PCN Test 3
42. traction is utilized to provide support for the patient with a hip fracture.
ANS: Buck's This traction is frequently used to maintain the reduction of a hip fracture before surgery. REF: Pages 1375, 1392-1393, Figure 44-32 TOP: Buck's traction
39. In gangrene, there is an acute infection to the skeletal muscle. If untreated, will destroy the tissue.
ANS: exotoxins These injuries can produce exotoxins that destroy tissue. The onset is usually sudden and may occur 1 to 14 days after injury. These organisms are anaerobic (grow and function without oxygen) and are spore-formers. REF: Page 1386 OBJ: N/A TOP: Gangrene
43. Among the most common fractures in older women are fractures.
ANS: hip Hip fractures or compression fractures of the spine. Changes in bone mass place older women at risk for hip fractures. REF: Page 1373 TOP: Fractures
49. B-type natriuretic peptide (BNP) is a , which is secreted by the heart in response to an expanded left .
ANS: neurohormone; ventricle B-type natriuretic peptide (BNP) is a neurohormone secreted by the heart in response to ventricular expansion. REF: Page 1547 TOP: Heart failure Step: Assessment
40. A patient's patellar-femoral cartilage has deteriorated due to arthritis. The medial and lateral cartilage is undamaged. This patient is likely to undergo knee replacement surgery.
ANS: partial unicompartmental Unicompartmental knee arthroplasty is also referred to as partial knee replacement and is performed on patients who have only one of the compartments of the knee affected by arthritis. REF: Pages 1369, 1408 TOP: Partial knee replacement
41. A female patient has been diagnosed with a pelvic fracture that she sustained during a fall. The physician has ordered strict bed rest for this patient. The patient is crying and states, "I'm not used to lying in bed all day. I have many things I need to do at home." An appropriate nursing diagnosis for this patient would be related to decreased mobility.
ANS: powerlessness Strict bed rest can cause a normally active person to feel powerless because she is unable to carry out her daily activities. REF: Page 1382 OBJ: N/A TOP: Nursing diagnosis Step: Planning
48. Serum cardiac markers are that indicate cardiac muscle damage after a myocardial infarction.
ANS: proteins Serum cardiac markers are certain proteins that are released into the blood in large quantities from necrotic heart muscle after a myocardial infarction. REF: Pages 1547, 1564 TOP: Myocardial infarction
11. A patient, age 34, is diagnosed with infective endocarditis. The nurse identifies the nursing diagnosis of Activity intolerance related to generalized weakness for him. Which intervention does the nurse plan while he is febrile? a. Decreased activity b. Activity as tolerated c. Monitoring vital signs during ambulation d. Allowing moderate activity if heart rate is not above 100
ANS: A During the acute phase, it is essential to maintain the patient on decreased activity and provide a calm, quiet environment. REF: Page 1579 TOP: Endocarditis Step: Planning
19. Dependent edema of the extremities, enlargement of the liver, oliguria, jugular vein distention, and abdominal distention are signs and symptoms of a. right-sided heart failure. b. left-sided heart failure. c. cardiac dysrhythmias. d. valvular heart disease.
ANS: A Inability of the right ventricle to pump blood forward into the lungs results in peripheral congestion. Edema is a sign of increased fluid in interstitial tissue and appears in dependent areas of the body such as the sacrum when supine and the feet and ankles while in an upright position. REF: Page 1570, Box 48-3 TOP: Heart failure Step: Assessment
19. Which nursing intervention would be appropriate for a patient with rheumatoid arthritis? a. Sleeping at least 8 hours at night and a nap during the day b. Sleeping at 4-hour intervals at night c. No exercise regimen and apply ice to joints as needed d. Jogging at least 20 minutes three days a week
ANS: A Rest is important because fatigue is a major problem. Sleeping 8 to 10 hours a night and taking a 2-hour nap during the day are recommended. REF: Page 1359 TOP: Rheumatoid arthritis
33. A thrombectomy is done to a. prevent the flow of emboli to the lungs. b. prevent the emboli from forming. c. improve blood flow. d. limit blood flow.
ANS: A A thrombectomy or the transvenous placement of a grid or umbrella in the vena cava may be done to prevent the flow of emboli into the lungs. This inferior venacaval interruption device is called a Greenfield filter. REF: Page 1600 TOP: Thrombophlebitis
1. The movement of an extremity away from the midline of the body is called a. abduction. b. adduction. c. flexion. d. extension.
ANS: A Abduction is movement of an extremity away from the midline of the body. REF: Page 1349, Box 44-2 TOP: Movements
23. The patient is a 20-year-old who has suffered a compound fracture of the femur. The nurse would expect the physician to order intramuscularly. a. tetanus toxoid b. morphine gluconate c. low-molecular-weight heparin d. calcium gluconate
ANS: A Administration of tetanus toxoid is an additional medical measure for compound fracture of the femur. REF: Page 1381 TOP: Fractures
14. The first priority nursing intervention for an impending fat embolism is to administer a. oxygen in a respiratory emergency. b. intravenous fluids in hypovolemic emergency. c. Lasix IV for fluid overload. d. blood therapy in a cardiac emergency.
ANS: A Airway is always the first priority. If hypoxia is present, the physician will order the administration of oxygen. It is important for the nurse to check the liter flow of oxygen and educate patients and their families as to safety precautions necessary when oxygen is administered. REF: Page 1386 TOP: Fat embolism
23. The patient, age 26, is hospitalized with cardiomyopathy. While obtaining a nursing history from her, the nurse recognizes that the increased incidence of cardiomyopathy in young adults who have minimal risk factors for cardiovascular disease is related to a. cocaine use. b. viral infections. c. vitamin B1 deficiencies. d. pregnancy.
ANS: A Cardiomyopathy caused by cocaine abuse is seen more frequently than ever before. Cocaine also causes high circulating levels of catecholamines, which may further damage myocardial cells, leading to ischemic or dilated cardiomyopathy. The cardiomyopathy produced is difficult to treat. Interventions deal mainly with the HF that ensues. REF: Page 1583 TOP: Cardiomyopathy
27. A 28-year-old male patient has a fractured left humerus. He has a cast on his arm. The nurse observes pallor, coolness, and a decrease in capillary refill time to his left hand and fingers. These observations are likely to indicate a. compartment syndrome. b. early infection. c. hemorrhage. d. shock.
ANS: A Collection of objective data involves assessment of the patient's ability to flex the fingers or toes, coolness of the extremity, and absence of pulse in the affected extremity all of which indicate the impaired circulation symptomatic of compartment syndrome. Assessment of skin color for signs of pallor or cyanosis is made. REF: Page 1384, Figure 44-26 TOP: Fractures
10. A patient, age 45, has worked as a basket weaver for the past 10 years. She is being seen at the clinic for symptoms of carpal tunnel syndrome. Collection of subjective data might include a. complaints of burning pain or tingling in the hands. b. edema of the fingers. c. radicular pain. d. complaints of weight loss and fatigue.
ANS: A Collection of subjective data includes the patient's description of discomfort, such as burning pain or tingling in the hands and numbness of thumb, index, and ring fingers. REF: Page 1399, Figure 44-38 TOP: Carpal tunnel syndrome
34. Certain foods may increase the pain associated with gout. Which foods have the highest concentration of purines? a. Brain, liver, kidney b. Lettuce, corn, potatoes c. Beef, pork, chicken d. Fruits and fruit juices
ANS: A Foods high in purines, such as brain, kidney, liver and heart, should be avoided, as well as alcohol. REF: Page 1363 TOP: Gout
25. The nurse identifies the problem of a potential complication—pulmonary edema— for a patient in acute congestive heart failure (CHF). For which early symptom of this problem does the nurse assess? a. Pink, frothy sputum b. Lethargy and faintness c. Decreased urinary output d. Bradycardia
ANS: A Frothy sputum is produced from air mixing with the fluid in the alveoli; the sputum is blood-tinged from blood cells that have exuded into the alveoli. REF: Page 1569 TOP: Pulmonary edema
20. A patient with newly diagnosed hypertension tells the nurse he uses a lot of salt on his foods and has not been able to lose the 30 pounds that he has gained in the last 10 years. He does not understand why he has hypertension, since he is not an anxious person. Which nursing diagnosis does the nurse identify for this patient? a. Ineffective health maintenance related to the lack of knowledge of disease process and management b. Risk of noncompliance related to lifestyle patterns c. Disturbed body image related to diagnosis of hypertension d. Anxiety related to complexity of management regimen and lifestyle changes associated with hypertension
ANS: A Hypertension is a blood pressure higher than 140/90 mm Hg, which increases and individual's risk of developing cardiovascular disease. Adhering to medical therapy for control of elevated blood pressure helps to modify the individual's risk. REF: Page 1580, Box 48-4 TOP: Hypertension
27. During the nursing history and physical assessment of a patient with left-sided heart failure, which finding might the nurse expect related to the patient's diagnosis? a. Orthopnea with bubbling crackles throughout the lungs b. Anorexia with weight loss of 3 pounds in 1 week c. Increased urinary output, especially during waking hours d. Periorbital and facial edema
ANS: A Left ventricular failure; the first is the signs and symptoms of decreased cardiac output. The second is pulmonary congestion. Signs and symptoms of this condition include dyspnea, orthopnea, pulmonary crackles, hemoptysis, and cough. REF: Page 1576, Box 48-5 TOP: Heart failure Step: Planning
30. In evaluating pain for the management of myocardial infarction, the most important aspect using objective data is a. patient's vital signs during painful periods. b. dilation of the patient's pupils. c. painful expression on the patient's face. d. report of the severity of the pain.
ANS: A MI: typical vital signs reveal hypotension, pulse abnormalities such as tachycardia, a barely perceptible pulse, and early temperature elevation. Administer oxygen per protocol for 24 to 48 hours and longer if pain, hypotension, dyspnea, or dysrhythmia persist. Administer medications as prescribed: IV morphine sulfate for relief of pain and apprehension and to produce vasodilation. REF: Page 1563, Table 48-2 TOP: Myocardial infarction Step: Evaluation
34. A patient has a diagnosis of heart failure. When the nurse walks into his room, he is orthopneic. The patient is a. sitting or standing in order to breathe deeply and comfortably. b. complaining of sudden awakenings from sleep because of shortness of breath. c. complaining of pain in lower extremities. d. unable to respond to simple questions.
ANS: A Orthopnea is an abnormal condition in which a person must sit or stand in order to breathe deeply and comfortably. REF: Page 1570 TOP: Orthopnea
26. A patient has a diagnosis of heart failure. When the nurse walks into his room he is leaning over his bedside table and is short of breath. The medical term to describe his respiratory status is a. orthopnea. b. dyspnea. c. dysrhythmia. d. disorientation.
ANS: A Orthopnea is an abnormal condition in which a person must sit or stand in order to breathe deeply and comfortably. REF: Page 1604 TOP: Orthopnea
11. A patient, age 24, had a traumatic amputation of his left foot in a motorcycle accident. He is receiving morphine by a patient-controlled analgesia (PCA) device. He complains of a burning sensation in his left foot. The nurse should explain that a. this is a phantom pain and that its cause is not clearly understood. b. this is not possible because his foot was amputated. c. his regular pain medication will relieve the pain. d. this phantom pain will disappear in about 1 week.
ANS: A Phantom pain (pain felt in the missing extremity as if it were still present) may occur and be frightening to the patient. Phantom pain occurs because the nerve tracts that register pain in the amputated area continued to send a message to the brain (this is normal). REF: Page 1404 TOP: Phantom pain
31. Rheumatoid arthritis is distinguished from osteoarthritis in that: a. Rheumatoid arthritis is an autoimmune, systemic disease; osteoarthritis is a degenerative disease of the joints. b. Rheumatoid arthritis is an autoimmune, degenerative disease; osteoarthritis is a systemic inflammatory disease. c. People with osteoarthritis are considered to be genetically predisposed; there is no known genetic component to rheumatoid arthritis. d. Osteoarthritis is often caused by a virus; viruses play no part in the pathogenesis of rheumatoid arthritis.
ANS: A RA is thought to be an autoimmune disorder. Degenerative joint disease is also known as osteoarthritis. REF: Pages 1353-1355, Table 44-4, Figure 44-7 TOP: Rheumatoid arthritis
4. The patient has right-sided heart failure. She will probably be comfortable in which position? a. Dorsal recumbent b. Trendelenburg c. Supine d. Orthopneic
ANS: A Restful sleep may be possible only in the sitting position or with the aid of extra pillows. REF: Page 1572 TOP: Heart failure Step: Planning
22. A 56-year-old patient was admitted to the emergency department with a myocardial infarction. Cardiac enzymes were drawn. In a patient with a myocardial infarction, which laboratory values would be abnormal? a. Elevated levels of serum glutamic oxaloacetic transaminase (SGOT) (AST), creatine phosphokinase (CPK-MB), and lactic dehydrogenase (LDH), troponin 1 b. Decreased levels of SGOT (AST), CPK and LDH, troponin 1 c. Elevated levels of SGOT (AST), decreased levels of CPK and LDH, troponin 1 d. Decreased levels of SGOT (AST), increased levels of CPK and LDH, troponin 1
ANS: A Serum cardiac markers are certain proteins that are released into the blood in large quantities from necrotic heart muscle after a myocardial infarction. These markers, specifically cardiac serum enzymes and troponin 1, are important screening diagnostic criteria for acute MI. REF: Pages 1547, 1564 TOP: Diagnostic procedures
31. A patient with angina pectoris is being discharged with nitroglycerin tablets. Which of the instructions does the nurse include in the teaching? a. "When your chest pain begins, lie down and place one tablet under your tongue. If the pain continues, take another tablet in 5 minutes." b. "Place one tablet under your tongue. If the pain is not relieved in 15 minutes, go to the hospital." c. "Continue your activity. If the pain does not go away in 10 minutes, begin taking the nitro tablets one every 5 minutes for 15 minutes, then go lie down." d. "Place one nitro tablet under your tongue. If a burning sensation and headache occur, call your doctor immediately."
ANS: A Sit and stand slowly after taking nitroglycerin. Place nitroglycerin tablets under the tongue at the onset of anginal pain; the second tablet can be taken after 5 minutes and the third tablet after another 5 minutes if pain is unrelieved. Then, if pain is not relieved, go to the hospital. REF: Page 1562, Patient Teaching box TOP: Angina pectoris
12. A patient, age 28, has a fractured tibia and fibula. The nurse is performing an assessment of her extremities. The purpose of assessing capillary filling or performing a blanching test is to assess for adequate a. arterial peripheral circulation. b. cardiac output. c. venous peripheral circulation. d. nutritional deficiency.
ANS: A The blanching test measures the rate of capillary refill, which signals circulation status. REF: Pages 1389, 1406 TOP: Fractures
21. A patient, age 72, was admitted to the medical unit with a diagnosis of angina pectoris. Characteristic signs and symptoms of angina pectoris include a. substernal pain that radiates down the left arm. b. epigastric pain that radiates to the jaw. c. indigestion, nausea, and eructation. d. fatigue, shortness of breath, and dyspnea.
ANS: A The pain often radiates down the left inner arm to the little finger and also upward to the shoulder and jaw. REF: Pages 1557-1558, Figure 48-11 TOP: Angina pectoris
24. A patient, age 72, has a left intertrochanteric fracture as a result of a fall. In planning ways to increase her safety, the nurse realizes it is most important to determine a. preexisting health conditions. b. nutritional status. c. psychosocial history. d. pain level.
ANS: A The patient's medical and surgical history is significant, as well as any family history of bone disease. Although pain level, nutritional status, and psychosocial history are important, they are not the most important. REF: Page 1374 TOP: Fracture of the hip
33. The patient, age 58, is diagnosed with osteoporosis after densitometry testing. She has been menopausal for 5 years and has been concerned about her risk for osteoporosis because her mother has osteoporosis. In teaching her about her osteoporosis, which information does the nurse include? a. Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise. b. Estrogen replacement therapy must be started to prevent rapid progression of her osteoporosis. c. With a family history of osteoporosis, there is no way to prevent or slow bone reabsorption. d. Continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis.
ANS: A To prevent osteoporosis, women are advised to have an adequate daily intake of calcium and vitamin D; exercise regularly; avoid smoking; decrease coffee intake; decrease excess protein in the diet; and engage in regular moderate activity such as walking, bike riding, or swimming at least 3 days a week. A contributing factor may be use of steroids. REF: Pages 1365-1366, Patient Teaching box TOP: Osteoporosis
17. The patient who undergoes total hip replacement may be prescribed prophylactic drugs such as heparin or warfarin (Coumadin). The rationale for this is that it a. decreases the risk of thrombus formation. b. decreases the risk of hemorrhage. c. facilitates the wound-healing process. d. decreases the risk of systemic infection.
ANS: A Treatment will include administration of anticoagulants, such as heparin or warfarin (Coumadin), which decreases the risk of deep vein thrombus. REF: Page 1387 TOP: Medication
4. The term unicompartmental knee arthroplasty is also referred to as a. partial knee replacement. b. removal of the kneecap. c. total knee replacement. d. total knee replacement bilaterally.
ANS: A Unicompartmental knee arthroplasty is also referred to as partial knee replacement. REF: Pages 1369, 1408 TOP: Knee replacement
44. The main purpose of traction is to (Select all that are correct) a. Align and stabilize a fracture b. Prevent deformities c. Relieve muscle spasms d. Promote bed rest e. Increase circulation to the rest of the body
ANS: A, B, C Skin and skeletal traction provide alignment and stabilize a fracture. This prevents deformities and relieves muscle spasms by putting muscles under tension until they are fatigued. REF: Page 1392 OBJ: N/A TOP: Traction
47. Which are signs of digoxin (Lanoxin) toxicity? a. Nausea b. Bradycardia c. Headache d. Visual disturbance e. Heart rate >60 f. Gastrointestinal complaints
ANS: A, B, C, D Major signs of digoxin toxicity are nausea, bradycardia (HR <60), headache, and visual disturbances, as well as fatigue and dysrhythmias. Heart rate >60 is normal. REF: Page 1554, Table 48-1, Table 48-7 TOP: Function of cardiovascular system
42. Which statements are true? (Select all that apply) a. Anticoagulant therapy is used for DVT prevention. b. Anticoagulant therapy prevents development of new clots, embolization, and clot extension. c. Anticoagulant therapy will dissolve clots. d. Pulmonary embolus is a life-threatening complication requiring treatment with anticoagulant therapy.
ANS: A, B, D Anticoagulant therapy is used for DVT prevention and treatment. For an existing DVT, anticoagulant therapy prevents extension of the clot, development of a new clot, or embolization (embolus traveling through the blood stream). Anticoagulants do not dissolve a clot. REF: Pages 1598-1599 TOP: Thrombophlebitis
39. Modifiable risk factors for coronary artery disease include: (Select all that apply.) a. weight. b. diet. c. genetics. d. exercise.
ANS: A, B, D Maintaining proper weight, dieting, and exercise are all modifiable risk factors. However, familial tendency to develop cardiovascular disease has been documented in the literature. A family member such as a parent or sibling who has a cardiovascular problem before 50 years of age places the patient at greater risk for developing cardiovascular disease. REF: Page 1571, Box 48-8 TOP: Risk factors
45. Three kinds of blood vessels are organized for carrying blood to and from the heart: (Select all that apply.) a. Veins b. Bronchioles c. Arteries d. Capillaries
ANS: A, C, D The arteries, veins and capillaries blood vessels carry blood to and from the heart. REF: Page 1543 TOP: Function of cardiovascular system
44. The functions of the cardiovascular system are to: (Select all that apply.) a. deliver oxygen and nutrients to the cells. b. deliver carbon dioxide and waste products to the cells. c. remove oxygen and nutrients from the cells as waste products. d. remove carbon dioxide and waste products from the cells.
ANS: A, D The functions of the cardiovascular system are to deliver oxygen and nutrients to the cells and to remove carbon dioxide and waste products from the cells REF: Pages 1541, 1543 TOP: Function of cardiovascular system
22. A patient, age 44, has chronic osteomyelitis. He should be taught to a. take antibiotics prophylactically. b. avoid trauma to the affected bone. c. decrease activity levels. d. increase dietary intake of calcium and vitamin D.
ANS: B The patient must avoid trauma to the affected bone because pathological fracture is common. REF: Page 1367 TOP: Osteomyelitis
17. A patient, age 65, has chronic angina pectoris. Her daughter had questions about the proper use of nitroglycerin for pain management. She was unsure about how many times she should take nitroglycerin for an episode of angina. The best reply the nurse could make is a. "Continue to take nitroglycerin sublingually at 5-minute intervals until the pain is relieved." b. "If the pain is not relieved after three doses of nitroglycerin at 5-minute intervals, call your physician and come to the hospital." c. "When nitroglycerin is not relieving the pain, lie down and rest." d. "Use oxygen at home to relieve pain when nitroglycerin is not successful."
ANS: B Administer prescribed nitroglycerin. Repeat every 5 minutes, three times. If pain is unrelieved, notify the physician. Nitroglycerin administered sublingually usually relieves angina symptoms but does not relieve the pain from an MI. Administering nitro more than three times will probably not relieve the pain. REF: Page 1560, Nursing Diagnoses box OBJ: 13 TOP: Angina pectoris
15. What is defined as a distended dilated segment of an artery? a. Embolism b. Aneurysm c. Angina d. Adhesion
ANS: B An aneurysm is an enlarged, dilated portion of an artery. REF: Page 1595 TOP: Aneurysm
3. The nurse identifies the nursing diagnosis of Ineffective tissue perfusion related to decreased arterial blood flow for a patient with chronic arterial insufficiency. In evaluating the patient outcomes after patient teaching, which statement by the patient does the nurse recognize as indicating a need for further instruction? a. "For about 40 minutes each day, I will walk to the point of pain, then rest, than walk again until I develop pain." b. "I will drink hot coffee several times a day to increase the circulation and warmth in my feet." c. "I will wear loose clothing that doesn't bind across my legs or waist." d. "I will change my position every hour and avoid long periods of sitting with my legs down."
ANS: B Avoiding vasoconstriction from nicotine, caffeine, and stress is an important precaution for patients with decreased arterial blood flow. REF: Pages 1553, 1603, Nursing Diagnoses boxesOBJ: 22 TOP: Arterial disorders Step: Evaluation
9. A patient, age 24, is recovering from a fractured tibia. She has been wearing a leg cast for the past month to immobilize the fracture and promote proper alignment. She is being seen at the clinic for follow-up radiographic evaluation of the fracture. The physician tells her that he is hoping for good callus formation to have occurred. When she asks what callus formation is, the nurse tells her it is a. when blood vessels of the bone are compressed. b. a part of the bone healing process after a fracture when new bone is being formed over the fracture site. c. the formation of a clot over the fracture site. d. when the hematoma becomes organized and a fibrin meshwork is formed.
ANS: B Callus formation occurs when the osteoblasts continue to lay the network for bone build-up and osteoclasts destroy dead bone. REF: Page 1380 TOP: Bone healing
32. Which ethnic group is at a highest risk of developing osteoporosis? a. African American women b. Caucasian and Asian women c. African American men d. Latino women
ANS: B Caucasian and Asian women have a higher incidence of osteoporosis than African American women or Hispanic women. REF: Page 1364, Cultural Considerations box TOP: Osteoporosis
5. A patient is admitted from the emergency department. The emergency department physician notes the patient has a diagnosis of heart failure with a New York Heart Association (NYHA) classification of IV. This indicates the patient's condition as a. moderate heart failure. b. severe heart failure. c. congestive heart failure. d. negligible heart failure.
ANS: B Class IV: Severe; patient unable to perform any physical activity without discomfort. Angina or symptoms of cardiac inefficiency may develop at rest. REF: Page 1570, Box 48-3 TOP: Classification of heart failure
8. A patient fell 2 days ago; he has a compound fracture of his left tibia. The physician performed an open reduction with internal fixation (ORIF) to treat the fracture. An important nursing assessment for him would include a. hyperactive bowel sounds. b. elevated temperature and presence of erythema at incision site. c. ecchymosis and edema at incision site. d. complaints of activity intolerance.
ANS: B Collection of objective data includes careful inspection of any wounds. The drainage is assessed for color, amount, and presence of odor. Vital signs are assessed for signs of infection (temperature elevation, tachycardia, and tachypnea). REF: Page 1367 TOP: Compound fracture
30. The office nurse has noted the presence of an increase in lumbar curvature in a 20- year-old female patient. This condition is known as a. scoliosis. b. lordosis. c. kyphosis. d. spondylitis.
ANS: B Common deformities include an increase in the curve at the lumbar space region that throws the shoulder back, making the "lordly or kingly" appearance that is known as lordosis. Scoliosis involves the S curvature of the spine. Kyphosis is the rounding of thoracic spine. REF: Page 1385 TOP: Lordosis
16. A patient, age 18, has multiple soft tissue injuries from a bicycle accident. Primary medical management for soft tissue injuries includes a. rest and heat to control edema. b. elevation and ice to control edema. c. immediate immobilization to halt pain. d. aspiration of excessive fluid.
ANS: B Contusions are the most common soft tissue injury. Most contusions are treated by applying ice bags or cold compresses. REF: Page 1396 TOP: Soft tissue injury Step: Planning
7. A patient admitted from the emergency department with a diagnosis of heart failure and a NYHA classification of IV has edema in his lower extremities of +4. Which nursing intervention would aid in decreasing this edema? a. Ambulate in the hallway. b. Elevate lower extremities. c. Keep the extremities in a dependent position. d. Stand at the bedside.
ANS: B Elevate extremities when sitting or lying to promote venous return and decrease incidence of edema and venous stasis. REF: Page 1572 TOP: Peripheral edema
18. The patient has been diagnosed as having gouty arthritis. He asks the nurse to explain the cause of the inflammation of his great toe. The most appropriate nursing response is a. "You have calcium oxalate deposits that are seen in gouty arthritis." b. "The inflammation is from small accumulations of uric acid crystals which are called tophi." c. "The small nodules are not related to the arthritis condition." d. "You have fat deposits that are common with gouty arthritis."
ANS: B Gout is a metabolic disease resulting from an accumulation of uric acid in the blood. It is an acute inflammatory condition associated with ineffective metabolism of purines. REF: Page 1363 TOP: Gouty arthritis
38. Prolonged bed rest puts the older adult at risk for a. ankylosing spondylitis. b. pathological fractures. c. osteomyelitis. d. gout.
ANS: B Immobilization results in bone resorption, and the bone tissue becomes less dense. Prolonged bed rest puts the patient at risk for pathological fracture. This is a serious concern for an older adult in terms of regaining mobility. REF: Pages 1353-1355, Table 44-4, Figure 44-7 TOP: Disorders of the musculoskeletal system
32. A type of medication useful for preventing venous thrombus is a. anticoagulant. b. low-molecular-weight heparin. c. intravenous thrombolytics. d. percutaneous angiography.
ANS: B Low-molecular-weight heparin (LMWH) is effective for the prevention of venous thrombosis, as well as prevention of extension or recurrence. REF: Page 1600 TOP: Medication
28. When providing discharge teaching to a patient with endocarditis regarding prevention of infections, what would the nurse stress? a. Avoid crowds. b. Take antibiotics as prescribed. c. Use only aspirin for mild pain. d. Weigh yourself daily.
ANS: B Patient teaching focuses on identifying causes, infective endocarditis precautions, dietary requirements, and gradually increasing activity levels, as well as teaching the need for prophylactic antibiotics before any invasive procedure if the patient has preexisting valvular heart disease. REF: Page 1582 TOP: Endocarditis
28. A patient, age 45, has had a left intramedullary rod placed into his left femur. He is presenting with signs and symptoms of postoperative shock. The recommended position for a person going into shock is a. semi-Fowler's. b. supine. c. Fowler's d. Trendelenburg.
ANS: B The patient should remain flat in bed. Avoid the Trendelenburg position because it pushes the abdominal organs against the diaphragm, affecting the lung and heart. REF: Page 1385, Figure 44-27 TOP: Fracture of the femur
41. Which information should be taught to patients starting on anticoagulant therapy? (Select all that apply.) a. Increase the dose of Aspirin for better therapy. b. Take medication at the same time each day. c. Report to physician cuts that do not stop bleeding with direct pressure. d. No restrictions for food or drink. e. Report for prescribed blood tests (PTT, INR, CBC, blood sugar).
ANS: B, C Aspirin should not be used with anticoagulant therapy because it will increase bleeding. Gums, nosebleeds, excessive bruising, and cuts that do not stop bleeding with direct pressure should be reported to the physician. Alcohol and dark green and yellow vegetables should be avoided because they contain vitamin K. Normal blood tests for anticoagulant therapy are PTT, INR, and PT. REF: Pages 1594, 1600, Nursing Diagnoses box, Safety Alert! TOP: Anticoagulant therapy Step: Planning
40. Which would be included in teaching for patients with Raynaud's disease? (Select all that apply.) a. Warm hands and feet with a heating pad b. Use mittens in cold weather c. Practice stress-reducing techniques d. Complete smoking cessation e. Use caution when cleaning the refrigerator or freezer
ANS: B, C, D, E Nursing interventions include patient teaching in techniques for stress reduction, avoiding exposure to cold, and techniques for smoking cessation. REF: Page 1598, Nursing Diagnoses box TOP: Raynaud's disease
46. When assessing a patient with a myocardial infarction (MI), which is objective data? (Select all that apply.) a. Pain radiating to left arm and jaw b. Hypertension c. Vomiting d. Diaphoresis e. Nausea f. Cardiac rhythm changes
ANS: B, C, D, F Hypertension, vomiting, diaphoresis, and cardiac rhythm changes are objective data seen in patients with a myocardial infarction (MI). Pain and nausea are subjective data felt by the patient but not measurable. REF: Page 1564 TOP: Myocardial infarction
43. Which patient teaching would help to prevent venous stasis? (Select all that apply.) a. Dangle legs when sitting. b. Avoid crossing legs at the knee. c. Elevate legs when lying in bed or sitting. d. Massage extremities to help maintain blood flow. e. Wear elastic stockings when ambulating.
ANS: B, C, E Avoid prolonged sitting or standing. Avoid crossing the legs at the knee. Elevate legs when sitting. Wear elastic stockings when ambulatory. Do not massage extremities because of danger of embolization of clots (thrombus breaking off and becoming an embolus). REF: Page 1600, Nursing Diagnoses box, Table 8-12 TOP: Thrombophlebitis Step: Planning
46. The three vital functions muscles perform when they contract are: (Select all that apply.) a. To allow for accumulation of uric acid in blood b. Maintenance of posture c. Motion d. To serve as a storage area for various minerals e. Production of heat f. To assist in return of venous blood to the left side of the heart
ANS: B, C, E The three vital functions muscles perform when they contract are maintenance of posture, motion and production of 85% of body heat. REF: Page 1346 TOP: Functions of muscular system
45. Which of the significant neurovascular impairment symptoms, following a musculoskeletal trauma, should be reported to the physician? (Select all that apply.) a. Extremity feels warm to touch b. Slow capillary refill c. Diminished or absent pulses, d. Extremity pink in color e. +1 edema of extremity f. Unrelieved pain after administration of pain medication
ANS: B, C, F Assessments of slow capillary refill, diminished or absent pulses, and unrelieved pain after administration of pain medication are complications needing immediate attention. The physician should be notified. The extremity should be warm to touch, pink in color, and may have a slight edema. REF: Pages 1371, 1375 TOP: Fractures
3. Which diagnostic exam is used to find pathological abnormalities of the brain? a. CT scan b. Nuclear medicine scan c. MRI d. Radiograph
ANS: C Magnetic resonance imaging (MRI) is used to detect pathological conditions of the cerebrum and spinal cord. REF: Page 1351 TOP: Diagnostic examination
3. The rehabilitation nurse instructs a paraplegic athlete that the rehabilitation experience will consist of: a. relearning former skills. b. learning to walk. c. learning new skills to adapt to a different lifestyle. d. developing muscle strength.
ANS: C The type and the focus of rehabilitation are individualized to the patient, the injury, and abilities. Skills will be taught to enhance the patient's adaptation to a new lifestyle. REF: Page 1209 TOP: Rehabilitation
12. A 53-year-old patient with a history of dysrhythmias is to wear a Holter monitor. The nurse should explain that Holter monitoring a. is a form of stress test. b. amplifies heart sounds. c. is a portable electrocardiographic device. d. regulates heart rate.
ANS: C A Holter monitor (a small portable recorder) is attached to the patient by one to four leads, with a 2-pound tape recorder carried on a belt or shoulder strap. REF: Page 1545 TOP: Dysrhythmias
29. A patient has been admitted after the insertion of a pacemaker because of bradycardia. She asks what third-degree heart block is, and the nurse replies a. "Coronary blood vessel occlusion causing slow contraction of the right ventricles." b. "Sclerosis of cardiac valves causing slow pulse." c. "A defect in AV junctions slows and impairs conduction of impulses from the SA node to the ventricles." d. "Increased pressure in the pulmonary vessels."
ANS: C Atrioventricular block occurs when a defect in the AV junction slows or impairs conduction of impulses from the SA node to the ventricles. REF: Page 1552 TOP: Dysrhythmias
35. Which nursing intervention reduces myocardial oxygen demand? a. Supplying a portable oxygen unit during activity b. Encouraging participation in cardiac rehabilitation program c. Elevating the head of the bed 30 to 45 degrees d. Positioning patient in supine position
ANS: C Bed rest and semi-Fowler's position reduce myocardial oxygen demands. REF: Page 1571 TOP: Myocardial infarction
37. A 76-year-old female patient is being seen for osteoarthritis of the knee in the clinic. In discussing strengthening exercises, which exercises would you recommend? a. Jogging b. Climbing stairs 2 to 3 times daily c. Bicycling for short distances d. Walking up and down small elevations
ANS: C Bicycling or swimming is recommended for osteoarthritis of the hip or knee. Jogging would put undue stress on knee joints. Climbing stairs should be avoided. Walking should be done on level ground, not up or down elevations. REF: Page 1361, Box 44-3 TOP: Osteoarthritis
6. A patient admitted from the emergency room with a diagnosis of heart failure and a NYHA classification of IV is requesting ambulation to the bathroom. Which nursing intervention would be appropriate for this patient? a. Assist the patient to the bathroom. b. Obtain a bedside commode. c. Offer a urinal or bedpan. d. Obtain assistance of another nurse and ambulate the patient to the bathroom.
ANS: C Class IV: Severe: patient unable to perform any physical activity without discomfort. REF: Page 1570, Box 48-3 TOP: Heart failure
14. The patient achieves comfort in breathing only when he assumes a sitting posture. During the charting of this position, the nurse can describe this as a. dyspnea. b. orthophrenia. c. orthopnea. d. orthuria.
ANS: C Collection of subjective data includes complaints of dyspnea and orthopnea (an abnormal condition in which a person must sit or stand in order to breathe deeply or comfortably). REF: Page 1604 TOP: Orthopnea
36. Calcium is a mineral found in many foods that can slow bone loss during the aging process. The following are high in calcium: a. Oranges, yogurt b. Oranges, bananas c. Broccoli, yogurt d. Skim milk, eggs
ANS: C Fresh oranges, bananas, and eggs are not good calcium choices. Broccoli and green vegetables, as well as yogurt, are considered calcium-rich foods. REF: Page 1396 TOP: Osteoporosis
35. The immediate medical management of any fracture is: a. Observe patient for signs of shock. b. Administer analgesics for pain. c. Splint and elevate the involved part. d. Apply heat to control pain.
ANS: C Immediate management includes splinting and elevation of the involved part to prevent edema. After the immediate management, analgesic for pain, application of cold to prevent edema, and observing for signs of shock must be part of the plan of care. REF: Page 1381 TOP: Contact dermatitis Step: Implementation
25. A patient has undergone a bipolar hip repair (hemiarthroplasty). She should be instructed to a. sit in whatever position is most comfortable. b. sit in a firm, straight-backed chair at a 90-degree angle. c. avoid crossing her legs. d. begin full weight-bearing as soon as tolerated.
ANS: C Instructing the patient not to cross the legs is important because crossing the legs can adduct the affected extremity and dislocate the hip. REF: Page 1375 TOP: Fracture of the hip
2. A 63-year-old patient with an acute myocardial infarction is on a cardiac monitor and begins to show some dysrhythmias. The physician will probably prescribe which intravenous medication? a. Nitroglycerin b. Digitalis c. Lidocaine d. Amyl nitrite
ANS: C Management of dysrhythmias is accomplished by suppressing the impulse that triggers dysrhythmias. REF: Pages 1552-1553, Table 48-1 TOP: Acute myocardial infarction
6. A patient, age 79, fell at home and suffered an intracapsular fracture of his left hip. The orthopedic surgeon inserted a prosthetic implant for a bipolar hip replacement. The physician has instructed the nurse to turn him every 2 hours. The nurse understands that the correct nursing intervention is to keep the legs a. together so they don't separate while turning. b. from rubbing together. c. abducted so the prosthesis does not become dislocated. d. abducted to prevent additional pain for the patient with turning.
ANS: C Nursing interventions also involve postoperative maintenance of leg abduction by using an abduction splint for 7 to 10 days to prevent dislocation of the prosthesis. REF: Pages 1375, 1378, Patient Teaching box, Figure 44-15 TOP: Fracture of the hip
5. A patient, age 89, has had a right below-the-knee amputation. He is progressing well but continues to complain of pain in the toes on his right foot. The physician told him that he is suffering from "phantom pain" in his amputated extremity. He asks the nurse to explain phantom pain. The most appropriate response would be a. "Phantom pain does not exist except in your mind." b. "I can't answer that. You'll have to ask the physician." c. "Phantom pain occurs because the nerve tracts that register pain in the amputated limb continue to send a message to the brain." d. "Phantom pain occurs when you start thinking about your loss. It's best to keep your mind occupied with other things."
ANS: C Phantom pain (pain felt in the missing extremity as if it were still present) may occur and be frightening to the patient. Phantom pain occurs because the nerve tracts that register pain in the amputated area continue to send a message to the brain (this is normal). REF: Pages 1404-1405 TOP: Amputation
13. A patient has sustained a fractured femur in a car accident. The physician has stated concern about the possibility of a fat embolism. The patient's wife asks the nurse about the cause of a fat embolism. The nurse's most appropriate response would be a. "Arterial blood flow is interrupted at the site of injury." b. "Floating fat sometimes causes problems." c. "The break in the bone forces molecules of fat into the bloodstream." d. "We don't know the cause. We just know that it sometimes happens."
ANS: C Pulmonary fat embolism involves the embolization of fat tissue with platelets and circulation of free fatty acids within the pulmonary circulation. REF: Page 1386 TOP: Fat embolism
4. The nurse who helps a family and a patient with a disability rejoice in the acquisition of the smallest new skill is following the rehabilitation philosophy of: a. resolving impairments. b. removing disabilities. c. increasing quality of life. d. returning to the community.
ANS: C Rehabilitation is based on the acquisition of new skills to better adapt and increase the quality of life. REF: Page 1208 TOP: Rehabilitation
1. The nurse who is part of a team focused on restoring an individual to the fullest physical, mental, social, vocational, and economic capacity is practicing: a. holistic nursing. b. conscientious nursing. c. rehabilitation nursing. d. comprehensive nursing.
ANS: C Rehabilitation is the process of restoring an individual to the fullest physical, mental, social, vocational, and economic capacity of which he or she is capable. REF: Page 1206 TOP: Rehabilitation
20. When caring for a patient who is 34 years old and has rheumatoid arthritis, the nurse should remember that a. exercise should be avoided to decrease pain. b. the patient should be discouraged from performing activities of daily living. c. rest and exercise are both important parts of therapy. d. pain is best controlled by use of narcotic analgesics.
ANS: C Rest is important because fatigue is a major problem. Exercise helps prevent the joints from "freezing" and the muscles from weakening. REF: Page 1359 TOP: Rheumatoid arthritis Step: Planning
24. Restlessness, diaphoresis, severe dyspnea, tachypnea, hemoptysis, audible wheezing, and crackles are signs and symptoms of a. heart failure. b. respiratory failure. c. pulmonary edema. d. peripheral edema.
ANS: C Signs and symptoms of pulmonary edema are restlessness; vague uneasiness; agitation; disorientation; diaphoresis; severe dyspnea; tachypnea; tachycardia; pallor or cyanosis; cough producing large quantities of blood-tinged, frothy sputum; audible wheezing and crackles; cold extremities. REF: Page 1576, Box 48-5 TOP: Pulmonary edema
36. There is a strong relationship between Buerger's disease (thromboangiitis obliterans) and a. Alcohol b. Cocaine c. Smoking d. Obesity
ANS: C The hazards of cigarette smoking and its relationship to Buerger's disease are the primary focus of patient teaching. None of the palliative treatments are effective if the patient does not stop smoking. Nowhere are the cause and effect of smoking so dramatically seen as with Buerger's disease. REF: Pages 1596-1597 TOP: Buerger's disease
26. A patient, age 64, has osteoarthritis of the left hip. He has had a left total hip replacement. The nurse should a. encourage use of the high Fowler's position. b. administer oxygen through a nasal cannula. c. encourage use of an incentive spirometer. d. turn the patient frequently from side to side.
ANS: C The use of incentive spirometers is valuable in assisting the patient to perform adequate respiratory ventilation to prevent pneumonia. REF: Page 1370 TOP: Total hip replacement
8. A patient, age 59, has Buerger's disease. The most important aspect of patient compliance in order to decrease signs and symptoms of Buerger's disease is a. a low-fat diet. b. weight loss. c. not smoking. d. keeping extremities warm.
ANS: C There is a very strong relationship between Buerger's disease and tobacco use. It is thought that the disease occurs only in smokers, and when smoking is stopped, the disease improves. None of the palliative treatments are effective if the patient does not stop smoking. REF: Page 1597 TOP: Buerger's disease Step: Evaluation
21. A 71-year-old patient is manifesting signs and symptoms of gout. When assessing him for signs and symptoms of gout, the nurse should pay particular attention to a. dietary intake of foods high in cholesterol. b. mobility in the hip and knee joints. c. edema or discoloration of the great toe. d. a history of trauma or occupational injury.
ANS: C Tophi (calculi containing sodium urate deposits that develop in periarticular fibrous tissue, typically in patients with gout) result in inflammation of the joint; it is unclear why this occurs. Typically the big toes are involved, but other joints can also be affected. Particular attention should be paid to foods high in purines. REF: Page 1363 TOP: Gout
7. A patient, age 24, has a compartment syndrome after a fracture of his radius and ulna. Nursing assessment will include careful observation for signs and symptoms of a. buccal petechiae. b. thromboembolism. c. Volkmann's contracture. d. fat embolism.
ANS: C Volkmann's contracture is a permanent contracture that can occur as a result of circulatory obstruction secondary to compartment syndrome. REF: Page 1385, Figure 44-27 TOP: Compartment syndrome
10. An old term defined as the condition in which the patient suffers peripheral or pulmonary congestion is called a. pneumonia. b. peripheral edema. c. pulmonary edema. d. congestive heart failure.
ANS: D Because many patients suffer pulmonary or systemic congestion with HF, the syndrome was once called congestive heart failure. REF: Page 1568 TOP: Heart failure Step: Assessment
15. A patient, age 68, has suffered an intertrochanteric fracture of the right hip. Before surgery, to provide support and comfort, an immobilizing device is applied. This is called a a. Thomas splint. b. Bryant's traction. c. Russell's traction d. Buck's traction.
ANS: D Buck's traction is a form of traction used as a temporary measure to provide support and comfort to a fractured extremity until a more definite treatment is initiated. REF: Page 1375, Figure 44-32 TOP: Fractures
13. After an influenza-like illness, the patient complains of chills and small petechiae in his mouth and his legs. A heart murmur is detectable. These are characteristic signs of a. congestive heart failure. b. heart block. c. aortic stenosis. d. infective endocarditis.
ANS: D Collection of subjective data includes noting patient complaints of influenza-like symptoms with recurrent fever, undue fatigue, chest pain, and chills. Objective data may reveal the significant signs of petechiae in the conjunctiva and mouth. Both subjective data and objective data are indicative of infective endocarditis. REF: Page 1581 TOP: Endocarditis Step: Assessment
9. A patient has heart failure. His physician's orders include complete bed rest. The nurse knows that this order means he a. is encouraged to rest as much as possible. b. is confined to bed but may assume responsibility for all of his personal care. c. is confined to bed but is allowed to go to the bathroom as needed. d. must remain as quiet as possible, with any task requiring physical effort done for him.
ANS: D Complete bed rest: Lowering oxygen requirements of the body systems with head of the bed elevated to 45 degrees to reduce myocardial oxygen demand and decrease circulating volume returning to the heart. REF: Page 1572 TOP: Heart failure Step: Planning
38. Edema and pulmonary congestion are treated with: a. Unlimited activity, high protein diet, weights weekly b. Bed rest, normal diet, weights four times daily c. Increase in fluids, no activity restrictions d. Diuretics, restriction of sodium diet and fluid intake
ANS: D Edema and pulmonary congestion are treated with diuretics, a sodium-restricted diet, and restriction of fluid intake. Weigh the patient daily to monitor fluid retention. REF: Page 1571 TOP: Right ventricular failure Step: Planning
37. In older adults, rapid infusion of fluids can lead to a. Hypotension b. Thrombophlebitis c. Mitral insufficiency d. Heart failure
ANS: D Heart failure can result from rapid infusion of intravenous fluids in older adults. DIF: Cognitive Level: Knowledge REF: Page 1548, Life Span Considerations box, Box 8-4 TOP: Function of cardiovascular system
16. A patient is admitted with a diagnosis of possible aortic aneurysm. In assessing her, it is most important to monitor her a. temperature. b. lung sounds. c. respirations. d. blood pressure.
ANS: D Initial nursing interventions include monitoring the status of an existing aortic aneurysm. The patient should be monitored for signs of rupture of the aneurysm, such as hypotension. REF: Page 1595 TOP: Aortic aneurysm
1. Modifiable risk factors for coronary artery disease (CAD) include which group? a. Diabetes, family history b. Family history, smoking c. Smoking, heredity d. High cholesterol, obesity
ANS: D Modifiable factors include smoking, hyperlipidemia, hypertension, diabetes mellitus, and obesity. REF: Page 1550 TOP: Risk factors
18. The patient has been hospitalized for congestive heart failure (CHF) three times in the last 4 months. While preparing the discharge teaching plan, the nurse assesses that he does not comply with his medication regimen. The nurse's immediate course of action would be to a. reteach him about his medications. b. have a serious talk with him and his family about compliance. c. arrange for home visits after discharge. d. collect more information to identify his reasons for noncompliance.
ANS: D Nursing interventions include measures to prevent disease progression and complications. Reteaching about medication will not identify the cause of noncompliance. REF: Pages 1558, 1572, Box 48-9 TOP: Heart failure Step: Evaluation
2. The large, fan-shaped muscle that covers the anterior chest from the sternum to the proximal end of the humerus and acts on the joint of the shoulder to flex, adduct, and rotate is a. serratus anterior. b. intercostal. c. transversus abdominis. d. pectoralis major.
ANS: D Pectoralis major is the large, fan-shaped muscle that covers the anterior chest and is an adductor muscle, which will cause the shoulder to flex. REF: Page 1348, Table 44-1, Figure 44- 5 TOP: Muscle functions
29. When caring for the patient who is in shock, the nurse should provide a. adequate oral fluids to replace blood loss. b. external heat to combat shivering. c. sedatives to decrease anxiety and apprehension. d. oxygen to support respiratory function.
ANS: D Respiratory assistance may be given by administering oxygen. IV fluids are required for rapid access to blood volume. Shock causes altered level of consciousness and does not require medication to decrease anxiety or apprehension. REF: Page 1385
2. The nurse recognizes that the rehabilitation process involves the efforts of various disciplines whose focus is to build on a person's: a. losses. b. long-term plans. c. drives. d. abilities.
ANS: D The underlying philosophy of rehabilitation is to focus on abilities. REF: Page 1209 TOP: Rehabilitation
50. An is an enlarged, dilated portion of an artery and may be the result of arteriosclerosis, trauma, or a congenital defect.
ANS: aneurysm REF: Page 1595 TOP: Aneurysm
