Med Surg Final

Infective endocarditis

The nurse is caring for a patient who is an intravenous drug user. The nurse anticipates the need for assessment for which complication?

Anxiety

The nurse is caring for a patient who is diagnosed with cocaine addiction. For which additional disorder should the nurse assess this patient?

Risk for Injury

The nurse is caring for a patient who is experiencing alcohol withdrawal. Which is the priority nursing diagnosis for this patient?

"It is more specific in diagnosing your condition."

The nurse is caring for a patient who is undergoing diagnostic tests to rule out lung cancer. The patient asks the nurse why a computed tomography (CT) scan was ordered. What is the best response by the nurse?

A patient with pericarditis is prescribed corticosteroids. What should the nurse emphasize when teaching about this medication?

Take the medication as prescribed

Alcohol withdrawal syndrome

Ten hours after admission to the ICU following an auto accident, a patient begins to exhibit mild tachycardia, irritability, and tremors. Three hours later the patient has a grand mal seizure. Which condition does the nurse suspect?

"You may be physically dependent on the medication, but not necessarily addicted."

The nurse is caring for a patient who requires an opiate medication for chronic pain associated with a previous injury. The patient tells the nurse, "Even though I don't feel like I'm addicted to the medication, I get tremors in my hands if I miss a dose." What is the nurse's best response?

Cuffed tracheostomy

The nurse is caring for a patient with a longstanding permanent tracheostomy that has been in place for several years in order to provide mechanical ventilation. Which type of tracheostomy does the nurse anticipate this patient may have based on the health history?

It encourages patient responsibility

The nurse is caring for a patient with a substance use disorder who is admitted to the rehabilitation unit of the inpatient treatment facility. The nurse collaborates with the patient to establish and redefine mutual goals of treatment. What is the primary purpose of this action?

Using a fenestrated tracheostomy tube

The nurse is caring for a patient with a tracheostomy tube in place connected to a mechanical ventilator. When facilitating communication, which strategy is inappropriate?

Determine the patient's and family's wishes regarding diagnostic testing

The nurse is caring for an older adult patient who is very thin and emaciated. The patient reports new onset of shortness of breath. A chest x-ray reveals a spot on the lungs that the physician believes is an inoperable lung cancer. Due to the patient's poor nutritional status, chemotherapy is not an option. The health-care provider also believes that the location of the cancer would make radiation therapy unsuccessful. In advocating for this patient, what should the nurse encourage the health-care team to do?

"I get good grades in school."

The nurse is completing a health history and determines the patient would benefit from teaching about substance abuse. Which patient statement does not support the need for this teaching?

Body mass index (BMI) 35.8

The nurse is concerned that a patient admitted for a total hip replacement is at risk for thrombus formation and pulmonary embolism. Which assessment finding supports the nurse's concern?

Complete a crisis assessment

The nurse is conducting a class in the community regarding alcohol use to a group of college seniors. During the class a participant admits to frequently using alcohol. Which is the priority action of the nurse?

-"What is the most significant stress/problem occurring in your life right now?" -"How long has this been a problem?" -"What other stresses do you have in your life?"

The nurse is conducting a crisis assessment for a patient who admits to cocaine use. Which questions are appropriate for the nurse to ask the patient during this process? Select all that apply

"How many alcoholic beverages do you drink each day?"

The nurse is conducting a health history for a patient and wants to determine the patient's alcohol use. What question from the nurse will provide the greatest amount of information?

Obtain at least six to eight hours of sleep per night

The nurse is evaluating outcome goals written by a student for a patient diagnosed with alcoholism who is being discharged from a detoxification program. Which outcome is appropriate for this patient?

"I can play ball again this weekend."

The nurse is evaluating teaching provided to a patient recovering from eye trauma. Which statement indicates that additional teaching is required?

"I should place my towel in the bathroom."

The nurse is evaluating teaching provided to a patient with bacterial conjunctivitis. Which patient statement indicates that additional teaching is required?

Adds salt when cooking eggs in a frying pan

The nurse is evaluating teaching provided to a patient with hypertension. Which observation indicates that additional instruction would be required?

Perform exercises every day

The nurse is identifying actions to reduce a patient's risk for developing another deep vein thrombosis (DVT). What should the nurse include?

Take no more than the prescribed number of doses each day

The nurse is instructing a patient who is prescribed ipratropium bromide (Atrovent) for asthma. Which should be included in this patient's teaching?

Flange

The nurse is performing tracheostomy care. Which portion of the trach will the nurse use when tying the new trach ties?

Heparin and warfarin (Coumadin) are usually initiated at the same time

The nurse is planning care for a newly admitted patient diagnosed with pulmonary embolism. The nurse anticipates the patient will need anticoagulant therapy. What is true regarding this therapy for the treatment of this condition?

Monitor pulmonary arterial pressures

The nurse is planning care for a patient with a pulmonary embolism. Which intervention would assist with the patient's decrease in cardiac output?

Encourage to wear corrective lenses while awake

The nurse is planning care for a patient with an astigmatism. What action should the nurse take to reduce this patient's headaches and blurred vision?

Chronic pain

The nurse is planning care for a patient with peripheral arterial disease. Which nursing diagnosis would be appropriate for this patient?

-Referring to a peer-led support group -Assessing peer-support when planning care -Collaborating with teachers for support in the school setting

The nurse is planning care for a young adolescent patient diagnosed with asthma. Which evidence-based age-appropriate interventions will the nurse include in the plan of care? Select all that apply

Ineffective Breathing Pattern

The nurse is planning care for the patient diagnosed with chronic obstructive pulmonary disease (COPD) who has a breathing rate of 32 per minute, elevated blood pressure, and fatigue. Which nursing diagnosis is the priority for this patient?

-Increase fluid intake to 3000 mL per day -Turn, cough, and deep breathe every two hours -Chest percussion every eight hours

The nurse is planning care to address ineffective airway clearance for a patient with lung cancer. Which interventions should the nurse include in the patient's plan of care? Select all that apply

Hereditary, as well as complex environmental influences, predisposes one to substance dependence

The nurse is planning to implement addiction treatment groups at the inner city clinic. Which knowledge regarding addictions and its related therapies will facilitate implementation of the groups?

-Obesity -Smoking -High blood pressure

The nurse is preparing a tool about macular degeneration that will be posted during a health fair. Which modifiable risk factors should the nurse include in this tool? Select all that apply

-Dizziness -Difficulty talking -Sudden vision changes -Sudden weakness on one side of the body

The nurse is preparing a tool to instruct patients on the manifestations of carotid artery disease. What should the nurse include with this information? Select all that apply.

-Obesity -Age over 60 -Family history -Chronic health problems

The nurse is preparing information about cataracts for a community health fair. What should the nurse include about risk factors for the disorder? Select all that apply

-Diabetes -Smoking -Hypertension -Sedentary lifestyle

The nurse is preparing material about peripheral artery disease (PAD) for a community fair. What should the nurse include about modifiable risk factors for the disease? Select all that apply.

Nitroglycerin

The nurse is preparing medications for a patient experiencing an acute myocardial infarction. Which medication will dilate the patient's coronary blood vessels?

Follow a low-fat, low-cholesterol diet

The nurse is preparing teaching material to help a patient with atherosclerosis manage lifestyle changes. What should the nurse emphasize in this teaching?

-Cardiac output -MAP -Central venous pressure

The nurse is preparing to determine a patient's left heart afterload. What measurements are needed to make this calculation? Select all that apply

Anticoagulant administration schedule

The nurse is preparing to discharge a patient recovering from a pulmonary embolism. Which topics are appropriate for the nurse to include in the teaching session?

Inflate the balloon 1.5 mL

The nurse is preparing to obtain a pulmonary artery wedge pressure (PAWP) on a patient. What action should be taken to ensure for the patient's safety?

"Manifestations exhibited are caused by changes in neurochemistry."

The nurse is providing an educational seminar for the families of patients diagnosed with a substance use disorder. Which statement will the nurse include in the teaching session regarding the addictive process?

Deep breathing and coughing every hour

The nurse is providing care for a patient diagnosed with chronic obstructive pulmonary disease (COPD). Which intervention is inappropriate to control the patient's breathing pattern?

Assessing the patient for airway obstruction

The nurse is providing care for a patient requiring mechanical ventilation. When the nurse enters the room at the beginning of the shift, the patient's monitor displays a heart rate of 64 and oxygen saturation of 88%. Which nursing action is the priority?

Assuring that tube cuff inflation is no greater than 15 cm H2O, and that there is no audible air leak

The nurse is providing care for the patient requiring mechanical ventilation. Which action by the nurse would be inappropriate when providing care to this patient?

Inaudible breath sounds

The nurse is providing care to a patient admitted after experiencing an acute asthma attack. Which assessment findings indicate the need for immediate intervention by the nurse?

Azelastine

The nurse is providing education to the patient regarding nasal sprays that can be used to treat congestion. Which drug should the nurse include for a patient who requires an antihistamine?

Saline

The nurse is providing education to the patient regarding nasal sprays that can be used to treat congestion. Which should the nurse recommend when the patient wants a natural?

"Even though I don't like tomatoes, I will eat them since they are not acidic."

The nurse is providing education to the patient who is receiving treatment for laryngeal cancer. Which patient statement regarding nutrition requires further education from the nurse?

"I can resume my ephedra when I return home."

The nurse is reviewing discharge instructions with a patient who is newly diagnosed with asthma. Which patient statement indicates a need for further teaching?

Digoxin

The nurse is reviewing medications prescribed for a patient with hypertrophic cardiomyopathy. Which medication should the nurse question before administering?

"I should call my doctor before taking any over-the-counter medications."

The nurse is reviewing teaching provided to a patient with glaucoma. Which patient statement indicates that teaching has been effective?

Fatigue

The nurse is reviewing the manifestations of an acute myocardial infarction with a patient diagnosed with type 2 diabetes mellitus. What should the nurse emphasize as being an atypical manifestation of this cardiac disorder?

"I should limit my fluid intake to 1-1.5 quarts daily."

The nurse is teaching a patient diagnosed with chronic obstructive pulmonary disease (COPD). Which patient statement indicates a need for further teaching?

Picks up a 3-year-old grandchild

The nurse is visiting the home of a patient recovering from laser trabeculoplasty. Which observation made by the nurse increases this patient's risk of developing a postoperative complication?

Walks around the house barefoot

The nurse is visiting the home of a patient with peripheral arterial disease. For which observation should the nurse immediately intervene?

Tonometry

The nurse notes that a patient is diagnosed with primary open-angle glaucoma. What diagnostic test would have been used to diagnose this health problem?

Macular degeneration

The nurse notes that a patient known to the community clinic was unable to recognize the health-care provider. What health problem should the nurse suspect is occurring with this patient?

Reduce afterload

The nurse notes that a patient with cardiomyopathy has been prescribed an angiotensin-converting enzyme inhibitor. What is the purpose of this medication?

Pain when walking

The nurse suspects that a patient has atherosclerosis. What finding did the nurse use to make this clinical determination?

Sees distance objects better than those near

The nurse suspects that a patient has undiagnosed hyperopia. What did the nurse assess to come to this conclusion?

Metabolic acidosis upon arterial blood gas analysis

The nurse suspects that a patient in cardiogenic shock is experiencing oxygen deprivation. What would confirm the nurse's suspicion?

Double vision in one eye

The nurse suspects that a patient is developing a cataract. What finding did the nurse use to make this clinical decision?

-Bleeding -Elevated body temperature -Acute onset of shortness of breath -Development of a cardiac dysrhythmia

The nurse suspects that a patient is experiencing a complication from a pulmonary artery catheter. What findings did the nurse use to make this clinical determination? Select all that apply

-Tearing -Eye pain -Squinting -Photophobia

The nurse suspects that a patient is experiencing a corneal abrasion. What did the nurse assess to come to this conclusion? Select all that apply

SOB when supine

The nurse suspects that a patient with cardiomyopathy is experiencing heart failure. What finding did the nurse use to make this clinical decision?

Measure the central venous pressure

The nurse wants to evaluate a patient's right heart preload. Which approach should be used to obtain this measurement?

Assessing the patient

The nurse working in the intensive care unit is assigned a patient requiring mechanical ventilation. When responding to the ventilator alarm, the nurse sees a high-pressure alarm. Which nursing action is the priority?

Decreased wheezing

The nurse working on a pediatric unit is caring for a patient newly diagnosed with asthma. Which assessment data indicates exhaustion and the need for immediate intervention?

"Assist control is a means of delivering ventilation that delivers a preset volume and/or pressure each time the patient begins an inspiration."

The nurse working with a student nurse is providing care for a patient requiring mechanical ventilation. The student nurse asks the meaning of assist control. Which response by the nurse is the most appropriate?

Removing the valve and notifying the health-care provider

When capping the patient's tracheostomy tube with a speaking valve, the nurse assesses the patient's breath sounds around the tube and hears no air leak. Which nursing action is the most appropriate based on this assessment finding?

Suctioning the tracheostomy tube

When preparing to cap the patient's tracheostomy tube with a speaking valve, which nursing action is inappropriate before placing the valve?

Fluorescein stain

A patient is diagnosed with a corneal abrasion. Which diagnostic test was used to confirm this diagnosis?

Preoperative and postoperative care

A patient is diagnosed with an abdominal aneurysm measuring 5 cm. Which teaching material should the nurse prepare for this patient?

Which of the following dysrhythmias requires defibrillation? A. Atrial tachycardia B. Atrial fibrillation C. Ventricular tachycardia with a pulse D. Ventricular fibrillation

D

"It is important to remain nonjudgmental when caring for any patient, even a drug addict."

After an assessment of a patient, a nursing student expresses a belief that drug addiction is not a real illness, as these patients "did it to themselves." Which response by the staff nurse is appropriate?

The nurse is conducting a health history with a patient diagnosed with erectile dysfunction. Which finding could provide a possible cause for the patient's problem?

Alcohol intake of four to six beers each day

Use relaxation exercises to reduce uncomfortable feelings from the mask

An adult patient diagnosed with sleep apnea has been prescribed a continuous positive airway pressure (CPAP) machine as treatment. The nurse is instructing the patient on how to use the machine. Which instruction should the nurse include?

Ineffective Breathing Pattern

An older adult patient diagnosed with asthma has a respiratory rate of 28 at rest with audible wheezes upon inspiration. Based on this data, which nursing diagnosis is the most appropriate?

Rupture of an abdominal aneurysm

An older patient seeks emergency care for a sudden onset of severe abdominal pain. Which health problem should the nurse suspect be occurring in this patient?

A patient is recovering from mechanical valve replacement surgery for valvular disease. What medication teaching should medication teaching should the nurse prepare for this patient?

Anticoagulant therapy for life

A patient is demonstrating manifestations of valvular disease. Which valve should the nurse expect to be affected with this disorder?

Aortic

-Purulent eye discharge -Matting of the eyelashes

A patient is diagnosed with bacterial conjunctivitis. What should the nurse expect to assess in this patient? Select all that apply A patient is diagnosed with viral conjunctivitis. What should the nurse expect to be prescribed for this patient? Select all that apply

Stroke

A patient is diagnosed with carotid artery disease. For which potential health problem should the nurse prepare teaching for this patient?

-Eye lubricants -Cold compresses -Ocular decongestants

A patient is diagnosed with viral conjunctivitis. What should the nurse expect to be prescribed for this patient? Select all that apply

CT scan with IV contrast

A patient is suspected of having an abdominal aortic aneurysm. For which gold standard diagnostic test should the nurse prepare teaching for this client?

Stop smoking

A patient learns of having a 1 cm abdominal aortic aneurysm. What should the nurse emphasize when discussing the health problem with this patient?

-Instruct that intubation and ventilation are temporary measures -Encourage family visits and participation in care. -Remain with the patient as much as possible

A patient receiving treatment for acute respiratory distress syndrome (ARDS) is demonstrating anxiety and fear of having to stay on the ventilator indefinitely. Which interventions by the nurse are appropriate? Select all that apply

Lower the head of the bed

A patient recovering from a carotid endarterectomy (CEA) has a blood pressure of 90/48 mm Hg. What should the nurse do first?

Important to obtain as much rest as possible

A patient recovering from cardiogenic shock is observed walking to the patient lounge. What should the nurse recommend to this patient?

Deep vein thrombosis

A patient scheduled for surgery is being instructed in leg exercises and the pneumatic compression device. The nurse includes these instructions to decrease which postoperative complication?

Tetanus vaccination

A patient seeks treatment for a corneal abrasion that occurred the previous week. What should the nurse expect to be prescribed to reduce this patient's risk of developing a complication?

-Heart rate -Lower extremities -Neurological system -BMI and waist circumference

A patient who comes to the community clinic for a wellness visit has a blood pressure of 164/92 mm Hg. What additional information should the nurse assess from this patient? Select all that apply.

To admit to having a problem

A patient who is attending a Narcotics Anonymous (NA) program asks the nurse what the most important initial goal of attending the meetings is. When responding to the patient, which indication will the nurse take into account?

-Diuretics -Vasodilators -ACE Inhibitors -Calcium channel blockers

A patient with a blood pressure over 160/90 mm Hg for two office visits is being started on antihypertensive medication for the first time. For which medication classifications should the nurse prepare teaching? Select all that apply.

-Being treated for hemophilia -Symptoms of a DVT present for a week -Diagnosis of DVT made upon symptoms

A patient with a deep vein thrombosis (DVT) is disappointed to learn that tissue plasminogen activator (tPA) is not an option. What information was used to make this treatment decision? Select all that apply.

Impaired Spontaneous Ventilation

A patient with a respiratory rate of eight breaths per minute has an oxygen saturation of 82%. Which nursing diagnosis is a priority for this patient?

Place in the Fowler position

A patient with acute respiratory distress syndrome (ARDS) is being weaned from mechanical ventilation. Which nursing action is appropriate for this patient?

"Tobacco smoke speeds the growth of atherosclerosis in coronary arteries, aorta, and the legs."

A patient with atherosclerosis asks why smoking cessation is important. What should the nurse respond to this patient?

-Q waves -ST segment elevation

A patient with atypical chest pain is prescribed a 12-lead electrocardiogram. What findings would support this patient experiencing an acute myocardial infarction? Select all that apply

Keep the affected leg straight at all times

A patient with cardiogenic shock has an intra-aortic balloon pump (IABP). What should the nurse include when caring for this patient?

"Restricting salt helps prevent the development of other health problems."

A patient with cardiomyopathy asks for salt when the breakfast tray arrives. What should the nurse respond to this request?

Signs of overexertion

A patient with cardiomyopathy comes into the emergency department with chest pain and dyspnea after running a 5K race. What should the nurse explain to this patient?

-A pacer wire is placed in the right and left ventricles -The automatic defibrillator will deliver a shock if necessary -The automatic defibrillator monitors the heart for dysrhythmias

A patient with cardiomyopathy is scheduled for a biventricular implantable cardioverter defibrillator. What should the nurse include when teaching the patient about this device? Select all that apply

Jugular vein distention

A patient with dilated cardiomyopathy has developed a productive cough. What additional manifestation supports fluid overload in this patient?

Aldosterone

A patient with hypertension has a low serum potassium level. Which mechanism should the nurse consider as being the cause for the elevated blood pressure?

Avoid indoor and outdoor light for five days after treatment

A patient with macular degeneration is being treated with verteporfin (Visudyne). What should the nurse emphasize in the patient teaching in order to reduce the risk of complications from this treatment?

-LASIK -Radical keratotomy -Phakic intraocular lens -Photorefractive keratotomy

A patient with myopia asks what can be done to correct the disorder. Which procedures should the nurse review with this patient? Select all that apply

"I might not feel the effect of this medication for up to two months."

A patient with peripheral arterial disease is instructed on the medication pentoxifylline (Trental). Which patient statement indicates that teaching has been effective?

148/118= 1.25

A patient's ankle systolic blood pressure is 148 mm Hg and brachial systolic pressure is 118 mm Hg. What is this patient's ankle-brachial index? Record your answer as a whole number. _____

Schedule an additional measurement in a few weeks

A patient's blood pressure is 158/90 mm Hg; however, previous measurements have been within normal limits. Which intervention would be appropriate for this patient?

3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with lung cancer. 4) The nurse is planning care to address ineffective airway clearance for a client with lung cancer. Which interventions should the nurse include in the client's plan of care? Select all that apply. A) Increase fluid intake to 3000 mL per day. B) Turn, cough, and deep breathe every 2 hours. C) Chest percussion every 8 hours D) Smoking cessation education E) Administer pneumococcal vaccine.

A, B, C Explanation An adequate fluid intake is needed. Clients with pneumonia should increase their fluid intake in order to decrease the viscosity of respiratory secretions. Turning, coughing, deep breathing and chest percussion can help clear secretions. Administering the pneumococcal vaccine and educating the client on smoking cessation are important in treating a client with pneumonia, but they would be aligned with a different nursing diagnosis. Page Ref: 109 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Planning

1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of cancer. 8) The nurse is providing discharge instructions to a client being treated for cancer. For which symptoms should the client be instructed to call for help at home? Select all that apply. A) Difficulty breathing B) Significant increase in vomiting C) Desire to end life D) Improved sense of well-being E) New onset of bleeding

A, B, C, E Explanation: The client should be instructed to call for help with any difficulty breathing, significant increase in vomiting, a desire to end life, or a new onset of bleeding. An increased sense of wellbeing would be a desired effect of treatment for cancer. Page Ref: 60 Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Nursing Process: Evaluation/Teaching and Learning

4. Differentiate common assessment procedures used to examine cellular regulation across the life span. 5) The nurse is caring for a client who has been diagnosed with cancer. Which diagnostic tests may be helpful to assist with treatment options? Select all that apply. A) Tumor markers B) Urinalysis C) Physical assessment D) MRI E) Stool analysis

A, B, D Explanation Many diagnostic tests are helpful in determining treatment for cancer. An MRI, urinalysis, and tumor markers are all diagnostic tests that may be used to determine treatment for cancer. A stool analysis is not a diagnostic test listed to determine treatment for cancer. A physical assessment may be useful to determine how a client is responding to treatment, but it is not considered a diagnostic test. Page Ref: 37 Cognitive Level: Understanding Client Need: Physiological Integrity Nursing Process: Planning

A patient is concerned about becoming impotent because of the inability to sustain an erection and a history of a sexually transmitted infection as a young adult. What is the nurse's best response to this patient's concerns?

"An occasional incident like this is normal and common, and there is no reason to be concerned."

A nursing instructor is teaching a group of student nurses about the cultural implications of prostate cancer. Which statement will the nursing instructor include in the teaching session?

"Approximately one in eight men ages 70 and older will be diagnosed with prostate cancer."

A patient asks for a prescription for tadalafil (Cialis). What would be important for the nurse know prior to planning interventions for this patient?

"Do you use nitroglycerine?"

A patient with infective endocarditis is being started on intravenous antibiotics. What should the nurse include when teaching about this medication?

"Expect to continue this medication for four to six weeks at home."

During a health history, the nurse learns that a patient has a recent onset of impotence. Which question will help identify a potential cause of this manifestation?

"For what diseases and disorders have you been treated?"

The nurse is caring for a patient diagnosed with benign prostatic hyperplasia (BPH) who is experiencing an increase in symptoms. Which statement by the patient would best explain the source of the increased symptoms?

"I am using an over-the-counter cold medication for a cold." Use of cold medications can increase symptoms because of their anticholinergic properties.

The nurse is instructing a patient about the medication sildenafil (Viagra). Which patient statement indicates teaching has been effective?

"I can take only one pill in a 24-hour period."

The nurse is evaluating teaching provided to a patient with coronary artery disease. Which patient statement indicates that additional teaching is required?

"I can take up to three doses of nitroglycerin 15 minutes apart."

A patient reports getting up to urinate several times a night and difficulty starting a stream of urine. After medical testing is completed, a diagnosis of benign prostatic hyperplasia (BPH) is made. After conducting teaching regarding BPH, which statement by the patient indicates the need for further education?

"I know I will get cancer of the prostate because of this."

The nurse is preparing to discharge a patient recovering from prostate surgery for cancer. What should the nurse emphasize when providing discharge instructions for this patient?

"It is quite common to notice blood in your urine following this type of surgery."

A nurse is caring for a patient who is prescribed a selective phosphodiesterase type 5 inhibitor for the treatment of erectile dysfunction. The nurse should include which statement when educating the patient regarding this medication?

"The action of this medication will last up to 36 hours."

The nurse is caring for a patient who returns to the unit following transurethral resection of the prostate due to prostate cancer with a three-way Foley catheter in place. The patient states that he has the urge to urinate and wants the catheter removed. Which response by the nurse is the most appropriate?

"This is an expected sensation, but the Foley catheter must remain in place."

A patient is scheduled to undergo a prostate biopsy. The patient asks the nurse what is expected immediately following the procedure. Which response by the nurse is the most appropriate?

"You will likely experience discomfort for 24-48 hours after the procedure."

The nurse is caring for a male patient of Japanese descent who is experiencing urinary retention. The patient asks the nurse if it is possible that he is experiencing benign prostatic hyperplasia (BPH). Which response by the nurse is the most appropriate?

"Your provider will run some tests; however, you are considered low-risk for BPH."

A patient is experiencing manifestations of infective endocarditis. Which diagnostic tests should the nurse expect to be prescribed for this client? Select all that apply.

1) Blood cultures 3) Electrocardiogram 4) Transthoracic echocardiogram (TTE) 5) Transesophageal echocardiogram (TEE)

While planning care the nurse identified interventions to reduce a patient's risk for developing heart failure. Which assessment findings did the nurse use to make this clinical determination? Select all that apply.

1) Body mass index 31.3 2) Smokes 1/2 pack of cigarettes 4) Blood pressure 168/90 mm Hg 5) Fasting blood glucose 146 mg/dL

The nurse is preparing a community program on the metrics to improve cardiovascular health. What should be included in this program? Select all that apply.

1) Healthy diet 3) Physical activity 4) Smoking cessation 5) Lower blood pressure

A patient with pericarditis is being prepared for an emergency pericardiocentesis. What did the nurse most likely assess to support this immediate procedure? Select all that apply.

1) Hypotension 2) Pulsus paradoxus 3) Muffled heart sounds 4) Jugular vein distention

The nurse notes that a patient with heart failure has a normal ejection fraction. What should this information indicate to the nurse? Select all that apply.

1) It is a common diagnosis 2) It is associated with older patients with obesity 3) It is seen in patients with diabetes mellitus and atrial fibrillation 5) There is less blood in the ventricle to eject because of the impaired filling

Airway maintenance with cervical spine protection

A patient is brought into the emergency department (ED) after being in a motor vehicle accident. The patient has suffered traumatic injury that may involve multiple body systems. Which is the priority nursing assessment for this patient?

A patient is scheduled for an exercise stress test. For which cardiac health problems is this patient being tested? Select all that apply.

3) Valvular disease 5) Coronary artery disease

The nurse is caring for a patient who has a continuous bladder irrigation running following a prostatectomy. During the shift, a total of 1500 mL of irrigant is infused. The Foley bag is emptied twice for the shift with totals of 850 mL and 950 mL. What is the patient's actual urine output for the shift?

300 mL

The nurse is concerned that a patient is at risk for developing infective endocarditis. What information in the patient's history caused the nurse to have this concern?

70 years of age

The nurse is providing care to a patient who is diagnosed with benign prostatic hyperplasia (BPH). Which items in the patient's health history may have contributed to this diagnosis? Select all that apply.

70 years of age Diet high in meat and fats African-American ethnicity

The nurse knows the heart's normal conduction system starts where? A. Sinoatrial (SA) node B. Artioventricular (AV) node C. Bundle of His D. Purkinje fibers

A

6. Plan evidence-based care for an individual with skin cancer and his or her family in collaboration with other members of the healthcare team. 11) A nurse working in a dermatology outpatient clinic is caring for a client who has been diagnosed with a lentigo maligna. The nurse will educate the client on all except: A) The lesion is also called Robertson freckle. B) The lesion is a precursor to melanoma. C) The lesion is a tan or black patch on the skin that looks like a freckle. D) The lesion grows slowly, becoming mottled, dark, thick, and nodular.

A Explanation: A lentigo maligna, also called a Hutchinson freckle, is a precursor to melanoma. The lesion is a tan or black patch on the skin that looks like a freckle. The lesion grows slowly, and becomes mottled, dark, thick, and nodular. Page Ref: 128 Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing Process: Assessment

1. Summarize the physiology of the hematological system related to cellular regulation. 2) A nursing instructor is explaining the term hyperplasia to the class. Which statement, made by a nursing student, indicates an understanding of why hyperplasia occurs with myocardial infarction? A) "The cells of the muscle experience hyperplasia with the prolonged need for oxygen." B) "The cells of the heart are metaplastic in response to muscle damage." C) "The cells of the heart muscle have lost fluid." D) "The cells of the heart muscle are responding to metabolic needs."

A Explanation: A) Hyperplasia is an increase in density or number of normal cells in response to stress-in this case, the increased demand for oxygen. Cells that lose fluid will shrink in size. The cells of a person's heart do not enlarge as a metabolic response. Metaplasia is a change in the normal pattern of differentiation of cells. Page Ref: 32 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Evaluation

6. Plan evidence-based care for an individual with sickle cell disease and his or her family in collaboration with other members of the healthcare team. 6) The nurse is planning care for a young child who is admitted with sickle cell crisis. The parents are with the child, and neither has much information about the disease. When planning care for this family, the nurse will set which goal with this family? A) The child will drink adequate amounts of fluid each day. B) The child will play outside in the sun. C) The family will not have the child vaccinated. D) The family will plan vacations in high-altitude areas.

A Explanation: For the client with sickle cell disease, dehydration can lead to life-threatening consequences. The client's oral intake should be adjusted as necessary to keep the child well hydrated. Teach clients and parents how to monitor intake and output, and provide client teaching regarding fluid management. Playing outdoors in the sun can lead to dehydration, which can precipitate a crisis. Oxygen supply at high altitudes is too low for the client with sickle cell disease. The family should be taught to select low-altitude areas for vacation. Infection and illnesses with fever will increase the body's demand for oxygen, so it is important for the family to keep up with the child's immunization schedule. Page Ref: 125 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Planning

4. Formulate priority nursing diagnoses appropriate for an individual with leukemia. Exemplar 2.6 Lung Cancer 1) The student nurse is questioning the instructor about the different types of chemotherapeutic agents used to treat cancer. Which statement by the instructor best explains why lung cancers are less sensitive to antineoplastic agents than other types of cancers? A) "Lung cancer cells have a low growth fraction, so they are less sensitive to antineoplastic agents." B) "Lung cancer cells grow in a high-oxygen environment, so they are not very sensitive to antineoplastic agents." C) "Lung cancer cells have been growing for a long time before detection, so they are less sensitive to antineoplastic agents." D) "Lung cancer cells have a very erratic cell cycle, so they are not very sensitive to antineoplastic agents."

A Explanation: Growth fraction is a ratio of the number of replicating cells to the number of resting cells. Antineoplastic drugs are much more toxic to tissues and tumors with high growth fractions. Breast and lung cancers have low growth fractions. Lung cancer cells may grow for a long time before detection, but this is not the primary reason they are less susceptible to antineoplastic agents. A high-oxygen environment is not the reason why lung cancer cells are less sensitive to antineoplastic agents. Lung cancer cells do not have a very erratic cell cycle. Page Ref: 108 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation

4. Formulate priority nursing diagnoses appropriate for an individual with sickle cell disease. 5) A client is admitted to the Emergency Department in a sickle cell crisis. The nurse assesses the client and documents the following clinical findings: temperature 102°F, O2 saturation of 89%, and complaints of severe abdominal pain. Based on the assessment findings, which intervention is the greatest priority? A) Apply oxygen per nasal cannula at 3 L/minute. B) Assess and document peripheral pulses. C) Administer morphine sulfate 10 mg IM. D) Administer Tylenol 650 mg by mouth.

A Explanation: Hypoxia is often the cause of a sickle cell crisis from the clumping of damaged RBCs, which creates an obstruction and hypoxia distal to the clumping. Administering the oxygen will improve the pain and increase the oxygen saturation of body tissues. Therefore, applying the oxygen should be the first action by the nurse. Although the temperature is elevated, and will increase oxygen demands in the body by increased basal metabolic activity, administering Tylenol is not the first action the nurse should take, because a sickle cell crisis is caused by oxygen deprivation in tissues, not by the fever. Morphine sulfate is a narcotic for pain, but it should be given after the oxygen is started, since the symptoms are caused by hypoxia. The morphine will decrease the pain and decrease metabolic oxygen needs by decreasing basal metabolic rates; therefore, supply is increased and demand is increased. Full body assessment, including peripheral pulses, is significant to identify the location of the potential obstruction, but this is secondary to treating the hypoxia that is known to be present from the sickling of the cells during sickle cell crisis. Page Ref: 123 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation

5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with sickle cell disease. 9) A pediatric nurse is educating the client with sickle cell disease and the client's family regarding the genetic implications of the disease. The nurse will include all information except: A) If both parents have the trait, then with each pregnancy, the risk of having a child with the disease is 50%. B) The disorder is transmitted as an autosomal recessive genetic defect. C) The sickle cell gene may have originated to protect against lethal forms of malaria. D) In African-Americans, sickle cell disease occurs in 1 out of every 500 births.

A Explanation: In educating the client and the client's parents regarding sickle cell disease, the nurse will state that the disorder is transmitted as an autosomal recessive genetic defect. If both parents have the trait, then with each pregnancy, the risk of having a child with the disease is 25%, not 50%. The sickle cell gene may have originated to protect against lethal forms of malaria. In African-Americans, sickle cell disease occurs in 1 out of every 500 births. Page Ref: 120 Cognitive Level: Understanding Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing Process: Assessment

5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with breast cancer. 10) The nurse instructs a client recovering from a mastectomy on ways to prevent lymphedema. Which client statement indicates that teaching has been successful? A) "I should do the exercises on my affected arm every day." B) "I have to take no special precautions." C) "I should avoid cleansing my skin with soap." D) "Eating fresh fruits and vegetables will prevent my arm from swelling."

A Explanation: Range-of-motion exercises in the affected arm helps develop collateral drainage and prevent the development of lymphedema. The client should be instructed to protect the affected limb by not permitting blood pressure measurement and avoiding tight jewelry and clothing on the limb. There is no reason for the client to avoid cleansing the skin of the affected arm with soap. Consuming fresh fruits and vegetables will not prevent the development of lymphedema. Page Ref: 81 Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Nursing Process: Evaluation/Teaching and Learning

2. Identify risk factors and prevention methods associated with sickle cell. 3) The nurse is assigned to care for a child with sickle cell disease who is being admitted with splenic sequestration crisis. Which room would be the most appropriate for this child? A) Private room B) Semi-private room C) Contact-isolation room D) Airborne-isolation room

A Explanation: Splenic sequestration can be life-threatening, and there is profound anemia. The child should not be placed in a room with any child who might have an infectious illness. A private room is appropriate for this child. The child should not be exposed to other children with potentially infectious illnesses, so a semi-private room is not appropriate. The child is not contagious; therefore, neither airborne nor contact isolation is necessary. Page Ref: 121 Cognitive Level: Applying Client Need: Safe and Effective Care Environment Nursing Process: Implementation

Amphetamines

A patient is brought to the emergency department by a parent. The nursing assessment reveals that the patient has been acting strangely for the past three hours and is hypervigilant, grandiose, and irritable. Vital signs reveal hypertension, tachycardia, and some arrhythmias. Which substance does the nurse suspect that the patient has been using?

Inner layers of the retina separate

A patient is demonstrating signs of a detached retina. What is the reason this occurred?

Keep the bed flat

A patient is diagnosed with a 7 cm abdominal aortic aneurysm. What should the nurse include in this patient's plan of care?

2. Identify risk factors and prevention methods associated with anemia. 4) An older client with renal failure is diagnosed with anemia. What does the nurse realize was the cause of this client's anemia? A) Loss of the kidney hormone erythropoietin B) A loss of appetite related to elevated blood urea nitrogen (BUN) and creatinine levels C) The renal dialysis used to treat the chronic renal failure D) Loss of blood through the urine because the failing kidney does not function properly

A Explanation: The anemia associated with renal failure is related to the loss of erythropoietin, which is produced by the healthy kidney and stimulates bone marrow to produce red blood cells. The anemia is not directly related to anorexia or hemodialysis, although these factors may be somewhat associated with the anemia. Renal failure causes the loss of protein, not blood, through the urine. Page Ref: 65 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Assessment

6. Plan evidence-based care for an individual with breast cancer and her family in collaboration with other members of the healthcare team. 7) The nurse is reviewing the plan of care for a client being treated with brachytherapy for breast cancer. Which assessment finding indicates that the client's skin integrity has been maintained? A) Skin intact B) Skin dry and excoriated C) Skin stretched D) Skin damp and sweaty

A Explanation: The goal for the client receiving radiation therapy to the chest is intact skin, which the nurse would expect to find. Skin that is damp with sweat, dry, or stretched is not consistent with radiation. If the goal were not met, the nurse would find excoriation. Page Ref: 82 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Evaluation

4. Formulate priority nursing diagnoses appropriate for an individual with breast cancer. 6) The nurse is caring for a client with metastatic breast cancer receiving chemotherapy. Even though the prognosis is poor, the client tells the nurse that the plan is to do everything to survive. How should the nurse respond to this client? A) "You have a great attitude and I am here to support you through education to help you survive." B) "It is important to plan for your death, even though there is a chance you will survive." C) "You should face the reality of the situation. You do not have a good chance of survival." D) "I am going to speak with your family regarding your unrealistic expectations."

A Explanation: This client is in the earliest stages of cancer treatment, with removal of the primary tumor about to take place. The nurse's role is to support this client's optimism and help in fighting the disease by teaching about nutrition and other supportive actions the client can take to minimize complications of treatment. While the prognosis may be poor, the outcome is not absolute, and the client's wish to do whatever is necessary to survive should be supported. Emphasizing the low survival rate, encouraging the client to prepare for death, and talking with the family about the client's unrealistic expectations would not support the client's optimism. Page Ref: 83 Cognitive Level: Analyzing Client Need: Psychosocial Integrity Nursing Process: Implementation

2. Identify risk factors and prevention methods associated with skin cancer. 5) An African-American client tells the nurse of plans to bask in the sun on an upcoming vacation. The nurse questions the client about sunscreen use. Which response indicates the client needs further education? A) "I don't need sunscreen because I am dark-skinned already." B) "I will avoid the sun between the peak hours of 10 am and 4 pm." C) "I can still experience sun damage despite my dark skin tones." D) "The melanocytes in my skin provide me with increased protection from the sun."

A Explanation: While the melanocytes in darker skin offer increased protection, the risk for skin cancer remains and sunscreen should be worn. The other client responses are correct. Page Ref: 131-132 Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Nursing Process: Evaluation

"Maintain blood glucose levels within normal limits."

A client with type 2 diabetes mellitus is newly diagnosed with carotid artery disease. What should the nurse emphasize when discussing blood glucose control with this patient?

Respiratory depression

A college student is incoherent after taking "downers with beer." For which health problem should the nurse also observe for in this patient?

Provide the patient and family privacy

A male Hispanic patient has had a lung biopsy. The results indicate a poor prognosis for the patient. The family is at the patient's bedside and begins to moan and cry loudly. The health-care provider has told the nurse that he needs to have the consent form signed for surgery. The patient has asked the nurse to allow the family private time. What should the nurse do at this time?

Tachycardia and nonspecific T-wave changes on EKG

A nurse caring for a patient with a pulmonary embolism expects to find which diagnostic result?

Maintain a patent airway

A nurse is caring for a patient recovering from a wedge resection of the left lung for a tumor. Which is an appropriate goal for the nursing diagnosis of ineffective airway clearance?

"We will replace the carpet in our child's bedroom with tile."

A nurse is teaching environmental control to the parents of a child with asthma. Which statement by the parents indicates effective teaching?

-Hyperpyrexia -Respiratory distress

A nurse working in the emergency department is caring for a patient who has overdosed on cocaine. The nurse receives a prescription to administer an antipsychotic medication from the health-care provider. Which symptom would this medication help to manage? Select all that apply

"The dopamine D3 receptor is involved in drug-seeking behaviors."

A nursing instructor is teaching a class about the role of dopamine in substance abuse. Which student statement indicates appropriate understanding?

"Methadone blocks the craving for and the action of opiates."

A patient addicted to heroin is prescribed methadone as part of the treatment process. The patient's spouse asks, "I don't understand the reason for the methadone treatment. Why replace heroin with methadone?" Which response by the nurse is accurate?

Mechanical ventilation

A patient admitted with smoke inhalation injuries develops signs and symptoms of acute respiratory distress syndrome (ARDS). Which health-care provider prescription does the nurse anticipate for this patient?

"The medication is still needed to decrease inflammation in your airways and help prevent an attack."

A patient asks why asthma medication is needed even though the patient's last attack was several months ago. Which response by the nurse is appropriate?

"The role of genetics in substance use disorders has not been determined."

A patient being treated for an alcohol use disorder asks the nurse, "Can my children inherit this?" Which response by the nurse is most appropriate?

Loosely cover both eyes

A patient comes into the emergency department with manifestations of retinal detachment. What should the nurse do to minimize this patient's eye movements?

Detached retina

A patient contemplating cataract surgery asks if there are any risk factors. How should the nurse respond?

Impaired Gas Exchange

A patient diagnosed with a pulmonary embolism has a reduction in arterial oxygen saturation level and dyspnea. Which is the priority nursing diagnosis for this patient?

Oxygen by nasal cannula at 3-4 liters/minute

A patient diagnosed with chronic obstructive pulmonary disease (COPD) has a pulse oximetry reading of 93%, increased red blood and white blood cell count, temperature of 101°F, pulse 100 bpm, respirations 35 bpm, and a chest x-ray that showed a flattened diaphragm with infiltrates. Based on this data, which prescription does the nurse question for this patient?

Stage III

A patient experiencing pain and burning in the legs at rest. Which stage of peripheral arterial disease should the nurse suspect this patient is experiencing?

Amsler grid

A patient has been experiencing a gradual loss of central vision. Which tool should the nurse use when assessing this patient?

Conjunctivitis

A patient has watery eye discharge affecting both eyes. Which health problem should the nurse suspect this patient is experiencing?

Increased heart rate

A patient in the intensive care unit is experiencing chest pain. What assessment finding indicates that cardiogenic shock is being compensated?

-Start an IV -Initiate seizure precautions -Administer ammonium chloride

A patient is admitted to the emergency department after overdosing on phencyclidine piperidine (PCP). Based on this actions, which actions are appropriate by the nurse? Select all that apply

Naloxone

A patient is admitted to the emergency department with signs of drug use. The patient reports having ingested Percocet and is experiencing respiratory depression. Based on this data, which prescription does the nurse anticipate for this patient?

Troponin

A patient is being evaluated for chest pain in the emergency department. Which laboratory test is the best to determine if this patient has experienced an acute myocardial infarction?

Liver cirrhosis

A patient is being evaluated for medication therapy to treat atherosclerosis. For which health problem would a statin be contraindicated?

2. Identify risk factors and prevention methods associated with breast cancer. 2) The nurse is teaching a 34-year-old client with client who has a sister and mother with a history of breast cancer about early screening for the health problem. Which should the nurse include in this teaching? Select all that apply. A) Routine monthly breast self-examination B) Annual screening mammography C) Routine breast exams to begin after age 35 D) Clinical breast examination every 3 years E) Reporting of any changes in breast tissue to the health provider at the next routine visit

A, B, D Explanation: American Cancer Society guidelines for cancer screening include routine breast self-examination starting at age 20; prompt reporting of any change in breast tissue to healthcare provider; clinical breast examination every 3 years from ages 20 to 39, and yearly thereafter; and annual screening mammography starting at age 40, except in women at increased risk, who may have more frequent mammography or other tests such as breast ultrasound exams. Since this client's mother and sister both have a history of breast cancer, she would be eligible for annual mammography. Page Ref: 58 Cognitive Level: Applying Client Need: Health Promotion and Maintenance Nursing Process: Implementation/Teaching and Learning

1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of anemia. 3) A client with a history of anemia has started a vegan diet. Which addition to meals should the nurse recommend to help ensure that this client has adequate amounts of iron in the diet? Select all that apply. A) Legumes B) Orange juice C) Brewer's yeast D) Okra E) Peas

A, B, E Explanation: While all these options are good ones for someone on a vegan diet, the ones that would best prevent iron deficiency are legumes, peas, and orange juice. Legumes and peas are good sources of nonheme iron. Orange juice supports iron absorption from foods since it is high in vitamin C. Brewer's yeast is a good source of vitamin B12, which is often low in vegan diets. Okra is not a good source of iron. Page Ref: 65 Cognitive Level: Applying Client Need: Health Promotion and Maintenance Nursing Process: Implementation/Teaching and Learning

6. Plan evidence-based care for an individual with leukemia and his or her family in collaboration with other members of the healthcare team. 14) A nurse is caring for a client with chronic myeloid leukemia (CML) who is neutropenic. To ensure safety for the client, the nurse will: Select all that apply. A) Place client in reverse isolation. B) Place patient in standard precaution isolation. C) Administer granulocyte colony-stimulating factor (G-CSF) as ordered. D) Administer neutrophil colony-stimulating factor (N-CSF) as ordered. E) Administer a prophylactic gram-negative antibiotic.

A, C Explanation: A client who is neutropenic has a decrease in the level of white blood cells (WBCs) and is susceptible to infection and/or disease. To ensure the safety of the client with neutropenia, the nurse will place the client in reverse isolation, administer granulocyte colony-stimulating factor (G-CSF) as ordered, and administer a broad-spectrum antibiotic as ordered. Standard precautions should be used for all clients and this does not ensure safety of the neutropenic client. Page Ref: 101 Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Nursing Process: Implementation

6. Plan evidence-based care for an individual with lung cancer and his or her family in collaboration with other members of the healthcare team. 6) A nurse is caring for a client recovering from a wedge resection of the left lung for a tumor. What would be appropriate goals for the nursing diagnosis of ineffective airway clearance? Select all that apply. A) Minimize accumulation of fluid. B) Participation in care by the client C) Maintain a patent airway. D) Maintain current weight. E) Express feelings and concerns.

A, C Explanation: All of the outcomes for this client are viable, but appropriate outcomes for the diagnosis of ineffective airway clearance are maintaining a patent airway and minimizing the accumulation of fluid. Page Ref: 109 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Planning

6. Explain management of cellular regulation and prevention of alterations in cellular regulation. 12) A nurse is caring for a client with cancer. The nurse teaches the client about which potentially undesirable cellular alterations that can occur during the cell cycle? Select all that apply. A) Hyperplasia B) Differentiation C) Anaplasia D) Dysphagia E) Adaptation

A, C Explanation: Potentially undesirable cellular alterations that can occur during the cell cycle include hyperplasia and anaplasia. Hyperplasia is an increase in the number or density of normal cells, while anaplasia is the regression of a cell to an immature or undifferentiated cell type. Differentiation is a normal process occurring over many cell cycles that allows cells to specialize in certain tasks. Dysphagia and adaptation are not a part of the cell cycle. Page Ref: 32 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation

5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with leukemia. 15) A nurse is planning care for a client with leukemia. The nurse chooses "Risk for Bleeding" as the nursing diagnosis. What interventions support this nursing diagnosis? Select all that apply. A) Educate client in use of soft toothbrush for oral care. B) Use non-electric razor when providing grooming for client. C) Limit parenteral injections. D) Apply pressure to arterial puncture sites for 5 minutes. E) Encourage client to deep breathe and huff cough frequently.

A, C Explanation: The client at risk for bleeding has specific interventions to which the nurse should adhere. The nurse should educate the client in the use of soft toothbrush and the use of an electric razor to avoid bleeding. The nurse should also limit the use of parenteral injections and apply 15-20 minutes of pressure to any arterial puncture sites. The nurse should discourage the client to forcefully cough to prevent further bleeding. Page Ref: 101 Cognitive Level: Applying Client Need: Safe and Effective Care Environment Nursing Process: Implementation

6. Explain management of cellular regulation and prevention of alterations in cellular function. 8) The nurse is caring for an 18-year-old Asian client with a strong family history of breast cancer. What should the nurse instruct the client regarding cancer prevention? Select all that apply. A) Encourage the client to learn more about the disease. B) Talk to family members who have the disease. C) Perform monthly breast self-examination. D) Teach the side effects of cancer treatment. E) Discuss cancer fears with the healthcare provider.

A, C Explanation: When there is a familial history of cancer, the family should be encouraged to learn more about the cancer. Talking to family members who have the disease will not help with early detection or prevention. In families with a disease, the nurse should inform clients about breast self-examination. Teaching the side effects of cancer treatment would be appropriate if the client was diagnosed with breast cancer. The client can discuss cancer fears with the nurse; however, this action will not help prevent the development of the disease. Page Ref: 36 Cognitive Level: Applying Client Need: Health Promotion and Maintenance Nursing Process: Implementation

1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of leukemia. 3) The nurse is teaching a class at a local community center about decreasing risk factors for cancer. Which risk factors should the nurse include in the teaching regarding leukemia? Select all that apply. A) Alkylating agents B) Diets low in fat C) Exposure to infectious agents D) Bloom syndrome E) Decreased exercise

A, C, D Explanation: A higher incidence of leukemia associated with chromosomal defects such as Bloom syndrome, exposure to infectious agents, and chemical agents used to treat previous cancer, such as alkylating agents. Low-fat diets are not a risk factor for leukemia, and neither is lack of exercise. Page Ref: 95 Cognitive Level: Applying Client Need: Health Promotion and Maintenance Nursing Process: Implementation

2. Identify risk factors and prevention methods associated with anemia. 5) A nursing student is preparing an educational program on hemolytic anemia for the residents of an assisted-living center. Which extrinsic causes of hemolytic anemia should the student include in the program? Select all that apply. A) Bacterial infection B) Thalassemia C) Ibuprofen use D) Prosthetic heart valves E) Acetaminophen use

A, C, D Explanation: Prosthetic heart valves, medications such as ibuprofen, and bacterial infections are all extrinsic causes of hemolytic anemia. Acetaminophen use is not associated with hemolytic anemia. Thalassemia is considered an intrinsic cause of hemolytic anemia and would not be appropriate to include in this particular teaching. Page Ref: 68 Cognitive Level: Applying Client Need: Health Promotion and Maintenance Nursing Process: Implementation/Teaching and Learning

3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with skin cancer. 6) The nurse is caring for an 18-year-old client diagnosed with malignant melanoma. Which nursing diagnoses would be appropriate when planning this client's care? Select all that apply. A) Impaired Skin Integrity B) Risk for Compromised Human Dignity C) Anxiety D) Risk for Acute Confusion E) Disturbed Body Image

A, C, E Explanation: Any client will likely experience anxiety and impaired skin integrity related to the diagnosis of skin cancer. The client will not likely have compromised human dignity or a risk for acute confusion. Disturbed body image could be an issue if the lesion is large. Page Ref: 136 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Planning

7. Evaluate expected outcomes for an individual with cancer. 9) The nurse instructs a group of community members on the difference between benign and malignant neoplasms. Which participant statements indicate that teaching has been effective? Select all that apply. A) "Benign tumors grow slowly." B) "Malignant tumors are easy to remove." C) "Benign tumors stay in one area." D) "Malignant tumors push other tissue out of the way." E) "Malignant tumors can grow back."

A, C, E Explanation: Benign tumors are slow-growing, stay in one area, are easy to remove, and push other tissue out of the way. Malignant tumors are more difficult to remove. They invade neighboring tissue and can return once removed. Page Ref: 42 Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Nursing Process: Evaluation/Teaching and Learning

1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of anemia. 13) A nurse is providing discharge instructions to a client with iron deficiency who is experiencing glossitis. The nurse includes which statements to provide information to the client? Select all that apply. A) Monitor the condition of the lips and tongue daily. B) Use an alcohol-based mouthwash every 2-4 hours. C) Provide frequent oral hygiene. D) Apply a non-petroleum-based lubricating jelly or ointment to the lips after oral care. E) Use a soft toothbrush or sponge to provide oral care.

A, C, E Explanation: Glossitis, inflammation of the tongue that may cause the tongue and lips to turn red, and cheilosis (fissures or cracks at the corners of the mouth) may occur with nutritional deficiencies of iron, folate, and vitamin B12. Client education should include monitoring the condition of lips and tongue daily and providing frequent oral hygiene with a soft-bristle toothbrush or sponge. The client should not use an alcohol-based mouthwash, as this would worsen the glossitis. The client should use a petroleum-based lubricating jelly or ointment to the lips after oral care. Page Ref: 74 Cognitive Level: Applying Client Need: Health Promotion and Maintenance Nursing Process: Implementation

6. Plan evidence-based care for an individual with anemia and his or her family in collaboration with other members of the healthcare team. Exemplar 2.3 Breast Cancer 1) The nurse is reviewing data collected during a health history and physical assessment and determines that a client is at risk for developing breast cancer. What did the nurse most likely assess in this client? Select all that apply. A) Age 60 B) Breastfed both children C) Sister had breast cancer D) Body mass index 22 E) Menopause at age 58

A, C, E Explanation: The risk for developing breast cancer increases with age. Having a first-degree relative with breast cancer increases the risk. Menopause after the age of 55 also increases the risk for developing breast cancer. Breastfeeding and maintaining a normal body weight lower a person's risk for developing breast cancer. Page Ref: 77 Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Nursing Process: Assessment

7. Evaluate expected outcomes for an individual with breast cancer. 8) A client with breast cancer is receiving 5-fluorouracil (5-FU). Based on knowledge of this medication and its anticipated adverse effects or side effects, which actions should the nurse perform? Select all that apply. A) Assess CBC results. B) Encourage daily fluid intake of 2-3 liters. C) Monitor ECG. D) Test stool for occult blood. E) Assess lung sounds.

A, D Explanation: The antimetabolite fluorouracil interferes with pyrimidine and purine synthesis, which are essential for DNA production. The nurses should monitor CBC with differential, electrolytes, and kidney and liver function studies; monitor for bleeding and protect client from traumatic injury; monitor for signs of infection; and monitor for dyspnea and cough. Encouraging a daily fluid intake of 2-3 liters is recommended for clients receiving alkylating agents because they could potentially develop renal failure. Monitoring the ECG is recommended in clients receiving antitumor antibiotics. Assessing lung sounds is recommended in clients receiving alkylating agents, due to the potential for developing pulmonary fibrosis. Page Ref: 88 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation

1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of skin cancer. 3) A client shows the nurse a new sore on the forearm that has been increasing in size and will not heal. Which characteristics could indicate to the nurse that this sore is a malignant neoplasm? Select all that apply. A) Invasive B) Slow-growing C) Localized D) Immovable E) Noncohesive

A, D, E Explanation: Malignant neoplasms are invasive, noncohesive, characterized by rapid growth, and not always easy to remove. They do not stop at the tissue border but invade and destroy surrounding tissues, metastasize to distant sites, and can recur. Benign neoplasms are local, cohesive, encapsulated, characterized by slow growth, and easily removed. They have well-defined borders, push other tissues out of the way, and do not recur. Page Ref: 129 Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Nursing Process: Assessment

3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with leukemia. 5) The nurse is planning care for a client with acute myeloid leukemia (AML). Which diagnoses are priorities for this client to minimize the risk of complications associated with AML? Select all that apply. A) Risk for Infection B) Ineffective Thermoregulation C) Imbalanced Nutrition D) Fluid Volume Excess E) Risk for Ineffective Protection (Bleeding)

A, E Explanation: AML results in neutropenia (decreased neutrophils = risk of infection) and thrombocytopenia (decreased platelets, which leads to increased risk of bleeding). Therefore, actions to minimize these risks include caution when moving or assisting the client to move, as well as strict hand hygiene to prevent possible cross-contamination. Weight loss is a symptom of chronic myeloid leukemia (CML), not AML. Therefore, dietary needs are not increased with AML. Restriction of fluids and salt are not needed. The client with AML does not have a problem with fluid shifts or edema that would require these restrictions. Fluids are encouraged to remove wastes that occur with chemotherapy treatment and cellular breakdown. Heat intolerance is a symptom of CML, not AML. CML has heat intolerance due to hypermetabolism state present with the condition. Page Ref: 100 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Planning

5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with cancer. 2) The nurse has completed a seminar teaching a group in the community about ways to reduce cancer risks. The nurse returns a month later to evaluate the effectiveness of the seminar. Which statements made by members of the group indicate retention and application of the material presented by the nurse to reduce the risk of developing cancer? Select all that apply. A) "I stopped using tanning booths." B) "I began drinking two glasses of red wine a day with dinner." C) "I have reduced my intake of fiber." D) "I have increased the amount of lean red meat in my diet." E) "I now limit my alcohol intake to three drinks per week."

A, E Explanation: Excessive use of alcohol, especially in women, has been linked to increased risk of breast cancer, so reduction in intake would demonstrate understanding. Use of tanning booths increases the risk of skin cancer, so discontinuing use would indicate understanding. Increasing the amount of lean red meat and drinking two glasses of red wine daily are not actions that reduce cancer risk. Increased fiber intake reduces the risk of colon cancer. Page Ref: 45 Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Nursing Process: Evaluation/Teaching and Learning

2. Identify risk factors and prevention methods associated with cancer. 3) The nurse is preparing a seminar that discusses the risk and incidence of cancer and culture. What information is considered culturally correct when teaching about the risk of developing cancer? Select all that apply. A) African-American men are more likely to develop prostate cancer than men of other ethnic and racial groups. B) Hispanics have an increased risk of cervical, stomach, and liver cancer. C) The incidence and mortality rate of all type of cancers are lowest in the Caucasian population. D) African-Americans are less likely to develop cancer than any other ethnic or racial group in the United States. E) The Asian/Pacific islander population has the lowest mortality rate of any racial or ethnic group.

A, E Explanation: The incidence and mortality for prostate cancer is highest among African-American men. There is no specific information about the Hispanic population. The incidence and mortality rate for cancer are lower in Native American men and women than in any other ethnic or racial group. African-Americans are more likely to develop cancer than any other ethnic or racial group in the United States. Mortality rates for cancer are the lowest amount the Asian/Pacific Islander population. Page Ref: 113 Cognitive Level: Applying Client Need: Health Promotion and Maintenance Nursing Process: Implementation

Which of the following is not an appropriate intervention for all atrial dysrhythmias? A. An ECG B. A pulse check C. Blood pressure D. Cardioversion

ABC

As the nurse caring for a patient on a cardiac monitor, you understand which of the following steps are necessary to correctly identify the rhythm? (Select all that apply.) A. Determine the rate. B. Determine the regularity. C. Determine if there is a QRS for every P wave. D. Determine if there is a P wave for every QRS. E. Determine if there is a U wave for every QRS.

ABCD

Key patient teaching points for AF include which of the following? (Select all that apply.) A. Medications for HR control B. Bleeding precautions C. Signs and symptoms of AF with RVR D. Cardioversion E. Defibrillation

ABCD

Signs or symptoms of symptomatic ventricular dysrhythmias include which of the following? (Select all that apply.) A. Hypotension B. Dizziness C. Fever D. Shortness of breath E. Hypertension

ABD

While educating a patient about AF, the nurse informs the patient that which of following can be symptoms of AF? (Select all that apply.) A. Shortness of breath B. Hypotension C. Weight loss D. Dizziness E. Sweating

ABDE

The nurse understands that rhythms originating in the ventricle have which of the following characteristics? (Select all that apply.) A. Wide QRS complexes B. Narrow QRS complexes C. Only QRS complexes D. Only fast rates E. Only slow rates

AC

A patient has VF. The nurse understands that the most effective treatment besides CPR is which of the following? A. Antiarrhythmics B. Defibrillation C. Ventilation D. Epinephrine

B

The nurse recognizes the QRS complex represents what? A. Atrial depolarization B. Ventricular depolarization C. Atrial repolarization and ventricular depolarization D. Atrial depolarization and ventricular repolarization

B

Your patient requires immediate cardioversion, which is defined as which of the following? A. A controlled electrical shock that is triggered by and fires on the P wave B. A controlled electrical shock that is triggered by and fires on the R wave C. A controlled electrical shock that is triggered by and fires on the T wave D. An electrical shock that fires randomly during the cardiac cycle

B

6. Plan evidence-based care for an individual with leukemia and his or her family in collaboration with other members of the healthcare team. 9) The nurse is caring for a school-aged child who had a bone marrow transplant for the treatment of leukemia several weeks ago. The child requires protective isolation. Which statement by the child's family indicates understanding of this type of isolation? A) "We will encourage oral hygiene twice a day. B) "We will encourage meticulous hand washing among all people in contact with our child." C) "You will have to administer all medications by IM injection." D) "It will be important to restrict all visitors."

B Explanation: A child on protective isolation will be at an increased risk for infection. It will be important to encourage meticulous hand washing among all people who come in contact with the child. Restrict only visitors with colds, flu, or infection. Medications by injection should be avoided. Oral hygiene should be encouraged after every meal. Page Ref: 101 Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Nursing Process: Evaluation

3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with anemia. 6) The home healthcare nurse is preparing a care plan for a client with severe anemia. The client currently lives alone and states, "I can't even walk to the kitchen without getting winded." What would be the priority nursing diagnosis for this client? A) Hopelessness B) Activity Intolerance C) Altered Nutrition, Less than Body Requirements D) Anxiety

B Explanation: Activity Intolerance would be a priority diagnosis for this client. While anxiety, hopelessness, and altered nutrition may be appropriate nursing diagnoses for this client, they are not the priority. Page Ref: 71 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Planning

6. Plan evidence-based care for an individual with leukemia and his or her family in collaboration with other members of the healthcare team. 12) A nurse working in the Pediatric Intensive Care Unit (PICU) is caring for a child with leukemia. What is the most common type of leukemia in children? A) Chronic lymphocytic leukemia B) Acute lymphocytic (lymphoblastic) leukemia C) Acute myeloid (myeloblastic) leukemia D) Chronic myeloid (myelogenous) leukemia.

B Explanation: Acute lymphoblastic leukemia is the most common type of leukemia in children and the most common cancer affecting children under 5 years of age. The other choices are also types of leukemia, but are incorrect choices. Page Ref: 93 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Assessment

1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of skin cancer. 2) During a routine physical examination of a client's lungs, the nurse notes a small, fleshy bump on the client's upper chest. What should the nurse suspect as the cause of this finding on the client's skin? A) Squamous cell carcinoma B) Basal cell carcinoma C) Actinic keratosis D) Malignant melanoma

B Explanation: Basal cell carcinoma often presents as a small, fleshy bump. Squamous cell carcinoma most often appears as a flesh-colored, erythematous, indurated scaly plaque. Malignant melanoma manifests as black, brown, or multicolored nodules or plaques. Actinic keratosis is a precancerous condition. The lesion appears as a sore, rough, scaly plaque. Page Ref: 129 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Assessment

5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with breast cancer. 9) A client prescribed tamoxifen (Nolvadex) for breast cancer treatment asks the nurse how the medication works. What is the best response by the nurse? A) "Tamoxifen works by inhibiting the cellular mitosis of breast cancer." B) "Tamoxifen works by blocking estrogen receptors on breast tissue." C) "Tamoxifen works by binding to the DNA of breast cancer cells." D) "Tamoxifen works by inhibiting the metabolism of breast cancer cells."

B Explanation: Breast cancer is dependent on estrogen for growth. Tamoxifen (Nolvadex) acts by blocking estrogen receptors; the tumor is deprived of estrogen. Tamoxifen does not inhibit the metabolism of breast cancer cells. Tamoxifen does not inhibit the cellular mitosis of breast cancer. Tamoxifen does not bind to the DNA of breast cancer cells. Page Ref: 79-80 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation

7. Demonstrate the nursing process in providing culturally competent and caring interventions across the life span for individuals with common alterations in cellular regulation. 9) A client with anemia is prescribed synthetic erythropoietin. What should the nurse expect the therapeutic effect of this treatment to be? A) Increase in platelets B) Increase in red blood cells C) Decrease in white blood cells D) Decrease in lymph fluid

B Explanation: Erythropoietin is a hormone produced in the body to stimulate production of red blood cells; synthetic forms are available for administration to cancer clients or others with significantly low red blood cell counts. Erythropoietin will not stimulate or decrease the production of platelets, white blood cells, or lymph fluid. Page Ref: 33 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Evaluation

5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with leukemia. 11) The nurse is caring for a client with leukemia who is experiencing neutropenia as a result of chemotherapy. Which action should the nurse include in the plan of care for this client? A) Replace hand hygiene with gloves. B) Restrict visitors with communicable illnesses. C) Restrict fluid intake. D) Insert an indwelling urinary catheter to prevent skin breakdown.

B Explanation: In the neutropenic client, visitors with communicable infections should be restricted. Fluid intake should be encouraged. Gloves may be appropriate but should never replace hand hygiene. Invasive procedures such as indwelling catheters should be avoided. Page Ref: 101 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation

4. Formulate priority nursing diagnoses appropriate for an individual with sickle cell disease. Exemplar 2.9 Skin Cancer 1) During an assessment, the nurse notes leukoplakia when examining the client's mouth. The client is a smoker and explains to the nurse that it has been there for more than a month. After documenting the finding and informing the healthcare provider, what should the nurse anticipate next? A) Antifungal medication will be prescribed. B) A biopsy will be performed. C) An order to provide thorough mouth care D) A dental consult

B Explanation: Leukoplakia is a smooth irregular white patch found on the tongue, lips, cheeks, or oral mucosa that can be rubbed off with force and is considered a precursor to oral cancer. A patch that lasts more than 2 weeks is generally biopsied. Mouth care and antifungal medication would not address the possibility of oral cancer. A dental consult may be advised, but a biopsy would take priority. Page Ref: 134 Cognitive Level: Applying Client Need: Health Promotion and Maintenance Nursing Process: Implementation

1. Summarize the physiology of the hematological system related to cellular regulation. 11) A nursing instructor is teaching student nurses about methods of cellular transport. When instructing on passive transportation, which information will the nurse include in the teaching plan? A) Endocytosis B) Facilitated diffusion C) Exocytosis D) Phagocytosis

B Explanation: Passive cellular transportation does not require energy and includes facilitated diffusion, diffusion, osmosis, and filtration. Active cellular transportation requires energy and includes active transport pumps, endocytosis, phagocytosis, pinocytosis, and exocytosis. Page Ref: 30 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Evaluation

5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with sickle cell disease. 8) The nurse is providing care to a client who has received multiple transfusions of packed red blood cells for treatment of sickle cell disease. Recent lab values for this client indicate high levels of iron. Which medication should the nurse expect to administer to the client experiencing an overload of iron? A) Acetaminophen B) Deferoxamine C) Morphine sulfate D) Tamoxifen

B Explanation: The client who experiences an overload of iron may be given an iron-chelating drug such deferoxamine and vitamin C to promote iron excretion. Morphine and acetaminophen may be given for the pain the client experiences during a sickle cell crisis. Tamoxifen is a medication used to treat breast cancer. Page Ref: 123 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Planning

6. Explain management of cellular regulation and prevention of alterations in cellular regulation. 7) The nurse is caring for a client with leukemia. Which treatment should the nurse expect to be prescribed for this client? A) Diuretic therapy B) Chemotherapy C) Electrolyte replacement therapy D) IV fluid therapy

B Explanation: The client with an alteration in cell growth has cancer and will most likely be treated with chemotherapy and antibiotics. Diuretic therapy, IV fluids, and electrolyte replacement are not typically used to treat the cancer, although they may be used if complications develop. Page Ref: 33 Cognitive Level: Understanding Client Need: Physiological Integrity Nursing Process: Planning

3. Identify commonly occurring alterations in cellular regulation and their related therapies. 13) The nurse is caring for a client with sickle cell anemia. The nurse teaches the client that the inherited alteration of which type of hemoglobin causes the abnormal shape to the red blood cell? A) Hgb A B) Hgb S C) Hgb B D) Hgb E

B Explanation: The inherited alteration of Hgb S causes the abnormal sickle-shaped red blood cell in sickle cell anemia. Page Ref: 34 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation

8. Compare and contrast common independent and collaborative interventions for clients with alterations in cellular regulation. 10) The nurse instructor is teaching a group of student nurses regarding human growth and development. The instructor knows that teaching has been effective when a student states: A) "The zygote undergoes differentiation to form a multicellular embryo, which becomes a fetus and then an infant." B) "Meiosis occurs only in the sex cells of the testes and ovaries." C) "Mitosis is also known as the reduction division of the cell." D) "When the two sex cells combine during fertilization, the total number of chromosomes (50) is present in the offspring's cells."

B Explanation: The zygote undergoes mitosis to form a multicellular embryo, which becomes a fetus and then an infant. Meiosis, the reduction division of the cell, occurs only in the sex cells of the testes and ovaries. When the two sex cells combine during fertilization, the total number of chromosomes present in the offspring's cells is 46, not 50. Page Ref: 32 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Evaluation

6. Plan evidence-based care for an individual with cancer and his or her family in collaboration with other members of the healthcare team. Exemplar 2.2 Anemia 1) A client complaining of mouth soreness had gastric bypass surgery 1 year ago. During the assessment, the nurse notes the client's tongue is beefy, red, and smooth and the client's skin appears yellowish. Which additional information is most likely needed before diagnosing this client? A) Vitamin B6 levels B) Vitamin B12 levels C) Potassium levels D) Iron levels

B Explanation: Vitamin B12 deficiency is associated with gastric bypass surgery. A deficiency of vitamin B12 levels will result in pernicious anemia. This deficiency will manifest as pallor, jaundice, and weakness, and a beefy, smooth red tongue. Iron deficiency anemia will manifest with weakness and fatigue. Vitamin B6 deficiencies are not typically seen with gastric bypass surgeries and are not manifested with a beefy, red, smooth tongue. The client's reports are not consistent with a potassium deficiency. Page Ref: 66 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Assessment

4. Formulate priority nursing diagnoses appropriate for an individual with cancer. 5) The nurse accompanies the physician into the client's room and listens as the diagnosis of cancer is shared with the client and family. Once the physician leaves the room, the nurse notes that the client and family are teary-eyed regarding the diagnosis. What is the nurse's most appropriate intervention at this time? A) Arrange for the client to complete a medical power of attorney form. B) Provide emotional support in coping with the diagnosis. C) Provide teaching about the treatment options for this form of cancer. D) Help the client and family remain realistic about prognosis.

B Explanation: When a client and family receive a new diagnosis of cancer, it tends to evoke many emotions, including fear, grief, and anger. This is not an opportune time to teach or set goals. The client and family require emotional support at this time, and other actions can be initiated when they have time to learn to accept and cope with the diagnosis. Page Ref: 61 Cognitive Level: Applying Client Need: Psychosocial Integrity Nursing Process: Implementation

1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of leukemia. 13) A pediatric nurse is caring for a child with acute lymphoblastic leukemia (ALL). When providing education to the child's parents regarding this disease, the nurse should include: Select all that apply. A) ALL is characterized by abnormal proliferation of all bone marrow elements. B) This form of leukemia is the most common type among children and adolescents. C) Most cases of ALL result from the malignant transformation of B cells. D) This form of leukemia is very rarely seen in children. E) The onset of ALL is usually gradual.

B, C Explanation Acute lymphoblastic leukemia (ALL) is the most common type of leukemia among children and adolescents. Most cases of ALL result from the malignant transformation of B cells. The onset of ALL is usually acute and rapid. Chronic myeloid leukemia (CML) is characterized by abnormal proliferation of all bone marrow elements. Page Ref: 93 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Implementation

1) The nurse is teaching a class to prospective parents about the roles that ribonucleic acid (RNA) and deoxyribonucleic acid (DNA) play in the development of the human fetus. The nurse concludes that the parents understand teaching when what is stated by the parents? Select all that apply. A) "RNA will determine what color eyes my baby has." B) "DNA molecules form the genetic material." C) "RNA is the messenger that carries DNA to the ribosomes." D) "DNA is outside the nucleus of the cell." E) "DNA plays a role in protein synthesis in our bodies."

B, C Explanation: DNA molecules form the basic genetic material called genes and contain the information about inherited characteristics. RNA is the messenger that carries DNA to the ribosomes. RNA does not determine the color of the eyes, but is responsible for protein synthesis. Both RNA and DNA are contained within the nucleus of each cell. Page Ref: 30 Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Nursing Process: Evaluation

1. Summarize the physiology of the hematological system related to cellular regulation. Exemplar 2.1 Cancer 1) During a treatment meeting on an oncology unit, the nurse learns that a client is scheduled for chemotherapy before and after surgery. What are the purposes for this client to receive chemotherapy at these specific times? Select all that apply. A) Eradicate all cancer cells. B) Shrink the tumor. C) Kill remaining cancer cells. D) Allow the immune system to kill cancer cells. E) Improve wound healing.

B, C Explanation: It is impossible to eradicate all cancer cells with chemotherapy. Chemotherapy before surgery is used to shrink the tumor. Chemotherapy is used after surgery to kill remaining cancer cells. The use of chemotherapy before and after surgery will not allow the immune system to kill the cancer cells. Chemotherapy is not used to improve wound healing. Page Ref: 56 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Planning

1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of sickle cell disease. 2) A nurse educator is teaching a group of parents how to prevent a sickle cell crisis in the child with sickle cell disease. What should the nurse instruct about the precipitating factors that could contribute to a sickle cell crisis? Select all that apply. A) Increased fluid intake B) Altitude C) Fever D) Vomiting E) Regular exercise

B, C, D Explanation: Fever, vomiting, and altitude are some of the precipitating factors that contribute to a sickle cell crisis. Regular exercise and increased fluid intake are recommended activities for a child with sickle cell disease and will not contribute to a sickle cell crisis. Page Ref: 120 Cognitive Level: Applying Client Need: Health Promotion and Maintenance Nursing Process: Implementation

5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with breast cancer. 11) While completing a physical examination, the nurse suspects a client has breast cancer. What did the nurse assess in this client? Select all that apply. A) Rash along the inside of the right arm B) Skin retraction near the left nipple C) Palpable lump in the right axillae D) Flaking skin over the right nipple E) Pain when extending the left arm

B, C, D Explanation: Manifestations of breast cancer include skin retraction in an area of the breast, unusual lump in the underarm region, and flaking skin near the nipple. A rash on the arm and arm pain upon extension are not manifestations of breast cancer. Page Ref: 78 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Assessment

2. Examine the relationship between cellular regulation and other concepts/systems. 3) A nurse is caring for a client who has been diagnosed with skin cancer. Which nursing interventions will reduce the growth of cancer cells and support normal cell function? Select all that apply. A) Encouraging mobility and exercise B) Encouraging increased rest and sleep C) Assessing normal functioning of organ systems D) Reducing oxygen supply to retard growth of cancer cells E) Increasing calorie intake

B, C, E Explanation: Cancer cells grow faster than normal cells, so they use more nutrients for growth, resulting in wasting, which can only be counteracted by increasing the caloric intake of the client. Increased rest and sleep give the client's body more energy to fight the cancer cells. Because cancer cells can grow in any area of the body, it is important for the nurse to assess normal functioning of all organ systems. Decreasing oxygen supply will retard cancer cell growth but it will also retard normal cell health. While clients should not be inactive, they should be taught to reduce activity to reduce weight loss and provide more energy to the healthy cells. Page Ref: 39 Cognitive Level: Applying Client Need: Health Promotion and Maintenance Nursing Process: Implementation

1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of cancer. 10) The nurse is caring for a thin, older client who was diagnosed with cancer and is receiving aggressive chemotherapy. The client is experiencing severe side effects from the therapy and has lost 10 pounds in the past week. What should the nurse teach the client to do? Select all that apply. A) Purchase fast foods and prepared foods. B) Eat cold foods rather than hot foods, because they are better tolerated. C) Keep a food diary and record intake. D) Eat large frequent meals high in calories. E) Drink liquid supplements to increase intake of nutrients.

B, C, E Explanation: Nutrition is an essential part of caring for all client with cancer but takes on even greater importance in the frail elderly, who may already have nutritional challenges such as poor dentition, inefficient absorption of nutrients, and mediation side effects. The goal of nutritional teaching is to help the client increase caloric and nutrient intake through the use of liquid supplements, small frequent meals, and a food diary that will help the nurse evaluate strengths and weaknesses of the current plan. The client receiving chemotherapy may tolerate cold foods better than hot foods. Fast foods and prepared foods tend to be high in fat and sodium and are not the best choice because they do not contain adequate healthy nutrients. Instead, involving the family in preparing meals or in enrolling in Meals on Wheels may be better options for easy ways of obtaining meals. Page Ref: 60 Cognitive Level: Applying Client Need: Health Promotion and Maintenance Nursing Process: Implementation/Teaching and Learning

6. Plan evidence-based care for an individual with leukemia and his or her family in collaboration with other members of the healthcare team. 2) A 51-year-old client reports to the nurse an inability to tolerate usual exercise and the feeling of fatigue. The client states that these symptoms have been gradual over time. Which physical assessment findings, along with the client's verbal complaints, would indicate chronic lymphocytic leukemia (CML)? Select all that apply. A) Joint pain B) Pallor C) Splenomegaly D) Abnormal bleeding E) Edema

B, C, E Explanation: The symptoms for CML are insidious and occur over time, affecting older adults. The client may exhibit splenomegaly, pallor, edema, and lymphadenopathy. Bone and joint pain with abnormal bleeding are characteristics of AML, which also occurs in older clients. Page Ref: 93 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Assessment

1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of sickle cell disease. 10) An Emergency Department nurse is caring for a child in a sickle cell crisis. The nurse suspects the etiology of the crisis as being thrombotic in nature due to which clinical manifestations? Select all that apply. A) The client has profound pallor and fatigue. B) The client is in extreme pain. C) The client has profound hypotension and shock. D) The client has a fever. E) The client's chest CT reveals a pulmonary infarct.

B, D Explanation: A thrombotic sickle cell crisis is manifested by extreme pain and fever. The client in profound hypotension and shock likely has splenic sequestration as the etiology, not thrombosis. The client with a pulmonary infarct likely has Acute Chest Syndrome, not thrombosis. The client with profound pallor and fatigue likely is in an aplastic crisis, not thrombosis. Page Ref: 121 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Assessment

1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of breast cancer. Exemplar 2.5 Leukemia 1) A pediatric client is receiving chemotherapy for acute lymphocytic leukemia. The nurse recognizes that a potential oncological emergency for this client would be tumor lysis syndrome. For which manifestations should the nurse monitor this client? Select all that apply. A) Thrombocytopenia B) Altered levels of consciousness C) Respiratory distress D) Oliguria E) Upper-extremity edema

B, D Explanation: Tumor lysis causes a metabolic emergency. Because of electrolyte imbalance, the signs can be oliguria and altered levels of consciousness. Thrombocytopenia occurs with a hematological emergency. Space-occupying lesions can cause respiratory distress and upper-extremity edema. Page Ref: 101 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Assessment

5. Describe diagnostic and laboratory tests to determine the individual's cellular regulation status. 6) The nurse instructs a group of community members about ways to reduce the development of cancer. Which participant statements indicate that teaching has been effective? Select all that apply. A) "I should eat at least 2 servings of fruits or vegetables each day." B) "Sunscreen should be applied before spending time outdoors." C) "I need to cut down on my smoking." D) "I need to get my home tested for radon." E) "I need to keep my children away from smokers."

B, D, E Explanation: Efforts to reduce the development of cancer include eating five servings of fruits and vegetables each day. Sunscreen should be used by those who spend time outside regularly for work or recreation. All smoking should be discouraged. The home should be tested for radon, which is a known cancer-causing substance. Children should be protected from exposure to tobacco smoke. Page Ref: 36 Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Nursing Process: Evaluation/Teaching and Learning

4. Formulate priority nursing diagnoses appropriate for an individual with anemia. 7) A nurse is providing discharge teaching for a client with iron deficiency anemia. The client has been prescribed ferrous sulfate and has been told to increase the intake of foods that are naturally high in iron. Which client statements indicate a need for further education? Select all that apply. A) "I will take my ferrous sulfate tablet with my morning oatmeal." B) "I will decrease my intake of green leafy vegetables while taking my ferrous sulfate tablet." C) "I will increase my fluid intake while I am taking my ferrous sulfate." D) "I will take my ferrous sulfate tablet on an empty stomach." E) "I will decrease milk intake while taking my ferrous sulfate tablet."

B, D, E Explanation: Ferrous sulfate can cause gastric irritation and constipation. Taking it with a meal can help minimize gastrointestinal distress. The client should not decrease milk or green leafy vegetables from the diet as these are natural sources of iron and should be encouraged. Increasing fiber (oatmeal) and fluid intake can also help prevent constipation. Page Ref: 71 Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Nursing Process: Evaluation/Teaching and Learning

5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with anemia. 10) The nurse is caring for an older client with hemolytic anemia. What should the nurse recall about this diagnosis? Select all that apply. A) It causes the red blood cells to be microcytic. B) It is associated with an increase in the reticulocyte count. C) It is the result of blood loss. D) It is a result of the premature destruction of red blood cells. E) It always requires treatment with folic acid.

B, D, E Explanation: Hemolytic anemia is more common with aging and is caused by the premature destruction of the red blood cells. The normal life span of a red blood cell is 120 days. All hemolytic anemias require treatment with folic acid because this vitamin is consumed by the increased bone marrow production of red blood cells in response to the anemia. It is not associated with blood loss. There is an increase, not a decrease, in the reticulocyte (immature red blood cells) count because they are released early from the bone marrow to compensate. Hemolytic anemias are normocytic (red blood cells are normal size), not microcytic. Page Ref: 68 Cognitive Level: Understanding Client Need: Physiological Integrity Nursing Process: Planning

6. Plan evidence-based care for an individual with cancer and his or her family in collaboration with other members of the healthcare team. 7) A client being treated for cancer has a tumor designation of Stage IV, T4, N3, M1. What does this staging indicate to the nurse? A) The tumor will respond to chemotherapy. B) The tumor is small in size. C) The tumor has metastasized with lymph node involvement. D) There is one single tumor to treat.

C Explanation: T refers to the depth of invasion. N refers to the absence or presence and extent of lymph node involvement. M refers to presence of metastasis. The numbers range from 0 to 4, with higher numbers indicating increased size and metastasis. Stage IV indicates metastasis. The staging system is not used to determine tumor response to chemotherapy. Page Ref: 53 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Assessment

As the nurse, you know that the following can cause rhythm disorders: (Select all that apply.) A. Exercise B. Electrolyte imbalances C. Myocardial hypertrophy D. Myocardial damage E. Eating red meat

BCD

2. Identify risk factors and prevention methods associated with lung cancer. 3) A male Hispanic client has had a lung biopsy. The results indicate a poor prognosis for the client. The family is at the client's bedside and begins to moan and cry loudly. The doctor has told the nurse that he needs to have the consent form signed for surgery. The client has asked the nurse to allow the family private time. What should the nurse do at this time? A) Ask the family to come back later. B) Have the doctor get the consent with the family present. C) Provide the client and family privacy. D) Take the client to another room.

C Explanation: As the client advocate, the nurse would allow this family to bond according to their customs. Asking the family to leave may cause extreme stress to the client and family. It would not be appropriate for the doctor to try to explain the surgery while the family is grieving. Taking the client to another room would deprive the client from participating in his family's customs. Page Ref: 110 Cognitive Level: Applying Client Need: Psychosocial Integrity Nursing Process: Implementation

The nurse recognizes the artioventricular (AV) node generates electrical impulses at a rate of: A. ≤ 20 bpm B. ≤ 40 bpm C. 40-60 bpm D. 60-100 bpm

C

The nurse understands that the normal conduction pathway for the heart is which of the following? A. AV → SA → Ventricles → Purkinje fibers B. Purkinje fibers → AV → Ventricles → SA C. SA → AV → Ventricles → Purkinje fibers D. Ventricles → Purkinje fibers → SA → AV

C

2. Identify risk factors and prevention methods associated with leukemia. 4) A child from a culture other than the nurse's has recently been diagnosed with leukemia. The client's sibling is 6 years old and expressing feelings of anger and guilt. This reaction by the sibling is very upsetting to the parents. How should the nurse explain the sibling's behavior? A) "This behavior is abnormal. I will have the physician refer you to a psychologist." B) "This behavior is just the sibling's way to get attention." C) "This is a normal response. Your other child is also affected by the diagnosis and anger and guilt are expected feelings for a 6-year-old." D) "Your other child should not be so upset. The cancer is easily treated."

C Explanation: A diagnosis of cancer affects the whole family, and initial feelings experienced by the sibling may be anger and guilt. Seldom will the sibling be unaffected; however, the response is not abnormal. Although the sibling may want attention, this is not the best response by the nurse. Page Ref: 37-38 Cognitive Level: Applying Client Need: Psychosocial Integrity Nursing Process: Implementation

7. Evaluate expected outcomes for an individual with lung cancer. 7) The nurse is caring for a client who is undergoing diagnostic tests to rule out lung cancer. The client asks the nurse why a computed tomography (CT) scan was ordered. What is the best response by the nurse? A) "The doctor prefers this test." B) "To rule out the possibility that your problems are caused by pneumonia." C) "It is more specific in diagnosing your condition." D) "Why are you concerned about this test?"

C Explanation: Computed tomography (CT) is used to evaluate and localize tumors, particularly tumors in the lung parenchyma and pleura. It also is done before needle biopsy to localize the tumor. In addition, CT scanning can detect distant tumor metastasis and evaluate tumor response to treatment. A chest x-ray can be used to diagnose pneumonia. The client's question is valid and should not be minimized by asking why the client is having concerns about the test. Page Ref: 108 Cognitive Level: Applying Client Need: Safe and Effective Care Environment Nursing Process: Implementation

2. Identify risk factors and prevention methods associated with skin cancer. 8) A client is scheduled to have a suspected cancerous lesion removed from the arm. When planning care for this client, which outcome would be a priority? A) The client will make nutritional changes. B) The client will experience minimal pain after healing. C) The client will heal without signs of infection. D) The client will not need to make lifestyle changes.

C Explanation: Following removal of a skin lesion, the nurse directs care aimed at the prevention of infection while the skin heals. The client should not experience pain after healing and will need to make lifestyle changes to prevent further occurrences of skin cancer. Nutritional changes may or may not be needed; however, prevention of infection is the priority. Page Ref: 136 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Planning

4. Formulate priority nursing diagnoses appropriate for an individual with leukemia. 6) A pediatric client being treated for acute lymphocytic leukemia (ALL) has a white blood cell count of 1,000/mm3. Which nursing diagnosis would be a priority for this client? A) Readiness for Enhanced Immunization Status B) Impaired Gas Exchange C) Risk for Infection D) Activity Intolerance

C Explanation: In leukemia, the WBCs that are present are immature and incapable of fighting infection. The client with a WBC count of 500-1,000/mm3 is considered a moderate risk for infection. The client may or may not have activity intolerance, but it is not the priority nursing diagnosis. Impaired gas exchange is not evident in this client. Children with cancer would not be receiving immunizations during treatment. Page Ref: 100 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Planning

6. Plan evidence-based care for an individual with anemia and his or her family in collaboration with other members of the healthcare team. 8) The nurse is evaluating a client's understanding of dietary needs to treat dietary deficiency anemia. Which client statement indicates a need for additional teaching? A) "I will eat more fruits and vegetables, especially green leafy ones, to get more iron in my diet." B) "I will need to include more protein foods in my diet such as meats, dried beans, and whole-grain breads." C) "I will decrease foods high in vitamin C, as they decrease my absorption of iron." D) "I will take vitamins with extra iron in addition to eating a balanced diet with meat to correct my anemia."

C Explanation: Increasing foods high in vitamin C will increase absorption of iron. The lack of iron is the problem that needs to be addressed. Extra iron is needed to help replace RBCs and treat the dietary deficiency anemia. Green leafy vegetables will increase iron in the diet. Protein foods such as meats, dried beans, and whole-grain breads do contain iron that will help dietary deficiency anemia. Page Ref: 71 Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Nursing Process: Evaluation/Teaching and Learning

3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with breast cancer. 5) During an assessment, the nurse notes that a client receiving radiation treatments for breast cancer has excoriated skin. What is the priority nursing diagnosis for this client? A) Excess Fluid Volume B) Ineffective Breathing Pattern C) Risk for Infection D) Activity Intolerance

C Explanation: Radiation causes skin excoriation. With the excoriation, the client is at risk for infection due to skin breakdown. The client who receives radiation is more at risk for fluid volume deficit. Depending on the assessment, the client may or may not have activity intolerance. There is no evidence of respiratory difficulties in this client. Page Ref: 82 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Assessment

5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with lung cancer. Exemplar 2.8 Sickle Cell Disease 1) Parents of a newborn infant are concerned that their baby may have sickle cell disease. The nurse reviews the medical record and finds that both parents have the sickle cell trait. Which is the best response for the nurse to give the parents? A) "Since neither of you actually has sickle cell disease, your baby is not at risk." B) "Your baby has the disease, as you both carry the trait." C) "As you both have the sickle cell trait, your baby will be tested for the disease." D) "Have you talked to a genetic counselor about your concerns?"

C Explanation: Sickle cell disease is an autosomal recessive disorder. Both parents must have the trait in order for a child to have a 25% chance of having this disease. The most appropriate response by the nurse is to tell the parents the baby will be tested for the disease. Page Ref: 120 Cognitive Level: Applying Client Need: Health Promotion and Maintenance Nursing Process: Implementation

5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with skin cancer. 10) The nurse is caring for a client who has recently been diagnosed with skin cancer. The client is tearful and states, "How did I get skin cancer? I don't believe in tanning!" What response by the nurse is indicated at this time? A) "Can you tell me more about your feelings?" B) "This is unusual, as skin cancer normally only occurs in sunbathers." C) "Sun exposure can happen as we carry out our daily activities." D) "We frequently never find out why cancer strikes."

C Explanation: Sun exposure occurs as we carry out our daily activities. Riding in the car, going in and out of buildings, and so on permit sun exposure. The client is asking for information; the other options do not provide adequate or correct information. Page Ref: 131 Cognitive Level: Applying Client Need: Psychosocial Integrity Nursing Process: Implementation

2. Identify risk factors and prevention methods associated with skin cancer. 12) A client presents to the primary care clinic for an annual physical. The nurse caring for the client notes that the client's physician uses the ABCD mnemonic to assess suspicious skin lesions. What does the "D" in ABCD represent? A) Diameter of lesion greater than 8mm B) Distance of lesion to an additional lesion C) Diameter of lesion greater than 6mm D) Depth of lesion

C Explanation: The ABCD rule is used to assess suspicious lesions: Asymmetry (One half of the nevus does not match the other half.) Border irregularity (Edges are ragged, blurred, or notched.) Color variation or dark black color Diameter greater than 6 mm (size of a pencil eraser) Page Ref: 134 Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing Process: Assessment

1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of sickle cell disease. 11) A nurse is planning care for a client with sickle cell disease and chooses "Acute Pain" as the nursing diagnosis. The nurse plans all interventions to support this diagnosis except: A) Administer ordered analgesic medications around the clock. B) Place patient in position of comfort. C) Use heat or cold packs as tolerated. D) Support the client's joints and extremities with pillows.

C Explanation: The client with sickle cell disease who is in a sickle cell crisis will likely have extreme pain. To aid in caring for this client, the nurse will administer ordered analgesic medications around the clock, place the patient in position of comfort, and support the client's joints and extremities with pillows. The use of heat or cold packs is contraindicated in the sickle cell client. Ischemic tissue is fragile and has reduced sensation, increasing the risk of burn injury from hot compresses, whereas cold compresses promote sickling. Page Ref: 125 Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Nursing Process: Implementation

7. Evaluate expected outcomes for an individual with leukemia. 10) The nurse is assisting the physician with a bone marrow aspiration and biopsy on a client who has leukemia. The client also has thrombocytopenia. When the physician has completed this test, which intervention is a priority for the nurse? A) Dispose of the equipment used, and clean the area properly. B) Label and refrigerate the specimen obtained by the physician. C) Hold pressure on the wound for approximately 5 minutes. D) Make certain the client understands the purpose of the test.

C Explanation: The most important task for the nurse is to prevent bleeding after the biopsy. Holding pressure on the wound for 5 minutes is effective. Dealing with the specimen is accomplished by a third party or after the nurse stabilizes the client. An explanation of the test is performed before the procedure is begun. Cleaning the area is completed after the client is stable and the specimen is sent to the laboratory. Page Ref: 101 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation

1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of skin cancer. 4) The nurse is teaching a group of community members about preventing skin cancer. Which participant would be at the greatest risk for skin cancer? A) A 25-year-old lifeguard at the community pool who wears sunscreen B) A baby underneath a large beach umbrella C) An 60-year-old farmer who wears a cap when working D) A teenager who wears a ski outfit when skiing

C Explanation: The older adult client has had more years of living to increase the risk of skin cancer from exposure to the sun. In addition, the farmer wears a cap, but no mention is made of protectant sunscreens or long-sleeved shirts and pants. The lifeguard, baby, and teenager have lesser risk because there are physical barriers to the sun identified in each option: sunscreen, umbrella, and ski outfit. Page Ref: 131 Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Nursing Process: Assessment

3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with anemia. 12) A nurse is educating a client with anemia about the pathophysiological mechanisms of anemia. The nurse's teaching should include all except: A) Altered hemoglobin synthesis. B) Altered DNA synthesis. C) Decreased hemolysis. D) Bone marrow failure.

C Explanation: The pathophysiological mechanisms of anemia include altered hemoglobin synthesis, altered DNA synthesis, bone marrow failure, and increased hemolysis. Altered hemoglobin synthesis is the mechanism involved in iron deficiency anemia, Thalassemia, and chronic inflammation. Altered DNA synthesis is the mechanism involved in Vitamin B12 malabsorption or deficiency, and folic acid malabsorption or deficiency. Bone marrow failure is the mechanism in aplastic anemia, red cell aplasia, myeloproliferative leukemias, and lymphomas. Page Ref: 65 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Assessment

2. Identify risk factors and prevention methods associated with breast cancer. 3) A client recovering from a hysterectomy does not want to take the prescribed estrogen replacement therapy because of the fear of developing breast cancer. What should the nurse respond to this client? A) "The risk of breast cancer is slightly increased for women who opt to take estrogen replacement therapy." B) "Perhaps you should consider an estrogen-progestin combination therapy." C) "The risk of breast cancer is not increased for women who have had a hysterectomy and take estrogen replacement medications." D) "Taking estrogen replacement is required after a hysterectomy."

C Explanation: The risk for the development of breast cancer is not greater for women who take estrogen replacement therapy after undergoing a hysterectomy. Progestin therapies are not used for women who are in surgical menopause. Further, it is inappropriate for the nurse to make suggestions of a prescriptive nature, as it violates the scope of practice. While it is not mandatory for the client to take estrogen replacement therapy after surgery, the nurse should clarify and correct misconceptions of the client. Estrogen replacement therapy is not associated with breast cancer for women who have undergone a hysterectomy. Taking estrogen after a hysterectomy is optional, not required. Page Ref: 77 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation

3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with cancer. 4) A client being treated with chemotherapy for cancer complains of fatigue, pallor, progressive weakness, exertional dyspnea, headache, and tachycardia. Which diagnosis should the nurse use as the priority when planning this client's care? A) Powerlessness B) Imbalanced Nutrition, Less than Body Requirements C) Activity Intolerance D) Ineffective Coping

C Explanation: The symptoms (fatigue, pallor, progressive weakness, exertional dyspnea, headache, and tachycardia) are caused by aplastic anemia from bone marrow suppression, which is a side effect of the chemotherapy drugs. Decreased red blood cells cause less oxygen to be delivered to body tissues, resulting in tissue hypoxia. Tachycardia is a compensation mechanism to speed up the delivery of oxygen that is available in the fewer number of cells that are present. Tissue hypoxia will result in muscle fatigue, and the symptoms that are related to aplastic anemia will decrease endurance and ability to perform activities. Thus, this NANDA diagnosis should be the first priority. Nutrition or iron deficiency is not the cause of the symptoms, which are related to tissue hypoxia. Powerlessness is the lack of control over current situations, but this is not the client's current problem. Her needs/symptoms are physical, and according to Maslow's theory must be met prior to emotional needs. Although the client might be having coping issues, the physical symptoms are her greatest complaints; therefore, coping is not the top priority in planning her care. Again, physiological needs must be met prior to self-actualization needs. Page Ref: 71 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Assessment

4. Formulate priority nursing diagnoses appropriate for an individual with leukemia. 7) A 6-year-old male child is being admitted with newly diagnosed acute lymphocytic leukemia. The multidisciplinary team is meeting to plan care for this child and family. Which statement by the parents should receive priority in the nursing planning process? A) "His brother is upset about the amount of time we are away from home." B) "Can we plan a trip out of town sometime this summer?" C) "We are afraid that he will dislodge his central line at school." D) "How do we get our parking validated?"

C Explanation: This is an imminent, potentially life-threatening concern. Financial worries, although a significant concern, would not take precedence over a potentially life-threatening concern. Questions about travel and other family matters should be addressed, but they are not acute issues. The impact of the illness on the client's brother is a realistic concern, but not acute or lifethreatening. Page Ref: 101 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Planning

1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of lung cancer. 2) The nurse is caring for a client in a community clinic who wishes to quit smoking. The client asks the nurse, "If I quit smoking, will my risk of lung cancer be the same as a nonsmoker?" Which is the best response by the nurse? A) "No one knows for sure what the risk is for someone who quits smoking." B) "Your risk of lung cancer will be equal to that of a non-smoker." C) "Your risk of lung cancer will decline if you quit, but it will remain higher than a non-smoker's." D) "Your risk of lung cancer will never drop because the damage has already been done."

C Explanation: While the client's risk for lung cancer will diminish sharply upon quitting smoking, it will not drop to the level of someone who never smoked. Another factor when calculating risk is the client's exposure to secondhand smoke, which also increases risk. Although damage has been done, the client's risk will drop dramatically upon quitting smoking. The risk for someone who quits is known to be dramatically less than for someone who continues to smoke. Page Ref: 105 Cognitive Level: Applying Client Need: Health Promotion and Maintenance Nursing Process: Implementation

2. Identify risk factors and prevention methods associated with breast cancer. 4) The nurse is instructing a group of women between the ages of 40 and 50 about early detection of breast cancer. What should the nurse include in this teaching? A) Perform monthly breast self-exams. B) See a healthcare provider if there is a strong family history of breast cancer. C) Have a yearly mammogram. D) Have a clinical breast exam performed by a healthcare provider every 5 years.

C Explanation: Yearly mammography for all women over the age of 40 is encouraged, as it decreases the mortality from breast cancer. Breast self-exam is no longer recommended for all women. The American Cancer Society recommends that young women who choose to do breast self-exams have their technique validated by a healthcare practitioner at a yearly physical exam. The earlier a lump is discovered, the greater the effectiveness of treatment. Discussing a family history of breast cancer would be part of the annual breast exam performed by a healthcare provider. It is inappropriate for women in this age group to have a clinical breast exam every 5 years. Page Ref: 58 Cognitive Level: Applying Client Need: Health Promotion and Maintenance Nursing Process: Implementation/Teaching and Learning

6. Plan evidence-based care for an individual with cancer and his or her family in collaboration with other members of the healthcare team. 6) A preschool-age child is being seen in a pediatric oncology clinic. The nurse assigned to care for the client anticipates a diagnosis of cancer. Which reaction is considered common for the preschool-age child to experience with illnesses and hospitalizations? Select all that apply. A) Unawareness of the illness and its severity B) Understanding of what cancer is and how it is treated C) Thoughts that they caused their illness and are being punished D) Confusion as to why a parent is unable to make the illness go away E) Acceptance, especially if able to discuss the disease with children their own age

C, D Explanation: Preschool-age children are egocentric and have magical thinking, and thus might believe they caused their own illness. This age group may also be confused as to why their parents cannot make the illness go away. Immediate acceptance will not occur with children of any age. Adolescents find contact with others who have gone through their experience helpful. Schoolage children can understand a diagnosis of cancer. Infants and toddlers are unaware of the severity of the disease. Page Ref: 50 Cognitive Level: Analyzing Client Need: Psychosocial Integrity Nursing Process: Assessment

3. Identify commonly occurring alterations in cellular regulation and their related therapies. 4) The nurse is preparing to perform a health assessment on a 32-year-old client who has a family history of cancer. Which questions should the nurse ask the client to assess for the early warning signs of cancer? Select all that apply. A) "Do you have a cough that is associated with seasonal allergies?" B) "Have you noticed a change in your appetite?" C) "Have you noticed any cuts that have not healed?" D) "Have you had any changes in bowel or bladder habits?" E) "Have you experienced any problems swallowing?"

C, D, E Explanation: Nurses should assess all clients, especially those with a history of cancer, for early warning signs of cancer. The early warning signs include change in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, thickening or lump in the breast or elsewhere, indigestion or difficulty swallowing, obvious change in wart or mole, or a nagging cough or hoarseness. Changes in appetite or cough that is associated with seasonal allergies are not associated with the early warning signs of cancer. Page Ref: 36 Cognitive Level: Applying Client Need: Health Promotion and Maintenance Nursing Process: Assessment

7. Evaluate expected outcomes for an individual with anemia. 9) The nurse suspects that a client with severe shortness of breath in the absence of cyanosis is experiencing anemia. Which laboratory tests should the nurse review to confirm anemia? Select all that apply. A) Serum electrolytes B) Cardiac enzymes C) Hemoglobin D) Blood sugar E) Hematocrit

C, E Explanation: In order to exhibit cyanosis, the client's blood must contain about 5 g or more of unoxygenated hemoglobin per 100 mL of blood and the surface blood capillaries must be dilated. Severe anemia will interfere with the development of cyanosis, so the nurse should review the hemoglobin and hematocrit. Blood sugar, cardiac enzymes, and serum electrolytes are not implicated in this phenomenon. Page Ref: 70 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Assessment

The nurse understands transcutaneous pacing is necessary for which symptomatic patient? A. Sinus tachycardia B. Sinus rhythm with PACs C. Atrial fibrillation D. Complete heart block

D

4. Formulate priority nursing diagnoses appropriate for an individual with lung cancer. 5) The nurse is caring for an 86-year-old client who is very thin and emaciated. The client reports new onset of shortness of breath. A chest x-ray reveals a spot on the lungs that the physician believes is an inoperable lung cancer. Due to the client's poor nutritional status, chemotherapy is not an option. The physician also believes that the location of the cancer would make radiation therapy unsuccessful. In advocating for this client, what should the nurse encourage the healthcare team to do? A) Provide palliative care to keep the client comfortable without diagnostic testing. B) Perform any procedure necessary to diagnose the client properly. C) Promote the use of blood tests to diagnose the suspected cancer. D) Determine the client's and family's wishes regarding diagnostic testing.

D Explanation: An elderly emaciated client may have few options for treatment of cancer, if confirmed. The best course of treatment may be palliative care, but it is the choice of the client and family that should direct the plan of care and choices of diagnostic testing. Page Ref: 110 Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Nursing Process: Implementation

1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of anemia. 2) A client experiencing fatigue, pallor, and dyspnea on exertion has a complete blood count drawn. Which red blood cell disorder should the nurse anticipate the client is experiencing? A) Polycythemia B) Erythropoiesis C) Herpes simplex D) Anemia

D Explanation: Anemia is the most common red blood cell disorder, involving a low count and decreased hemoglobin content. Signs and symptoms of anemia can include pallor of the skin and mucous membranes and dyspnea on exertion. Polycythemia is an abnormally high RBC count. Herpes simplex is not a red blood cell disorder; erythropoiesis is the term for RBC production. Page Ref: 66 Cognitive Level: Understanding Client Need: Physiological Integrity Nursing Process: Assessment

6. Plan evidence-based care for an individual with leukemia and his or her family in collaboration with other members of the healthcare team. 8) The nurse is caring for a client who has just been diagnosed with chronic myeloid leukemia (CML). The client and the nurse are discussing the anticipatory grieving process. Which action by the nurse would be inappropriate at this time? A) Make referrals for support or bereavement groups. B) Identify family stress management strategies. C) Encourage the client to see an attorney now to get affairs "in order" before it is too late. D) Encourage the client to share feelings and discuss grieving.

D Explanation: Encouraging the client to get affairs "in order" now to avoid waiting until it is too late is not appropriate at this time: Although this topic is helpful to prepare for the actual death, this is not the time because this removes all hope. Establishing open communication and sharing of feelings to discuss grieving is appropriate at this time: The nurse should establish a rapport and use therapeutic communication to allow the client to express feelings and emotions about the new diagnosis of CML. Making referrals for support or bereavement groups is appropriate at this time: Offering information and resources about agencies that deal with grieving is an option to show the client that agencies can assist when the need is felt or when the client is ready to use them. In addition, this helps the client understand that anticipatory grieving is a normal process that occurs. Identifying family stress management strategies is appropriate at this time: Exploring possible stressors and strategies associated with the disease progression will give the client a realistic approach to understanding the disease process and its consequences. This also helps the client begin to share with the family to build a foundation for mutual understanding and trust. Page Ref: 102 Cognitive Level: Applying Client Need: Psychosocial Integrity Nursing Process: Implementation

7. Evaluate expected outcomes for an individual with sickle cell disease. 7) The nurse is caring for a client who was admitted to a medical-surgical unit in a sickle cell crisis. Which medication should the nurse expect to administer to this client? A) Acetaminophen (Tylenol) B) Ibuprofen (Advil) C) Meperidine (Demerol) D) Hydroxyurea

D Explanation: Hydroxyurea decreases production of abnormal blood cells and leads to a lesser amount of pain being experienced. Meperidine is not used for pain control for client in sickle cell crisis, because it can cause seizures. Acetaminophen or ibuprofen is used for mild pain, and would not be effective for the severe pain experienced by a child in sickle cell pain crisis. Page Ref: 122 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation

3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with sickle cell disease. 4) A client in sickle cell crisis reports taking a recent skiing trip that caused a respiratory infection from the cold weather. The client reports a pain level of 8 on a pain scale from 0 to 10. Which nursing diagnosis is a priority for this client? A) Fluid Volume Excess B) Risk for Self-Mutilation C) Knowledge Deficit D) Acute Pain

D Explanation: The priority for this client would be pain. The client has reportedly been skiing, which would be in an area of high altitude, which is contraindicated for someone with sickle cell. This client appears to have a knowledge deficit about self-care. This diagnosis, however, does not take priority. There is no evidence from the information given that the client has fluid volume excess or is at risk for self-mutilation. Page Ref: 124 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Planning

1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of anemia. 11) The nurse is instructing a client with iron deficiency anemia about appropriate menu choices. Which diet choice indicates that teaching has been effective? A) Tofu with mixed vegetables in curry, milk, whole-wheat bun B) Broiled fish, lettuce salad, grapefruit half, carrot sticks C) Pork chop, mashed potatoes and gravy, cauliflower, tea D) Roast beef, steamed spinach, tomato soup, orange juice

D Explanation: This client is anemic and needs iron. This meal contains iron in the beef, folic acid in the spinach, and vitamin C in the tomato soup and orange juice. Vitamin C helps absorption of the iron; folic acid is needed for production of red cells. The meal of tofu with mixed vegetables in curry, milk, and a whole-wheat bun is high in calcium, but the client has iron deficiency anemia and requires a high-iron diet. The meal with a pork chop, mashed potatoes and gravy, cauliflower, and tea has a moderate amount of protein, but no vitamin C. The meal of fish, lettuce, grapefruit, and carrot sticks is high in fiber, low in fat, and moderately high in protein, but low in iron. Page Ref: 71 Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Nursing Process: Evaluation/Teaching and Learning

7. Evaluate expected outcomes for an individual with skin cancer. 9) The nurse is reviewing the medical records for several clients who will be seen in the clinic today. According to the ABCD rule, which client may require removal of the skin lesion? A) A client with a lesion that is symmetrical with an irregular border, a single color, and increased diameter B) A client with a lesion that is symmetrical, with a smooth border, a single color, and diameter that has stayed the same C) A client with a lesion that is asymmetrical with a regular border, two colors, and decreased diameter D) A client with a lesion that is asymmetrical with an irregular border, two colors, and increased diameter

D Explanation: To meet all four criteria for removal of a lesion, the lesion will be asymmetrical, have irregular borders, show color change or more than one color, and have increased in diameter. Page Ref: 134 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Evaluation

4. Formulate priority nursing diagnoses appropriate for an individual with skin cancer. 7) The nurse is talking to a group of young adults about decreasing the risk for skin cancer. A young woman asks the nurse about the safety of ultraviolet light tanning salons. Which response by the nurse is most appropriate? A) "Using tanning beds without clothing contaminates skin and leads to infections." B) "Tanning from ultraviolet light is safer than sunshine." C) "Using sunscreen will prevent skin cancers, even in tanning beds." D) "Skin damage from ultraviolet light is more likely than from indirect sunlight."

D Explanation: Ultraviolet light exposure greatly increases risk of skin cancer, both basal cell and melanoma types. While direct sunshine contains ultraviolet light, the amount is decreased in indirect light. The use of sunscreen can reduce the risk of cancer but not prevent it, especially in tanning beds where the ultraviolet light is intensified. That using tanning beds without clothing causes infection may or may not be true, depending on the disinfectant methods used. Page Ref: 131 Cognitive Level: Applying Client Need: Health Promotion and Maintenance Nursing Process: Implementation

A nurse is treating a patient with diabetes mellitus who reports erectile dysfunction (ED). Which hormonal cause contributes to ED?

Decreased thyroid-stimulating hormone Hormonal causes of ED include decreased testosterone, decreased prolactin, and alterations in thyroid function. A decrease in thyroid-stimulating hormone (TSH) would be a cause of this disorder.

"The medications will help treat the effects of your current health problem and prevent any future events."

During a home visit the nurse notes that a patient recovering from an acute myocardial infarction has not had medication prescriptions filled at the pharmacy. What should the nurse say in response to this observation?

Thigh swelling to the knee

During a physical assessment the nurse suspects that a client is experiencing a femoral thrombosis. What finding did the nurse use to make this clinical determination?

Edema

During a softball game a child was hit in the eye with a bat. What common manifestation should the nurse expect when assessing this patient?

Primary open-angle glaucoma

During a vision test, the nurse notes that a patient has decreased peripheral vision of both eyes. Which health problem should the nurse suspect that this patient is experiencing?

The nurse is concerned that a patient with heart failure is decompensating. What assessment finding supports the nurse's clinical decision?

Dyspnea on exertion

The nurse is assessing a patient for symptoms of prostate cancer. Which symptoms would indicate the patient is experiencing an enlarged prostate?

Dysuria

The nurse is caring for a patient with pericardial effusion. Which action should the nurse use to relieve shortness of breath and pain?

Elevate the head of the bed

A patient with heart failure is having a B-type natriuretic peptide (BNP) level drawn. What is the purpose of this laboratory test?

Evaluate effectiveness of medication therapy

A nurse is screening a patient for prostate cancer. Which assessment findings would cause the nurse to suspect that the patient has prostate cancer? Select all that apply.

Fatigue Back pain Hematuria

A book

Friends of a patient hospitalized with asthma would like to bring the patient a gift. Which gift would the nurse recommend for this patient?

After completing a physical assessment the nurse anticipates the health-care provider to prescribe diagnostic testing for valvular disease. What did the nurse assess to come to this conclusion?

Heart murmur

While receiving discharge teaching, an adult patient recovering from a prostatectomy is distressed to learn that episodes of incontinence may occur. Which should the nurse teach the patient to help minimize incontinence?

Kegel exercises

The nurse is providing follow-up care for a patient was recently diagnosed with benign prostatic hyperplasia (BPH). Which nursing diagnosis is the priority for the nurse to include in the patient's plan of care?

Impaired Urinary Elimination

A patient with pericarditis asks the nurse to explain the health problem. Which phrase should the nurse use when responding to this patient?

Inflammation of the tissue surrounding the heart

The nurse is explaining the development of atherosclerosis to a patient. What should the nurse emphasize as beginning this process?

Injury to the vessel wall

Vitreous fluid moves under the retina and separates the retina from the pigmented cell layer

It is documented in the medical record that a patient has a rhegmatogenous detached retina. How should this diagnosis be explained to the patient?

A patient with heart failure is prescribed an angiotensin-converting enzyme inhibitor. What should the nurse explain as being the purpose of this medication?

Reduce afterload

A patient is admitted for treatment of pericarditis. For which additional health problem should the nurse expect the patient to be evaluated?

Myocardial infarction

A patient is recovering from minimally invasive surgery due to a diagnosis of benign prostatic hyperplasia (BPH). After assessing the patient, the nurse expects which outcome for this patient?

No postoperative treatment A patient who is diagnosed with mild BPH is often treated with lifestyle changes and a "wait and see" approach. Urinating at first urge is a lifestyle change that is appropriate for this patient.

The nurse is preparing teaching for a patient being treated for coronary artery disease. What dietary information should the nurse emphasize?

Reduce saturated fat and sodium intake

After an assessment the nurse concludes that a patient is experiencing infective endocarditis. What finding caused the nurse to make this decision?

Painless spots on the palms and soles

The nurse notes that a newly admitted patient has an elevated sedimentation rate. For which health problem should the nurse plan care for this patient?

Pericarditis

A patient with prostate cancer is being discharged from the hospital. Which educational topic is inappropriate for this patient?

Provide information on doses of complementary herbs

The nurse is caring for a patient with erectile dysfunction (ED). Which medication should the nurse anticipate being prescribed for this patient? Select all that apply.

Tadalafil (Cialis) Sildenafil (Viagra) Vardenafil (Levitra)

A male patient tells the nurse that he has no idea why his wife wants to stay married to him because he has not been able to "perform" sexually since his prostate surgery. Which diagnosis would be appropriate for this patient?

Situational Low Self-Esteem

During an assessment a patient describes experiencing chest pain with exercise that disappears with rest. For which health problem should the nurse plan care for this client?

Stable angina

The nurse applies oxygen two liters via nasal cannula on a patient with coronary artery disease. What should the nurse explain as being the purpose of the oxygen?

Supports myocardial oxygen demand

Urine toxicology testing

The employee health nurse is providing care to an employee who was injured on the job. The patient has a history of drug addiction and is currently enrolled in a 12-step recovery program. In order to determine whether the employee was impaired at the time of the accident, which diagnostic tool will the nurse use?

Distal lumen

The health-care provider wants an SvO2 level on a patient with a pulmonary artery catheter. From where should this sample be taken?

Pulmonary artery measurement

The health-care provider wants to determine a patient's cardiac contractility. What should be used to make this determination?

Elevate the head of the bed 45 degrees

The nurse is caring for a patient recovering from cataract removal surgery. Which action should the nurse take to reduce intraocular pressure (IOP)?

Imbalanced Nutrition: Less Than Body Requirements

The nurse assesses a patient with a history of alcoholism who is hospitalized with anorexia, dysphagia, odynophagia, and chest pressure after eating. Which nursing diagnosis is a priority for this patient?

Carotid duplex ultrasound

The nurse auscultates a bruit over a patient's carotid artery. Which noninvasive diagnostic test should the nurse expect to be prescribed for this patient?

Oxygen saturation of 92%

The nurse caring for a newborn on a ventilator for acute respiratory distress syndrome (ARDS) informs the parents that the newborn is improving. Which data supports the nurse's assessment of the newborn's condition?

Tachypnea

The nurse caring for a patient admitted with septic shock is aware of the need to assess for the development of acute respiratory distress syndrome (ARDS). Which early clinical manifestation would indicate the development of ARDS?

Dyspnea and shortness of breath

The nurse caring for a patient recovering from an abdominal hysterectomy suspects the patient is experiencing a pulmonary embolism. Which clinical manifestation supports the nurse's suspicion?

-Septic shock -Viral pneumonia -Aspirin overdose -Head injury

The nurse educator prepares to speak to a group of nursing students about direct and indirect insults to the lungs that may lead to the development of acute respiratory distress syndrome (ARDS). Which conditions will the nurse include in the teaching session? Select all that apply

"I need to use a soft toothbrush and an electric razor, and avoid injuries."

The nurse has instructed a patient recovering from a pulmonary embolism on long-term anticoagulant therapy. Which patient statement indicates that instruction has been effective?

Pulmonary edema

The nurse hears crackles when auscultating the lung sounds of a patient with cardiomyopathy. What should this finding indicate to the nurse?

Urine output 25mL/hr

The nurse in the intensive care unit (ICU) is caring for a patient diagnosed with acute respiratory distress syndrome (ARDS). Vital signs prior to endotracheal intubation: HR 108 bpm, RR 32 bpm, BP 88/58 mm Hg, and oxygen saturation 82%. The patient is intubated and placed on mechanical ventilation with positive pressure ventilation. Which assessment finding indicates a further decrease of cardiac output secondary to positive pressure ventilation?

"I will walk for at least 30 minutes three times a week."

The nurse instructs a patient recovering from an acute myocardial infarction on the Life's Simple 7 actions. Which patient statement indicates that additional teaching is required?

"The medication widens the airways because it stimulates the fight-or-flight response of the nervous system."

The nurse instructs a patient with asthma on bronchodilator therapy. Which statement indicates patient understanding?

-Perform line care -Use aseptic technique -Use normal saline to flush the line -Ensure an occlusive dressing is applied

The nurse is assigned to a patient with a newly inserted central line. What actions should be taken to prevent the patient from developing an infection? Select all that apply

Fenestrated tracheostomy tube

The nurse is caring for a patient being weaned from the ventilator, and wants to improve the patient's ability to communicate. Which item will the nurse request an order for from the health-care provider?

Low urine output

The nurse is caring for a patient experiencing an acute myocardial infarction. Which assessment finding indicates a decrease in this patient's cardiac output?

Dobutamine hydrochloride (Dobutamine)

The nurse is caring for a patient experiencing cardiogenic shock. Which medication should the nurse expect to be prescribed to improve this patient's cardiac output?

"Your risk of lung cancer will decline if you quit, but it will remain higher than a nonsmoker's."

The nurse is caring for a patient in a community clinic who wishes to quit smoking. The patient asks the nurse, "If I quit smoking, will my risk of lung cancer be the same as a nonsmoker?" Which is the best response by the nurse?

-Initiation of ARDS -Onset of pulmonary edema -Alveolar collapse -End-stage ARDS

The nurse is providing care to a patient admitted to the emergency department with the diagnosis of acute respiratory distress syndrome (ARDS). When educating the patient's family on the disease progress, in which order will the nurse present the material? (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234) 1) Initiation of ARDS 2) Onset of pulmonary edema 3) End-stage ARDS 4) Alveolar collapse

Multivitamin with folic acid

The nurse is providing care to a patient diagnosed with alcoholism. The patient's physical examination reveals a BMI of 18. Which prescription does the nurse anticipate to manage the patient's nutritional status?

Barrel chest

The nurse is providing care to a patient diagnosed with chronic obstruction pulmonary disease (COPD) after years of experiencing emphysema. Which clinical manifestation does the nurse anticipate when assessing this patient?

Encourage a diet high in protein and fats

The nurse is providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD). A nursing diagnosis for this patient is Imbalanced Nutrition: Less than Body Requirements. Which intervention is appropriate for this nursing diagnosis?

Patient conducts morning care and ambulates in room while maintaining an oxygen saturation of 92% on room air per oximetry reading

The nurse is providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD). Which observation would indicate that care provided to this patient has been effective?

-Working in an industrial environment -History of asthma -Current cigarette smoking

The nurse is providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD)? Which factors in the patient's history support the current diagnosis? Select all that apply

Place in Fowler position

The nurse is providing care to a patient newly diagnosed with asthma. When developing the patient's plan of care, which intervention would be most appropriate to promote airway clearance?

White blood cell count

The nurse is providing care to a patient receiving chemotherapy for the treatment of laryngeal cancer. Which laboratory test should the nurse anticipate to monitor the patient for neutropenia?

"My therapy includes washing my skin with a harsh soap and applying lotion."

The nurse is providing care to a patient receiving radiation in the treatment of laryngeal cancer. Which patient statement indicates the need for further education regarding radiation treatments?

Dyspnea

The nurse is providing care to a patient who is diagnosed with acute respiratory distress syndrome (ARDS). Which clinical manifestation does the nurse anticipate for this patient who is experiencing hypoxia as a result of the ARDS diagnosis?

Fluticasone

The nurse is providing care to a patient who is diagnosed with rhinitis and prescribed a corticosteroid nasal spray. Which drug should the nurse educate the patient about based on this data?

Guaifenesin

The nurse is providing care to a patient who is diagnosed with rhinitis and prescribed a decongestant. Which drug should the nurse educate the patient about based on this data?

Diphenhydramine

The nurse is providing care to a patient who is diagnosed with rhinitis and prescribed a first generation antihistamine. Which drug should the nurse educate the patient about based on this data?

Loratadine

The nurse is providing care to a patient who is diagnosed with rhinitis and prescribed a second generation antihistamine. Which drug should the nurse educate the patient about based on this data?

"Naltrexone diminishes the cravings your daughter will feel for alcohol and opioids."

The nurse is providing care to a patient with alcohol and opioid dependency. A family member states, "I don't understand why Naltrexone treatment is prescribed because it causes a high too, right?" Which response by the nurse is appropriate?

Acute respiratory distress syndrome

The nurse is providing care to a patient with an infected leg wound. The patient is exhibiting symptoms of a systemic infection and is receiving intravenous antibiotics. The patient states to the nurse, "I am having trouble breathing." Based on this data, which does the nurse suspect the patient is experiencing?

Attempt to clear the obstruction by delivering back blows and chest thrusts

The nurse is providing care to an infant in the emergency department (ED). Initial assessment indicates that the infant is experiencing an asthma attack. The infant is unresponsive to medication and a chest x-ray reveals a foreign body partially obstructing the airway. While placing an oxygen mask on the infant, the nurse notes a total obstruction of the airway. Which nursing action is appropriate?

The patient who is postoperative from a femur fracture repair

The nurse is providing care to several patients on a medical-surgical unit. Which patient is at highest risk for a nonthrombotic pulmonary embolism?

Use compression stockings

The nurse is providing discharge instructions to an older adult patient who is going home after having a total knee replacement. Which will the nurse include in the discharge teaching to decrease the patient's risk for developing a thrombosis or pulmonary embolism?

"I should use a firm-bristle toothbrush to ensure food particles are removed."

The nurse is providing education to a patient receiving radiation therapy for the treatment of laryngeal cancer. Which patient statement indicates the need for further education regarding oral care?

Antiemetic

The nurse is providing education to a patient who is receiving chemotherapy in the treatment of laryngeal cancer. Which medication should the nurse include to decrease the risk for nausea and vomiting?

Fluticasone

The nurse is providing education to the patient regarding nasal sprays that can be used to treat congestion. Which drug should the nurse include for a patient who requires a corticosteroid?

Oxymetazonline

The nurse is providing education to the patient regarding nasal sprays that can be used to treat congestion. Which drug should the nurse include for a patient who requires a decongestant?

A patient is recovering from prostate surgery on a medical-surgical unit. The patient will be ready for discharge within the next few days. Which teaching point is appropriate for this patient?

The patient should increase the fiber in his diet. The patient should be encouraged to increase the fiber in his diet, as straining for bowel movements after surgery can cause increased pressure in the prostate area. The patient and family are taught good dietary habits to keep bowel movements regular and soft.

Disulfiram

The patient with a history of alcohol abuse is being discharged to a treatment facility. Which prescription does the nurse anticipate for this patient?

The nurse is preparing an educational program on risk factors for the development of prostate cancer. Which information will the nurse include as being the greatest risk factor for developing prostate cancer?

The patient's age

"Lung cancer cells have a low growth fraction, so they are less sensitive to antineoplastic agents."

The student nurse is questioning the instructor about the different types of chemotherapeutic agents used to treat cancer. Which statement by the instructor best explains why lung cancers are less sensitive to antineoplastic agents than other types of cancers?

The nurse is planning care for a patient with erectile dysfunction. What should the nurse include in this patient's plan of care?

Types of devices and surgeries available to help with the disorder

The nurse is providing care to a patient who is diagnosed with mild benign prostatic hyperplasia (BPH). Which lifestyle change is appropriate for this patient?

Urinating at first urge

The nurse is caring for a patient with infective endocarditis. For which reason would a referral to social services be needed?

Uses intravenous drugs

During a home visit the nurse determines that teaching provided to a patient recovering from infective endocarditis has been effective. What did the nurse observe to make this clinical determination?

Using a soft toothbrush

The nurse explains about the development of tissue clumps within the innermost layer of the heart to a patient with infective endocarditis. What aspect of the disease process is the nurse describing?

Vegetation

-Vital signs -Medication administration -I/O -Neurological assessment

Which are the priority nursing interventions when providing care to patients at various stages of the detoxification process? Select all that apply

Tachypnea

Which assessment data collected by the nurse indicates a patient with laryngeal trauma is experiencing issues with airway clearance?

-Dyspnea -Restlessness -Tachycardia

Which assessment data would cause the nurse to document the patient is experiencing early respiratory distress? Select all that apply

-Rectal prolapse -Steatorrheic stools

Which assessment data would cause the nurse to suspect that an infant requires further testing for cystic fibrosis? Select all that apply

Cough in the morning producing clear sputum

Which assessment finding supports the nurse's suspicion that a patient is experiencing chronic obstructive pulmonary disease (COPD)?

-New onset of headache after five or six days -Symptoms that last more than 10 days without clinical improvement -Temperature greater than or equal to 102°F [39°C] with purulent nasal discharge for four days

Which criteria is used to diagnosis acute bacterial rhinosinusitis (ABRS) in adult patients? Select all that apply

Intranasal corticosteriods

Which drug prescription does the nurse anticipate for adjuvant therapy when providing care to an adult patient diagnosed with acute bacterial rhinosinusitis (ABRS)?

Amoxicillin-clavulante

Which drug prescription does the nurse anticipate for empiric therapy when providing care to an adult patient diagnosed with acute bacterial rhinosinusitis (ABRS)?

-Bupropion -Varenicline -Nicotine gum

Which first-line medications should the nurse include in a teaching session for a patient who wants to quit smoking? Select all that apply.

Maintaining NPO status

Which intervention should the nurse implement for a patient who is at risk for aspiration as a result of laryngeal trauma?

Ineffective airway clearance

Which is the priority nursing diagnosis for a patient who experiences a laryngeal trauma?

-"Exercise decreases stress." -"Exercise decreases anxiety." -"Exercise decreases cravings."

Which patient statements accurately reflect the benefits of physical activity during the smoking cessation process? Select all that apply

-Need for greater amounts of the substance to achieve the same effect -Neglect of normal activities due to focus on obtaining or using more of the substance -Persistent craving for the substance

Which symptoms common to substance abuse will the nurse include in the assessment process for a patient who is suspected of having a substance use disorder? Select all that apply

-Respiratory -Reproductive -Gastrointestinal

Which systems should the nurse anticipate will be affected when planning care for a patient diagnosed with cystic fibrosis? Select all that apply

Worked for 30 years as a tailor

While reviewing collected data the nurse notes that a patient has been newly diagnosed with myopia. What information in the patient's history might have contributed to this refractive error?