Sleep and frequency of menstrual periods are not significant, but the heaviness of the period is significant. History can reveal information pertinent to assisting the physician in making a diagnosis. DIF: Cognitive Level: Application REF: p. 625 OBJ: 2 TOP: Assessment of Patients with Hematologic Disorders KEY: Nursing Process Step: Assessment MSC:

11. A nurse explains that a lumbar puncture is most helpful as a diagnostic tool for a new patient who has had a CVA. What would this diagnostic test help determine regarding the stroke? a. It is lacunar. b. It is hemorrhagic or embolic. c. It is complete or in evolution. d. It will result in paralysis.

ANS: B Blood in the spinal fluid indicates a hemorrhagic stroke and will help direct medical protocol in the subsequent treatment. DIF: Cognitive Level: Comprehension REF: p. 491 OBJ: 5 TOP: CVA Diagnostic Tests KEY: Nursing Process Step: N/A

21. A family member of a patient who has returned to the special unit after renal transplantation is alarmed by blood in the urine of the patient. What is the nurse's best explanation when explaining the reason for hematuria in this patient? a. "It is related to the immunosuppressant drugs taken before transplantation." b. "It is a normal postoperative expectation." c. "It is caused by dye injected during surgery." d. "It is caused by a small vessel that may be bleeding but will coagulate as urine flow increases."

ANS: B Blood in the urine is an expected postoperative expectation and will gradually clear up. DIF: Cognitive Level: Comprehension REF: p. 936 OBJ: 5 TOP: Postoperative Care for Transplant Recipients KEY: Nursing Process Step: Implementation

7. When a patient with type 2 diabetes says, "Why in the world are they looking at my hemoglobin? I thought my problem was with my blood sugar." What should the nurse explain about the level of hemoglobin A1c? a. Shows how a high level of glucose can cause a significant drop in the hemoglobin level b. Shows what the glucose level has done during the past 3 months c. Indicates a true picture of the patient's nu-tritional state d. Reflects the effect of a high level of glu-cose on the ability to produce red blood cells (RBCs)

ANS: B By analyzing the amount of glucose bound to the hemoglobin, the level of blood glucose can be evaluated for the past 3 months because the glucose stays bound to the hemoglobin for the life of the RBC. DIF: Cognitive Level: Comprehension REF: p. 1075 OBJ: 9 TOP: Hemoglobin A1c: Glycosylated Hemoglobin Level KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

5. A nurse assesses a patient's capillary refill time as less than 3 seconds. What does this assessment indicate? a. Hypertension b. Tissue perfusion c. Excess fluid volume d. Increased blood viscosity

ANS: B Capillary refill is determined by compressing the nail bed until it blanches. With a normal capillary refill, color returns to the blanched skin within 3 seconds. DIF: Cognitive Level: Comprehension REF: p. 742 OBJ: 2 TOP: Capillary Refill KEY: Nursing Process Step: Implementation MSC:

17. A nurse is administering heparin, subcutaneous twice daily, to a patient in cardiogenic shock. What is the expected action of this drug? a. Inotropic to improve cardiac contractibility b. Anticoagulant to prevent blood clots c. Antidysrhythmic to restore normal cardiac contractibility d. Vasopressor to increase blood pressure

ANS: B Cardiogenic shock may produce clots because of blood stasis, and the heparin will delay clot formation. DIF: Cognitive Level: Knowledge REF: p. 311 OBJ: 5 | 6 TOP: Heparin for Anticoagulation KEY: Nursing Process Step: Implementation

25. A patient with Raynaud disease has a nursing diagnosis of "Ineffective tissue perfusion, related to vasoconstriction" and is being given discharge instructions. What should the nurse include when providing this information? a. Avoid sun exposure. b. Wear gloves and warm socks when outdoors. c. Chafe hands frequently to warm them. d. Wash dishes in warm water.

ANS: B Chafing hands to warm them does not provide vasodilation and may cause tissue damage. Avoiding exposure to cold is paramount to prevent pain and tissue damage. Raynaud disease involves the constriction of the arterioles of the hands, toes, and nose. Pain is a cardinal symptom and can be relieved with methods to promote vasodilation. DIF: Cognitive Level: Application REF: p. 758 OBJ: 4 TOP: Raynaud Disease KEY: Nursing Process Step: Nursing Diagnosis MSC:

11. A nurse is caring for a patient who has had an angiogram. What should the nurse make a point of care to assess and document on this patient? a. Fluid intake b. Peripheral pulses in the affected leg c. Inquiring about an allergy to iodine d. Decreased blood pressure

ANS: B Checking and recording the presence and strength of the pulses in the affected leg ensure that the injection site has not occluded the vessel and that vascular spasm has not impaired circulation. An inquiry about an iodine allergy is made before the procedure. DIF: Cognitive Level: Application REF: p. 744-745 OBJ: 3 TOP: Postangiogram Care KEY: Nursing Process Step: Implementation MSC:

10. A nurse is caring for a patient diagnosed with Addison disease. Which signs and symptoms should lead the nurse to suspect an adrenal crisis? a. Hypertension and abdominal pain b. Confusion and tachycardia c. Bradycardia and nausea d. Widening pulse pressure and shortness of breath

ANS: B Confusion and tachycardia are signs that the patient may be in adrenal crisis, which is a medical emergency and should be brought to the attention of the charge nurse. DIF: Cognitive Level: Application REF: p. 1026 OBJ: 3 TOP: Adrenal Crisis KEY: Nursing Process Step: Assessment

5. A patient recovering from a CVA asks the purpose of the warfarin (Coumadin). What is the best response by the nurse regarding the purpose of Coumadin? a. Dissolves the clot. b. Prevents the formation of new clots. c. Dilates the vessels to improve blood flow. d. Suppresses the formation of platelets.

ANS: B Coumadin and heparin prevent more clots rather than dissolving them. Coumadin has no effect on vasodilation or blood cell production. DIF: Cognitive Level: Comprehension REF: p. 486 OBJ: 3 TOP: Coumadin Therapy KEY: Nursing Process Step: Implementation

24. A nurse caring for a patient with crushing injuries from an automobile accident notes that the patient is bleeding profusely from the nose, mouth, and rectum, as well as from the injuries. What should the nurse suspect as the cause of this patient's bleeding? a. Hemophilia b. Disseminated intravascular coagulation (DIC) c. Leukemia d. Thrombocytopenia

ANS: B DIC occurs in massive crushing injuries, burns, and allergic responses. The body's clotting ability is exhausted because of its attempt to repair so many areas with coagulation. When the platelet supply is gone, the clotting ability is lost, and massive hemorrhaging occurs. DIF: Cognitive Level: Analysis REF: p. 639 OBJ: 4 TOP: DIC KEY: Nursing Process Step: Assessment MSC:

8. A nurse records that a patient has a 3+ edema to the right foot. How deep did the nurse's thumb depress the edematous area? a. More than 1 inch b. To 1 inch c. To inch d. Less than inch

ANS: B Edema is measured by the depth of the depression of the thumb: 1 = less than inch, 2 = to inch, 3 = to 1 inch, and 4 = more than 1 inch. DIF: Cognitive Level: Comprehension REF: p. 742 OBJ: 2 TOP: Assessing for Edema KEY: Nursing Process Step: Assessment MSC:

17. Vascular disease disorders often require the use of elastic stockings. Which action should the nurse implement when caring for a patient with elastic stockings? a. Apply the stockings and roll down the cuff. b. Remove the stockings for skin inspection two times a day. c. Remove the stockings when the patient is ambulating. d. Inspect the skin for pressure or irritation daily.

ANS: B Elastic stockings improve blood flow. They should be applied early in the morning. They should be removed twice daily for 20 to 30 minutes, and the skin integrity of the feet should be examined. DIF: Cognitive Level: Application REF: p. 746 OBJ: 5 TOP: Vascular Disease and Elastic Stockings KEY: Nursing Process Step: Implementation MSC:

24. How can the nurse help reduce ICP in caring for the patient after a craniotomy? a. Keeping the patient flat in bed b. Elevating the head of the bed 30 degrees c. Closely monitoring the IV rate d. Turning the patient to the right side

ANS: B Elevating the head of the bed at least 30 degrees helps reduce ICP. DIF: Cognitive Level: Application REF: p. 452 OBJ: 6 TOP: Intervening for Increased ICP KEY: Nursing Process Step: Implementation

12. A patient makes an appointment with her gynecologist because she is having difficulty conceiving. Which laboratory test should the nurse anticipate the physician will order? a. Complete blood count b. Progesterone level c. Prothrombin time d. Erythrocyte count

ANS: B Evaluation of the female partner includes basal body temperature, serum progesterone level, and endometrial biopsy to assess for infertility. DIF: Cognitive Level: Comprehension REF: p. 1131 OBJ: 4 TOP: Infertility Diagnostic Tests KEY: Nursing Process Step: Planning

3. What causes the large flattened features of a patient with acromegaly? a. Prolactin b. Growth hormone c. Thyroid-stimulating hormone d. Adrenocorticotropic hormone

ANS: B Excess growth hormone in an adult will cause the flat bones to grow because the adult has little capacity for heightened growth. In a child, this same excess would cause giantism. DIF: Cognitive Level: Knowledge REF: p. 1010 OBJ: 3 TOP: Acromegaly KEY: Nursing Process Step: Assessment

8. A patient with gonorrhea is taking a protocol of tetracycline antibiotics. Which statement by the nurse is most likely to help overcome patient noncompliance? a. "You should take all of this medicine." b. "Failing to take the entire medicine amount will make your disease resistant to it." c. "You will become sterile if you do not complete the supply of medicines." d. "The doctor wants you to take all of this medication."

ANS: B Explain to the patient that medication-resistant disease is a real possibility if the entire amount of the prescription is not taken. Sterility is not related to noncompliance with the medication, but it is related to repeated occurrence of the gonorrhea. DIF: Cognitive Level: Application REF: p. 1170 OBJ: 8 TOP: Treatment Noncompliance KEY: Nursing Process Step: Planning

7. A patient tells a nurse that she is afraid of getting cervical cancer because her mother died of cervical cancer. What is the most appropriate response by the nurse? a. "You need to a have a pelvic examination every 6 months because of your history." b. "If you have regular Pap smears, cervical cancer is usually diagnosed early and cured." c. "There's no need to worry so much. Cervical cancer does not run in families." d. "Cervical cancer is sexually transmitted. Don't switch partners often, and you don't have to worry."

ANS: B For patients who have regular annual pelvic examinations and Papanicolaou (Pap) smears, cervical cancer is usually diagnosed and treated in its early stage. DIF: Cognitive Level: Comprehension REF: p. 1125 OBJ: 4 TOP: Cervical Cancer KEY: Nursing Process Step: Implementation

25. A nurse documents and reports the presence of foul, bulky stool in a patient with cystic fibrosis (CF). What does this finding indicate about the patient? a. Is being adequately maintained on the present dose of pancreatic enzyme b. Is not adequately digesting food c. Has diarrhea related to excess mucus in the bowel d. Has inadequate hydration

ANS: B Foul, bulky stools are the result of inadequately digested food if oral pancreatic enzymes are inadequate. DIF: Cognitive Level: Application REF: p. 612 OBJ: 3 TOP: Foul Stools with Cystic Fibrosis KEY: Nursing Process Step: Assessment

20. Which statement by a patient on dialysis, taking gentamicin (Garamycin), should cause the nurse the most concern? a. "I have a horrible headache." b. "Speak up! I can't hear you." c. "I've had diarrhea once or twice today." d. "I'm thirsty. I can't get enough water."

ANS: B Garamycin is ototoxic. Indication of hearing impairment suggests drug toxicity. DIF: Cognitive Level: Comprehension REF: p. 905 OBJ: 2 TOP: Garamycin KEY: Nursing Process Step: Assessment

23. What is the cause of glaucoma? a. Cloudiness in the lens b. Increase in intraocular pressure c. Failed eye surgery d. Retinal tears

ANS: B Glaucoma is caused by an increase in intraocular pressure. DIF: Cognitive Level: Knowledge REF: p. 1240 OBJ: 5 TOP: Glaucoma KEY: Nursing Process Step: Planning MSC:

5. A patient with Addison disease asks why she must take hydrocortisone. What should the nurse relay that the action of hydrocortisone is with Addison disease? a. Increases cardiac output b. Regulates the excretion of potassium and sodium c. Decreases the level of cortisol d. Lowers the blood sugar level

ANS: B Hydrocortisone helps regulate the excretion of potassium and sodium, the two electrolytes that control fluid distribution. DIF: Cognitive Level: Comprehension REF: p. 1027 OBJ: 3 TOP: Addison Disease KEY: Nursing Process Step: Implementation

22. A family member asks why her father, who is being treated for cardiogenic shock, needs parenteral feeding because he is capable of eating small amounts. What is the best response by the nurse? a. "Parenteral feedings reduce the risk of constipation." b. "Parenteral feedings meet the patient's hypermetabolic needs." c. "Parenteral feedings are more convenient and less time consuming." d. "Parenteral feedings decrease the hazard of infection."

ANS: B Hyperbolic nutritional needs of the person in shock are best met by parenteral feedings, which guarantee adequate calories. DIF: Cognitive Level: Comprehension REF: p. 312 OBJ: 6 TOP: Parenteral Feedings KEY: Nursing Process Step: Implementation

12. A nurse includes in the discharge plan for a patient with Addison disease, "Risk for injury." What should measures to deal with this include? a. Arranging for uncluttered floor space b. Rising slowly from a lying position c. Keeping the room well lit d. Providing instructions in the use of a walker

ANS: B Hypovolemia lowers the blood pressure and may cause orthostatic hypotension. DIF: Cognitive Level: Comprehension REF: p. 1027 OBJ: 4 TOP: Addison Disease KEY: Nursing Process Step: Implementation

24. A patient has been admitted with hyperglycemic hyperosmolar nonketotic syndrome (HHNS). The blood glucose level is very high (880 mg/dL) on admission. The physician believes that the condi-tion is the result of large amounts of glucose solutions administered intravenously (IV) during re-nal dialysis. What should the nurse anticipate that the patient would exhibit? a. Fruity breath and a high level of ketones in her urine b. Severe dehydration and hypernatremia caused by the hyperglycemia c. Exactly the same symptoms and signs as DKA d. Kussmaul respirations, nausea, and vomit-ing

ANS: B IV solutions containing glucose bypass the digestive system; consequently, the pancreas is not triggered to release insulin. However, just enough insulin is present to prevent the breakdown of fatty acids and the formation of ketones. DIF: Cognitive Level: Application REF: p. 1066 OBJ: 5 TOP: Hyperglycemic Hyperosmolar Nonketotic Syndrome KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

6. A very anxious young man comes to the clinic believing that he may have HIV infection because of his persistent influenza-like symptoms and his risky sexual behavior. What should the nurse anticipate that a positive blood analysis would show? a. High levels of CD8 cells b. High levels of HIV-infected cells c. Low levels of T cells d. Low levels of antibodies

ANS: B In the initial phase of HIV infection, high levels of HIV-infected cells, high levels of T cells, and high levels of antibodies are present as the body attempts to rid the body of the virus through the immune response. DIF: Cognitive Level: Comprehension REF: p. 668-669 OBJ: 2 TOP: Diagnosis of AIDS KEY: Nursing Process Step: Assessment

8. A young man at the HIV clinic tells the nurse how relieved he is that he does not have HIV because he now has no symptoms at all when just a few weeks ago he felt awful. What is the most appropriate nursing response? a. "Flulike symptoms frequently are misdiagnosed as HIV." b. "In the latent stage, the physical symptoms are reduced, but the HIV is still present in the lymph nodes." c. "A high antibody count can overwhelm HIV infection in the early stage." d. "Antiretroviral drugs are very effective in the first stage in reducing symptoms."

ANS: B In the latent stage, the symptoms are reduced as the virus enters the lymph nodes. DIF: Cognitive Level: Application REF: p. 668 OBJ: 2 TOP: Stages of HIV Infection KEY: Nursing Process Step: Implementation

21. Which nursing assessment would indicate a need for suctioning a patient with Guillain-Barré who is experiencing impaired breathing patterns because of neuromuscular failure? a. Decreased pulse rate and respiration of 20 breaths/min b. Increased pulse rate and adventitious breath sounds c. Increased pulse rate and respiration of 16 breaths/min d. Decreased pulse and abdominal breathing

ANS: B Increased pulse rate, adventitious breath sounds, and abdominal breathing indicate an impaired breathing pattern. DIF: Cognitive Level: Application REF: p. 466 OBJ: 6 TOP: Nursing Care of the Patient with Guillain-Barré Syndrome KEY: Nursing Process Step: Assessment

17. A patient in the emergency department states that she fell and hit her head and blacked out for a while but became alert again. The nurse suspects an epidural hematoma. For what should the nurse be diligent to assess? a. Headache b. Drowsiness c. Increasing respiration rate d. Vomiting

ANS: B Increasing BP, drowsiness, and a widening pulse pressure are indicators of increased ICP. DIF: Cognitive Level: Application REF: p. 458 OBJ: 5 TOP: Epidural Hematoma Assessment KEY: Nursing Process Step: Implementation

24. An older Japanese patient in progressive shock lingers on the verge of death. What intervention does the patient's cultural background dictate? a. Allow any and all cultural rituals at the bedside. b. Encourage the family to talk to the patient who can be comforted by their familiar voices. c. Restrict the ministrations of the folk healer. d. Suggest that small children not see the patient.

ANS: B Japanese cultural behavior for the dying patient advocates that the entire family be in attendance and take part in the nursing care. DIF: Cognitive Level: Application REF: p. 310 OBJ: 7 TOP: Psychologic Care of the Patient in Shock KEY: Nursing Process Step: Implementation

19. A nurse is preparing to administer low-molecular-weight heparin (LMWH). What is a major advantage related to the administration of LMWH? a. It can be given orally. b. It is provided fixed doses. c. It is given only after partial thromboplastin time (PTT) laboratory work. d. It provides an immediate effect.

ANS: B LMWH can be given as a fixed dose without waiting for the results of the PTT. It is only given subcutaneously and does not have an immediate effect. PTT is not done to monitor LMWH. DIF: Cognitive Level: Comprehension REF: p. 751 OBJ: 4 TOP: Anticoagulant Drug Therapy KEY: Nursing Process Step: Implementation MSC:

19. A patient with homonymous hemianopsia is in the rehabilitation phase of a CVA. When arranging this patient's environment where should the nurse assure persons approaching and important items are visible and available? a. Unaffected side b. Affected side c. Direct front d. Either side

ANS: B Making the patient scan the affected side helps stimulate the return of normal function in the rehabilitation phase. DIF: Cognitive Level: Application REF: p. 504 OBJ: 8 TOP: Hemianopsia KEY: Nursing Process Step: Planning

13. Which assessment on a patient on mannitol therapy for cerebral edema indicates the medication is effective in decreasing ICP? a. Increased BP b. Increased urinary output c. Decreased pulse d. Widening pulse pressure

ANS: B Mannitol is a hyperosmolar diuretic that draws fluid from brain tissue into the bloodstream, which is then excreted by the kidneys. Decreasing pulse and widening pulse pressure indicate increased ICP. DIF: Cognitive Level: Comprehension REF: p. 452-453 OBJ: 6 TOP: Mannitol Therapy in Increased Intracranial Pressure (ICP) KEY: Nursing Process Step: Assessment

16. A nurse is demonstrating breast self-examination to a patient. What should the nurse point out as the most common area in the breast for tumors to occur? a. Under the nipple b. Upper outer quadrant c. Six o'clock position d. Axillary lymph nodes

ANS: B Nearly half of all malignant breast tumors are located in the upper outer quadrant. DIF: Cognitive Level: Knowledge REF: p. 1121 OBJ: 5 TOP: Breast Self-Examination KEY: Nursing Process Step: Implementation

17. The nursing staff of an oncology unit cautions visitors to be free of infections before visiting patients. What can chemotherapy and decreased bone marrow production cause in these patients? a. Hemorrhage b. Neutropenia c. Edema d. Hypovolemia

ANS: B Neutropenia occurs when the total number of neutrophils is abnormally low, placing the patient at increased risk for infection. DIF: Cognitive Level: Comprehension REF: p. 655 OBJ: 4 TOP: Neutropenia KEY: Nursing Process Step: Planning

20. Which antiviral drug is commonly used to relieve symptoms of herpes simplex virus (HSV)? a. Tetracycline (Achromycin) b. Acyclovir (Zovirax) c. Erythromycin (E-Mycin) d. Metronidazole (Flagyl)

ANS: B No cure is available for HSV infection, but oral antiviral drugs similar to acyclovir (Zovirax) help partially control the signs and symptoms during initial and recurrent episodes. DIF: Cognitive Level: Knowledge REF: p. 1168 | p. 1173 OBJ: 8 TOP: Drugs to Treat STIs KEY: Nursing Process Step: Assessment

2. What instruction should a nurse provide to a patient after a culdoscopy? a. Clean the incision site daily with hydrogen peroxide. b. Avoid vaginal intercourse. c. Return to the clinic for suture removal in 7 days. d. Use tampons.

ANS: B Nothing should be inserted into the vagina (e.g., intercourse, tampons) for the time specified by the physician. No incision or sutures are present. DIF: Cognitive Level: Application REF: p. 1095 OBJ: 2 TOP: Culdoscopy KEY: Nursing Process Step: Implementation

1. Which population, according to statistics from the Centers for Disease Control and Prevention (CDC), has the greatest incidence of human immunodeficiency viral (HIV) infection in the United States? a. Asian Americans b. African Americans c. Latinos d. Whites

ANS: B Of those with HIV infection in the United States, African Americans make up 49%, whites 27%, and Latinos 12%. Asian Americans were not reported. DIF: Cognitive Level: Knowledge REF: p. 664 OBJ: 3 TOP: Human Immunodeficiency Virus (HIV) Incidence in the United States KEY: Nursing Process Step: Implementation

16. An older patient with hypothyroidism asks why her daily dose of thyroid hormone, which she has taken for 15 years, has been reduced. What is nurse's best rationale when explaining what the decreased dose is related to? a. Improved efficacy of the thyroid preparation b. Age-related reduction in metabolic rate c. Drug-related hypertrophy of the thyroid d. Changes in your diet and activity level

ANS: B Older patients have slower drug metabolism; consequently, the drug stays in their systems. All patients receiving hormone replacement need to be periodically evaluated. DIF: Cognitive Level: Comprehension REF: p. 1036 OBJ: 3 TOP: Age-Related Changes in Therapy KEY: Nursing Process Step: Implementation

3. A 75-year-old patient has normal age-related changes in his ear. What change should not be considered a normal change in the aging patient? a. Dry and wrinkled skin on the auricle b. Otitis externa c. Dry cerumen d. Hair in the ear canal

ANS: B Otitis externa is an outer ear infection and therefore an exception. The other three options are normal age-related changes. DIF: Cognitive Level: Comprehension REF: p. 1251 OBJ: 5 TOP: Age-Related Changes KEY: Nursing Process Step: Assessment MSC:

11. A mother of a newborn with cryptorchidism asks if this condition will be permanent. What is the nurse's best response? a. "Yes, but your child can develop normally with hormone replacement therapy." b. "No, several medical and surgical remedies can be performed after your baby's first birthday." c. "Yes, but the undescended testicle is still able to function in a normal manner." d. "No, the process of sexual maturity will cause it to descend at puberty."

ANS: B Partial or incomplete descent of the testicles may be resolved by medical or surgical implementation. Medical implementation starts between the first and second years of life. DIF: Cognitive Level: Comprehension REF: p. 1159 OBJ: 6 TOP: Cryptorchidism KEY: Nursing Process Step: Implementation

3. What should nursing care focus on when caring for a patient with a ureteral catheter in place after the removal of a kidney stone? a. Irrigating the catheter regularly b. Assessing for patency c. Including ureteral output with the bladder output d. Early ambulation

ANS: B Patency of the ureteral catheter is essential to prevent injury to the kidney. The patient is on bedrest until the ureteral catheter is removed. The output from the ureteral catheter is measured and recorded separately, and irrigation, if performed, is not done on a regular schedule and is not more than 5 mL. DIF: Cognitive Level: Application REF: p. 903 OBJ: 2 TOP: Ureteral Catheter KEY: Nursing Process Step: Implementation

8. Which nursing intervention is inappropriate in the immediate postprocedure care of a patient who has had a fiberoptic bronchoscopy? a. Place the patient in a semi-Fowler position. b. Offer fluids to assess swallowing ability. c. Assess for diminished breath sounds. d. Assess for stridor.

ANS: B Patients are placed on nothing by mouth diet until the gag reflex returns. DIF: Cognitive Level: Application REF: p. 564 OBJ: 3 TOP: Diagnostic Tests KEY: Nursing Process Step: Implementation

7. A patient taking dexamethasone (Decadron) reports insomnia. What is the best information to provide this patient regarding administration of this medication? a. Take with milk. b. Take at breakfast. c. Dissolve in fruit juice. d. Take at bedtime.

ANS: B Patients taking steroids should take them early in the day to avoid sleep disturbances. DIF: Cognitive Level: Knowledge REF: p. 660 OBJ: 4 TOP: Insomnia with Steroids KEY: Nursing Process Step: Implementation

14. Which nursing diagnosis is most appropriate for a patient having ear surgery? a. Disturbed body image b. Risk for injury c. Acute confusion d. Ineffective protection

ANS: B Patients who have had ear surgery are at risk for vertigo, fluid accumulation, or pressure in the operative ear. Because of the surgery and potential postoperative conditions, the patient may be at risk for a fall. DIF: Cognitive Level: Application REF: p. 1259-1260 OBJ: 7 TOP: Care Planning for Ear Surgery KEY: Nursing Process Step: Planning MSC:

16. Which nursing diagnosis is not appropriate for a visually impaired patient? a. Impaired sensory perception b. Risk for delayed development c. Self-care deficit d. Ineffective coping

ANS: B Patients with a visual impairment are not at risk for delayed development. They will have a nursing diagnosis of "Impaired sensory perception," "Ineffective coping," and "Self-care deficit." DIF: Cognitive Level: Comprehension REF: p. 1232-1233 OBJ: 6 TOP: Nursing Diagnosis, Goals, Outcomes KEY: Nursing Process Step: Planning MSC:

1. A nurse is assessing a patient with renal impairment. Which facial characteristic is a sign of fluid retention? a. Broken blood vessels around the nose b. Periorbital edema c. Rash on cheeks and neck d. Facial twitching

ANS: B Periorbital edema is a sign of fluid retention. Because the patient with renal impairment has generalized edema, this facial feature is extremely significant in assessing edema. DIF: Cognitive Level: Comprehension REF: p. 895 OBJ: 1 TOP: Sign of Fluid Retention KEY: Nursing Process Step: Assessment

24. A patient with chronic renal failure is to begin renal dialysis treatment and asks for advice about which type of dialysis would be best. The patient is considering peritoneal dialysis because it is less expensive and has fewer dietary and fluid restrictions. What is the most accurate information for the nurse to provide about peritoneal dialysis? a. It has literally no drawbacks. b. It gives more independence and more closely resembles normal kidney function. c. It is a lot more work than hemodialysis, in which the health care staff takes care of everything. d. It usually does not work very well and has many complications, such as a high blood sugar level.

ANS: B Peritoneal dialysis increases independence and resembles normal kidney function. It can be performed in any hospital or at home. DIF: Cognitive Level: Comprehension REF: p. 930-931 OBJ: 5 TOP: Peritoneal Dialysis KEY: Nursing Process Step: Planning

14. A 60-year-old man who had a prostatectomy 3 weeks earlier asks if the ongoing incontinence will ever stop. What should the nurse understand about this procedure in order to answer the patient? a. Postprostatectomy incontinence is usually permanent. b. Postprostatectomy incontinence usually clears up in 6 months. c. Although the constant dribbling will stop, stress incontinence will continue. d. Postprostatectomy incontinence frequently requires a second surgery to correct the problem.

ANS: B Postprostatectomy incontinence clears up in approximately 6 months in most patients. DIF: Cognitive Level: Knowledge REF: p. 1152 OBJ: 4 TOP: Postprostatectomy Incontinence KEY: Nursing Process Step: Implementation

24. A 75-year-old patient reports having difficulty hearing in crowds but can hear just fine at home with his wife. What hearing disorder should the nurse suspect? a. Otitis media b. Presbycusis c. Ototoxicity d. Central deafness

ANS: B Presbycusis is a conductive hearing loss associated with normal aging and is caused by changes in the cochlea. DIF: Cognitive Level: Comprehension REF: p. 1269 OBJ: 5 TOP: Presbycusis KEY: Nursing Process Step: Implementation MSC:

13. A nursing report on a newly admitted patient who is profoundly deaf says that the patient is confused and difficult to assess because she does not appropriately respond to questions or sometimes fails to respond at all. What should be the first action of the oncoming nurse? a. Consider asking the physician to assess the patient for dementia. b. Assess the patient to determine whether her hearing aids are in. c. Report to the physician that the patient is exhibiting signs of the sundown syndrome. d. Assess the patient's medications to check for an overdose.

ANS: B Profoundly deaf persons can be mistakenly assessed as being confused or disoriented when not wearing their hearing aids. DIF: Cognitive Level: Application REF: p. 1258 OBJ: 5 TOP: Hearing Aids KEY: Nursing Process Step: Planning MSC:

15. What instruction should be included by a health educator giving a presentation on how to use condoms correctly? a. Condoms are 100% effective when used correctly. b. The effectiveness of condoms deteriorates in heat. c. Any style and material of condom is safe to use. d. Use of petroleum jelly will ease application.

ANS: B Protect condoms from heat and sunlight to keep them from deteriorating. DIF: Cognitive Level: Comprehension REF: p. 1180 OBJ: 9 TOP: Condoms KEY: Nursing Process Step: Implementation

13. During the acute CVA phase, a risk for falls related to paralysis is present. Which intervention best protects the patient from injury? a. Keep the bed in a high position for ease of nursing care. b. Keep the side rails up, according to agency policy. c. Assess vision deficit related to ptosis. d. Monitor the condition every 2 hours.

ANS: B Rails keep patients in bed. The bed should be low, monitoring the patient should be more frequent than every 2 hours, and visual assessment is not directly related to fall prevention. DIF: Cognitive Level: Application REF: p. 495 OBJ: 8 TOP: Acute Care: Fall Prevention KEY: Nursing Process Step: Implementation

17. A patient in the acute phase of an embolic CVA has an order for 400 units of heparin per hour IV. The heparin is in a solution of 5000 units/100 mL normal saline (NS). The nurse should set the electronic IV monitor at how many milliliters per hour? a. 6 b. 8 c. 10 d. 16

ANS: B Regardless of the method of calculation, 50 units of heparin are in each milliliter of the solution; 8 mL/hr delivers 400 units (5000 units ÷ 100 mL NS = 50 units/mL. 400 units ÷ 50 units/mL = 8 mL). DIF: Cognitive Level: Analysis REF: p. 485-486 OBJ: 8 TOP: Heparin Therapy KEY: Nursing Process Step: Implementation

3. A male student comes to the campus clinic complaining of painful scrotal edema, nausea, vomiting, chills, and fever. What should the nurse recognize these signs and symptoms as being associated with? a. Orchitis b. Epididymitis c. Urethritis d. Cystitis

ANS: B Signs and symptoms of epididymitis are painful scrotal edema, nausea, vomiting, chills, and fever. DIF: Cognitive Level: Comprehension REF: p. 1147 OBJ: 2 TOP: Epididymitis KEY: Nursing Process Step: Assessment

23. An obese postsurgical patient complains of sudden discomfort in her leg. The nurse assesses the leg and finds it cold and pale with no pedal or popliteal pulse. What should the nurse suspect? a. Venous thrombosis b. Arterial occlusion c. Vascular spasm d. Paresthesia

ANS: B Signs of an acute arterial occlusion can include severe pain, absent pulses, or very pale or mottled skin. DIF: Cognitive Level: Application REF: p. 754 OBJ: 4 TOP: Acute Arterial Occlusion KEY: Nursing Process Step: Assessment MSC:

23. A patient with COPD delightedly tells the nurse that he has quit smoking and is using chewing tobacco. What is the most appropriate nursing intervention? a. Congratulate him on his quitting smoking. b. Warn him of the dangers of oral cancer. c. Suggest that he add nicotine patches in addition to the chewing tobacco. d. Point out that he is still addicted and is using tobacco.

ANS: B Smokeless tobacco has adverse effects, including oral cancer. DIF: Cognitive Level: Application REF: p. 610 OBJ: 2 TOP: COPD: Quit Smoking KEY: Nursing Process Step: Implementation

10. A patient with TB asks the nurse how long he will have to take his TB medications. What is the nurse's best response? a. "Generally about 2 weeks." b. "Depending on the drug, it may be as long as 2 years." c. "TB drugs are usually taken throughout the lifespan." d. "People frequently ask that question. It depends on many things."

ANS: B Some TB drugs are continued over the course of several years. DIF: Cognitive Level: Knowledge REF: p. 613-614 OBJ: 2 TOP: TB Drug Protocol KEY: Nursing Process Step: Implementation

3. Which assessment would indicate the resolution of spinal shock? a. Extension and rigidity in affected limbs b. Spastic involuntary movements in affected limbs c. Tingling and burning in affected limbs d. Voluntary purposeful movements of affected limbs

ANS: B Spastic involuntary movements after a period of flaccid paralysis announce the end of spinal shock. DIF: Cognitive Level: Comprehension REF: p. 516 OBJ: 3 TOP: Resolution of Spinal Shock KEY: Nursing Process Step: Assessment

24. A patient in the emergency department complains of severe pain in his eye and is seeing halos around lights and feeling nauseous. Which diagnosis should the nurse suspect? a. Open-angle glaucoma b. Angle-closure glaucoma c. Cataracts d. Retinal detachment

ANS: B Sudden onset of acute eye pain with nausea and vomiting and halos around lights are all symptoms of angle-closure glaucoma. The acute pain is caused by sudden blockage of the fluid channels in the eye. DIF: Cognitive Level: Comprehension REF: p. 1242 OBJ: 5 TOP: Glaucoma KEY: Nursing Process Step: Assessment MSC:

9. A patient with syphilis is seen at the clinic and complains of body aches, pustules, fever, and sore throat. Which stage of syphilis should the nurse recognize these symptoms identify? a. Primary b. Secondary c. Latent d. Late

ANS: B Symptoms in the secondary stage are body aches, rash, pustules, fever, and sore throat. DIF: Cognitive Level: Comprehension REF: p. 1171 OBJ: 4 TOP: Syphilis KEY: Nursing Process Step: Assessment

15. After an accident at a track meet, a young male runner is brought to the emergency department complaining of intense pain in his scrotum and nausea and vomiting. What should the nurse suspect based on these initial findings? a. Cryptorchidism b. Testicular torsion c. Varicocele d. Epididymitis

ANS: B Symptoms of testicular torsion are intense pain, often accompanied by nausea and vomiting. DIF: Cognitive Level: Comprehension REF: p. 1159 OBJ: 4 TOP: Testicular Torsion KEY: Nursing Process Step: Assessment

7. How does the intraaortic balloon pump (IABP) assist a patient who is in cardiogenic shock to increase cardiac output? a. Provides generalized vasoconstriction b. Inflates during the diastole phase c. Constricts the vena cava d. Adds hypertonic fluid to the circulating volume

ANS: B The IABP inflates during diastole (relaxation) phase and deflates during the systole (constriction) phase, which improves cardiac output. DIF: Cognitive Level: Comprehension REF: p. 306 | p. 308 OBJ: 6 TOP: IABP KEY: Nursing Process Step: Implementation

13. A patient with asthma asks the purpose of learning how to use a peak expiratory flow rate (PEFR) device. What is the nurse's best response regarding PEFR? a. Dilates the bronchi to relieve dyspnea b. Measures expired air to evaluate ventilation c. Soothes inflamed bronchi, reducing spasm d. Liquefies sputum for easier expectoration

ANS: B The PEFR measures expired air. When the PEFR rate decreases 20% below the baseline, adjustments are usually made in the medications. DIF: Cognitive Level: Comprehension REF: p. 601 OBJ: 3 TOP: Peak Expiratory Flow Rate (PEFR) KEY: Nursing Process Step: Implementation

16. Which position enhances cerebral blood flow to counteract the symptoms of compensatory shock? a. Fowler b. Trendelenburg c. Gravity neutral d. Side lying

ANS: B The Trendelenburg position, with the patient's head down, allows gravity to pull blood to the cerebrum. All other positions are ineffective for improving cerebral perfusion. DIF: Cognitive Level: Knowledge REF: p. 311 OBJ: 5 TOP: Positions to Counteract Shock KEY: Nursing Process Step: Implementation

26. A nurse is giving iron dextran intramuscularly (IM). Why should the nurse implement the Z-track method? a. Makes the injection less painful b. Prevents staining of the skin c. Prevents postinjection pain d. Allows another injection to be given at the same location

ANS: B The Z-track method only ensures that no iron will be staining the skin after injection. The amount of pain is the same and, after all IM injections, the needle is cleaned on withdrawal. Injections are never given at recent injection sites. DIF: Cognitive Level: Comprehension REF: p. 634 OBJ: 6 TOP: Z-Track Method KEY: Nursing Process Step: Implementation MSC:

20. What symptoms should a nurse anticipate in the history of a patient with hyperparathyroidism? a. Fatigue, hyperactive reflexes, muscle cramps, and twitching b. Poor muscle tone, bone pain, urinary calculi, and fractures c. Hunger, thirst, and urinary retention d. Tachycardia, air hunger, and nervousness

ANS: B The calcium has been leeched from the bones, leading to hypercalcemia and leaving the patient with multiple problems such as a risk for fractures, urinary calculi, and bone pain. DIF: Cognitive Level: Comprehension REF: p. 1051-1052 OBJ: 3 TOP: Hyperparathyroidism KEY: Nursing Process Step: Assessment

13. What is the usual cause of the autoimmune disease of acute glomerulonephritis? a. Frequent cystitis b. Streptococcal infection c. Childhood disease of mumps d. Recent wound infection

ANS: B The cause is an upper respiratory infection caused by a beta-hemolytic Streptococcus. DIF: Cognitive Level: Comprehension REF: p. 911 OBJ: 5 TOP: Acute Glomerulonephritis KEY: Nursing Process Step: Implementation

4. A nurse is caring for a patient receiving a transfusion and assesses that the patient is wheezing and is complaining of back pain. What nursing action should take place after stopping the transfusion? a. Discontinue the intravenous (IV) transfusion. b. Notify the charge nurse. c. Administer heparin. d. Raise the patient's head.

ANS: B The charge nurse should be notified immediately after the transfusion is stopped. The charge nurse will notify the physician and the laboratory or blood bank. The head of the bed should be raised to aid in respiration, and oxygen should be administered in high doses. The blood tubing and bag should not be discarded because the blood bank will want it to check the accuracy of the typing. DIF: Cognitive Level: Application REF: p. 632 OBJ: 4 TOP: Blood Transfusion Reactions KEY: Nursing Process Step: Implementation MSC:

1. A nurse explains that the spinal cord extends from the brainstem to the level of which vertebra? a. Last thoracic b. Second lumbar c. First sacral d. Coccygeal

ANS: B The cord starts at the brainstem and extends to the second lumbar vertebra. DIF: Cognitive Level: Knowledge REF: p. 510 OBJ: N/A TOP: Anatomy and Physiology of the Central Nervous System (CNS) KEY: Nursing Process Step: N/A

9. A nurse is caring for an 80-year-old patient with COPD and suspects right-sided heart failure after assessing and recording the data. What should decrease with right-sided heart failure? a. Blood pressure b. Urine output c. Respirations d. Heart rate

ANS: B The decreasing urine output is one of the signs. The fluid, instead of being excreted as urine, is trapped in the tissues as edema. Blood pressure, respirations, and heart rate will increase with right-sided heart failure. DIF: Cognitive Level: Comprehension REF: p. 611 OBJ: 2 TOP: Dyspnea KEY: Nursing Process Step: Implementation

9. What is an appropriate nursing action to implement when performing eye irrigation? a. Ask the patient to tip up her head and run the irrigation fluid over her open eye. b. Direct the irrigating fluid from the inner canthus to the outer canthus. c. Not allow the patient to blink. d. Place the irrigating syringe directly onto the corner of the eye and allow the fluid to move across the eye.

ANS: B The direction of the flow should be from the inner canthus to the outer canthus. DIF: Cognitive Level: Application REF: p. 1226 OBJ: 3 TOP: Eye Irrigation KEY: Nursing Process Step: Implementation MSC:

12. What should a nurse inform a 50-year-old patient who has been prescribed nilutamide (Nilandron), a testosterone blocker, to expect while taking this drug? a. His urine will have a fishy odor. b. Liver functions will need to be monitored. c. Skin rash will appear on his face. d. Episodes of hypotension will occur.

ANS: B The drug nilutamide (Nilandron) is hepatoxic. While taking the drug, the patient will have to have periodic evaluations of his liver function. The patient should also be informed to report any jaundice or darkening of the urine. DIF: Cognitive Level: Comprehension REF: p. 1153 OBJ: 6 TOP: Testosterone Blockers KEY: Nursing Process Step: Implementation

17. A patient with acute bronchitis is being discharged with a prescription for an antimicrobial medication to be taken for the next 14 days. What should the nurse stress when providing discharge teaching? a. Take the drug on an empty stomach before meals. b. Complete the entire course as prescribed. c. Maintain a thorough oral hygiene regimen. d. Maintain a daily fluid intake of 500 mL.

ANS: B The entire course of the prescription should be taken to destroy the pathogen completely; otherwise, the pathogen may become resistant to the drug. DIF: Cognitive Level: Comprehension REF: p. 583 OBJ: 6 TOP: Acute Bronchitis KEY: Nursing Process Step: Planning

8. Which statement by a patient indicates he understands the teaching relative to how to perform a testicular self-examination? a. "It's not necessary to feel the testes; just look at them in a mirror." b. "The best time to do a self-examination is after a shower, when my body is warm." c. "It doesn't really matter when I do it; just do it sometime." d. "The physician is really the best person to check this for me."

ANS: B The examination is best done after a warm bath or shower. DIF: Cognitive Level: Comprehension REF: p. 1161 OBJ: 6 TOP: Testicular Cancer KEY: Nursing Process Step: Evaluation

10. What information should a nurse include when providing information to a patient using topical eye medications? a. Look upward and drop the medication into the inner canthus. b. Pull the lower eyelid down and drop the medication into the conjunctival sac. c. Hold both eyelids open and drop the medication onto the sclera. d. Tilt the head to the side and drop the medication into the outer canthus.

ANS: B The eye drops should be dropped into the lower eyelid, and the nurse should press the tear duct to slow absorption. DIF: Cognitive Level: Comprehension REF: p. 1229 OBJ: 3 TOP: Topical Medications KEY: Nursing Process Step: Implementation MSC:

3. Which portion of the eye makes it possible for a person to see in a darkened environment? a. Macula b. Rods c. Cones d. Optic nerve

ANS: B The eye uses rods to accommodate to dim light. Cones are the color receptors, the optic nerve transmits all sensory input from the eye to the brain, and the macula is an oval-shaped yellow spot near the center of the retina that mediates clear, detailed vision. DIF: Cognitive Level: Knowledge REF: p. 1220 OBJ: 1 TOP: Anatomy and Physiology of the Eye: Eyeball KEY: Nursing Process Step: Assessment MSC:

15. What should the initial action of a nurse be when providing first aid to a person with spontaneous epistaxis? a. Apply direct pressure for 3 to 5 minutes. b. Have the person sit down and lean forward. c. Have the person lie down and apply an ice pack. d. Have the person clear the nasal passages by blowing the nose.

ANS: B The first action is to sit down and lean forward. Applying pressure just below the nose will also help. DIF: Cognitive Level: Application REF: p. 542 OBJ: 4 TOP: Epistaxis KEY: Nursing Process Step: Implementation

14. What is the major advantage of the halo device over the Gardner-Wells tongs? a. Separates the cervical vertebrae b. Allows the patient out of bed c. Aligns the cervical spine d. Relieves pain

ANS: B The halo device and the Gardner-Wells tongs do exactly the same thing in terms of separation and alignment. The only advantage of the halo device is the mobility it allows. Neither traction modality specifically relieves pain. DIF: Cognitive Level: Comprehension REF: p. 518 OBJ: 4 TOP: Halo Device KEY: Nursing Process Step: Implementation

26. Two days after a hypophysectomy a patient complains of a headache and nuchal rigidity. What action should the nurse take based on these assessments? a. Medicate with the prescribed analgesic. b. Report suspected meningitis to the head nurse. c. Closely monitor the patient's blood pressure. d. Elevate the head of the bed to 45 degrees.

ANS: B The headache and the nuchal rigidity are signs of meningitis. DIF: Cognitive Level: Application REF: p. 1016 OBJ: 3 TOP: Signs of Meningitis KEY: Nursing Process Step: Assessment

7. How long does the initial stage of an HIV infection usually last? a. 2 to 4 weeks b. 4 to 8 weeks c. 8 to 12 weeks d. 12 to 16 weeks

ANS: B The initial phase of an HIV infection lasts from 4 to 8 weeks. DIF: Cognitive Level: Knowledge REF: p. 668 OBJ: 2 TOP: Initial Phase of HIV Infection KEY: Nursing Process Step: Implementation

18. Which nursing diagnosis is most appropriate when considering the impact of a hearing deficit when planning care for a child who has been diagnosed with a hearing impairment? a. Risk for injury, related to hearing impairment b. Risk for social isolation, related to hearing impairment c. Knowledge deficit, related to hearing impairment d. Anxiety, related to hearing impairment

ANS: B The loss of hearing and the mild stigma associated with hearing impairment place the newly diagnosed child at risk for social isolation. DIF: Cognitive Level: Application REF: p. 1262 OBJ: 7 TOP: Impact of Hearing Impairment KEY: Nursing Process Step: N/A MSC:

1. What portion of the internal nose traps particles and kills bacteria? a. Turbinates b. Mucous membrane c. Vestibular formations d. Cilia

ANS: B The mucous membrane traps particles and bacteria that are inhaled; then an enzyme in the mucus destroys them. The cilia then sweep the particles into the throat to be swallowed. DIF: Cognitive Level: Knowledge REF: p. 531 OBJ: 4 TOP: Anatomy and Physiology of the Nose KEY: Nursing Process Step: Implementation

15. A patient has come to the physician's office after finding out that her blood glucose level was 135 mg/dL. She states that she had not eaten before the test and was told to come and see her physician. She asks the nurse if she has diabetes. What is the most accurate nursing response? a. "Having a fasting serum glucose that high certainly indicates diabetes." b. "That test indicates that we need to perform more tests that are specific for diabetes." c. "How do you feel? Do you have any other signs of diabetes?" d. "Do you have a family history of diabetes, stroke, or heart disease? We need to know before making a diagnosis."

ANS: B The nurse needs to answer the patient's question in a way that gives information and is not mis-leading. Although 135 mg/dL is high, a nonpathologic explanation may be found. More tests should be performed to evaluate the patient. DIF: Cognitive Level: Comprehension REF: p. 1066 OBJ: 9 TOP: Laboratory Tests for Diabetes KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

17. Which nursing diagnosis should take priority in a nursing care plan for a patient with Ménière disease? a. Social isolation, related to anxiety b. Risk for injury, related to falls c. Risk for deficient fluid intake, related to weakness d. Nutrition: Less than body requirements, related to fatigue

ANS: B The nursing diagnosis that should take priority is that of preventing injury to the patient. A patient with Ménière disease is prone to falls because of dizziness. DIF: Cognitive Level: Application REF: p. 1266 OBJ: 7 TOP: Nursing Care Plan for Ménière Disease KEY: Nursing Process Step: Assessment MSC:

7. A nurse is explaining Graves disease to a newly diagnosed patient. Which statement by the nurse best clarifies the pathophysiologic changes of Graves disease? a. "Your thyroid gland is not producing enough hormones; consequently, you will need replacement therapy." b. "Your thyroid gland is overactive, but there are ways to treat it through medicine or surgery." c. "It's an autoimmune disorder that has no satisfactory treatment." d. "Graves disease is a temporary disorder that will gradually subside."

ANS: B The patient needs to recognize the nurse's role in giving accurate, timely information. DIF: Cognitive Level: Comprehension REF: p. 1038 OBJ: 3 TOP: Graves Disease KEY: Nursing Process Step: Implementation

9. What is the rationale for administering injections of vitamin B12 to patients with pernicious anemia? a. The patient's body does not normally manufacture enough vitamin B12. b. The patient may lack the intrinsic factor necessary for vitamin B12 absorption. c. Vitamin B12 is found in very small quantities in the patient's body. d. Vitamin B12 is a mineral necessary to aid in the formation of strong bones.

ANS: B The patient with pernicious anemia lacks the intrinsic factor, found in the stomach, which is essential for vitamin B12 absorption. DIF: Cognitive Level: Comprehension REF: p. 635 OBJ: 5 TOP: Pernicious Anemia KEY: Nursing Process Step: Evaluation MSC:

18. Which is the best candidate for a tonsillectomy? a. A 52-year-old patient with a hearing deficit related to otitis media from tonsillitis b. A 23-year-old patient with a peritonsillar abscess c. A 34-year-old patient with enlarged tonsils and adenoids d. A 15-year-old patient with one bout of tonsillitis in the previous 12 months

ANS: B The patient with the peritonsillar abscess is the most likely candidate. The hearing deficit in a middle-aged person would need more investigation before surgery. Enlarged tonsils and adenoids without a respiratory obstruction does not qualify as a need for surgery; only one episode of tonsillitis in a year does not qualify. DIF: Cognitive Level: Analysis REF: p. 545 OBJ: 4 TOP: Tonsillitis KEY: Nursing Process Step: Assessment

11. What intervention should a nurse implement when providing tracheostomy care? a. Wash and rinse the inner cannula in tap water and then dry it. b. Use a sterile solution of normal saline or other solution to wash the inner cannula and then rinse with sterile water. c. Clean the area around the stoma with tap water and a gentle soap. d. Remove the inner cannula, wash both hands with a bactericidal soap, and then don sterile gloves to clean the inner cannula.

ANS: B The recommendation is to use a sterile technique for tracheotomy care. DIF: Cognitive Level: Application REF: p. 538 OBJ: 5 TOP: Tracheostomy Care KEY: Nursing Process Step: Implementation

1. A patient asks the nurse how air goes from the nose to the lung. The nurse draws the route according to which sequence? a. Trachea, larynx, bronchi b. Pharynx, trachea, bronchi, alveoli c. Bronchi, trachea, bronchioles d. Larynx, trachea, alveoli, bronchi

ANS: B The route of inspired air is pharynx, trachea, bronchi, and alveoli. DIF: Cognitive Level: Knowledge REF: p. 558 OBJ: N/A TOP: Physiology of Ventilation KEY: Nursing Process Step: Implementation

18. What action should a nurse implement to address the nursing diagnosis, "Risk for impaired skin integrity, related to dry skin" in the patient with hypothyroidism? a. Increase the frequency of bathing to get rid of dry skin. b. Apply lotions and creams to help maintain moisture. c. Increase activities to stimulate circulation in the skin. d. Take antihistamines to prevent itching.

ANS: B The skin requires moisturizing lotion to decrease the risk breakdown. Frequent bathing and antihistamines will dry the skin. Exercise does little for skin perfusion. DIF: Cognitive Level: Application REF: p. 1048 OBJ: 3 TOP: Hypothyroidism KEY: Nursing Process Step: Implementation

16. What discharge teaching is appropriate for the nurse to provide to a patient who has had a lithotripsy? a. Check for edema of the legs and ankles. b. Watch for stone debris in the urine in 1 to 4 weeks. c. Decrease fluid intake to 1000 mL/day. d. Remain on restricted activity for a week.

ANS: B The stones that have shattered with the sound waves will show up as debris in 1 to 4 weeks. Fluid intake is encouraged, and activity is resumed the next day. Edema is not a concern. DIF: Cognitive Level: Application REF: p. 913-914 OBJ: 5 TOP: Extracorporeal Shock Wave Lithotripsy KEY: Nursing Process Step: Implementation

8. A young patient with acquired immunodeficiency syndrome (AIDS) reports debilitating night sweats. Why should the home health nurse suggest that the patient visit the clinic? a. To get a prescription for antibiotics b. Tuberculosis (TB) screening c. Complete blood count (CBC) d. Treatment with an aerosol inhalant

ANS: B The symptoms of TB are low-grade fever, night sweats, and cough. Patients with AIDS and anyone who is immunosuppressed are extremely prone to TB and should be carefully monitored for the development of the disease. DIF: Cognitive Level: Application REF: p. 613 OBJ: 2 TOP: Tuberculosis KEY: Nursing Process Step: Assessment

19. What information should a nurse stress when teaching a patient with Ménière disease about managing the disorder? a. Limiting fluid intake b. Avoiding the use of alcohol and tobacco c. Using antiemetic medications sparingly d. Staying active during the day

ANS: B The use of alcohol and tobacco products affects the amount of fluid in the middle ear, worsening the symptoms of Ménière disease. The patient with Ménière disease should drink adequate fluid, use antiemetic medications as needed, and conserve energy during the day. DIF: Cognitive Level: Application REF: p. 1266 OBJ: 7 TOP: Ménière Disease KEY: Nursing Process Step: Implementation MSC:

4. A 68-year-old patient tells the nurse that her sense of smell is not as acute as before, her nose is drier, and she occasionally gets a nosebleed. What should the nurse suspect? a. An infection b. Normal age-related changes c. A nasal defect d. Allergies that are causing her symptoms

ANS: B These options describe normal age-related changes. A suggestion that would make the patient more comfortable would be to use a humidifier to keep the mucous membranes moist. DIF: Cognitive Level: Application REF: p. 533 OBJ: 2 TOP: Age-Related Changes in the Nose and Sinuses KEY: Nursing Process Step: Assessment

18. Which intervention should be added to the nursing care plan for supporting nutritional intake in a patient with Parkinson disease? a. Offer large meals with a variety of finger foods. b. Thicken liquids to make them easier to swallow. c. Puree all foods and drink through a straw. d. Offer a diet high in carbohydrates and fat and low in protein.

ANS: B Thickened feedings are easier to swallow. Several small, protein-rich meals are preferable to large ones. A pureed diet is unappealing. DIF: Cognitive Level: Application REF: p. 469 OBJ: 7 TOP: Nutrition in Parkinson Disease KEY: Nursing Process Step: Planning

14. A nurse is assigned to care for a patient with the diagnosis of centriacinar (centrilobar) emphysema. What is a characteristic of this type of emphysema? a. No significant smoking history in the patient b. Enlarged and broken down bronchioles with intact alveoli c. Hypoelastic bronchi and bronchioles d. Deficiency of the enzyme inhibitor alpha1-antitrypsin.

ANS: B This type of emphysema is characterized by a long smoking history, enlarged and broken down bronchioles, and hypoelastic bronchi. DIF: Cognitive Level: Knowledge REF: p. 604 OBJ: 2 TOP: Emphysema KEY: Nursing Process Step: Assessment

24. A patient with hypopituitarism must take medications for the rest of his or her life. What should the patient teaching plan include? a. "Constipation must be prevented because straining increases intracranial pressure." b. "You must become familiar with the signs and symptoms of inadequate or excessive hormone replacement." c. "It is not necessary to wear a medical alert bracelet or necklace." d. "Your self-image is important. Take positive steps to improve your appearance."

ANS: B To prevent complications, recognizing the importance of continuing to replace the missing hormones is essential for the patient. DIF: Cognitive Level: Comprehension REF: p. 1018 OBJ: 4 TOP: Hypopituitarism KEY: Nursing Process Step: Planning

6. What technique should the nurse implement to move the impaired legs of a patient with an SCI to avoid stimulation muscle spasm? a. Firmly grasping the calf muscle and the thigh muscle b. Manipulating the limb by supporting the knee and ankle joints c. Holding the foot upright and slowly dragging the limb into position d. Requesting assistance to support the calf and thigh

ANS: B Undue muscle stimulation can cause spasticity. Using the joint locations to support limbs when repositioning them reduces likelihood of spasticity. DIF: Cognitive Level: Application REF: p. 516 OBJ: 3 TOP: Spasticity KEY: Nursing Process Step: Implementation

3. A nurse is assessing a patient who is in shock. What should the nurse be aware that one common sign will be, regardless of the cause of the shock? a. The skin is cool and dry with cyanotic nail beds. b. The skin is cool and moist with cyanotic nail beds. c. The nail beds are reddened, and the skin is moist and warm. d. The nail beds are reddened, and the skin is dry and warm.

ANS: B Venous blood pools in the extremities of the fingers as a result of the lack of adequate perfusion of tissues, which makes the skin cool and moist from a lack of oxygen and waste exchanges. DIF: Cognitive Level: Comprehension REF: p. 304-305 OBJ: 3 TOP: Common Signs of Shock KEY: Nursing Process Step: Assessment

13. A patient inquires how something as simple as walking could help his venous vascular disorder. What is the best response by the nurse when explaining the benefits of walking? a. Improves the strength of the vascular walls b. Boosts venous circulation through leg muscle activity c. Increases cardiac output d. Clears plaques from the veins

ANS: B Walking is helpful because the muscle action of the legs that massage the valves of the veins boosts circulation. DIF: Cognitive Level: Comprehension REF: p. 745 OBJ: 5 TOP: Benefits of Walking KEY: Nursing Process Step: Implementation MSC:

20. The family members of a patient with an SCI, who is in the rehabilitation phase, wants to take the patient outdoors for a visit. It is 90° F outside and very humid. What should the nurse suggest? a. Do not go outside at all but remain in the hospital. b. Take a spray bottle to spray water to cool the patient by evaporation. c. Take a light sweater to insulate the patient. d. Have the patient drink at least 32 oz of water during the outing.

ANS: B Water will evaporate and cool the patient, similar to perspiration. DIF: Cognitive Level: Application REF: p. 525 OBJ: 3 TOP: Impaired Thermal Regulation KEY: Nursing Process Step: Planning

14. A patient has come into the emergency department accompanied by a friend who states that the patient had been acting very strangely and seems confused. The friend states that the patient has diabetes and takes insulin. Which signs of hypoglycemia might the nurse assess? a. Slow pulse rate and low blood pressure b. Irritability, anxiety, confusion, and dizzi-ness c. Flushing, anger, and forgetfulness d. Sleepiness, edema, and sluggishness

ANS: B When blood sugar levels fall, hormones are activated to increase serum glucose. One of the hor-mones is epinephrine, which causes these symptoms. DIF: Cognitive Level: Comprehension REF: p. 1084 OBJ: 1 TOP: Hypoglycemia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. A nurse is completing a history of illnesses for a young woman who suspects she may have a sexually transmitted infection (STI). What specific symptom(s) should the nurse ask this patient if she experienced? a. Lethargy and fatigue b. Genital discharge c. Abdominal cramps d. Heavy menses

ANS: B With an STI, the patient usually complains of genital discharge. DIF: Cognitive Level: Application REF: p. 1176 OBJ: 7 TOP: Collecting Data KEY: Nursing Process Step: Assessment

26. How should a nurse explain that the breathing pattern has been altered when a patient complains of tachypnea? (Select all that apply.) a. Increased pH levels stimulate chemoreceptors in the aorta and carotid arteries, which stimulates the phrenic nerve. b. Decreased oxygen level signals the phrenic nerve to alter the respiration rate. c. Muscles of respiration respond to the stimulus. d. The brain has become hypoxic and causes an alteration in the respiration rate. e. Deflated lung tissue results in an altered respiration rate.

ANS: B, C A decreased oxygen level stimulates the phrenic nerve to signal the muscles of respiration to do the work of breathing. A decreasing pH level is the stimulus to the chemoreceptors. Neither the brain nor the lungs signal for tachypnea. DIF: Cognitive Level: Comprehension REF: p. 558 OBJ: 1 TOP: Respiration Center KEY: Nursing Process Step: Implementation

28. A nurse uses a picture to demonstrate the bullae and blebs associated with emphysema. How do blebs differ from bullae? (Select all that apply.) a. They are between the alveolar spaces in the lungs. b. They are in the lung parenchyma. c. They can rupture, causing the lungs to collapse. d. They are responsible for diaphragm flattening. e. They are precancerous.

ANS: B, C Blebs are growths inside the organ of the lung that enlarge and rupture, causing lung collapse. Bullae are the lesions between the alveolar spaces. Neither are the cause of diaphragm flattening nor are they precancerous. DIF: Cognitive Level: Comprehension REF: p. 604 OBJ: 2 TOP: Blebs and Bullae of Emphysema KEY: Nursing Process Step: Implementation

29. A patient who has had surgery this morning for cataracts is now going home. What should the nurse include when providing discharge instructions? (Select all that apply.) a. Sleep on the affected side. b. Use stool softeners. c. Avoid bending over. d. Avoid lifting anything heavier than 5 lb. e. Do not wear an eye shield at night.

ANS: B, C, D After cataract surgery, the patient should sleep on the unaffected side with the eye shield in place. He or she should avoid heavy lifting and use stool softeners to prevent straining. DIF: Cognitive Level: Application REF: p. 1240 OBJ: 3 TOP: Discharge Instructions for Cataract Surgery KEY: Nursing Process Step: Implementation MSC:

27. What should a nurse caring for a patient with hyperthyroidism include when developing a plan of care? (Select all that apply.) a. Decreasing weight b. Provision of a cool environment c. Eye care d. Nutritional support e. Prevention of diarrhea

ANS: B, C, D, E A patient with hyperthyroidism does not need to lose weight, but he or she needs to gain it. All other options are appropriate concerns for such a patient. DIF: Cognitive Level: Application REF: p. 1043-1044 OBJ: 4 TOP: Care Plan for Patient Hyperthyroidism KEY: Nursing Process Step: Planning

26. Which transitory symptoms might occur when a patient is diagnosed with a TIA? (Select all that apply.) a. Incontinence b. Dysphagia c. Ptosis d. Tinnitus e. Dysarthria

ANS: B, C, D, E All, except transitory incontinence, are classic symptoms of a TIA. These deficits usually disappear without permanent disability in approximately 24 hours. DIF: Cognitive Level: Comprehension REF: p. 484-485 OBJ: 3 TOP: Symptoms of TIA KEY: Nursing Process Step: Assessment

26. What should the postoperative care of a patient who has had nasal surgery include? (Select all that apply.) a. Changing the nasal packing when saturated b. Placing the patient in a semi-Fowler position without a pillow c. Giving frequent oral hygiene d. Providing humidification for dry mucous membranes e. Assessing the back of the throat for bleeding

ANS: B, C, D, E Only the physician removes the nasal packing. The nurse may change the mustache dressing, however. DIF: Cognitive Level: Knowledge REF: p. 539 OBJ: 4 TOP: Postnasal Surgery Care KEY: Nursing Process Step: Planning

27. A nurse is planning the care for an older adult patient. Which age-related changes in kidney function should the nurse consider when providing care to this patient? (Select all that apply.) a. Thinning of nephron membranes b. Sclerosis of renal blood vessels c. Decreasing glomerular filtrations d. Decreasing ability to concentrate or dilute urine e. Decreasing erythropoietin

ANS: B, C, D, E Sclerosis of renal blood vessels, decreasing glomerular filtration, decreasing ability to concentrate urine, and decreasing erythropoietin are associated with aging. DIF: Cognitive Level: Knowledge REF: p. 894 OBJ: 6 TOP: Age-Related Changes to the Kidney KEY: Nursing Process Step: Planning

27. What assessment findings would indicate respiratory dysfunction when examining a patient with respiratory difficulty? (Select all that apply.) a. Flushed facial skin b. Cyanotic nail beds c. Abdominal distention d. Curved spine e. Clubbed fingers

ANS: B, C, E Clues to respiratory dysfunction are a distended abdomen, cyanotic nail beds, and clubbed fingers from inadequate oxygenation. DIF: Cognitive Level: Comprehension REF: p. 563 OBJ: 1 TOP: Clues to Respiratory Dysfunction KEY: Nursing Process Step: Assessment

29. What changes occur with the intervertebral disks in older adults that increase the risk of injury? (Select all that apply.) a. Fill with calcium deposits b. Are less shock absorbent c. Are herniated d. Enlarge and swell e. Lose water

ANS: B, E Age affects the water content in intervertebral disks, which makes them less able to absorb shock. Herniation and swelling can occur at any age. Disks do not fill with calcium. DIF: Cognitive Level: Knowledge REF: p. 510 OBJ: N/A TOP: Age-Related Changes to Intervertebral Disks KEY: Nursing Process Step: Implementation

25. What direction should a nurse provide when instructing a patient who is to have a semen analysis? (Select all that apply.) a. Collect specimen in a rubber condom. b. Keep the specimen at room temperature until given to the laboratory. c. Keep the specimen container in warm tap water. d. Bring the specimen to the laboratory within 4 hours. e. Abstain from sexual activity 3 to 5 days before the test.

ANS: B, E Sexual activity should be avoided for 3 to 5 days before collection. The specimen should be collected in a clean container, not a rubber condom, and presented to the laboratory within 1 hour of collection. DIF: Cognitive Level: Application REF: p. 1142 OBJ: 3 TOP: Semen Collection KEY: Nursing Process Step: Implementation

30. Before taking a magnetic resonance image (MRI), a patient asks why metal objects and the MRI machine are such concerns. What is the best explanation by the nurse regarding the MRI machine? (Select all that apply.) a. Causes metal objects to spark, similar to a microwave b. Deactivates the battery in a pacemaker c. Causes metal to heat up and burn the patient d. Does not transmit clear data if metal is present e. Attracts any metal into the MRI chamber

ANS: B, E The magnetic field will deactivate the batteries in a pacemaker and will also attract any metal object into the MRI chamber. DIF: Cognitive Level: Knowledge REF: p. 513 OBJ: 2 TOP: Metal Precautions with MRI KEY: Nursing Process Step: Implementation

19. A patient with type 1 diabetes asks why his 0700 insulin has been changed from NPH insulin to 70/30 premixed insulin. What is the best explanation by the nurse that explains about 70/30 insulin mixture? a. It is absorbed more rapidly into the blood-stream. b. It has no peak action time and lasts all day. c. It makes insulin administration easier and safer. d. It provides a bolus of rapid-acting insulin to prevent hyperglycemia after breakfast.

ANS: C 70/30 insulin is 30% rapid-acting insulin and 70% intermediate-acting insulin. The rapid action of the 0700 premixed insulin prevents hyperglycemia after the morning meal and the mixed drug re-duces the risk of error in drawing up two insulins. DIF: Cognitive Level: Comprehension REF: p. 1070 OBJ: 8 TOP: Use of 70/30 Insulin KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

27. Which nursing action should be implemented when performing skin testing? a. Select an 18-gauge needle. b. Inject 1 mL intradermally. c. Check the site in 2 to 3 days for swelling. d. Wrap the site with a pressure dressing.

ANS: C A cell-mediated response will show swelling in 2 to 3 days, indicating antibodies working at the site of the exposure to an antigen. DIF: Cognitive Level: Application REF: p. 650 OBJ: 3 TOP: Skin Testing Procedure KEY: Nursing Process Step: Implementation

19. A nurse tells a patient with quadriplegia that he is being treated with intravenous (IV) drugs because this method is more effective than intramuscularly (IM). What explanation should the nurse provide about IM medications to explain to the patient why they are less effective than IV? a. Too concentrated b. Too irritating to poorly perfused tissue c. Not absorbed well below the level of the injury d. Too small a dose to be effective

ANS: C A patient with quadriplegia has a high cervical lesion, which causes nearly the entire vascular tree to have poor perfusion. This condition would make absorption of medications from the tissues unpredictable. DIF: Cognitive Level: Comprehension REF: p. 523 OBJ: 4 TOP: Injections for the Patient with an SCI KEY: Nursing Process Step: Implementation

5. When is a patient with HIV considered to have progressed to AIDS? a. Two or more opportunistic infections are diagnosed. b. Kaposi sarcoma appears. c. CD4 cell level drops to 200. d. Patient tested positive for enzyme-linked immunosorbent assay (ELISA).

ANS: C A person with an HIV infection is not diagnosed with AIDS until the CD4 count falls to 200. Other AIDS markers exist as well. DIF: Cognitive Level: Knowledge REF: p. 668 OBJ: 5 TOP: AIDS KEY: Nursing Process Step: Implementation

8. What does a pneumatonometric study of the eye require? a. Regional anesthesia b. A pneumotonometer to be placed into the eye c. A puff of air directed at the surface of the eye d. An applanation performed with a slit-lamp microscope

ANS: C A pneumotonometer directs a puff of air at the surface of the eye, measuring intraocular pressure by measuring the resistance to the air. The eye is anesthetized before the evaluation. DIF: Cognitive Level: Comprehension REF: p. 1224 OBJ: 2 TOP: Tonometry KEY: Nursing Process Step: Implementation MSC:

6. A nurse performs Homans maneuver by flexing the knee and sharply dorsiflexing the foot. What response indicates a positive Homans sign? a. Cramping of the toes b. Resisting dorsiflexion c. Pain in the calf area d. Blanching of the sole

ANS: C A positive Homans sign indicates the possible presence of a DTV because of the pain produced in the calf of the leg when the foot is dorsiflexed. DIF: Cognitive Level: Comprehension REF: p. 742 OBJ: 2 TOP: Homans Sign KEY: Nursing Process Step: Assessment MSC:

25. During an intake physical examination, a patient reports that he has been taking 10 aspirin tablets a day for his arthritis. What question should the nurse ask based on this information? a. "Can you hear high-pitched sounds?" b. "Have you noticed deafness in just one ear?" c. "Do you have ringing in your ears?" d. "Do you experience dizziness when you stand?"

ANS: C A ringing in the ears (tinnitus) is an indication of aspirin toxicity. The patient should be advised to stop taking aspirin. DIF: Cognitive Level: Application REF: p. 1252-1253 OBJ: 5 TOP: ASA Toxicity KEY: Nursing Process Step: Implementation MSC:

18. A nurse recognizes that a patient diagnosed with COPD has a rising level of partial pressure of carbon dioxide (CO2) in arterial blood (PaCO2). How should the nurse interpret this assessment? a. More arterial O2 is available than is needed. b. The ventilation-perfusion ratio is becoming balanced. c. Respiratory acidosis has begun. d. The anticholinergic medications are effective.

ANS: C A rising PaCO2 level is acidic in nature and causes respiratory acidosis. DIF: Cognitive Level: Analysis REF: p. 604 OBJ: 2 TOP: PaCO2 KEY: Nursing Process Step: Assessment

6. A patient has had a complete stroke as a result of a ruptured vessel in the left hemisphere. How should this patient's CVA be classified? a. Ischemic, embolic b. Hemorrhagic, subarachnoid c. Hemorrhagic, intracerebral d. Ischemic, thrombotic

ANS: C A ruptured vessel in a hemisphere is an intracerebral hemorrhagic CVA. It did not occur in the subarachnoid space. Ischemic CVAs are the result of occluded vessels. DIF: Cognitive Level: Analysis REF: p. 487 OBJ: 2 TOP: CVA Classification KEY: Nursing Process Step: Assessment

5. A patient is stuporous but reacts by withdrawing from painful stimuli. What term is most appropriate for this patient? a. Comatose b. Lethargic c. Semicomatose d. Somnolent

ANS: C A stuporous patient who reacts to pain is semicomatose. The patient with no reaction to pain is comatose. DIF: Cognitive Level: Knowledge REF: p. 443 OBJ: 3 TOP: Neurologic Assessment KEY: Nursing Process Step: Assessment

21. What sign should a nurse report when caring for the patient with AIDS who has cutaneous Kaposi sarcoma? a. Nausea b. Fatigue c. Abdominal pain d. Weight loss

ANS: C Abdominal pain may be an indication of organ involvement from Kaposi sarcoma. DIF: Cognitive Level: Comprehension REF: p. 673 OBJ: 2 TOP: Kaposi Sarcoma KEY: Nursing Process Step: Assessment

21. A patient comes to the primary care clinic complaining of a head cold and ear pain with drainage. What should the nurse suspect this patient is experiencing? a. Otitis externa b. Hearing loss c. Acute otitis media d. Mastoiditis

ANS: C Acute otitis media is connected with colds and drainage from the ear. A hearing loss may be experienced as well, but the pain and drainage place the need to intervene for the infection first. DIF: Cognitive Level: Comprehension REF: p. 1264 OBJ: 1 TOP: Middle Ear KEY: Nursing Process Step: Assessment MSC:

13. How should a nurse assist a visually impaired patient to ambulate? a. Hold the visually impaired person by his or her nondominant arm and walk side by side. b. Hold the nondominant hand, wrap the arm around his or her waist, and walk side by side. c. Allow the visually impaired person to hold the helper's arm, with the helper slightly ahead. d. Allow the visually impaired person to hold the shoulder of the helper and walk slightly behind the helper.

ANS: C Allowing the visually impaired person to walk slightly behind the helper and holding the helper's arm is the most effective way to guide someone who is visually impaired. DIF: Cognitive Level: Application REF: p. 1232-1233 OBJ: 6 TOP: Assisting the Visually Impaired with Ambulation KEY: Nursing Process Step: Implementation MSC:

16. Which assessment made by a nurse indicates that respiratory arrest is imminent in a patient with asthma? a. Agitation b. Tachycardia c. Absence of wheezing d. Flaring nares

ANS: C An absence of wheezing indicates a diminished ventilation effort. DIF: Cognitive Level: Comprehension REF: p. 599 OBJ: 2 TOP: Asthma: Respiratory Arrest KEY: Nursing Process Step: Assessment

20. Which statement made by a patient indicates to the nurse that a teaching plan for the use of warfarin was not effective? a. "I don't take aspirin anymore." b. "I read that grapefruit interferes with warfarin." c. "I'm drinking too much tea. My urine looks like tea." d. "I wear my medical alert bracelet all the time."

ANS: C Anticoagulants, such as warfarin (Coumadin), can cause bleeding. A sign of bleeding may be bruising, tea- or cola-colored urine, or dark-colored stool. DIF: Cognitive Level: Application REF: p. 751 OBJ: 5 TOP: Anticoagulant Therapy KEY: Nursing Process Step: Evaluation MSC:

2. A nurse is caring for a patient 2 hours after a transurethral resection and immediately reports to the charge nurse the presence of large clots in the catheter and drainage bag. What should the nurse anticipate the physician will order? a. Instill ice water into the bladder. b. Decrease the amount of fluid in the balloon of the indwelling catheter. c. Apply traction to the catheter by taping it to the patient's thigh. d. Prescribe a potent vasoconstrictor to reduce hemorrhage.

ANS: C Applying traction to the catheter may reduce the bleeding. An increase of fluid in the catheter balloon is also helpful, but ice water will have no better effect than the continuous bladder irrigation that is already in place. DIF: Cognitive Level: Application REF: p. 1155 OBJ: 4 TOP: Transurethral Resection of the Prostate KEY: Nursing Process Step: Implementation

1. What is a normal age-related change in older adults that makes them susceptible to cardiovascular disease? a. Increase in cardiac output b. Increase in stroke volume c. Stiff peripheral vessels d. Oxygen capacity improvement

ANS: C As adults age, their peripheral vessels become stiff, their oxygen capacity and stroke volume are reduced, and their aorta thickens and calcifies. DIF: Cognitive Level: Knowledge REF: p. 740 OBJ: 1 TOP: Changes in Older Adults KEY: Nursing Process Step: Assessment MSC:

21. Which observation by a nurse indicates a patient's acceptance of the diagnosis of acute leukemia? a. Plans a 14-day cruise in 2 weeks b. States that he will be fine in a few months c. Asks for educational material about acute leukemia d. Rests after a chemotherapy session

ANS: C Asking for educational material indicates beginning acceptance. DIF: Cognitive Level: Application REF: p. 654-657 OBJ: 5 TOP: Nursing Care KEY: Nursing Process Step: Evaluation

1. What is responsible for initiating the inflammatory response in addition to immunoglobulin E (IgE)? a. Eosinophils b. Lymphocytes c. Basophils d. Neutrophils

ANS: C Basophils initiate a massive inflammatory response with histamine that quickly brings other white blood cells (WBCs) to the site of an infection. DIF: Cognitive Level: Knowledge REF: p. 643 OBJ: 1 TOP: Components of the Immune System KEY: Nursing Process Step: Implementation

21. A patient being treated for hyperparathyroidism is to receive calcitonin (Calcimar). Which patient assessment should occur before this medication is administered? a. Assessment for hydration status b. Evaluation for cardiac dysrhythmia c. Test for sensitivity d. Radiography for the presence of urinary calculi

ANS: C Because anaphylaxis is not an uncommon side effect of calcitonin, sensitivity testing should be performed before administering the drug. DIF: Cognitive Level: Application REF: p. 1052-1053 OBJ: 3 TOP: Antihyperparathyroidism Drug KEY: Nursing Process Step: Implementation

8. A patient has a nephrostomy tube that has been inserted because of an obstruction in the ureter. What special precautions in the care of the nephrostomy tube should the nurse implement? a. Clamping every 2 hours to allow expansion of the kidney pelvis b. Instilling no more than 50 mL of sterile water if sterile irrigations are ordered c. Being certain the tube is connected, not kinked, or not clamped to ensure that it continually drains d. Leaving the nephrostomy site open to air

ANS: C Because of the small capacity of the renal pelvis, drainage must be continuous; otherwise, the urine may back up and destroy the kidney. DIF: Cognitive Level: Application REF: p. 903 OBJ: 4 TOP: Nephrostomy Tube KEY: Nursing Process Step: Evaluation

25. The family of a patient with an SCI is concerned with the lack of bowel function 2 days after the injury. What is the best response by the nurse? a. "Because of his injury, he will always need to have enemas for bowel evacuation." b. "Medical management is delaying bowel action because it places pressure on the injury." c. "Bowel function should return in approximately 3 days after the accident." d. "We'll just have to wait and see if bowel action returns this week."

ANS: C Bowel action usually returns with peristalsis on the third day after the accident. The bowel responds to dilation from the content in the bowel and moves without voluntary action from the patient. DIF: Cognitive Level: Application REF: p. 524 OBJ: 1 TOP: Impaired Bowel Function KEY: Nursing Process Step: Implementation

8. A nurse is instructing a patient on breast self-examination. When is the best time of the month to instruct this patient to perform a breast self-examination? a. Before the menstrual period b. During the menstrual period c. After the menstrual period d. On the first day of the month

ANS: C Breast self-examination should be performed at the same time each month, at the end of the menstrual cycle. DIF: Cognitive Level: Knowledge REF: p. 1097 OBJ: 2 TOP: Breast Self-Examination KEY: Nursing Process Step: Implementation

8. A nurse assessing a patient 1 day after a subtotal thyroidectomy notes that the patient's color is poor, the pulse and respirations are rapid, and the patient feels warm to the touch. The patient says that she feels frightened. What is the best initial implementation by the nurse? a. Tell her that there is nothing to be afraid of and stay to calm her. b. Ask her if she would like pain medication. c. Call the charge nurse; these are signs of a thyroid storm. d. Get a tracheostomy set at the bedside.

ANS: C Call the charge nurse; these signs and symptoms suggest excessive stimulation caused by an elevated level of thyroid hormones, and the patient needs immediate care. DIF: Cognitive Level: Application REF: p. 1038 OBJ: 3 TOP: Thyroid Storm KEY: Nursing Process Step: Evaluation

21. Which medication is used to stimulate or mimic actions of natural pituitary gonadotropins in the treatment of infertility? a. Estrogen only (diethylstilbestrol) b. Danazol (Danocrine) c. Clomiphene citrate (Clomid) d. Raloxifene (Evista)

ANS: C Clomid stimulates the actions of natural pituitary gonadotropins. DIF: Cognitive Level: Knowledge REF: p. 1101 OBJ: 4 TOP: Ovulatory Stimulant Drugs KEY: Nursing Process Step: Assessment

11. A patient with TB asks how to protect family members from the disease. Which discharge instruction given by the nurse is most informative? a. "Your family will need to take treatments to prevent infection." b. "You will need to wear a mask at home to protect your family members." c. "You should always cover your mouth and nose if coughing or sneezing." d. "You should avoid intimate contact with everyone."

ANS: C Covering the mouth and nose to prevent droplet spread and carefully disposing of tissues are two significant way to control the spread of infection. Masks or isolation is not necessary because before discharge, the patient will have been stabilized on an anti-TB medication. DIF: Cognitive Level: Application REF: p. 615 OBJ: 2 TOP: TB Infection Control KEY: Nursing Process Step: Implementation

15. Which assessment indicates a fluid volume excess in a patient in the acute phase of a CVA? a. Decreased BP b. Weak pulse c. Adventitious breath sounds d. High urine-specific gravity

ANS: C Crackles in the lung fields are a major indicator of fluid excess. The pulse and BP are elevated in fluid excess. Urine-specific gravity is low in fluid excess. DIF: Cognitive Level: Application REF: p. 499 OBJ: 8 TOP: Fluid Excess KEY: Nursing Process Step: Assessment

9. A patient comes to the medical clinic with complaints of urgency, frequency, pain in the area of the symphysis pubis, and dark cloudy urine. What should the nurse suspect that this patient has? a. Urinary calculi, probably located in the ureter b. Kidney infection, most likely pyelonephritis c. Cystitis, probably from bacterial contamination d. Interstitial cystitis (although rare in a male patient)

ANS: C Cystitis causes urgency, dysuria, and pain behind the symphysis pubis. Cystitis is usually caused by bacterial infection. DIF: Cognitive Level: Analysis REF: p. 908 OBJ: 5 TOP: Urinary Tract Infection KEY: Nursing Process Step: Assessment

21. Which is the most effective intervention for best support of regular bowel elimination and the prevention of constipation? a. Limit fluid intake from 32 to 50 oz daily to compact the stool. b. Administer small soapsuds enema every other day to cleanse the bowel. c. Give stool softeners daily, establishing a consistent time to attempt elimination. d. Administer a strong laxative on a daily basis to encourage evacuation.

ANS: C Daily stool softeners, rather than daily laxatives or frequent enemas, help restore regularity and bowel tone. DIF: Cognitive Level: Application REF: p. 506 OBJ: 8 TOP: Bowel Elimination KEY: Nursing Process Step: Planning

6. A licensed practical/vocational nurse (LPN/LVN) is assisting in developing a nursing care plan for a patient in shock. Which nursing diagnosis should be included? a. Increased cardiac output, related to hypertension b. Increased cardiac output, related to hypotension c. Decreased cardiac output, related to hypovolemia d. Decreased cardiac output, related to hypertension

ANS: C Decreased amount of blood is ejected from the heart because of a decreased volume of fluid in the intravascular compartment. DIF: Cognitive Level: Application REF: p. 308 OBJ: 7 TOP: Nursing Diagnosis for Patients in Shock KEY: Nursing Process Step: Planning

3. Which neurologic finding would be considered abnormal in an 88-year-old patient? a. Slow papillary response to light b. Jerky eye movements c. Dizziness and problems with balance d. Absence of the Achilles tendon jerk

ANS: C Dizziness and vertigo, although common, are considered abnormal. DIF: Cognitive Level: Comprehension REF: p. 439 OBJ: 1 TOP: Age-Related Neurologic Changes KEY: Nursing Process Step: Assessment

22. What should discharge planning for a patient who underwent a hypophysectomy focus on? a. Finding a support group b. Nutritional maintenance c. Education on self-care d. Self-image improvement

ANS: C Educate the patient about the responsibility for his or her own care, such as knowledge of medications, activities, and knowing when to call the physician. DIF: Cognitive Level: Application REF: p. 1015 OBJ: 4 TOP: Discharge Planning after Hypophysectomy KEY: Nursing Process Step: Planning

16. How should a nurse position a patient who had a left pneumonectomy in the morning in an effort to enhance gas exchange? a. On the right side b. On the left side c. In a semi-Fowler position d. In a flat position with a small pillow

ANS: C Elevation of the head helps gas exchange in the patient with a new pneumonectomy. A complete side-lying position on the unaffected side may cause mediastinal shift. DIF: Cognitive Level: Application REF: p. 577 OBJ: 5 TOP: Postpneumonectomy KEY: Nursing Process Step: Implementation

16. A nurse is performing an intake examination on a patient with peripheral vascular disease (PVD). Which lifestyle information identified by the patient aggravates vascular disease? a. Riding a bicycle to work b. Drinking red wine every day c. Being employed as an air traffic controller d. Eating chocolate candy every day

ANS: C Employment as an air controller is a stressful occupation. Stress increases vasoconstriction and increases vascular resistance. Wine and chocolate actually have beneficial effects on circulation, as does bicycle riding. DIF: Cognitive Level: Application REF: p. 746-747 OBJ: 5 TOP: Stress and PVD KEY: Nursing Process Step: Assessment MSC:

21. What has most likely occurred in a patient who has been diagnosed with endogenous hypoglyce-mia? a. Taken an overdose of hypoglycemic drugs b. Been following a very restricted fasting diet or is malnourished c. Excessive secretion of insulin or an in-crease in glucose metabolism d. Exercised unwittingly without replenishing needed fluids and nutrients

ANS: C Endogenous refers to within; in this patient, it refers to internal factors, such as an increase of insu-lin or glucose metabolism. Both conditions would lead to hypoglycemia. DIF: Cognitive Level: Application REF: p. 1084 OBJ: 1 TOP: Hypoglycemia KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

23. Erythropoietin is a hormone produced by the kidney. What will a deficiency of erythropoietin in a patient in chronic renal failure result in? a. Diminished immunologic function with fewer white blood cells b. Elevated lipid levels in the bloodstream, contributing to accelerated atherosclerosis c. Anemia as a result of the diminished number of red blood cells being produced d. Hypertension as a result of the increased, concentrated blood volume

ANS: C Erythropoietin is excreted by the kidneys and stimulates bone marrow to produce red blood cells. DIF: Cognitive Level: Comprehension REF: p. 894 OBJ: 5 TOP: Erythropoietin KEY: Nursing Process Step: N/A

23. Which nursing concern takes priority in the care of a patient after a laryngectomy? a. Encouraging nutrition b. Avoiding infection c. Establishing a communication system d. Ensuring adequate fluid intake

ANS: C Establishing a communication system with the patient who has undergone a laryngectomy is a primary concern. DIF: Cognitive Level: Application REF: p. 553 OBJ: 5 TOP: Postoperative Laryngectomy KEY: Nursing Process Step: Planning

11. A home health care nurse is assessing a patient with type 1 diabetes who has been controlled for 6 months. The nurse is surprised and concerned about a blood glucose reading of 52 mg/dL. What action by this patient most likely caused this episode of hypoglycemia? a. Taking a new form of birth control pill this morning b. Using large amounts of sugar substitute in her tea this morning c. A 2-hour long exercise class at the spa this morning d. Administering an insufficient dose of insu-lin this morning

ANS: C Excessive exercise used up the glucose that was made available by the insulin taken by the patient. The patient now has too much insulin for the available glucose and has become hypoglycemic. DIF: Cognitive Level: Application REF: p. 1068 OBJ: 10 TOP: Diabetes: Treatment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

18. A 52-year-old man has a diagnosis of aplastic anemia. What information in the patient history is pertinent to this diagnosis? a. Long family history of cancer b. Regular blood donor c. 25-year employee in a chemical plant d. Gain of 5 lb in the last 2 years

ANS: C Exposure to toxic chemicals can cause aplastic anemia. DIF: Cognitive Level: Analysis REF: p. 633 OBJ: 5 TOP: Aplastic Anemia KEY: Nursing Process Step: Assessment MSC:

27. What is the major difference between fresh-frozen plasma (FFP) and cryoprecipitate (CPP)? a. FFP contains more albumin. b. FFP has a longer infusion time. c. FFP contains no platelets. d. FFP has a very high probability of causing an allergic reaction.

ANS: C FFP contains no platelets. DIF: Cognitive Level: Knowledge REF: p. 631 OBJ: 5 TOP: FFP versus CPP KEY: Nursing Process Step: Implementation MSC:

19. What is best for a nurse to offer when encouraging a new patient after a tonsillectomy to increase fluids? a. Chilled citrus juices b. Tap water sipped through a straw c. Flavored popsicles to suck d. Ice cubes

ANS: C Flavored popsicles provide fluid and cold applications to the surgical area. Citrus juices, the use of a straw, and ice cubes have the potential to injure the operative site. DIF: Cognitive Level: Application REF: p. 547 OBJ: 5 TOP: Posttonsillectomy KEY: Nursing Process Step: Implementation

27. What should a nurse encourage a patient with an SCI to do after a computed tomography (CT) scan? a. Sit up at a 30-degree angle. b. Prevent chilling. c. Drink plenty of water. d. Avoid bearing down.

ANS: C Fluids are pushed after a CT scan to flush the contrast media through the kidneys. DIF: Cognitive Level: Application REF: p. 512 OBJ: 2 TOP: Post-CT Scan Intervention KEY: Nursing Process Step: Implementation

10. Doxycycline (Vibramycin) has been prescribed for a patient who has gonorrhea. What instruction should the nurse provide to the patient before beginning the medication? a. Take the medication with food or crackers. b. Refrain from sexual relations for 4 weeks. c. Follow up to determine if the treatment was effective. d. Keep the medication in the refrigerator.

ANS: C Follow-up examinations are important to determine whether treatment has been effective to prevent reinfection of the partner. DIF: Cognitive Level: Application REF: p. 1170 OBJ: 6 TOP: Drugs to Treat STIs KEY: Nursing Process Step: Implementation

16. The patient has had anterior nasal packing placed for severe epistaxis. The nurse notes that he is swallowing frequently. What should a nurse suspect? a. The patient's throat is dry. b. Posterior packing is uncomfortable. c. The patient is bleeding. d. The patient's saliva production is excessive.

ANS: C Frequent swallowing after nasal surgery is a sign of bleeding. DIF: Cognitive Level: Analysis REF: p. 539 OBJ: 3 TOP: Epistaxis KEY: Nursing Process Step: Assessment

22. What should a nurse anticipate will happen when a patient's first ELISA result is positive? a. The diagnosis of AIDS is confirmed. b. The test is repeated in 6 to 8 months. c. Another blood sample must be obtained for testing. d. A Western blot test is performed on the same sample.

ANS: C If the ELISA result is positive, the ELISA is repeated. If the second ELISA result is positive, a Western blot test is performed. DIF: Cognitive Level: Application REF: p. 673 OBJ: 5 TOP: HIV Laboratory Tests KEY: Nursing Process Step: Planning

12. As part of a teaching plan in preparation for discharge, a patient with type 1 diabetes needs guidelines for exercise. Which guideline should be included? a. Plan exercise so that it coincides with the peak action of insulin. b. Insulin should be injected into the lower extremity before exercise because that site provides the greatest absorption. c. Exercise should be performed daily at the same time of day and at the same intensity. d. Keep exercise at a minimum to conserve your energy.

ANS: C If the body is using more glucose than available, the body will draw on fatty acids, which will give off ketones. DIF: Cognitive Level: Application REF: p. 1068 OBJ: 10 TOP: Exercise KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

21. What can bring on an addisonian crisis? a. Sudden atmospheric temperature change b. Hyperglycemia c. Infection d. Change of altitude

ANS: C Infection is one of the many stresses that can bring on an addisonian crisis. DIF: Cognitive Level: Knowledge REF: p. 1025 OBJ: 2 TOP: Addisonian Crisis KEY: Nursing Process Step: Planning

3. A patient has been diagnosed with herpes simplex virus, type 2 (HSV type 2). What instruction should the nurse provide? a. Avoid telling anyone about the condition. b. Wear close-fitting undergarments. c. Wash towels and personal items daily. d. Soak the sores with peroxide every day.

ANS: C Inform the patient that the virus can survive on objects such as towels. DIF: Cognitive Level: Application REF: p. 1174 OBJ: 8 TOP: Herpes Simplex Virus, Type 2 KEY: Nursing Process Step: Implementation

16. Which intervention should the nurse include in a patient's plan of care to help preserve joint mobility in the acute phase of a CVA? a. Pull the limbs on the affected side into a functional position. b. Perform aggressive full range-of-motion exercises for all extremities. c. Support affected points in good functional alignment. d. Exercise the limbs every 8 hours.

ANS: C Limbs maintained in a functional anatomic position and gently exercised (never pulled) into an acceptable range of motion several times during a shift will maintain optimal mobility. DIF: Cognitive Level: Application REF: p. 500-501 OBJ: 8 TOP: Preserving Joint Mobility KEY: Nursing Process Step: Implementation

2. Where are histamine-releasing mast cells located? a. Circulating in the blood b. Circulating in the lymph c. Attached to organ tissue d. Embedded in the bone marrow

ANS: C Mast cells are located in organ tissue when they release their histamine. The organ to which they are attached is the host of the inflammatory response. If the organ is the lung, the response may be asthma; if the organ is the colon, the response may be diarrhea. DIF: Cognitive Level: Knowledge REF: p. 643 OBJ: 1 TOP: Mast Cells KEY: Nursing Process Step: Assessment

8. What diagnostic test might be contraindicate for a patient who has a pacemaker? a. Computed tomography (CT) b. Electromyography (EMG) c. Magnetic resonance imaging (MRI) d. Electroencephalography (EEG)

ANS: C Metal appliances may be affected by the magnetic field during MRI. DIF: Cognitive Level: Knowledge REF: p. 442 | p. 449 OBJ: 3 TOP: Neurologic Assessment KEY: Nursing Process Step: Assessment

6. A patient states that he is confused because the physician told him that his diabetes insipidus (DI) is nephrogenic. What should the nurse state when describing the difference between nephrogenic DI and neurogenic DI? a. Nephrogenic DI will eventually resolve without medication. b. Nephrogenic DI requires the nasal spray lypressin. c. Nephrogenic DI does not respond to ADH. d. Nephrogenic DI will require dialysis.

ANS: C Nephrogenic DI does not respond to ADH. DIF: Cognitive Level: Comprehension REF: p. 1019 OBJ: 3 TOP: Addison Disease KEY: Nursing Process Step: Implementation

15. A 25-year-old patient with cystic fibrosis (CF) tells the home health nurse that he wants to take a nice vacation. What is the best suggestion for the nurse to make? a. Greece in July b. Colorado in May c. New York in November d. The Mexican coast in August

ANS: C New York is the best choice because individuals with CF sweat profusely and lose many salts, leading to significant electrolyte imbalance. Those with CF also have impaired respiration and should avoid heat (Greece in July, Mexico in August) and higher altitudes (Colorado at any time). DIF: Cognitive Level: Application REF: p. 612 OBJ: 2 TOP: Cystic Fibrosis: Avoiding Heat KEY: Nursing Process Step: Implementation

13. A newborn infant has developed significant jaundice and has a positive Coombs test result resulting from high levels of bilirubin. What should a nurse be aware that these symptoms may indicate? a. Aplastic anemia b. Hemophilia c. Hemolytic anemia d. Sickle cell anemia

ANS: C Newborns can develop hemolytic anemias resulting from blood incompatibility to their mother. These are typical signs of hemolytic anemia in the newborn. DIF: Cognitive Level: Comprehension REF: p. 634-635 OBJ: 5 TOP: Hemolytic Anemia KEY: Nursing Process Step: Assessment MSC:

23. Which intervention would be inappropriate for decreasing the risk of further emboli in a patient with a pulmonary embolism? a. Carefully applying compression stockings b. Performing passive range-of-motion exercises, especially of the lower limbs c. Placing pillows under the knees to elevate the legs d. Ambulating frequently

ANS: C Nothing should be placed under the knees; doing so might impair circulation. DIF: Cognitive Level: Application REF: p. 594 OBJ: 6 TOP: Pulmonary Embolism KEY: Nursing Process Step: Implementation

6. A 75-year-old patient reports to a nurse that although she has cleaned her ears with cotton-tipped applicators for weeks, she still cannot hear her television unless the volume is loud, and she misses a great deal of conversations. What should the nurse anticipate when examining her ears? a. Otitis externa b. Purulent drainage c. Dry cerumen across the canal d. Pearly tympanic membrane

ANS: C Obstruction of the external canal with cerumen will result in a hearing loss. Cleaning the ears with something such as an applicator will pack the cerumen in the canal. DIF: Cognitive Level: Comprehension REF: p. 1251 OBJ: 6 TOP: External Auditory Canal KEY: Nursing Process Step: Assessment MSC:

27. What nursing action should be implemented to help combat anorexia in a patient with COPD? a. Recommend a large meal in the middle of the day. b. Suggest taking only cold liquid nutritional drinks. c. Perform oral hygiene before meals. d. Gently exercise for 10 minutes before a meal.

ANS: C Oral hygiene freshens the mouth and removes unpleasant tastes from medications or coughed-up secretions. DIF: Cognitive Level: Application REF: p. 611 OBJ: 3 TOP: Imbalanced Nutrition KEY: Nursing Process Step: Planning

1. A nurse reads in a patient's history that the patient has experienced otalgia. How should the nurse interpret this term? a. Difficulty hearing b. Buildup of cerumen c. Ear pain d. Ringing in the ears

ANS: C Otic- is the root word for ear, and -algia is the root term for pain of any type. DIF: Cognitive Level: Knowledge REF: p. 1252 OBJ: 5 TOP: Definitions KEY: Nursing Process Step: Assessment MSC:

11. A patient, newly diagnosed with hypothyroidism, is anxious to begin her drug regimen. What should the nurse's instructions relative to hormone replacement include? a. "Be certain that no dose is skipped." b. "Be sure and take these drugs just before bedtime." c. "Know the signs and symptoms of hyperthyroidism." d. "You will be able to notice the benefits of thyroid replacement therapy right away."

ANS: C Overdosing on the thyroid replacement medication will lead to signs and symptoms of hyperthyroidism. The medication is best taken every morning so as not to unduly interrupt sleep patterns. DIF: Cognitive Level: Application REF: p. 1045 OBJ: 3 TOP: Thyroid Replacement Therapy KEY: Nursing Process Step: Implementation

10. Which position is the most appropriate for a patient returning from surgery with a nasal pack and mustache dressing? a. Side-lying position to prevent aspiration of drainage b. Semi-Fowler position and apply a warm compress to reduce pain c. High Fowler position and apply a cold dressing to reduce swelling d. Sims position and apply a cold dressing to facilitate drainage and reduce swelling

ANS: C Patients who have a nasal pack should be placed in semi- or high Fowler position with a cold dressing. The position and cold dressing will reduce swelling. Any side-lying position makes it more difficult for the patient to breathe with a nasal pack in place. DIF: Cognitive Level: Application REF: p. 539 OBJ: 4 TOP: Nasal Pack KEY: Nursing Process Step: Implementation

17. Which statement by a patient diagnosed with Cushing syndrome leads a nurse to conclude that teaching has been effective? a. "I know I should add salt to everything I eat." b. "I make a point to avoid excessive exposure to sun." c. "I avoid being exposed to anyone with an infection." d. "I am careful to wear well-fitting shoes."

ANS: C Patients with Cushing syndrome are especially prone to infection. Adding salt would increase fluid retention. Sun exposure and well-fitting shoes are not significant for Cushing syndrome. DIF: Cognitive Level: Comprehension REF: p. 1032 OBJ: 3 TOP: Cushing Syndrome KEY: Nursing Process Step: Evaluation

13. What should a patient be encouraged to do before the initiation of any anti-HIV drug protocol? a. Give up sexual activity for several months. b. Follow the strict dietary guidelines. c. Comply with the drug protocol. d. Involve the partner in a support program.

ANS: C Patients with HIV are assessed for their willingness to comply with the drug protocol because nonadherence causes the HIV organisms to become resistant to the drug. DIF: Cognitive Level: Application REF: p. 676 OBJ: 7 TOP: Compliance KEY: Nursing Process Step: Implementation

13. What is most appropriate for a nurse to include when preparing discharge plans for a patient with SLE? a. Need to consume 2 L of fluid daily b. Close monitoring of daily blood glucose level c. Use of daily sunscreens with a sun protection factor (SPF) higher than 15 d. Careful concern for certain food allergies

ANS: C Patients with SLE are photosensitive to sunlight. DIF: Cognitive Level: Application REF: p. 658 OBJ: 6 TOP: Systemic Lupus Erythematosus KEY: Nursing Process Step: Implementation

15. A nurse assesses a neutrophil count of 900/mm3 in a patient with acute leukemia. What should the nurse anticipate initiating? a. A high-protein diet b. Increased doses of steroids c. Compromised host precautions d. Injections of blood-building medication

ANS: C Patients with neutrophil counts of approximately 1000 cells/mm3 are placed on compromised host precautions. DIF: Cognitive Level: Application REF: p. 655-656 OBJ: 5 TOP: Compromised Host Precautions KEY: Nursing Process Step: Evaluation

19. What can men who have sustained spinal cord injuries with resultant ED use to aid in the ability to have sexual intercourse? a. Testosterone injections b. Papaverine penile injections c. Inflatable penile implants d. Oral sildenafil (Viagra)

ANS: C Penile implants may be prescribed for patients with the inability to initiate, fill, or restore an erection. DIF: Cognitive Level: Knowledge REF: p. 1156 OBJ: 4 TOP: Erectile Dysfunction KEY: Nursing Process Step: Assessment

21. A patient has returned from a vein ligation and stripping. What are the appropriate instructions for a nurse to provide? a. Dangle the legs to prevent edema. b. Cross the legs to apply pressure. c. Wear compression stockings to promote circulation. d. Remove the drain after 24 hours.

ANS: C Postoperative care of a patient with a vein ligation and stripping includes elevating the extremity, wearing compression stockings, taking anticoagulant therapy, and assessing the circulation of the affected extremity. DIF: Cognitive Level: Application REF: p. 761 OBJ: 5 TOP: Vein Ligation and Stripping KEY: Nursing Process Step: Implementation MSC:

19. A 52-year-old patient reports that he must hold his paper farther and farther away from his face to read it. What is the nurse's most informative response? a. "You are describing myopia. Glasses will help you read." b. "You may have astigmatism, but your eyes will finally adjust." c. "You have presbyopia. Nonprescription reading glasses will help you." d. "An eye infection may be the problem. Check with your physician for medication."

ANS: C Presbyopia is a normal age-related change. Changes in the ciliary muscles cause the condition. Corrective lenses such as bifocals are used to correct this visual change. DIF: Cognitive Level: Application REF: p. 1222 | p. 1237 OBJ: 5 TOP: Error of Refraction KEY: Nursing Process Step: Assessment MSC:

11. A home health patient diagnosed with cystitis has been prescribed the medication phenazopyridine (Pyridium). When providing patient teaching, what should the nurse caution the patient about? a. Staying out of the heat b. Nausea c. Staining of clothing d. Skin rash

ANS: C Pyridium causes the urine to be a bright orange color, which can stain clothing. DIF: Cognitive Level: Comprehension REF: p. 909 OBJ: 6 TOP: Urinary Drugs KEY: Nursing Process Step: Planning

17. What should be the immediate intervention when a nurse recognizes autonomic dysreflexia in the patient with an SCI? a. Flex the patient's legs using the knee gatch of the bed. b. Cool the patient with alcohol solution. c. Raise the head of the bed to at least 45 degrees. d. Administer oxygen per mask.

ANS: C Raising the head of the bed reduces the BP. Flexed legs, cooling, and oxygen will not alleviate the syndrome. DIF: Cognitive Level: Application REF: p. 523 OBJ: 6 TOP: Autonomic Dysreflexia KEY: Nursing Process Step: Implementation

5. A 94-year-old patient is receiving gentamicin sulfate (Garamycin) in a continuous intravenous (IV) infusion. The nurse adds to the nursing care plan the diagnosis "Risk for injury." What nursing action should be implemented? a. Pull side rails in place. b. Assist with ambulation. c. Measure intake and output. d. Provide for a possible seizure.

ANS: C Reduced urine output would cause the drug to stay in the system rather than being excreted, which could result in a drug saturation. Gentamicin is ototoxic and can cause hearing impairment. DIF: Cognitive Level: Application REF: p. 1253 OBJ: 7 TOP: Gentamicin KEY: Nursing Process Step: Assessment MSC:

10. A nurse is caring for a patient with HIV infection taking Retrovir, a nucleoside antiviral that is a reverse transcriptase inhibitor. For what should the nurse be especially observant? a. Decreased urine output b. Hypertensive episodes c. Jaundice d. Edema of the face

ANS: C Retrovir has the potential of causing a fatal hepatotoxic reaction. Jaundice is a possible sign of hepatic impairment. DIF: Cognitive Level: Comprehension REF: p. 675 OBJ: 6 TOP: Drug Side Effects KEY: Nursing Process Step: Assessment

2. What does enzyme reverse transcriptase transcribe? a. DNA to mimic CD4 cells b. T4-helper cells to RNA c. HIV RNA to HIV DNA d. T4 cells to HIV virions

ANS: C Reverse transcriptase reverses the normal process and allows the RNA to be transcribed to the DNA rather than the DNA to be transcribed to the RNA. DIF: Cognitive Level: Knowledge REF: p. 668 OBJ: 2 TOP: Pathophysiology KEY: Nursing Process Step: Implementation

12. A nurse is providing education to a patient taking rifampin as a result of an exposure to TB. What side effect of this drug should the nurse include? a. Extreme drowsiness b. Illness if aged cheese or smoked meats are consumed c. Body fluids to become red-orange d. Oral contraceptive pills to become ineffective

ANS: C Rifampin will color body fluids red-orange and will result in stained clothing and soft contact lenses. DIF: Cognitive Level: Comprehension REF: p. 615 OBJ: 2 TOP: Rifampin KEY: Nursing Process Step: Assessment

22. Which statement made by a male patient with an SCI could be assessed as a positive adaptation to the nursing diagnosis of "Sexual dysfunction, related to altered body function"? a. "I know I will never have a sexual relationship again." b. "I need some suggestions as to how to direct my sexual energy into gardening or painting . . . or just anything." c. "Can you arrange an appointment with a sex counselor so I can begin to examine alternative methods of sexual activity?" d. "I think that after a while I will be able to have sexual relationships just like I had before my accident."

ANS: C Seeking help from a counselor indicates an acceptance of learning alternative techniques. Remarks eliminating all possibilities of a sexual relationship are defeatist remarks and are not positive. However, a patient should realize that his or her sexual relationships will alter as a result of the SCI. DIF: Cognitive Level: Analysis REF: p. 525 OBJ: 7 TOP: Sexual Dysfunction KEY: Nursing Process Step: Evaluation

10. While shopping in the mall, a nurse sees a lady suddenly fall to the floor. On immediate assessment, the nurse realizes she is not in cardiac arrest and has no need for cardiopulmonary resuscitation (CPR). What should be the immediate actions by the nurse? a. Check the pulse and respirations and call for a blood pressure cuff. b. Check the pulse, respirations, skin color, and temperature. c. Call for help and check the pulse, respiration, and mental status. d. Ask someone to help place large blankets or coats under her legs and trunk.

ANS: C Shock treatment requires expert medical implementation. However, the nurse may provide first-line support until such help arrives. Circulatory collapse has to be monitored first; pulse, respiration, and mental status should be assessed to evaluate whether oxygen is reaching the brain. DIF: Cognitive Level: Application REF: p. 305 OBJ: 4 TOP: Emergency Aid for Shock Victim KEY: Nursing Process Step: Implementation

4. A nurse is caring for a patient taking acyclovir (Zovirax). Which side effects of this drug should the nurse be alert for? a. Fever and bone marrow suppression b. Vaginal burning and skin irritation c. Dizziness, headache, and nausea d. Leukopenia and peripheral neuropathy

ANS: C Side effects include dizziness, headache, nausea and vomiting, renal failure, and seizures. DIF: Cognitive Level: Comprehension REF: p. 1168 OBJ: 6 TOP: Drugs to Treat STIs KEY: Nursing Process Step: Planning

19. What action should a nurse implement to initiate the Chvostek sign? a. Ask the patient to grimace and note if the facial response is symmetrical. b. Inflate a blood pressure cuff to the systolic level and watch for a carpopedal spasm. c. Tap the face over the facial nerve and watch for a spasm of the facial muscle. d. Check the pupillary response to light and determine whether the pupil accommodates and reacts.

ANS: C Spasm of the facial muscles is an indicator of low serum calcium levels. DIF: Cognitive Level: Application REF: p. 1051 OBJ: 3 TOP: Hypocalcemia KEY: Nursing Process Step: Assessment

2. On admission to the emergency department, a patient with a C5 compression fracture can move only his head and has flaccid paralysis of all extremities. The distraught family asks if the paralysis is permanent. What is the best response by the nurse? a. "Yes. In all likelihood, the paralysis is probably permanent." b. "No. Significant recovery of function should occur in a few days." c. "It is too early to tell. When the spinal shock subsides, we will know more." d. "You should talk to your physician about things of that nature."

ANS: C Spinal shock caused by swelling may last from a few days to months, clouding the issue of the true extent of the injury. DIF: Cognitive Level: Application REF: p. 516 OBJ: 3 TOP: Spinal Shock KEY: Nursing Process Step: Implementation

5. Which instruction should increase the comfort of a patient who is recovering from prostatitis? a. Avoid bathing for 2 days. b. Exercise. c. Take stool softeners. d. Limit fluid intake.

ANS: C Stool softeners may be prescribed to prevent constipation, which is painful with prostatitis. Fluid intake is also encouraged to reduce the risk of constipation. DIF: Cognitive Level: Comprehension REF: p. 1146 OBJ: 4 TOP: Prostatitis KEY: Nursing Process Step: Implementation

21. What should a nurse be careful to observe for when assessing a patient with thrombocytopenia? a. Distended neck veins and skin discoloration b. Discoloration of the nails and sclera c. Petechiae on the skin and bleeding gums d. Enlarged thyroid gland and excitability

ANS: C Symptoms of thrombocytopenia include petechiae, purpura, bleeding gums, and epistaxis. DIF: Cognitive Level: Analysis REF: p. 638 OBJ: 5 TOP: Thrombocytopenia KEY: Nursing Process Step: Assessment MSC:

12. What patient recommendation should a nurse include when preparing to present presurgical teaching of a patient scheduled for a subtotal thyroidectomy? a. Lie flat on her back for 24 hours to prevent undue strain on the suture line. b. Be able to verbalize the signs and symptoms of thyroid crisis. c. Demonstrate how to deep breathe and support her head during position changes. d. Have a tube in her trachea to assist in breathing.

ANS: C Teaching the patient to hold and support the head after a thyroidectomy will ease the postoperative period. Consistently supporting the head will prevent stress on the suture line. DIF: Cognitive Level: Application REF: p. 1043 OBJ: 4 TOP: Thyroidectomy KEY: Nursing Process Step: Implementation

6. A patient with exophthalmos is distressed about her appearance and asks when it will go away. What is the best response by the nurse? a. It is not reversible. b. It can be disguised with sunglasses and makeup. c. It usually subsides after medication for hyperthyroidism is started. d. It can be minimized with plastic surgery to the eyelids.

ANS: C The "startled" appearance of the patient with exophthalmos usually subsides several weeks after therapy for hyperthyroidism becomes effective. DIF: Cognitive Level: Comprehension REF: p. 1043 OBJ: 2 TOP: Exophthalmia KEY: Nursing Process Step: Implementation

5. During the initial assessment of a very thin patient at the eye clinic, a nurse notes that the patient has very prominent eyes. What medical diagnosis might the nurse find in this patient's history? a. Diabetes b. Glomerulonephritis c. Graves disease d. Hypertension

ANS: C The appearance of the patient and the prominence of the eye (exophthalmos) would lead the nurse to inquire about a thyroid disorder such as Graves disease or hyperthyroidism. DIF: Cognitive Level: Comprehension REF: p. 1222 OBJ: 1 TOP: Medical History KEY: Nursing Process Step: Assessment MSC:

17. A nurse taking the blood pressure of a patient who had a total thyroidectomy 2 days earlier notes that the patient's hand goes into a carpopedal spasm. What should the nurse recognize this movement as an indication of? a. Hyperkalemia, called the Allen sign b. Hypernatremia, called the Hogan sign c. Hypocalcemia, called the Trousseau sign d. Hypokalemia, called the Chvostek sign

ANS: C The carpopedal spasm is the Trousseau sign, which indicates hypercalcemia. Chvostek sign also signals hypocalcemia. DIF: Cognitive Level: Application REF: p. 1051 OBJ: 4 TOP: Hypothyroidism KEY: Nursing Process Step: Assessment

3. A patient tells a nurse that she eats "huge" amounts of food but stays hungry most of the time. What should the nurse explain as the cause of hunger experienced by persons with type 1 diabetes? a. Excess amount of glucose b. Need for additional calories to correct the increased metabolism c. Fact that the cells cannot use the blood glucose d. Need for exercise to stimulate insulin se-cretion

ANS: C The cells cannot use the glucose without insulin, so the patient with diabetes still feels hungry event though abundant glucose is circulating in the blood. DIF: Cognitive Level: Comprehension REF: p. 1059 OBJ: 3 TOP: Hunger in the Patient with Diabetes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. A patient who has been taking opioid medication for postoperative pain exhibits pinpoint pupils. Which anatomic portion of the eye has been affected by the medication? a. Sclera b. Retina c. Choroid d. Bulbar conjunctiva

ANS: C The choroid of the eye contains the pupil and iris. DIF: Cognitive Level: Comprehension REF: p. 1220 OBJ: 1 TOP: Anatomy and Physiology of the Eye: Eyeball KEY: Nursing Process Step: Assessment MSC:

18. Which group of patients should a nurse advise to have a vaccination with conjugated pneumococcal? a. Adults with diabetes b. Persons 65 years and older c. Parents of children younger than 24 months d. Persons with cardiovascular disorders

ANS: C The conjugated product is especially designed for young children. Unconjugated vaccine is recommended for older adults and those with cardiovascular disorders. DIF: Cognitive Level: Comprehension REF: p. 585 OBJ: 5 TOP: Pneumonia Vaccine KEY: Nursing Process Step: Implementation

22. A 10-year-old boy tells a nurse that he wants to give his kidney to his grandfather. How many years of age should the nurse explain that kidney donors must be? a. At least 14 years old b. At least 16 years old c. At least 18 years old d. At least 21 years old

ANS: C The donor must be at least 18 years old, have no systemic disease, and have normal renal function. DIF: Cognitive Level: Knowledge REF: p. 934 OBJ: 1 TOP: Kidney Donor KEY: Nursing Process Step: Implementation

9. A patient has been given an antithyroid drug called propylthiouracil. What appropriate nursing implementations should be included? a. Using special radioactive precautions for her urine for the first 24 hours b. Monitoring her vital signs and withholding the medications if her pulse is greater than 100 beats/min c. Teaching her to watch for and report any signs and symptoms of hypothyroidism or infections d. Keeping her on a low-calorie, low-protein diet

ANS: C The drug targets the thyroid gland to slow its function. Thionamides may cause suppression of neutrophils leading to a lowered resistance. DIF: Cognitive Level: Application REF: p. 1041 OBJ: 3 TOP: Antithyroid Medications KEY: Nursing Process Step: Implementation

13. Which assessment indicates to the nurse that the chest tube in a water seal drainage device is working correctly? a. Constant bubbling in the suction control chamber b. Decrease of accumulation in the drainage chamber c. Fluctuation of the column of water in the water seal d. Constant bubbling in the water seal chamber

ANS: C The fluctuation of the level in the water seal indicates patency of the tubes with the reinflating lung. Constant bubbling in the wet suction control is normal. Constant bubbling in the water seal indicates an air leak. Decreasing drainage is normal. DIF: Cognitive Level: Comprehension REF: p. 575-576 OBJ: 4 TOP: Water Seal Drainage KEY: Nursing Process Step: Assessment

23. What should a nurse emphasize regarding the rehabilitation of the patient with an SCI? a. Rehabilitation is usually achieved within a few months after stabilization. b. Rehabilitation will return the patient with an SCI to the preaccident functional level. c. Rehabilitation focuses on adjustments necessary to reenter society and the workplace. d. Rehabilitation completely targets self-care.

ANS: C The goals of rehabilitation are modification of lifestyle, as well as expectations and adjustments, necessary to attain the highest level of independence possible. DIF: Cognitive Level: Comprehension REF: p. 526 OBJ: 7 TOP: Rehabilitation KEY: Nursing Process Step: Planning

27. What should the nurse implement before giving an enteral feeding to a patient? a. Palpate the abdomen to check for residual feeding. b. Warm the feeding. c. Elevate the head of the bed 30 degrees. d. Ask the patient to tip his head forward.

ANS: C The head of the bed should be elevated 30 degrees to prevent aspiration. DIF: Cognitive Level: Application REF: p. 466 OBJ: 7 TOP: Enteral Feedings KEY: Nursing Process Step: Implementation

5. The self-care goal of a patient with diabetes is to keep the blood sugar within normal limits. What causes hyperglycemia to occur? a. Blood glucose levels rise, stimulating the production of insulin. b. Insulin conversion of glycogen to glucose is inhibited. c. The body responds to glucose-starved tis-sues by changing stored glycogen into glucose. d. Glycogen is unable to be stored in the liver and muscles.

ANS: C The hypothalamus is receiving a message that the cells need glucose, so it responds by adding more glucose to the already overburdened blood. DIF: Cognitive Level: Comprehension REF: p. 1059 OBJ: 3 TOP: Hyperglycemia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

4. What does the lack of insulin in patients with type 1 diabetes cause that increases the risk for cardiovascular disorders? a. High glucose levels that irritate and shrink the vessels b. Inadequate metabolism of proteins, which causes ketosis c. Increased fatty acid levels d. Increased metabolism of ketones, which causes hypertension

ANS: C The increase in fatty acid levels causes an increase in the level of triglycerides and an attendant rise in low-density lipoprotein levels. DIF: Cognitive Level: Knowledge REF: p. 1059-1060 OBJ: 5 TOP: Diabetes: Complications KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

12. What nursing action should be implemented when irrigating a patient's ear? a. Straighten the ear canal and irrigate with a large-tipped bulb syringe. b. Direct the solution to the middle of the canal to avoid damaging the ear. c. Use a body temperature solution and have the patient hold a basin under the ear while directing the solution toward the top of the canal. d. Repeat the irrigation with hotter water.

ANS: C The irrigation is done with warm water using a small-tipped syringe. The flow is directed upward. If the cerumen does not wash out, the procedure can be repeated but with the same water temperature. DIF: Cognitive Level: Application REF: p. 1257 OBJ: 3 TOP: Irrigation KEY: Nursing Process Step: Implementation MSC:

8. Which technique of opening the airway in the newly admitted patient with an SCI is the most appropriate? a. Chin lift b. Head tilt c. Jaw thrust d. Neck flexion

ANS: C The jaw thrust does not require spinal movement. DIF: Cognitive Level: Comprehension REF: p. 518 OBJ: 6 TOP: Opening Airway KEY: Nursing Process Step: Implementation

1. A patient believed to have acromegaly asks the purpose of the diagnostic glucose tolerance test (GTT). What is the most accurate response by the nurse? a. "The doctor wants to know if you have either diabetes or acromegaly." b. "The growth hormone will cause the glucose to be used up very quickly during the test." c. "It measures the growth hormone in the presence of oral glucose levels at specified times." d. "It tells whether your thyroid reacts to the high levels of sugar taken during this test."

ANS: C The level of growth hormone will drop in the presence of oral glucose. In a patient with acromegaly, the growth hormone level drops dramatically. The GTT is the best diagnostic tool for acromegaly. DIF: Cognitive Level: Comprehension REF: p. 1010-1011 OBJ: 2 TOP: Acromegaly KEY: Nursing Process Step: Implementation

20. Which outcome criterion is the most appropriate for a patient with "Imbalanced nutrition, related to dysphagia, with the goal of adequate nutrition"? a. Offers a variety of food groups b. Eats half of all meals offered c. Maintains body weight of 150 to 155 lb d. Eats all meals independently

ANS: C The maintenance of a desired weight is indicative of adequate nutrition. Eating a portion of a meal or eating independently does not adequately measure the extent to which the goal was met. Offering a variety of foods is a nursing or dietary function, not an outcome. DIF: Cognitive Level: Application REF: p. 504 OBJ: 9 TOP: Rehabilitation: Nutrition KEY: Nursing Process Step: Planning

14. What should a nurse include when planning education to a patient with Addison disease? a. Discontinue hormonal replacement therapy if the patient becomes nauseated or has diarrhea. b. Decrease medication if the patient is under stress or is being treated for an infection. c. Wear a medical alert tag and carry emergency dexamethasone. d. Begin a vigorous exercise program to overcome weakness and muscle wasting.

ANS: C The medical alert bracelet will reduce the patient's risk of not receiving appropriate and timely care in an emergency situation. DIF: Cognitive Level: Application REF: p. 1027 OBJ: 4 TOP: Addison Disease KEY: Nursing Process Step: Implementation

5. During a neurologic assessment, a nurse asks a patient to dorsiflex the foot against the resistance of the nurse's hand. The patient is unable to perform this action. Where does this assessment confirm that cord damage has occurred? a. C4 to C5 b. L2 to L4 c. L5 d. S1

ANS: C The muscle group that controls the feet is at L5. DIF: Cognitive Level: Comprehension REF: p. 515-517 OBJ: 2 TOP: Neurologic Assessment KEY: Nursing Process Step: Assessment

12. What is the most appropriate nursing diagnosis for a patient who has had nose surgery? a. Risk for imbalanced body temperature b. Social isolation c. Decreased cardiac output d. Risk for activity intolerance

ANS: C The nose has a large number of blood vessels, which cause a great deal of bleeding during surgery. Decreased cardiac output is the postoperative result. DIF: Cognitive Level: Application REF: p. 539 OBJ: 5 TOP: Nasal Surgery KEY: Nursing Process Step: Planning

17. Which implementation is appropriate in the care plan for a visually impaired person? a. Leaving the bed in the highest position b. Keeping the door closed c. Announcing your presence when you enter and leave the room d. Leaving the radio on all the time to help the patient know the time of day

ANS: C The nurse should announce her or his presence in the room and address the patient before touching him or her. The bed should be in the lowest position, and the door should be open to avoid social isolation. DIF: Cognitive Level: Application REF: p. 1232 OBJ: 6 TOP: Implementation KEY: Nursing Process Step: Implementation MSC:

27. What purposes exist for a stent in the carotid artery of a person with a TIA? (Select all that apply.) a. Capture circulating clots. b. Help with subsequent angioplasties. c. Keep the artery open. d. Prevent hemorrhage. e. Measure the pressure in the artery.

ANS: C The only purpose of a stent is to keep an artery open. DIF: Cognitive Level: Knowledge REF: p. 485 OBJ: 3 TOP: Use of Stent KEY: Nursing Process Step: Implementation

8. A patient with type 2 diabetes shows a blood sugar reading of 68 at 6 AM. What action should the nurse implement based on the reading of 72 mg/dL? a. Notify the charge nurse of the reading. b. Give regular insulin per a sliding scale. c. Give him 8 oz of skim milk. d. Administer the oral glucose tablet.

ANS: C The patient is hypoglycemic and needs an immediate source of glucose, such as milk or orange juice. The oral hypoglycemic agent will not work quickly enough. The charge nurse can be notified later. Giving insulin per a sliding scale would lower the blood sugar level. DIF: Cognitive Level: Application REF: p. 1064 OBJ: 10 | 11 TOP: Hypoglycemic Reaction KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

15. What significant instruction should a nurse include to a patient being discharged after ear surgery? a. Use stool softeners with caution. b. Assume your usual activities. c. Avoid blowing your nose. d. Shampoo your hair with baby shampoo.

ANS: C The patient should avoid blowing the nose to prevent back pressure in the eustachian tube. The patient should take stool softeners, limit activity until balance returns, and delay shampooing. DIF: Cognitive Level: Application REF: p. 1259-1260 OBJ: 7 TOP: Nursing Diagnosis and Outcome Criteria KEY: Nursing Process Step: Implementation MSC:

24. How should a nurse position a patient during a thoracentesis? a. Side-lying with bed in a Trendelenburg position b. High Fowler position with feet elevated c. Sitting on the side of the bed bent over bedside table d. Prone with the bed elevated

ANS: C The patient sits on the side of the bed and leans the upper torso over the bedside table with the head resting on folded arms or pillows. If the patient is unable to sit up, then a side-lying position with the head of the bed elevated 30 degrees may be used. DIF: Cognitive Level: Application REF: p. 569 OBJ: 3 TOP: Thoracentesis KEY: Nursing Process Step: Implementation

1. A nurse in the outpatient clinic notes that a patient has been treated for syphilis three separate times in the past 2 years. What should the antibiotic treatment for this patient consist of this time? a. Penicillin G b. Penicillin G today and a follow-up with another injection in 1 month c. Penicillin G today and 3 months of oral tetracycline antibiotic medications d. Penicillin G today and a 2-month protocol of oral antiviral agents

ANS: C The patient who has had syphilis for more than 1 year will need a long-term antimicrobial remedy, as well as an initial dose of penicillin G. Antiviral agents are not used in the treatment of a bacterial disease. DIF: Cognitive Level: Comprehension REF: p. 1172-1173 OBJ: 4 TOP: Drug Protocol for Syphilis KEY: Nursing Process Step: Planning

24. A patient with a chlamydial infection is taking a 7-day course of doxycycline (Vibramycin). What information should the nurse provide? a. Return in 1 month for a follow-up culture. b. Take the drug on an empty stomach with a minimum of fluid. c. Delay sexual activity until cured. d. Expect genital or anal itching or burning.

ANS: C The patient with a chlamydial infection should delay sexual activity until completely clear. Follow-up cultures are obtained 4 to 7 days after the initiation of the drug, and the drug should be taken with food or milk. DIF: Cognitive Level: Application REF: p. 1169-1170 OBJ: 6 TOP: Vibramycin KEY: Nursing Process Step: Implementation

4. Which assessment leads the emergency department nurse to suspect that a patient's spinal cord injury (SCI) is below C4? a. Voluntary eye movement b. Ability to blink the eyelids c. Unlabored respiration d. Ability to make a facial grimace

ANS: C The phrenic nerve, which is at C1 to C4, controls the diaphragm and intercostal function for ventilation. DIF: Cognitive Level: Comprehension REF: p. 516 OBJ: 3 TOP: Level of SCIs KEY: Nursing Process Step: Assessment

5. A patient asks about his laboratory test, which showed a high level of thyroid-stimulating hormone (TSH) and a low level of T4. What is the most accurate explanation? a. "It means that you have an inconsistency in your thyroid tests, and you will need more testing." b. "I am sorry. You will have to ask your physician about your laboratory results. We are not allowed to discuss them." c. "The TSH is sending a message to your thyroid gland to increase production, but your thyroid isn't producing enough hormone." d. "That means that you will have to go on hormone therapy for the rest of your life."

ANS: C The test determines whether the problem is in the pituitary gland or in the thyroid gland. In this patient, the high level of TSH is coming from the pituitary gland as it should, but the thyroid gland is not responding with adequate hormone production. DIF: Cognitive Level: Comprehension REF: p. 1036 OBJ: 2 TOP: Thyroid Laboratory Tests KEY: Nursing Process Step: Implementation

2. What is the function of the tonsils and adenoids in small children? a. Help promote antibody formation b. Assist in some digestive processes c. Protect against bacterial infections of the throat d. Support blood cell production

ANS: C The tonsils and adenoids consist of lymphatic tissue that acts as a bacterial barrier for the respiratory and gastrointestinal tracts. DIF: Cognitive Level: Knowledge REF: p. 532 OBJ: 4 TOP: Tonsils KEY: Nursing Process Step: Implementation

11. A 16-year-old girl seen in the student health clinic has been diagnosed with Trichomonas vaginalis and given medication for the infection. What should a nurse explains about treatment of the girl's sexual partner? a. He will require a 1-day treatment with the same drug. b. He will not develop the infection or require treatment. c. He will be treated, although he is asymptomatic. d. He is required by law to be examined by a physician.

ANS: C The woman's sexual partner(s) may be treated for some infections to avoid reinfection. DIF: Cognitive Level: Comprehension REF: p. 1106 OBJ: 5 TOP: Trichomonas vaginalis KEY: Nursing Process Step: Implementation

16. Which findings are expected when assessing a patient with Cushing syndrome? a. Edema of the trunk, extremities, and face b. Wasting of the abdomen with thick, calloused skin c. Excess adipose tissue in the trunk, slender extremities, and moon face d. High levels of potassium and low levels of sodium, weakness, and wasting

ANS: C Truncal obesity, thin extremities, and moon face are the classical signs of Cushing syndrome caused by long-term corticosteroid therapy. DIF: Cognitive Level: Comprehension REF: p. 1031 OBJ: 1 TOP: Cushing Syndrome KEY: Nursing Process Step: Assessment

1. A nurse explains that type 1 diabetes mellitus is a disease in which the body does not produce enough insulin. What is the reason that the blood glucose is elevated? a. Prolonged elevation of stress hormone (cortisol, epinephrine, glucagon, growth hormone) levels b. Malfunction of the glycogen-storing capa-bilities of the liver c. Destruction of the beta cells in the pancreas d. Insulin resistance of the receptor cells in the muscle tissue

ANS: C Type 1 diabetes mellitus is a disease in which the pancreas does not produce adequate insulin be-cause of the destruction of beta cells. DIF: Cognitiv`e Level: Comprehension REF: p. 1059 OBJ: 2 TOP: Type 1 Diabetes Mellitus KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

14. The stages of shock proceed in a definite sequence. What is the correct order? a. Progressive, compensatory, refractory b. Refractory, progressive, compensatory c. Compensatory, progressive, refractory d. Distributive, compensatory, refractory

ANS: C Understanding the sequence of the progression of shock allows the medical team to plan and implement the correct steps to reverse it. DIF: Cognitive Level: Knowledge REF: p. 303 OBJ: 1 TOP: Stages of Shock KEY: Nursing Process Step: N/A

23. A mother of a 6-foot, 2-inch, 16-year-old girl who is being treated for hyperpituitarism says, "I can't stand it that my beautiful daughter is a freak." What is the nurse's best response? a. "Gigantism is treatable." b. "Her height could help her be a basketball star or a model." c. "What is it about her height that makes her a freak?" d. "All parents feel responsible when their children have problems."

ANS: C Using a question that encourages further discussion will help the nurse understand the distress that the parent is trying to convey. Listening to the parents' concerns helps them get in touch with their own feelings. DIF: Cognitive Level: Application REF: p. 1010-1015 OBJ: 1 TOP: Gigantism KEY: Nursing Process Step: Implementation

18. Which assessment indicates that a patient with a CVA is in transition to the rehabilitation phase? a. BP has been within normal limits for 24 hours. b. Patient makes positive statements about his condition. c. No further neurologic deficits are observed. d. Successful attempts are made at independent function.

ANS: C When no further deficits are noted and all vital signs have stabilized, the patient is considered to be in the rehabilitation phase. Positive statements and attempts at independence are not sufficient. DIF: Cognitive Level: Application REF: p. 502 OBJ: 8 TOP: Rehabilitation Phase KEY: Nursing Process Step: Assessment

4. What should a nurse assessing a patient in the progressive stage of shock expect to find? a. Bounding pulse, decreased respirations, and decreased blood pressure b. Bounding pulse, shallow respirations, and significantly increased blood pressure c. Thready pulse and deep respirations with decreased blood pressure d. Thready pulse and irregular respirations with increased blood pressure

ANS: C When the heart fails as a pump, the pulse is weak; the respirations increase in an effort to decrease the carbon dioxide level; and, with less volume being pumped, the blood pressure falls. DIF: Cognitive Level: Comprehension REF: p. 304 OBJ: 3 TOP: Signs of Shock KEY: Nursing Process Step: Assessment

14. A female student, seen in the campus clinic, states that she uses feminine hygiene douches every day and after intercourse. What is the best response from the nurse? a. "Douching has been used as an effective means of birth control for years." b. "Commercially prepared douches will neutralize the female vaginal tract." c. "Douching should only be done when ordered by a physician or nurse practitioner." d. "Douching protects the vaginal tract from microorganisms."

ANS: C Women should not douche unless it is ordered by a physician or nurse practitioner. DIF: Cognitive Level: Comprehension REF: p. 1098 OBJ: 3 TOP: Douching KEY: Nursing Process Step: Implementation

31. A nurse is caring for a despondent young female patient with an SCI at C5. The patient verbalizes concern regarding sexual dysfunction. What should the nurse assure this patient she can still experience? (Select all that apply.) a. Vaginal sensation b. Vaginal orgasm c. Normal menses d. Intercourse e. Children

ANS: C, D, E Intercourse, normal menses, and childbirth are all possible for a woman with a C5 lesion, but no vaginal sensation occurs. Orgasm is possible but not vaginally stimulated. DIF: Cognitive Level: Comprehension REF: p. 517 OBJ: 3 TOP: Risk for Sexual Dysfunction KEY: Nursing Process Step: Implementation

28. What medical history information is significant to potential bleeding problems? (Select all that apply.) a. Drinks two glasses of wine a day b. Eats red meat three times a week c. Takes nonsteroidal antiinflammatory drugs (NSAIDs) for the relief of arthritic pain four times a day d. Has hepatitis B e. Had a cardiac valve replaced 6 months earlier

ANS: C, D, E NSAIDs and liver disorders enhance the probability of bleeding. The valve replacement of a few months earlier suggests that the patient is using anticoagulant drugs. DIF: Cognitive Level: Comprehension REF: p. 625 OBJ: 2 TOP: Factors Predisposing to Bleeding Tendency KEY: Nursing Process Step: Assessment MSC:

29. How does a lacunar stroke differ from an ischemic CVA? (Select all that apply.) a. Causes a great deal of pain b. Alters the personality c. Affects small arteries d. Nearly always results in blindness e. Produces a small amount of neurologic damage

ANS: C, E The lacunar CVA only affects small arteries and produces a small amount of neurologic damage. DIF: Cognitive Level: Comprehension REF: p. 488 OBJ: 2 TOP: Lacunar CVA KEY: Nursing Process Step: Implementation

3. A patient experienced a period of momentary confusion, dizziness, and slurred speech but recovered in 2 hours. Which assessment in the diagnosis of this episode would be most helpful? a. Patient's complaint of nausea b. Blood pressure (BP) of 140/90 mm Hg c. Patient's complaint of headache d. Auscultation of a bruit over the carotid artery

ANS: D A carotid bruit is evidence of a narrowing in that vessel, a symptom of a possible CVA or transient ischemic attack (TIA). BP of 140/90 mm Hg, although at the high end, is considered within normal limits. Headache and nausea alone are too common to be definitive. DIF: Cognitive Level: Application REF: p. 485 OBJ: 2 TOP: TIA Diagnosis KEY: Nursing Process Step: Assessment

5. What does age-related relaxation of the esophageal sphincter in a 70-year-old patient cause? a. Excessive belching b. Dumping syndrome c. Tickling sensation, requiring frequent coughing d. Burning in the throat when lying down

ANS: D A common age-related change in the throat is a weakened esophageal sphincter. This allows gastric contents to flow back up into the throat and irritate the larynx. Elevating the head of the bed is a common treatment. DIF: Cognitive Level: Comprehension REF: p. 533 OBJ: 4 TOP: Age-Related Changes KEY: Nursing Process Step: Implementation

26. What should a nurse explain when a patient with an SCI inquires what the physician means by a cone-down? a. A cone is surgically placed over the spine to protect the cord. b. Marks will be placed on either side of the injury to mark the area. c. A cone-shaped wedge of bone will be placed between the vertebrae. d. A detailed radiographic image will be taken of the spinal injury.

ANS: D A cone-down radiographic image provides a very detailed picture of the lesion. DIF: Cognitive Level: Knowledge REF: p. 510 OBJ: 2 TOP: Cone-Down X-Ray KEY: Nursing Process Step: Implementation

11. What does electroretinography measure? a. A fluorescein dye is injected intravenously (IV) into a vein in the arm, and the retina is observed as the dye circulates. b. Electrodes are placed on the scalp, each eye is stimulated, and retinal activity is assessed. c. A small plunger is used to apply pressure on the sclera while the retinal vessels are evaluated. d. A contact lens electrode is placed on the eye and exposed to flashes of light to evaluate the retinal response.

ANS: D A contact lens electrode is placed on the eye, and retinal activity is assessed as lights are flashed into the eye. The other three options describe fluorescein angiography, visual-evoked response, and tonometry. DIF: Cognitive Level: Knowledge REF: p. 1224-1225 OBJ: 2 TOP: Electroretinography KEY: Nursing Process Step: Implementation MSC:

23. The nursing staff decides on a nursing diagnosis of "Imbalanced nutrition: less than body requirements for a patient with leukemia." Which goal is most realistic for this patient? a. To gain 5 lb, eat foods high in calories at each meal. b. To avoid nausea, eat slowly, and eat small meals. c. To consume all food at every meal, offer three large meals. d. To maintain a stable weight, eat small meals, and avoid vomiting.

ANS: D A goal for "Imbalanced nutrition: less than body requirements" would be maintaining a stable weight. DIF: Cognitive Level: Comprehension REF: p. 656 OBJ: 6 TOP: Nursing Care of Leukemia Patients KEY: Nursing Process Step: Planning

12. A pregnant patient with HSV type 2 has a Herp-Test performed in the physician's office 1 day before she is due to deliver by cesarean section. The test result is negative. What should the nurse know this means? a. The delivery must be by cesarean section. b. The patient must start on an antiviral protocol today. c. The baby will have to have antiviral medication 24 hours after birth. d. The delivery may be accomplished vaginally.

ANS: D A negative Herp-Test result shows no active viral disease, and the birth can be accomplished vaginally if the physician prefers. DIF: Cognitive Level: Comprehension REF: p. 1166 OBJ: 4 TOP: Herp-Test KEY: Nursing Process Step: Planning

16. A patient with diabetes says that he needs a hearing aid because he cannot hear well, and everything sounds garbled and distant. What type of hearing loss should the nurse suspect? a. Mixed hearing loss b. Conductive hearing loss c. Central hearing loss d. Sensorineural hearing loss

ANS: D A patient with long-term diabetes may have a sensorineural hearing loss that is not helped by hearing aids. DIF: Cognitive Level: Comprehension REF: p. 1261 OBJ: 5 TOP: Types of Hearing Loss KEY: Nursing Process Step: Assessment MSC:

4. A nurse is alerted by the laboratory regarding a patient's complete blood count that shows a large shift to the left. What should the nurse assess this to mean about cell level count? a. Neutrophils have dropped by 10%. b. Basophils have increased by 25%. c. Neutrophils have increased by 25%. d. Neutrophils have increased by 60%.

ANS: D A shift to the left indicates a sharp rise in the neutrophils to approximately 60%. The outpouring of these cells from the marrow indicates a serious and perhaps overpowering infection. Many of the cells are young and will not be able to keep up their work of immunity for as long as more mature cells would maintain immunity. DIF: Cognitive Level: Comprehension REF: p. 651 OBJ: 3 TOP: Nursing Diagnosis KEY: Nursing Process Step: Nursing Diagnosis

22. A skin test shows redness and swelling a few days after injection. What type of hypersensitivity reaction should the nurse document? a. I b. II c. III d. IV

ANS: D A type IV reaction is set in motion when immune cells migrate to the site of an antigen exposure and set up a local inflammatory response. DIF: Cognitive Level: Application REF: p. 657 OBJ: 5 TOP: Hypersensitivity Reactions KEY: Nursing Process Step: Evaluation

22. A patient at the outpatient clinic who has received an intramuscular dose of ceftriaxone sodium (Rocephin) calls and complains of pain and induration at the injection site. What should the nurse advise the patient to do? a. Undergo 30 minutes of active exercise to speed absorption of the drug. b. Make an appointment at the clinic for evaluation to initiate another drug. c. Immediately come to the clinic for treatment of the allergic reaction. d. Place a warm compress on the area.

ANS: D A warm compress may be applied to the area because these symptoms are the expected results of the injection, not allergic reactions. Another drug is not needed. DIF: Cognitive Level: Application REF: p. 1167 OBJ: 6 TOP: Rocephin KEY: Nursing Process Step: Implementation

14. A gynecologist caring for a pregnant patient who has gonorrhea prescribed cefixime (Suprax) instead of the more common tetracycline hydrochloride (Achromycin). What is the rationale for this decision? a. Gonorrhea is less likely to be resistant to Suprax. b. Achromycin requires a longer treatment protocol than Suprax. c. Suprax is a more potent drug that Achromycin. d. Achromycin is contraindicated in a patient who is pregnant.

ANS: D Achromycin is contraindicated during pregnancy and lactation. DIF: Cognitive Level: Application REF: p. 1170 OBJ: 6 TOP: Drugs to Treat STIs KEY: Nursing Process Step: Planning

25. What type of bone marrow transplant uses the patient's own bone marrow? a. Allergenic b. Allogeneic c. Peripheral blood stem cell d. Autologous

ANS: D An autologous bone marrow transplant uses the patient's own bone marrow. DIF: Cognitive Level: Knowledge REF: p. 653 OBJ: 3 TOP: Bone Marrow Transplantation KEY: Nursing Process Step: Implementation

4. A nurse is assessing a patient with AIDS for risk factors. What is recognized as the most risky behavior in the patient history? a. Oral sex without contact with the glans penis b. Oral sex with a condom c. Use of sex toys d. Anal sex with a condom

ANS: D Anal sex, even with a condom, is a higher risk behavior than the other three options. DIF: Cognitive Level: Comprehension REF: p. 667 OBJ: 3 TOP: Risk Factors KEY: Nursing Process Step: Assessment

4. What should a nurse explain to a young man being treated for infertility as the purpose of a semen analysis? a. Determine the history of sexually transmitted infections. b. Evaluate the potential for genetic problems. c. Determine whether any urethral obstructions are present. d. Microscopically assess the sperm for number and motility.

ANS: D Analysis of the semen is performed to assess male fertility based on number, appearance, and motility of the sperm. DIF: Cognitive Level: Knowledge REF: p. 1142 OBJ: 2 TOP: Semen Analysis KEY: Nursing Process Step: Assessment

24. What should a nurse include in a patient's plan of care when considering interventions for the outcome of prevention of contractures in a patient with an SCI? a. Apply cold wraps to the limbs twice a day. b. Perform full ROM exercises every 2 hours. c. Use significant tactile stimuli each shift. d. Apply splints to the limbs.

ANS: D Applying splints will reduce contractures. Cold application, agitation of the limb with ROM exercises too frequently, and tactile stimuli increase spasticity. DIF: Cognitive Level: Application REF: p. 524 OBJ: 7 TOP: Rehabilitation KEY: Nursing Process Step: Planning

7. What should patient education for a patient being given nose drops for the first time include? a. Asking the patient to sit down and tip her head to the side to allow for a better angle for the instillation of the drops b. Holding the dropper against the side of the nose so that all the medication flows into the nares c. Asking the patient to return any unused medication to the bottle d. Tipping the head back and holding the dropper over the nostril and then telling the patient to keep her head back for a few minutes

ANS: D Appropriate instillation of nose drops requires that the head be tipped back and the bottle not touch the nose. DIF: Cognitive Level: Comprehension REF: p. 535 OBJ: 3 TOP: Nose Drops KEY: Nursing Process Step: Implementation

9. A nurse notes ulcerations on the surfaces of a patient's toes. What should this assessment most likely indicate? a. Skin breakdown from pressure b. Nutritional deficit c. Venous stasis d. Arterial stasis

ANS: D Arterial stasis ulcers on the tips of the patient's toes are indicators of arterial insufficiency. This is a serious and probably progressive disorder that leads to further risk of impaired skin integrity. DIF: Cognitive Level: Application REF: p. 742 OBJ: 2 TOP: Arterial Toe Ulcers KEY: Nursing Process Step: Assessment MSC:

7. A patient reports that her hearing loss has become more severe over the past 3 months. The clinic nurse makes arrangements for an evaluation for a hearing aid. What health care provider should provide this service? a. Otologist b. Otolaryngologist c. Audiometrist d. Audiologist

ANS: D Audiologists assess patients for hearing aids. The other specialists treat ear, nose, and throat (ENT) disorders. DIF: Cognitive Level: Knowledge REF: p. 1253 OBJ: 7 TOP: Audiometry KEY: Nursing Process Step: Implementation MSC:

16. A nurse is evaluating the goal of teaching for the nursing diagnosis of "Knowledge deficit, related to conservation of energy in a patient with multiple sclerosis" (MS). Which statement by the patient indicates a positive outcome? a. "Now that I am taking steroids, I will be able to work like I used to." b. "I'm making a list of things that are important and things I will simply have to let go." c. "I will make a plan to allow for long rest periods at least four times a day." d. "I am working on balancing time among rest, work, and family time."

ANS: D Balancing time between various activities indicates that the patient with MS understands the need to conserve energy, not just to give up things or attempt to perform at a preillness level. DIF: Cognitive Level: Application REF: p. 470-472 OBJ: 7 TOP: Altered Energy in Patients with Multiple Sclerosis (MS) KEY: Nursing Process Step: Evaluation

14. What is the appropriate action of the nurse when assessing for hemorrhage in a postthyroidectomy patient? a. Assess upper chest for the patient positioned in high Fowler position. b. Turn the patient to the side to check; the patient must be kept flat in the bed. c. Lift up the neck dressing to assess for excessive bleeding. d. Examine behind patient's neck and upper back to assess for hemorrhage.

ANS: D Because the dressing is on the front of the neck, blood might flow under the dressing to the back of the neck, since it flows to the most-dependent position. Patients are positioned in a high Fowler position after a thyroidectomy to diminish swelling. DIF: Cognitive Level: Application REF: p. 1045 OBJ: 3 TOP: Postthyroidectomy Care KEY: Nursing Process Step: Implementation

15. A 16-year-old patient with acute glomerulonephritis complains of boredom with bed rest and asks when he can become more active. He asks, "What has to happen for me to get off of bed rest?" What is the most accurate statement by the nurse? a. Dialysis starts. b. The antibiotic protocol is completed. c. Potassium levels are normal. d. Blood pressure drops to normal levels.

ANS: D Bed rest, when ordered, is for the protection of the patient because of high blood pressure. Bed rest will continue until the treatment causes diuresis and a drop in the blood pressure. DIF: Cognitive Level: Application REF: p. 912 OBJ: 6 TOP: Glomerulonephritis with Bed Rest KEY: Nursing Process Step: Implementation

8. A nurse is explaining to a family member the pathophysiologic characteristic of vasogenic shock. What information should the nurse include? a. The intravascular compartment fills beyond capacity, allowing fluid to leak out, compressing vital organs. b. The circulating volume causes excessive constriction of the vessels, causing blood pooling. c. Widely fluctuating blood pressures stimulate vascular collapse, causing severe alterations in peripheral perfusion. d. Although the circulating volume is intact, excessive vascular dilation causes drastic drops in the blood pressure.

ANS: D Blood pooling from dilated vessels drops the blood pressure without loss of circulating volume. DIF: Cognitive Level: Knowledge REF: p. 302 OBJ: 2 TOP: Vasogenic Shock KEY: Nursing Process Step: Implementation

16. A patient with an SCI begins to have seizures, and the blood pressure (BP) rises rapidly to 210/160 mm Hg. Which is the third indicator of the syndrome of autonomic dysreflexia? a. Profuse vomiting b. Hives on face and neck c. Excessive urine output d. Bradycardia

ANS: D Bradycardia, hypertension, and seizure are the three signs of autonomic dysreflexia. DIF: Cognitive Level: Knowledge REF: p. 516 OBJ: 3 TOP: Autonomic Dysreflexia KEY: Nursing Process Step: Assessment

15. Which three symptoms are characteristic of Cushing triad associated with increased ICP? a. Hypotension, tachycardia, and narrowing pulse pressure b. Hypertension, tachycardia, and headache c. Widening pulse pressure, headache, and seizure d. Bradycardia, hypertension, and widening pulse pressure

ANS: D Bradycardia, increasing BP, and widening pulse pressure are all signs of increased ICP. DIF: Cognitive Level: Knowledge REF: p. 452 OBJ: 6 TOP: Increased ICP: Cushing Triad KEY: Nursing Process Step: Assessment

9. Brown-Séquard syndrome results in which neurologic deficit? a. Bilateral loss of pain sensation below the level of injury b. Bilateral loss of temperature and motor function below the level of injury c. Motor and sensory loss in the upper extremities only d. Ipsilateral loss of motor function and contralateral loss of pain sensation and temperature

ANS: D Brown-Séquard syndrome is a hemisection of the cord resulting in ipsilateral motor loss and contralateral loss of pain and temperature. DIF: Cognitive Level: Knowledge REF: p. 515 OBJ: 3 TOP: Brown-Séquard Syndrome KEY: Nursing Process Step: Assessment

15. A nurse collecting data on the reproductive system from a female patient is told that the patient has a vaginal discharge that is cottage cheese-like in appearance. What should the nurse recognize this as a common sign of? a. Pelvic inflammatory disease (PID) b. Trichomonas vaginalis infection c. Atrophic vaginitis d. Candida albicans infection

ANS: D Candida albicans infection has a distinctive odor and a cottage cheese-like appearance. DIF: Cognitive Level: Comprehension REF: p. 1105 OBJ: 4 TOP: Sexually Transmitted Infections KEY: Nursing Process Step: Assessment

14. A patient with HIV complains to the home health nurse that he has been having watery diarrhea for the past 10 days. The nurse suspects toxoplasmosis. What is the most significant question for the nurse to ask? a. "Have you stopped taking your antiviral medication?" b. "Have you been drinking alcohol?" c. "Have you been eating aged cheese or organ meats?" d. "Do you have a cat?"

ANS: D Cat litter boxes and undercooked meats are the major sources of toxoplasmosis, which causes a persistent watery diarrhea. DIF: Cognitive Level: Comprehension REF: p. 669 OBJ: 4 TOP: Toxoplasmosis KEY: Nursing Process Step: Assessment

18. What childhood exposure causes painful shingles experienced by the patient with HIV? a. Measles b. Mumps c. Impetigo d. Chickenpox

ANS: D Chickenpox can be reactivated as shingles. DIF: Cognitive Level: Knowledge REF: p. 671 OBJ: 4 TOP: Shingles KEY: Nursing Process Step: Implementation

6. What happens to the sickle-shaped red blood cells during a sickle cell crisis? a. Rupture b. Production of hemoglobin S c. Interference with blood production d. Obstruction of major arteries

ANS: D Circulatory obstruction causes severe pain in patients with sickle cell anemia, which is the major symptom in sickle cell crisis. The hemoglobin S does not, in itself, cause the crises until the cells obstruct a vessel. DIF: Cognitive Level: Comprehension REF: p. 635 OBJ: 5 TOP: Sickle Cell Anemia KEY: Nursing Process Step: Assessment MSC:

5. Which urine test provides the most accurate measurement of renal function? a. BUN b. Phosphates c. Specific gravity d. Creatinine

ANS: D Creatinine is not affected by diet, hydration, or liver function and is a better measurement of liver function than the BUN. DIF: Cognitive Level: Knowledge REF: p. 896 OBJ: 2 TOP: Creatinine KEY: Nursing Process Step: N/A

10. A patient has been admitted to the hospital with the diagnosis of DKA. What vital signs should a nurse anticipate that the patient will exhibit? a. Temperature, 99° F; pulse, 62 beats/min; respirations, 16 breaths/min and shallow b. Temperature, 98.6° F; pulse, 76 beats/min; respirations, 16 breaths/min and deep c. Temperature, 98° F; pulse, 84 beats/min; respirations, 18 breaths/min and shallow d. Temperature, 97.4° F; pulse, 110 beats/min; respirations, 26 breaths/min and deep

ANS: D DKA is caused by the attempt of the body to metabolize fat for energy, which results in an acidotic state. The classic signs of DKA are hypothermia, tachycardia, and Kussmaul respirations (rapid and deep) to blow off the acid ions via respirations. The respirations will have a fruity odor. DIF: Cognitive Level: Analysis REF: p. 1065 OBJ: 7 TOP: Diabetic Ketoacidosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

15. A home health nurse that is caring for an 88-year-old patient with severe hypertension in addition to a respiratory problem notices several drugs on the bedside table. Which medication should the nurse suggest the patient avoid? a. Aspirin b. Colace c. Expectorant d. Decongestant

ANS: D Decongestants increase the blood pressure. DIF: Cognitive Level: Application REF: p. 578 OBJ: 5 TOP: Respiratory Drugs KEY: Nursing Process Step: Assessment

9. An 11-year-old girl is diagnosed with idiopathic thrombocytopenic purpura (ITP). Which parental statement helps the nurse evaluate that teaching is successful? a. "Our daughter can still be involved in gymnastics." b. "When our daughter's hemoglobin falls below 3.5, she'll need blood." c. "Our daughter will need genetic counseling before she marries." d. "Our daughter should avoid drugs containing sulfonamides."

ANS: D Drugs known to induce ITP include sulfonamides. DIF: Cognitive Level: Application REF: p. 657 OBJ: 6 TOP: Idiopathic Thrombocytopenic Purpura Care Plan KEY: Nursing Process Step: Evaluation

5. What should a nurse expect of a patient's respirations caused by the falling blood pressure and impaired blood circulation during the refractory stage of shock? a. Rapid and deep b. Rapid and shallow c. Slow and deep d. Slow and shallow

ANS: D During the refractory stage of shock, as the body systems are failing, the respirations become slow, shallow, and irregular. Death is imminent at this stage. DIF: Cognitive Level: Application REF: p. 305 OBJ: 2 TOP: Respirations in Shock KEY: Nursing Process Step: Assessment

8. When a patient has a suspected vestibular disorder, the physician orders an electronystagmography test. Which instruction should the nurse include when educating the patient about this test? a. Use tea or coffee on the morning of test. b. Electrodes will be placed on the scalp. c. Air will be blown into the external ear. d. The patient should have nothing to eat or drink (NPO) 3 hours before the test.

ANS: D Electronystagmography is used to detect vestibular lesions and requires a 3-hour period of NPO before the test. Coffee and tea should also be avoided before the test. DIF: Cognitive Level: Comprehension REF: p. 1255 OBJ: 3 TOP: Testing for Ear Disorders KEY: Nursing Process Step: Planning MSC:

22. A patient who had a prostatectomy 1 year earlier now has elevations in serum alkaline phosphatase and calcium levels. What should the nurse be aware that this indicates? a. Reduction of cancer risk b. Orchiditis c. Testicular cancer d. Metastasis

ANS: D Elevations of the tumor marker alkaline phosphatase and an increased level of calcium indicate metastasis to the bone. DIF: Cognitive Level: Comprehension REF: p. 1152 OBJ: 3 TOP: Laboratory Tests KEY: Nursing Process Step: Assessment

24. When completing a health history with a patient, a nurse should encourage the patient to describe the symptoms in objective terms. Which statement is a good example of the description of pain? a. "This spot seems to hurt more right here." b. "This pain is the worst pain in the world." c. "My pain reminds me of when I hurt my foot last year." d. "I would say my pain is a 5 on a scale from 1 to 10."

ANS: D Encourage the patient to use descriptive terms such as stinging or aching and ask him to indicate the intensity on a scale from 1 to 10. DIF: Cognitive Level: Application REF: p. 1140 OBJ: 2 TOP: Health History KEY: Nursing Process Step: Assessment

3. A 90-year-old patient complains to the nurse of shortness of breath after walking up a flight of stairs. What age-related change should the nurse explain results in this problem? a. Flexible rib cage b. High-arched diaphragm c. Increased chest movement d. Enlarged bronchioles

ANS: D Enlarged bronchioles require the inspiration of greater amounts of air. Other age-related changes make increased inspiration difficult. DIF: Cognitive Level: Comprehension REF: p. 558 OBJ: 2 TOP: Age-Related Changes KEY: Nursing Process Step: Implementation

5. A patient receiving Epogen asks how soon an increase in the red blood cell count will occur. When should the nurse say that the initial increase in red blood cells should be seen? a. 2 days b. 1 week c. 10 days d. 2 weeks

ANS: D Epoetin alfa (Epogen) stimulates the bone marrow to produce more red blood cells in approximately 2 weeks. DIF: Cognitive Level: Comprehension REF: p. 634 OBJ: 6 TOP: Colony-Stimulating Medication KEY: Nursing Process Step: Planning MSC:

22. A nurse is helping prepare a nursing care plan for a 90-lb, 82-year-old woman with iron-deficiency anemia with a hemoglobin of 5.2. What is the most appropriate nursing diagnosis? a. Impaired tissue integrity related to immobility b. Disturbed body image related to weight loss c. Anxiety related to an unfamiliar hospital environment d. Activity intolerance related to fatigue

ANS: D Fatigue and activity intolerance are common complaints of patients with hematologic disorders. DIF: Cognitive Level: Application REF: p. 635 OBJ: 6 TOP: Hematologic Nursing Diagnosis KEY: Nursing Process Step: Nursing Diagnosis MSC:

8. What information should a nurse be sure to include when preparing discharge plans for a patient recently diagnosed with pernicious anemia? a. Adding daily high-fat, low-fiber supplements b. Adding a rigorous daily workout c. Avoiding prolonged exposure to direct sunlight d. Providing sufficient rest periods throughout the day

ANS: D Fatigue and weakness are seen in all anemias. DIF: Cognitive Level: Application REF: p. 635 OBJ: 6 TOP: Pernicious Anemia KEY: Nursing Process Step: Planning MSC:

9. A nurse is caring for a patient after a modified radical mastectomy for a breast tumor that has been determined to be positive for estrogen receptors (ER positive) and has been placed on a protocol of tamoxifen. The patient then asks the nurse, "Do you think I should take this medication?" Which statement is the most appropriate? a. "Tamoxifen will probably not be effective because your tumor was ER positive." b. "If I were you, I would do what the physician recommends." c. "I think that you should take tamoxifen, because the tumor was ER positive." d. "Tamoxifen is an option to consider, because your tumor was ER positive."

ANS: D For tumors that are ER positive, tamoxifen citrate may be prescribed because such drugs interfere with estrogen production. ER-positive tumors need estrogen to grow. DIF: Cognitive Level: Comprehension REF: p. 1122 OBJ: 4 TOP: Drugs Used in Treatment for Breast Cancer KEY: Nursing Process Step: Implementation

14. Pneumonia is the most frequent cause of death after a stroke. Which intervention would be contraindicated in the acute care of a patient with a hemorrhagic CVA? a. Thicken liquids to ease swallowing and prevent aspiration. b. Change position every 30 to 60 minutes. c. Maintain adequate fluid intake, orally or IV. d. Encourage forceful coughing to stimulate deep breathing.

ANS: D Forceful coughing is contraindicated for the patient with a hemorrhagic CVA because it may cause increased intracranial pressure. DIF: Cognitive Level: Comprehension REF: p. 497 OBJ: 8 TOP: Prevention of Pneumonia KEY: Nursing Process Step: Implementation

9. A nurse is caring for a patient who has a cervical spine injury and assesses progressive hypotension. What does this signify? a. Anaphylaxis b. Respiratory alkalosis c. Multiple organ dysfunction syndrome (MODS) d. Neurogenic shock

ANS: D Gradually decreasing blood pressure in a person with a spinal injury is an indicator of neurogenic shock related to the parasympathetic stimulation, which causes generalized vasodilation. DIF: Cognitive Level: Comprehension REF: p. 303 OBJ: 3 TOP: Implementation KEY: Nursing Process Step: Evaluation

20. A patient with Parkinson disease is considering taking St. John's wort, an herbal remedy for depression, in addition to Sinemet and L-dopa. What is the most appropriate nursing response? a. Depression is reduced by the use of herbal remedies such as St. John's wort. b. Doses of St. John's wort and parkinsonian drugs should be taken on alternate days. c. St. John's wort must be taken in large doses to reduce depression. d. Herbal remedies can interfere with the effectiveness of the parkinsonian drugs.

ANS: D Herbal remedies interfere with effectiveness of prescribed parkinsonian drugs. DIF: Cognitive Level: Application REF: p. 469 OBJ: 7 TOP: Treatment of Parkinson Disease KEY: Nursing Process Step: Implementation

11. After a bone marrow transplant, a patient is placed on a protocol of chemotherapy and radiation and the nursing diagnosis of risk for injury is added. Which nursing assessment should cause the nurse concern? a. Increased urine output b. Decreasing bilirubin levels c. Increasing blood pressure d. Increasing abdominal girth

ANS: D High doses of chemotherapy and radiation can damage the liver, which would lead to increasing abdominal girth with ascites and increasing bilirubin levels. DIF: Cognitive Level: Application REF: p. 651-653 OBJ: 6 TOP: Bone Marrow Transplantation Risk KEY: Nursing Process Step: Assessment

17. A patient with type 1 diabetes has an insulin order for NPH insulin, 35 U, to be given at 0700. The patient has also been instructed not to take anything by mouth (NPO) in preparation for laboratory work that will not be drawn until 1000. What action should the nurse implement? a. Give the insulin as ordered. b. Give the insulin with a small snack. c. Inform the charge nurse. d. Hold the insulin until after the blood draw.

ANS: D Holding the insulin to adhere to the NPO order is appropriate. The patient will not be getting food until after the laboratory work; consequently, the insulin will not be needed until then. Giving the insulin as ordered will create a possibility of hypoglycemia before the blood is drawn. Giving a snack to a patient who is NPO is inappropriate. DIF: Cognitive Level: Application REF: p. 1071-1072 OBJ: 8 TOP: Insulin with NPO Order KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

25. Which intervention is necessary to assist a patient with hypothyroidism to understand how he can live a full and normal life? a. Teach the importance of taking antithyroid medication until it is no longer needed. b. Encourage exercise to burn extra calories and maintain a normal weight. c. Teach him to take care of energy needs through adequate nutrition. d. Encourage treatment with thyroid replacement therapy.

ANS: D Hormones can adequately and effectively replace the missing thyroid hormone. DIF: Cognitive Level: Application REF: p. 1047 OBJ: 3 TOP: Hypothyroidism: Pharmacology KEY: Nursing Process Step: Implementation

13. A patient has been prescribed flutamide (Eulexin) for the treatment of prostate cancer. What possible side effect should the nurse remind the patient might occur? a. Incontinence b. Insomnia c. Weight loss d. Hot flashes

ANS: D Hot flashes, ED, edema, hypertension, and confusion are some of the side effects of flutamide. DIF: Cognitive Level: Knowledge REF: p. 1153 OBJ: 4 TOP: Flutamide KEY: Nursing Process Step: Implementation

22. How long does it take for Humulin R 20 units to peak? a. 15 minutes b. 30 minutes c. 1 hour d. 2 hours

ANS: D Humulin R has its onset in approximately 30 minutes, but its peak is in 2 hours. DIF: Cognitive Level: Knowledge REF: p. 1070 OBJ: 8 TOP: Humulin R Insulin Peak KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

12. A child with sickle cell anemia is prescribed the drug hydroxyurea. What effect from the drug should the patient expect to have? a. Increase energy b. Decrease cardiomegaly c. Clean out obstructed vessels d. Produce a hemoglobin that resists sickling

ANS: D Hydroxyurea produces a hemoglobin that resists sickling. DIF: Cognitive Level: Comprehension REF: p. 636 OBJ: 3 TOP: Hydroxyurea KEY: Nursing Process Step: Implementation MSC:

25. The wife of a husband who has had a CVA asks why he is being treated with insulin since he has no history of diabetes. What is the best response by the nurse as to why hyperglycemia occurs after a stroke? a. Brain swelling b. Hypertension c. Immobility d. Stress

ANS: D Hyperglycemia occurs after a CVA as the body's response to stress. If left untreated, the hyperglycemia will cause increased brain damage and worsen the outcome of the stroke. DIF: Cognitive Level: Comprehension REF: p. 492 OBJ: 3 TOP: Hyperglycemia KEY: Nursing Process Step: Implementation

18. A nurse is caring for a patient with an atrioventricular (AV) fistula in the forearm and assesses that a trill is absent when palpating the venous side of the fistula. What action should the nurse implement? a. Inject the ordered amount of heparin into the fistula. b. Apply warm compresses and lower the arm below the heart level. c. Send the patient to dialysis for remedy. d. Report to the charge nurse that the fistula is occluded.

ANS: D If the trill is absent, the fistula is occluded and should be reported. Dialysis is not possible with the occlusion. Injecting the shunt is not in the scope of practice of the licensed practical nurse (LPN). Warm compresses are not helpful. DIF: Cognitive Level: Application REF: p. 929-930 OBJ: 5 TOP: Occluded Fistula KEY: Nursing Process Step: Implementation

2. A nurse is caring for a patient with asthma with a nursing diagnosis of "Impaired gas exchange, related to air trapping." Which intervention is the most appropriate to add to the nursing care plan? a. Provide postural drainage. b. Administer oxygen (O2) at 8 L/min. c. Position the patient flat in bed with small pillow. d. Increase fluid intake.

ANS: D Increasing fluid intake thins the mucus in the lungs, making it easier to cough up, which helps clear the bronchioles and decrease ventilation-perfusion mismatch. Increasing O2 is not helpful if no air pathway exists to the alveoli. Increasing O2 to 8 L is excessive. DIF: Cognitive Level: Application REF: p. 603 OBJ: 3 TOP: Asthma KEY: Nursing Process Step: Implementation

16. A nurse is caring for a patient in the last stages of leukemia and is aware that the patient is at risk from the bacteria of his own body. Which is an example of internal bacteria? a. Beta-hemolytic streptococci b. Streptococcus pneumoniae c. Streptococcus viridans d. Pseudomonas aeruginosa

ANS: D Internal bacteria such as P. aeruginosa and Escherichia coli are capable of attacking the compromised immune system from inside the body. DIF: Cognitive Level: Comprehension REF: p. 656 OBJ: 5 TOP: Risk for Infection in Leukemia KEY: Nursing Process Step: Nursing Diagnosis

6. A young patient complains that diabetes is causing her to "have no life at all. It's too hard." What is the most helpful response by the nurse? a. "Yes, you must make some sacrifices." b. "It's hard, but with significant alterations in your lifestyle, you can live a long life." c. "What's hard about exercise, diet, and medicine?" d. "Let's talk about what makes it so hard."

ANS: D Involving the patient in decisions about how she will cope with her diabetes will make the goals more realistic and personal, which will give her a greater chance of success in meeting them. DIF: Cognitive Level: Application REF: p. 1081 | p. 1083 OBJ: 8 TOP: Diabetes Lifestyle KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

6. A nurse giving instruction to a patient with an STI says, "I am supposed to tell you about STIs, but you probably know more about them than I do." What is this nurse doing? a. Admitting her own ignorance about STIs b. Trying to get the patient's attention c. Referencing current statistics d. Making a judgmental statement

ANS: D Judgmental behavior on the part of health care providers discourages people from seeking appropriate medical care. DIF: Cognitive Level: Comprehension REF: p. 1179 OBJ: 5 TOP: Behavior of Health Care Workers KEY: Nursing Process Step: Implementation

3. What is the most common form of transmission of the HIV virus? a. Injection drug use b. Heterosexual contact c. Exposure to contaminated blood products d. Male to male

ANS: D Male-to-male transmission is still the most common mode. DIF: Cognitive Level: Knowledge REF: p. 664 OBJ: 3 TOP: Transmission of HIV KEY: Nursing Process Step: Planning

18. A 24-year-old woman is admitted to the hospital for a complete medical examination. Her current complaints are indicative of SLE. Which symptom would indicate this diagnosis? a. Recent weight gain of 10 lb b. Difficulty breathing in the morning c. Frequent episodes of diarrhea d. Musculoskeletal pain in the hands

ANS: D Musculoskeletal symptoms are experienced by 95% of patients with SLE at some time during the course of their disease. DIF: Cognitive Level: Comprehension REF: p. 658 OBJ: 2 TOP: Systemic Lupus Erythematosus KEY: Nursing Process Step: Assessment

2. Which patient is at the greatest risk for a CVA? a. A 20-year-old obese Latin woman who is taking birth control pills b. A 40-year-old athletic white man with a family history of CVA c. A 60-year-old Asian woman who smokes occasionally d. A 65-year-old African American man with hypertension

ANS: D Older African Americans have a higher incidence of CVA than occasional smokers, young persons, or athletes. Hypertension increases the risk. DIF: Cognitive Level: Analysis REF: p. 483 OBJ: 1 TOP: CVA Risk Factors KEY: Nursing Process Step: Assessment

22. What medication obtained in a patient's history will lessen the effects of warfarin (Coumadin)? a. Iron supplement for anemia b. Simvastatin (Zocor) for the control of cholesterol c. Furosemide (Lasix) for fluid retention d. Yaz (drospirenone/estradiol) as an oral contraceptive

ANS: D Oral contraceptives lessen the effects of warfarin (Coumadin). DIF: Cognitive Level: Knowledge REF: p. 751 OBJ: 5 TOP: Drug Therapy KEY: Nursing Process Step: Assessment MSC:

2. What should a nurse ask a patient related to past history of deep-vein thrombosis (DVT) and other vascular problems? a. An aneurysm b. Rheumatoid arthritis c. A peptic ulcer d. Recurring chest pain

ANS: D Pain in the chest or dyspnea suggests that a pulmonary embolism may have occurred from the presence of a DVT. Approximately 10% of individuals with DVT develop pulmonary emboli. DIF: Cognitive Level: Application REF: p. 741 OBJ: 4 TOP: Venous Disorders KEY: Nursing Process Step: Assessment MSC:

16. When a nurse is preparing to give ferrous sulfate (Feosol) to a home health care patient, what is the most appropriate nursing action to implement? a. Mix the drug with a high-protein milkshake. b. Give it undiluted with a small snack. c. Mix it with coffee or cola to disguise the bitter taste. d. Dilute it and offer through a straw and a few crackers.

ANS: D Patients should avoid taking iron with milk or caffeine because both inhibit drug absorption. The liquid form of the drug is offered with food in a diluted form through a straw to prevent staining the teeth. DIF: Cognitive Level: Application REF: p. 634 OBJ: 6 TOP: Administration of Feosol KEY: Nursing Process Step: Implementation MSC:

22. What should a nurse expect when assessing the CBC results of a patient with chronic bronchitis? a. Decreased platelets b. Decreased white blood cells (WBCs) c. Increased eosinophils d. Increased red blood cells (RBCs)

ANS: D Patients with chronic bronchitis show a large increase of RBCs with an attendant higher hemoglobin level because they must produce more RBCs for the transport of O2. Frequently, the WBCs are elevated because of the chronic inflammation. Decreased levels of platelets and increased eosinophils are indicative of pathologic characteristics other than bronchitis. DIF: Cognitive Level: Comprehension REF: p. 604-605 OBJ: 2 TOP: Chronic Bronchitis KEY: Nursing Process Step: Assessment

4. What should the nurse exclude when documenting the findings in the functional assessment portion of the nursing assessment for a patient with a respiratory disorder? a. Occupation b. Usual diet c. Smoking history d. Previous respiratory disorders

ANS: D Previous respiratory disorders are assessed in the medical history portion of the assessment. DIF: Cognitive Level: Comprehension REF: p. 560 OBJ: 1 TOP: Respiratory Assessment KEY: Nursing Process Step: Assessment

17. A female patient, newly diagnosed with gonorrhea, screams, "I am going to kill my husband. I mean it." What is the nurse's best response? a. "Are you sure it is your husband who gave you gonorrhea?" b. "Yikes! Killing your spouse seems extreme." c. "Shall I report your spouse as a sexual contact?" d. "I can understand your anger. How best can you deal with it?"

ANS: D Provide an opportunity to talk. Help the patient focus on the source of anxiety with the use of open-ended questions. DIF: Cognitive Level: Application REF: p. 1165 | p. 1179 OBJ: 9 TOP: STI Implementations KEY: Nursing Process Step: Implementation

12. A nurse is collecting data from a hospital patient who has been admitted with pyelonephritis. He is acutely ill with a high fever, chills, nausea, and vomiting. He also has severe pain in the flank area. What is the primary goal of treatment? a. Provide adequate nutrition with a stable body weight. b. Provide adequate hydration with pulse and blood pressure within patient norms. c. Give pain relief with analgesics and antispasmodics. d. Prevent further damage to his kidneys that could lead to renal failure.

ANS: D Pyelonephritis can cause scarring of the renal parenchyma and result in atrophy of the affected kidney, which means the kidney is failing. DIF: Cognitive Level: Application REF: p. 910 OBJ: 6 TOP: Pyelonephritis KEY: Nursing Process Step: Planning

22. A patient in the rehabilitation phase after a CVA accidentally knocks the adapted plate from the table and bursts into tears after failing to feed himself. What is the best response by the nurse? a. "Don't cry. You'll be mastering eating in no time." b. "I don't believe crying will help. Let's try drinking from a special cup." c. "Bless your heart! Let me get a new meal and feed you." d. "Learning new skills is hard. Let's see what may have caused the trouble."

ANS: D Recognizing effort and showing support are the best approaches to depression and frustration. Babying the patient and admonitions against crying add to the problem. Redirection to the task at hand is therapeutic. DIF: Cognitive Level: Application REF: p. 504 OBJ: 8 TOP: Rehabilitation: Coping KEY: Nursing Process Step: Implementation

17. Which outcome is most necessary for a patient diagnosed with renal calculi? a. Patient states an awareness of signs and symptoms of kidney stones and knows where to find pain relief. b. Patient will measure intake and output so that they will be approximately equal. c. Patient will avoid infections and situations that would increase stress. d. Patient is able to describe measures to prevent recurrence of calculi.

ANS: D Recurrence of renal calculi is common. The patient needs to possess the information necessary to understand the formation of stones to reduce the risk of their recurrence. DIF: Cognitive Level: Application REF: p. 914-915 OBJ: 6 TOP: Renal Calculi KEY: Nursing Process Step: N/A

26. What assessment should a nurse perform on a patient after the repair of an abdominal aortic aneurysm? a. Periorbital edema b. Tremor or facial twitching c. Rising blood pressure d. Bowel sounds

ANS: D Repair of aortic abdominal aneurysms cause a temporary cessation of peristalsis. Although this condition is expected, the beginning of bowel sounds indicates important progress in the recovery. Rising blood pressure is an expected recovery indication from surgery. DIF: Cognitive Level: Application REF: p. 759-760 OBJ: 4 TOP: Aneurysm of the Abdominal Aorta KEY: Nursing Process Step: Assessment MSC:

3. What is a characteristic of chronic obstructive pulmonary disease that places a patient at risk for the nursing diagnosis of "Imbalanced nutrition: Less than body requirements"? a. Increased metabolism b. Anxiety c. Chronic constipation d. Excessive respiratory effort

ANS: D Respiratory effort interferes with swallowing, depletes energy, and increases caloric needs. DIF: Cognitive Level: Comprehension REF: p. 610 OBJ: 3 TOP: COPD: Nutrition KEY: Nursing Process Step: Planning

23. A patient's family voices concern regarding the purpose of some of the interventions for systemic inflammatory response syndrome (SIRS). What explanation by the nurse is most appropriate when explaining the rationale of treatment? a. "Applying a MAST garment is mandatory to promote and conserve body heat." b. "Inserting an IABP is required to decrease fluid leaking into the extravascular space." c. "Maintaining strict isolation is vital to prevent an overlying bacterial infection." d. "Aggressive treatment is necessary to support the multiple failing organs."

ANS: D SIRS is the final and possibly fatal stage of shock. The body's defenses are supported aggressively and rapidly. MAST and IABP are measures used to increase circulating volume. Isolation is not indicated. DIF: Cognitive Level: Comprehension REF: p. 312 OBJ: 6 TOP: SIRS Treatment KEY: Nursing Process Step: Implementation

25. A patient is receiving the medication octreotide (Sandostatin) as a treatment for acromegaly. What should the nurse explain regarding this medication? a. It reverses the effects of acromegaly. b. It should be given on a daily basis by injection. c. It increases insulin secretion causing hypoglycemia. d. It suppresses the growth hormone.

ANS: D Sandostatin will suppress growth hormone, but it will not reverse the effects of acromegaly. It is administered three times a week, and suppresses insulin secretion causing hyperglycemia. DIF: Cognitive Level: Comprehension REF: p. 1013-1014 OBJ: 3 TOP: Growth Hormone Suppression KEY: Nursing Process Step: Implementation

22. A family member asks the nurse what would be an appropriate gift for a patient with Parkinson disease. What is the most useful suggestion? a. Soft-soled house shoes b. Jigsaw puzzle c. Set of card games d. Satin sheets

ANS: D Satin sheets make moving in bed easier. Card games and jigsaw puzzles are frustrating because of the palsy. Hard-soled shoes provide better support than soft-soled shoes. DIF: Cognitive Level: Comprehension REF: p. 469 OBJ: 7 TOP: Care of the Patient with Parkinson Disease KEY: Nursing Process Step: Planning

25. Which surgical implementation is most effective with retinal detachment? a. Removing the lens b. Macular bonding c. Lasik surgery d. Scleral buckling

ANS: D Scleral buckling is used to hold the retinal repair in place. The band is left in place to keep together the layers of the eye tissue. DIF: Cognitive Level: Knowledge REF: p. 1245 OBJ: 5 TOP: Retinal Detachment KEY: Nursing Process Step: N/A MSC:

14. A 3-year-old African American child is diagnosed with sickle cell anemia. The parents know that sickle cell anemia is hereditary but do not understand why their child has the disease because neither of them has it. What is the most accurate information to provide? a. At least one of the parents has to have the disease. b. Only one parent has to have the disease or the trait. c. Someone in previous generations had the disease. d. Both parents were carriers of the sickle cell trait.

ANS: D Sickle cell anemia is a genetic disease carried by the recessive genes of both parents, who will not exhibit any symptoms of the disease. DIF: Cognitive Level: Comprehension REF: p. 636 OBJ: 5 TOP: Anemia KEY: Nursing Process Step: Implementation MSC:

18. A nurse is assessing a patient with Simmonds cachexia. What symptom should the nurse anticipate the patient will exhibit? a. High body temperature b. Ruddy complexion c. Silky body hair d. Muscle wasting

ANS: D Simmonds cachexia is a panhypopituitarism condition in which muscle wasting, small organs, very pale complexion, virtually no body hair, and subnormal body temperature are symptoms. DIF: Cognitive Level: Comprehension REF: p. 1017 OBJ: 3 TOP: Panhypopituitarism KEY: Nursing Process Step: Assessment

13. A patient complains of morning headaches, a feeling of fullness in her head, and a pain similar to that of a toothache under her eye. What should the nurse recognize that these symptoms indicate? a. Nasal polyps b. Impacted wisdom teeth c. Allergic rhinitis d. Sinusitis

ANS: D Sinusitis has the classic signs of headache, sense of fullness in the head, and a sensitive area over the sinuses. DIF: Cognitive Level: Comprehension REF: p. 539-540 OBJ: 4 TOP: Sinusitis KEY: Nursing Process Step: Assessment

15. A nurse cautions a patient with peripheral vascular disease (PVD) that continued smoking causes detrimental vasoconstriction for up to ____ after only one cigarette. a. 10 minutes b. 20 minutes c. 30 minutes d. 1 hour

ANS: D Smoking restricts circulation by vasoconstriction and lasts up to 1 hour after a cigarette; it also causes vasospasm. DIF: Cognitive Level: Knowledge REF: p. 746 OBJ: 5 TOP: Smoking Cessation KEY: Nursing Process Step: Implementation MSC:

1. To what does the neural synapse refer? a. Length of time it takes for afferent neurons to carry impulses to the central nervous system (CNS) b. Length of time it takes for efferent neurons to carry impulses to the motor neurons c. Space between the axons and the dendrites of a neuron d. Space between the axons of one neuron and the dendrites of the next

ANS: D Smooth, coordinated transmission must travel from one neuron to another across the neural synapse. DIF: Cognitive Level: Knowledge REF: p. 436 OBJ: N/A TOP: Anatomy and Physiology of the Central Nervous System (CNS) KEY: Nursing Process Step: Implementation

6. A hospitalized patient has been prescribed dexamethasone (Decadron) for an allergic reaction. Which teaching instruction should the patient be given with discharge relative to this drug? a. Report blurry vision. b. Take the medication on an empty stomach. c. Do not operate heavy machinery. d. Take this medication with meals.

ANS: D Steroid therapy can cause gastrointestinal discomfort when taken on an empty stomach. DIF: Cognitive Level: Application REF: p. 660 OBJ: 4 TOP: Drug Therapy Used to Treat Immunologic Disorders KEY: Nursing Process Step: Implementation

2. An older adult patient is experiencing extreme stress related to an admission to the hospital. What should the nurse expect the patient to demonstrate? a. Decreased heart rate b. Decreased blood pressure (BP) c. Irregular respiration d. Dilation of the pupils

ANS: D Stress stimulates the fight-or-flight reaction with the release of epinephrine and norepinephrine, which causes increased heart rate and BP, reduced peristalsis, and pupil dilation. DIF: Cognitive Level: Comprehension REF: p. 438-440 OBJ: 1 TOP: Effects of Sympathetic Nervous System KEY: Nursing Process Step: Assessment

2. A nurse charts that a patient has had periods of tachypnea during the night. What does this means in regard to the respiration rate? a. Below 12 breaths/min b. Uneven, with periods of apnea c. Gradually deepening, then shallow, and then periods of apnea d. Above 20 breaths/min

ANS: D Tachypnea is a respiration rate above 20 breaths/min. Option a describes bradypnea, option b describes Biot respirations, and option c describes Cheyne-Stokes respirations. DIF: Cognitive Level: Comprehension REF: p. 559 OBJ: 1 TOP: Respiration Rate KEY: Nursing Process Step: Assessment

7. Which technique should the nurse implement when performing the Allen test on a patient to evaluate the adequacy of circulation in the radial artery? a. Asks the patient to relax the hand by the side b. Compresses only the ulnar artery to blanch the hand c. Releases pressure on both arteries at the same time d. Observes whether the color is returning to the hand, which indicates perfusion

ANS: D The Allen test is performed to evaluate circulation in the hand, both in the radial and the ulnar arteries. The patient is asked to make a fist. The nurse compresses both the ulnar and the radial artery to blanch the hand. The patient is asked to open the hand as the nurse releases pressure on one or the other of the arteries. Color returning to the hand confirms perfusion. DIF: Cognitive Level: Application REF: p. 742 OBJ: 2 TOP: Allen Test KEY: Nursing Process Step: Assessment MSC:

13. A distressed family member asks about the purpose of the Gardner-Wells tongs. Which is the most helpful explanation by the nurse regarding the action of Gardner-Wells tongs? a. Compress the cervical vertebrae. b. Immobilize the head. c. Allow the patient to be moved out of bed. d. Align the cervical vertebrae.

ANS: D The Gardner-Wells tongs are secured to the skull to separate and align the cervical vertebrae, but they do not immobilize the head. When the tongs are in place, the patient is bedridden. DIF: Cognitive Level: Comprehension REF: p. 518 OBJ: 4 TOP: Gardner-Wells Tongs KEY: Nursing Process Step: Implementation

4. What is the most reliable indicator of neurologic status? a. Blood pressure b. Pulse rate c. Temperature d. Level of consciousness

ANS: D The ability to respond readily and correctly to person, place, and time is good evidence of intact sensorium. DIF: Cognitive Level: Knowledge REF: p. 443 OBJ: 3 TOP: Neurologic Assessment KEY: Nursing Process Step: Assessment

6. A nurse is caring for a patient after urinary diversion surgery. What postoperative nursing assessment is the priority? a. Level of fluid intake b. Position on the left side c. Keep the bed flat d. Bowel sounds

ANS: D The bowel is manipulated during urinary diversion surgeries and frequently leads to the patient with a paralytic ileus. DIF: Cognitive Level: Application REF: p. 903 OBJ: 6 TOP: Urinary Diversion KEY: Nursing Process Step: Assessment

5. To auscultate breath sounds in the right middle lobe from the anterior aspect, the nurse should place the diaphragm of the stethoscope at which intercostal space? a. Second b. Third c. Fourth d. Fifth

ANS: D The fifth intercostal space is the optimal position for auscultating the right middle lobe. DIF: Cognitive Level: Application REF: p. 561 OBJ: 3 TOP: Breath Sounds KEY: Nursing Process Step: Assessment

1. What are the four types of shock? a. Multiple organ, cardiogenic, renal, and anaphylactic b. Cardiogenic, renal, hypovolemic, and septic c. Renal, hypervolemic, obstructive shock, and neurogenic d. Hypovolemic, cardiogenic, obstructive shock, and vasogenic

ANS: D The four large categories of shock are hypovolemic (low-circulating volume), cardiogenic (low-cardiac output), obstructive (occluded vascular pathway), and vasogenic (massive vasodilation). DIF: Cognitive Level: Knowledge REF: p. 301 OBJ: 1 TOP: Types of Shock KEY: Nursing Process Step: Planning

9. A nurse is educating patients about the progression of HIV infections. Which statement by the patient in the latent stage indicates that teaching has been effective? a. "I had better get my affairs in order. I don't have a lot of time left." b. "Whew! I thought when I got AIDS that I was a 'goner.'" c. "Now I won't have to take all those expensive drugs that I have been using." d. "I can still enjoy life and live pretty much as I want for the next several years."

ANS: D The latent stage may last as long as 12 years without developing into AIDS. Medications will be continued. DIF: Cognitive Level: Application REF: p. 668 OBJ: 7 TOP: Latent Stage of HIV Infection KEY: Nursing Process Step: Evaluation

1. What should be a major focus in a teaching plan for a teenager with sickle cell anemia? a. Limit tobacco use to no more than two cigarettes a day. b. Eat foods high in iron and vitamin B. c. Maintain environmental temperature at 65° F to 68° F. d. Maintain adequate hydration.

ANS: D The maintenance of adequate fluid intake (4-6 L/day) prevents hemoconcentration. The use of alcohol and tobacco are contraindicated for the patient with sickle cell anemia as the cause vasoconstriction. Warm environments are more therapeutic as warm environments do not cause vasoconstriction. DIF: Cognitive Level: Application REF: p. 638 OBJ: 6 TOP: Sickle Cell Anemia KEY: Nursing Process Step: Planning MSC:

19. Which early characteristic in a patient with emphysema gives rise to the term pink puffer? a. Dyspnea b. Barrel chest c. Thin body d. Normal arterial blood gases (ABGs)

ANS: D The normal ABGs give the patient with emphysema a normal pink color early in the onset of the disease process, rather than a cyanotic color, as observed in a blue bloater. DIF: Cognitive Level: Comprehension REF: p. 605 OBJ: 2 TOP: Emphysema KEY: Nursing Process Step: Assessment

17. After months of infertility procedures, a physician informs a 32-year-old patient that she will never conceive. As the nurse enters the examination room, the patient states, "I guess I'm a failure as a woman." Based on this statement, what is the most appropriate nursing diagnosis? a. Sexual dysfunction b. Ineffective health maintenance c. Disturbed body image d. Ineffective coping

ANS: D The nurse may be the only person with whom the patient feels comfortable to discuss feelings and to explore coping strategies. The distorted view of herself indicates that, at this time, she is ineffectively coping. DIF: Cognitive Level: Application REF: p. 1131-1132 OBJ: 5 TOP: Infertility KEY: Nursing Process Step: Implementation

20. A mastectomy care plan should address psychosocial problems of the patient. What should this be directed toward? a. Caring for the wound and dressings b. Finding an appropriate support group c. Educating for methods for controlling edema d. Helping the patient express feelings and concerns

ANS: D The nurse should gently explore how the patient is feeling about the surgery and encourage her to express her concerns. The other options are significant care concerns but are not psychosocial in nature. DIF: Cognitive Level: Comprehension REF: p. 1122 OBJ: 5 TOP: Breast Cancer KEY: Nursing Process Step: Implementation

15. A patient with HIV is diagnosed with progressive multifocal leukoencephalopathy (PML). What should a nurse encourage the patient to do? a. Take daily exercise for 30 minutes. b. Avoid excessive fats in the diet. c. Remove all potted plants from inside the home. d. Prepare advanced directives.

ANS: D The of advanced directives is essential as this disease is rapidly progressing, and death usually occurs 4 to 6 weeks after diagnosis. DIF: Cognitive Level: Application REF: p. 672 OBJ: 7 TOP: PML KEY: Nursing Process Step: Planning

4. Which significant need should be included in instructions to a patient scheduled for a thyroid scan (123I)? a. Provision of a special container to collect urine for the next 24 hours b. Wear a protective apron to shield him or her from radiation for the next 24 hours c. Request that visitors keep a distance of at least 6 feet away for the next 24 hours d. Wash their hands with soap and water after every voiding for the next 24 hours

ANS: D The patient needs to be instructed to use soap and water to wash his or her hands after each voiding for the next 24 hours. If caregivers discard the urine, gloves should be worn and then washed and removed. Caregivers should wash their hands after glove removal. DIF: Cognitive Level: Application REF: p. 1039 OBJ: 2 TOP: Thyroid Diagnostic Tests KEY: Nursing Process Step: Implementation

25. What is one major postoperative difficulty for a patient having a supraglottic laryngectomy? a. Teaching the patient to use an assistive device to speak b. Coughing without letting food escape through the tracheostomy c. Taking care of the tracheostomy, because the patient will always have to have one d. Teaching the patient to swallow without aspiration

ANS: D The patient who has had a supraglottic laryngectomy may never be able to swallow correctly, which could easily lead to aspiration pneumonia. DIF: Cognitive Level: Comprehension REF: p. 555 OBJ: 5 TOP: Supraglottic Laryngectomy KEY: Nursing Process Step: Planning

10. What is the most appropriate nursing diagnosis for the patient recently diagnosed with hyperthyroidism? a. Hypothermia, related to increased metabolic processes b. Constipation, related to increased hormonal stimulation c. Disturbed body image, related to weight gain d. Disturbed sleep pattern, related to metabolic disturbance

ANS: D The patient with hyperthyroidism has trouble staying asleep because of the metabolic disorder. Persons with hyperthyroidism feel uncomfortably warm, which also contributes to their sleeping difficulty. DIF: Cognitive Level: Application REF: p. 1042 OBJ: 4 TOP: Hyperthyroidism KEY: Nursing Process Step: Planning

11. A nurse performs an Allen test before performing the arterial stick for an arterial blood gas. What does this test assess? a. Respiratory function b. Tidal volume c. Concentration of oxygen d. Perfusion of the hand

ANS: D The perfusion of the hand by the radial and ulnar arteries is assessed because the puncture of the radial artery might cause it to occlude. DIF: Cognitive Level: Comprehension REF: p. 565 OBJ: 3 TOP: Diagnostic Tests KEY: Nursing Process Step: Assessment

6. When a patient with sleep apnea says, "I'm not wearing that silly mask. I look like something out of Star Wars," what should the nurse remind the patient about the function of the mask? a. Increases oxygen intake b. Stimulates regular respirations c. Sounds an alarm when the oxygen concentration drops d. Uses positive pressure to keep the airway open

ANS: D The sleep apnea mask, through positive pressure, keeps the airway open during sleep. DIF: Cognitive Level: Comprehension REF: p. 547 OBJ: 4 TOP: Sleep Apnea Mask KEY: Nursing Process Step: Implementation

15. What is the correct term to use for a patient with a vision disorder? a. Blind b. Handicapped c. Partially blind d. Visually impaired

ANS: D The term visual impairment is a medically accepted term to use for patients with a vision loss. DIF: Cognitive Level: Knowledge REF: p. 1231 OBJ: 5 TOP: Nursing Care of the Visually Impaired Patient KEY: Nursing Process Step: N/A MSC:

23. What should a nurse caution a patient taking Flagyl for Trichomonas to do? a. Double the dose if any doses are missed. b. Report dark urine. c. Take the drug on an empty stomach. d. Abstain from alcohol while taking the drug.

ANS: D The use of alcohol while taking Flagyl has serious side effects. Dark urine is expected, doses should not be doubled, and the drug should be taken with a full glass of water. DIF: Cognitive Level: Application REF: p. 1168 OBJ: 6 TOP: Flagyl KEY: Nursing Process Step: Implementation

21. A patient comes to the emergency department with a sucking chest wound. Which type of dressing should the nurse apply to begin the process of lung reinflation? a. Petroleum dressing covered with an airtight bandage b. No dressing at all c. Pillow weighted down with a sandbag d. Air-occlusive dressing taped on three sides (vented dressing)

ANS: D The vented dressing occludes air from entering but allows air to escape, avoiding a tension pneumothorax and mediastinal shift. DIF: Cognitive Level: Application REF: p. 589 OBJ: 6 TOP: Pneumothorax Care KEY: Nursing Process Step: Implementation

3. A nurse is caring for a patient who is having radiation treatment for cancer. How many days after the start of radiation should the nurse know that the threat of thrombocytopenia exists? a. 2 b. 5 c. 9 d. 12

ANS: D Thrombocytopenia becomes a nursing concern 10 to 14 days after therapy has begun. This concern is true for radiation and chemotherapy. DIF: Cognitive Level: Knowledge REF: p. 638 OBJ: 6 TOP: Thrombocytopenia KEY: Nursing Process Step: Assessment MSC:

32. A home health nurse encourages the family of a patient with an SCI to use the assisted cough technique. What does this technique require the caregiver to do? (Select all that apply.) a. Assist the patient to inhale a bronchodilator spray and then cough. b. Forcefully press on patient's back below the rib cage while the patient is in the prone position. c. Assist the patient to lean forward, breathe deep, and then cough. d. Apply pressure to diaphragm as the patient coughs. e. Slap the patient on upper back while the patient is in the prone position.

ANS: D To assist the patient with an SCI to cough, the caregiver applies pressure on the diaphragm as the patient attempts to cough after having taken a deep breath. DIF: Cognitive Level: Comprehension REF: p. 523 OBJ: 6 TOP: Assisted Cough KEY: Nursing Process Step: Intervention

18. A patient comes to the diabetes clinic and confides to the nurse that she does not follow the diet exchange program that she was given. What is the best response by the nurse? a. "The exchange program is a carefully de-veloped and very important program that allows you to take control of your disease." b. "A lot of people have trouble with that program. You aren't the first one to go off your diet." c. "We had better check your blood work to see what you've done to yourself." d. "Okay. Let's talk about what you do eat and drink and how you manage your dia-betes."

ANS: D To evaluate the effectiveness of treatment, the nurse must first find out how the patient perceives the importance of diet, drugs, and exercise. DIF: Cognitive Level: Application REF: p. 1067 OBJ: 8 TOP: Nutrition KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

24. A patient who had a laryngectomy 3 months earlier returns to the physician's office with the complaint of increasing dyspnea. Which common postlaryngectomy complication should the nurse recognize this complaint as indicating? a. Hypertrophied stoma b. Salivary fistula c. Carotid blowout d. Tracheal stenosis

ANS: D Tracheal stenosis causes the otherwise healthy recovering patient who has undergone a laryngectomy to experience increased dyspnea. DIF: Cognitive Level: Comprehension REF: p. 551 OBJ: 4 TOP: Postoperative Complications of Laryngectomy KEY: Nursing Process Step: Assessment

4. A nurse is teaching a health class for 12- and 13-year-old girls about routine vaginal hygiene. What should the nurse be sure to include? a. Wear clean polyester panties daily and at night. b. Douche weekly with a mild vinegar solution. c. Wash the external and internal genitalia daily. d. Wipe the perineal-anal area from front to back.

ANS: D Transfer of Escherichia coli from the anus to the vagina or to the urinary system can be avoided by wiping the perineal-anal area from front to back. DIF: Cognitive Level: Comprehension REF: p. 1106 OBJ: 5 TOP: Infections of the Reproductive Tract KEY: Nursing Process Step: Implementation

2. A patient newly diagnosed with type 2 diabetes mellitus asks the nurse why she has to take a pill instead of insulin. The nurse explains that in type 2 diabetes mellitus, the body still makes insulin. What other information is pertinent for the nurse to relay? a. Overweight and underactive people cannot simply use the insulin produced. b. Metabolism is slowed in some people, so they have to take a pill to speed up their metabolism. c. Sometimes the autoimmune system works against the action of the insulin. d. The cells become resistant to the action of insulin. Pills are given to increase the sen-sitivity.

ANS: D Type 2 diabetes mellitus is a disease in which the cells become resistant to the action of insulin and the blood glucose level rises. Oral hyperglycemic agents make the cells more sensitive. DIF: Cognitive Level: Comprehension REF: p. 1059 OBJ: 2 TOP: Type 2 Diabetes Mellitus KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

10. Which level of independence is an appropriate nursing care plan goal for a patient with a C8 transection? a. Manage a mechanical wheelchair with a joystick. b. Manage a mechanical wheelchair with hand control. c. Manage a specially equipped wheelchair. d. Manage an ordinary wheelchair.

ANS: D Upper extremity mobility and enhanced hand grip allow the use of an ordinary wheelchair by an individual with a C8 level SCI. DIF: Cognitive Level: Application REF: p. 515 OBJ: 6 TOP: Goal for Rehabilitation KEY: Nursing Process Step: Planning

20. What are the most common causes of laryngitis? a. Smoking and highly seasoned foods b. Alcohol and voice strain c. Nasal congestion and frequent coughing d. Respiratory infections and voice strain

ANS: D Upper respiratory infections and voice strain are the most common causes of laryngitis. DIF: Cognitive Level: Knowledge REF: p. 548 OBJ: 4 TOP: Disorders of the Larynx KEY: Nursing Process Step: Implementation

19. Which nursing action should be implemented to increase the comfort of a patient with oral hair leukoplakia? a. Allow aspirin to melt in the mouth and then wash out with warm water. b. Encourage mouth rinses with warm salt water several times a day. c. Limit intake of ice cream and other cold foods. d. Offer fluids through a straw.

ANS: D Using a straw keeps fluids from flooding the entire oral cavity. Warm or acidic items are to be discouraged because they add to the discomfort. Ice cream and popsicles can numb the area. DIF: Cognitive Level: Application REF: p. 672 OBJ: 4 TOP: Oral Hair Leukoplakia KEY: Nursing Process Step: Planning

23. What instruction should a nurse include when giving education about taking sildenafil (Viagra)? a. No more than two tablets should be taken in a 24-hour period. b. Erection occurs without stimulation. c. Nitrates should be taken at least 4 hours before taking Viagra. d. Tablet should be taken 1 hour before sexual activity.

ANS: D Viagra should be taken 1 hour before sexual activity. Erection depends on stimulation. No more than one tablet a day should be taken. Persons taking nitrates should not take Viagra because of the risk of a possibly fatal myocardial infarction. DIF: Cognitive Level: Comprehension REF: p. 1154 OBJ: 4 TOP: Sildenafil (Viagra) KEY: Nursing Process Step: Implementation

1. A nurse assesses wheezes in a patient with asthma. What should the nurse know is the cause of wheezes? a. Increased thickness of respiratory secretions b. Use of accessory muscles of respiration c. Tachypnea and tachycardia d. Movement of air through narrowed airways

ANS: D Wheezes are adventitious sounds made by air passing through narrowed passages. DIF: Cognitive Level: Comprehension REF: p. 598-599 OBJ: 1 TOP: Asthma: Wheeze KEY: Nursing Process Step: Assessment

13. A nurse preparing to administer insulin to a patient who has type 1 diabetes. The physician has prescribed two types of insulin, 10 U of regular insulin and 35 U of neutral protamine Hagedorn (NPH) insulin. Which is the proper procedure for the nurse to follow when preparing these medi-cations? a. Draw up the insulins in two separate sy-ringes to avoid confusion. b. Draw up the regular insulin before drawing up the NPH insulin. c. Inject air into the NPH insulin, draw it up to 35 U, and then inject air into the clear regular insulin and withdraw to 45 U. d. Inject 35 U air into the NPH insulin, inject 10 U air into the regular insulin, withdraw 10 U of the regular insulin, and withdraw 35 U of the NPH insulin.

ANS: D When drawing up two insulins, the vials are injected with air, and the regular insulin is drawn first. This slow and time-consuming activity has been greatly reduced with the advent of premixed insu-lins. DIF: Cognitive Level: Application REF: p. 1071 OBJ: 11 TOP: Insulin Administration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

8. When should a nurse recognize that the acute phase of a CVA has ended? a. Forty-eight hours has passed from its onset. b. The patient begins to respond verbally. c. BP drops. d. Vital signs and neurologic signs stabilize.

ANS: D When the vital and neurologic signs stabilize, the acute phase has ended. Verbal response, lower BP, and the passage of time without other signs are not adequate evidence that the acute phase has ended. DIF: Cognitive Level: Comprehension REF: p. 491 OBJ: 7 TOP: Acute Phase of CVA KEY: Nursing Process Step: Assessment

2. A nurse is assisting with a caloric test and notes that the specific patient response that indicates a hearing disorder is a problem in the labyrinth. Which response did the nurse witness? a. Blinking b. Grimacing c. Headache d. Nystagmus

ANS: D When warm or cold water is introduced into the ear, the appearance of nystagmus is a positive indication that the hearing problem has its cause in the labyrinth. DIF: Cognitive Level: Comprehension REF: p. 1256 OBJ: 2 TOP: Caloric Test KEY: Nursing Process Step: Assessment MSC:

10. A patient undergoing a Weber test says that the sound is louder in her left ear. What should this result indicate? a. Normal hearing b. Nerve damage from listening to loud music c. Blocked ear canal in the right ear d. Conductive hearing loss in the left ear

ANS: D With the Weber test, a conductive hearing loss is determined by the sound being heard loudest in the affected ear. DIF: Cognitive Level: Comprehension REF: p. 1256 OBJ: 2 TOP: Weber Test KEY: Nursing Process Step: Assessment MSC:

19. What does diagnosis with the human papilloma virus (HPV) increase a person's risk for? a. Uterine fibroids b. Chronic vaginitis c. Premature menopause d. Cervical cancer

ANS: D Women with HPV or condylomata acuminate are advised to have annual Pap smears because they are at an increased risk for cervical cancer. DIF: Cognitive Level: Knowledge REF: p. 1174 OBJ: 9 TOP: Human Papilloma Virus KEY: Nursing Process Step: Implementation

28. What signs and symptoms characterize expressive aphasia? (Select all that apply.) a. Speech that sounds normal but makes no sense b. Total inability to communicate c. Difficulty understanding the written and spoken word d. Stuttering and spitting e. Difficulty initiating speech

ANS: E Expressive aphasia makes it difficult for the patient to initiate speech. DIF: Cognitive Level: Knowledge REF: p. 489-490 OBJ: 3 TOP: Expressive Aphasia KEY: Nursing Process Step: Implementation

ANS: E, A, C, B, D, F The conduction pathway begins in the SA node, travels down the atrial wall, depolarizing the atria, to the AV node, bundle branches, and Purkinje fibers, contracting the ventricles. DIF: Cognitive Level: Comprehension REF: p. 684-685 OBJ: 4 TOP: Conduction Pathway for Cardiac Contraction KEY: Nursing Process Step: Assessment MSC:

OTHER 40. A nurse uses a picture to demonstrate the conduction pathway through the chambers of the heart. (Arrange the following options in the correct sequence. Separate letters by a comma and space as follows: A, B, C, D.) A. The atria contract. B. Conduction occurs through the bundle branches. C. The AV node fires. D. The Purkinje fibers conduct. E. The SA node fires. F. The ventricles contract.