NRSG 3420: EXAM 1

BREAST REPO

BREAST REPO

HEME IMMUNE

HEME IMMUNE

A clinic nurse is meeting with a 38-year-old client who states that she would like to resume using oral contraceptives, which she used for several years during her 20s. What assessment question is most likely to reveal a potential contraindication to oral contraceptive use? "Have you ever had gynecologic surgery?" "Have you ever had a sexually transmitted infection?" "When did you last have your blood sugar levels checked?" "Do you smoke?"

Correct response: "Do you smoke?" Explanation: Women who smoke and who are 35 years of age or older should not take oral contraceptives because of an increased risk for cardiac problems. Previous surgeries, STIs, and blood sugar instability do not necessarily contraindicate the use of oral contraceptives. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 56: Assessment and Management of Patients with Female Physiologic Processes, Nursing Management, p. 1681.

A client has been living with seasonal allergies for many years, but does not take antihistamines, stating, "When I was young I used to take antihistamines, but they always put me to sleep." How should the nurse best respond? "The newer antihistamines are different than in years past, and cause less sedation." "Have you considered taking them at bedtime instead of in the morning?" "Newer antihistamines are combined with a stimulant that offsets drowsiness." "Most people find that they develop a tolerance to sedation after a few months."

Correct response: "The newer antihistamines are different than in years past, and cause less sedation." Explanation: Unlike first-generation H1 receptor antagonists, newer antihistamines bind to peripheral rather than central nervous system H1 receptors, causing less sedation, if at all. Tolerance to sedation did not usually occur with first-generation drugs and newer antihistamines are not combined with a stimulant. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 37: Assessment and Management of Patients With Allergic Disorders, Antihistamines, p. 1068.

A man tells the nurse that his father died of prostate cancer and he is concerned about his own risk of developing the disease, having heard that prostate cancer has a genetic link. What aspect of the pathophysiology of prostate cancer would underlie the nurse's response? A number of studies have identified an association of BRCA-2 mutation with an increased risk of prostate cancer. HNPCC is a mutation of two genes that causes prostate cancer in men and it is autosomal dominant. Studies have shown that the presence of the TP53 gene strongly influences the incidence of prostate cancer. Recent research has demonstrated that prostate cancer is the result of lifestyle factors and that genetics are unrelated.

Correct response: A number of studies have identified an association of BRCA-2 mutation with an increased risk of prostate cancer. Explanation: A number of studies have identified an association of BRCA-2 mutation with an increased risk of prostate cancer. HNPCC is a form of colon cancer. The TP53 gene is associated with breast cancer. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 59: Assessment and Management of Patients with Male Reproductive Disorders, Cancer of the Prostate, p. 1764.

A woman who is in her third trimester of pregnancy has been experiencing an exacerbation of iron-deficiency anemia in recent weeks. When providing the client with nutritional guidelines and meal suggestions, what foods would be most likely to increase the woman's iron stores? Beef liver accompanied by orange juice Yogurt, almonds, and whole grain oats Mixed vegetables and brown rice Salmon accompanied by whole milk

Correct response: Beef liver accompanied by orange juice Explanation: Food sources high in iron include organ meats, other meats, beans (e.g., black and pinto), leafy green vegetables, raisins, and molasses. Taking iron-rich foods with a source of vitamin C (e.g., orange juice) enhances the absorption of iron. All of the listed foods are nutritious, but liver and orange juice are most likely to be of benefit to iron stores. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 33: Management of Patients With Nonmalignant Hematologic Disorders, Nursing Management, p. 931.

An older adult client is exhibiting many of the characteristic signs and symptoms of iron deficiency. In addition to a complete blood count, what diagnostic assessment should the nurse anticipate? Stool for occult blood Urinalysis Bone marrow biopsy Lumbar puncture

Correct response: Stool for occult blood Explanation: Iron deficiency in the adult generally indicates blood loss (e.g., from bleeding in the GI tract or heavy menstrual flow). Bleeding in the GI tract can be preliminarily identified by testing stool for the presence of blood. A bone marrow biopsy would not be undertaken for the sole purpose of investigating an iron deficiency. Lumbar puncture and urinalysis would not be clinically relevant. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 32: Assessment of Hematologic Function and Treatment Modalities, Iron Stores and Metabolism, p. 906.

A child has been diagnosed with a severe walnut allergy after suffering an anaphylactic reaction. What is the nurse's priority for health education? The need for the parents to carry an epinephrine pen The need for the child to avoid all foods that have a high potential for allergies The need to begin immunotherapy as soon as possible The need to vigilantly maintain the child's immunization status

Correct response: The need for the parents to carry an epinephrine pen Explanation: All clients with food allergies, especially seafood and nuts, should have an EpiPen device prescribed. The child does not necessarily need to avoid all common food allergens. Immunotherapy is not indicated in the treatment of childhood food allergies. Immunizations are important, but do not address food allergies. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 37: Assessment and Management of Patients With Allergic Disorders, Medical Management, p. 1077.

The school nurse is presenting a class on female reproductive health. The nurse should describe what aspect of Pap smears? The test may be performed at any time during the client's menstrual cycle. The smear should be done every 2 years. The test can detect early evidence of cervical cancer. False-positive Pap smear results often occur from not douching before the examination.

Correct response: The test can detect early evidence of cervical cancer. Explanation: The test should be performed when the client is not menstruating. Douching washes away cellular material. The test detects cervical cancer, and false-negative Pap smear results occur mostly from sampling errors or improper technique. For most women, a Pap smear should be done annually. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 56: Assessment and Management of Patients with Female Physiologic Processes, Cytologic Test for Cancer (Pap Smear), p. 1663.

NEURO

NEURO

A nurse is caring for a pregnant client with active herpes. The teaching plan for this client should include which of the following? Babies delivered vaginally may become infected with the virus. Recommended treatment is excision of the herpes lesions. Pain generally does not occur with a herpes outbreak during pregnancy. Pregnancy may exacerbate the mother's symptoms, but poses no risk to the infant.

Correct response: Babies delivered vaginally may become infected with the virus. Explanation: In pregnant women with active herpes, babies delivered vaginally may become infected with the virus. There is a risk for fetal morbidity and mortality if this occurs. Lesions are not controlled with excision. Itching and pain accompany the process as the infected area becomes red and swollen. Aspirin and other analgesics are usually effective in controlling the pain. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 57: Management of Patients With Female Reproductive Disorders, Pathophysiology, p. 1692.

An adolescent is brought to the clinic by her mother because of abnormal uterine bleeding. The nurse should understand that the most likely cause of this dysfunctional bleeding pattern is what? Lack of ovulation Chronic vaginitis A sexually transmitted infection Ectopic pregnancy

Correct response: Lack of ovulation Explanation: Dysfunctional uterine bleeding can occur at any age, but is most common at opposite ends of the reproductive lifespan. It is usually secondary to anovulation (lack of ovulation) and is common in adolescents. It is not suggestive of vaginitis, an STI, or ectopic pregnancy. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 56: Assessment and Management of Patients with Female Physiologic Processes, Abnormal Uterine Bleeding, p. 1668.

A client with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate? Restrain the client to prevent injury. Open the client's jaws to insert an oral airway. Place client in high Fowler position. Loosen the client's restrictive clothing.

Correct response: Loosen the client's restrictive clothing. Explanation: An appropriate nursing intervention would include loosening any restrictive clothing on the client. No attempt should be made to restrain the client during the seizure because muscular contractions are strong and restraint can produce injury. Do not attempt to pry open jaws that are clenched in a spasm to insert anything. Broken teeth and injury to the lips and tongue may result from such an action. If possible, place the client on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 66: Management of Patients With Neurologic Dysfunction, Chart 66-4, p. 1998.

A client has been diagnosed with a lymphoid stem cell defect. This client has the potential for a problem involving which of the following? Plasma cells Red blood cells Neutrophils Platelets

Correct response: Plasma cells Explanation: A defect in a myeloid stem cell can cause problems with erythrocyte, leukocyte, and platelet production. In contrast, a defect in the lymphoid stem cell can cause problems with T or B lymphocytes, plasma cells (a more differentiated form of B lymphocyte), or natural killer (NK) cells. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 32: Assessment of Hematologic Function and Treatment Modalities, Bone Marrow, p. 903.

An 83-year-old client has been prescribed finasteride. When performing client education with this client, the nurse should be sure to tell the client what? Report the planned use of dietary supplements to the health care provider. Decrease the intake of fluids to prevent urinary retention. Abstain from sexual activity for 2 weeks following the initiation of treatment. Anticipate a temporary worsening of urinary retention before symptoms subside.

Correct response: Report the planned use of dietary supplements to the health care provider. Explanation: Some herbal supplements are contraindicated with finasteride, thus their planned use should be discussed with the physician or pharmacist. The client should maintain normal fluid intake. There is no need to abstain from sexual activity and a worsening of urinary retention is not anticipated. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 59: Assessment and Management of Patients with Male Reproductive Disorders, Pharmacologic Therapy, p. 1763.

An adult client has sought care for the treatment of headaches that have become increasingly severe and frequent over the past several months. Which of the following questions addresses potential etiologic factors? Select all that apply? "Are you exposed to any toxins or chemicals at work?" "How would you describe your ability to cope with stress?" "What medications are you currently taking?" "When was the last time you were hospitalized?" "Does anyone else in your family struggle with headaches?"

Correct response: "Are you exposed to any toxins or chemicals at work?" "How would you describe your ability to cope with stress?" "What medications are you currently taking?" "Does anyone else in your family struggle with headaches?" Explanation: Headaches are multifactorial, and may involve medications, exposure to toxins, family history, and stress. Hospitalization is an unlikely contributor to headaches. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 66: Management of Patients With Neurologic Dysfunction, Assessment and Diagnostic Findings, p. 2005.

An individual has accidentally cut his hand, immediately initiating the process of hemostasis. Following vasoconstriction, what event in the process of hemostasis will take place? Fibrin will be activated at the bleeding site. Thromboplastin will form a clot. Prothrombin will be converted to thrombin. Platelets will aggregate at the injury site.

Correct response: Platelets will aggregate at the injury site. Explanation: Following vasoconstriction, circulating platelets aggregate at the site and adhere to the vessel and to one another, forming an unstable hemostatic plug. Events involved in the clotting cascade take place subsequent to this initial platelet action. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 32: Assessment of Hematologic Function and Treatment Modalities, Hemostasis, p. 908.

A nurse is caring for a teenage girl who has had an anaphylactic reaction after a bee sting. The nurse is providing client teaching prior to the client's discharge. In the event of an anaphylactic reaction, the nurse informs the client that she should self-administer epinephrine in what site? Forearm Thigh Deltoid muscle Abdomen

Correct response: Thigh Explanation: The client is taught to position the device at the middle portion of the thigh and push the device into the thigh as far as possible. The device will automatically inject a premeasured dose of epinephrine into the subcutaneous tissue. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 37: Assessment and Management of Patients With Allergic Disorders, Chart 37-3, p. 1067.

The nurse is being trained to perform assessment screenings for abuse on clients who come into the walk-in clinic where the nurse works. Which of the following assessment questions is most appropriate? "Would you describe your relationship as healthy and functional?" "Have you ever been forced into sexual activity?" "Do you make your husband uncontrollably angry?" "How is conflict usually handled in your home?"

Correct response: "Have you ever been forced into sexual activity?" Explanation: Asking about abuse directly is effective in identifying the presence of abuse and should be included in the health history of all women. Oblique questions that relate to the character of the relationship or conflict resolution are less useful clinically. Asking about making a partner angry is not an appropriate way to screen for family violence because it does not directly address the problem. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 56: Assessment and Management of Patients with Female Physiologic Processes, Intimate Partner Violence, p. 1657.

The nurse is taking the sexual history of an adolescent who has come into the free clinic. What question best assesses the client's need for further information? "Are you involved in an intimate relationship at this time?" "How many sexual partners have you had?" "What questions or concerns do you have about your sexual health?" "Have you ever been diagnosed with a sexually transmitted infection?"

Correct response: "What questions or concerns do you have about your sexual health?" Explanation: An open-ended question related to the client's need for further information should be included while obtaining a sexual history. None of the other listed questions are open-ended. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 56: Assessment and Management of Patients with Female Physiologic Processes, Sexual History, p. 1657.

The nurse is caring for a client in the postoperative period following an abdominal hysterectomy. The client states, "I don't want to use my pain meds because they'll make me dependent and I won't get better as fast." Which response is most important when explaining the use of pain medication? "You will need the pain medication for at least 1 week to help in your recovery. What do you mean you feel you won't get better faster?" "Pain medication will help to decrease your pain and increase your ability to breath. Dependency is a risk with pain medication, but you are young and won't have any problems." "Pain medication can be given by mouth to prevent the risk of dependency that you are worried about. The pain medication has not been shown to affect your risk of a slowed recovery." "You will move more easily and heal more quickly with decreased pain. Dependence only occurs when it is given for an extended period of time."

Correct response: "You will move more easily and heal more quickly with decreased pain. Dependence only occurs when it is given for an extended period of time." Explanation: Postoperatively, medications are given to relieve pain and maintain comfort without increasing the risk of inadequate air exchange. The nurse should address the client's concerns about drug dependency and the nurse's need to increase the client's ability to move and recover from surgery. The other responses offer incorrect information, such as increasing the client's ability to breathe or specifying the time needed to take the medication. Opioids will cause respiratory depression. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 17: Preoperative Nursing Management, Pain Management, p. 429.

A pelvic examination reveals that a woman's uterus is retroflexed. Which of the following best depicts this position? *PICTURES* A. Uterus turned posteriorly as a whole unit B. Fundus bent posteriorly C. Uterus tilted forward as a whole unit D. Uterus bent anteriorly

Correct response: B. Fundus bent posteriorly Explanation: In retroflexion, the uterus bends posteriorly, as shown in option B. In retroversion, the uterus turns posteriorly as a whole unit, as shown in option A. In anteversion, the uterus tilts forward as a whole unit, as shown in option C. In anteflexion, the uterus bends anteriorly, as shown in option D. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 57: Management of Patients With Female Reproductive Disorders, Figure 57-5, p. 1700.

A nurse in the preoperative holding area is admitting a woman prior to reduction mammoplasty. What should the nurse include in the care given to this client? Select all that apply. Establishing an IV line Verifying the surgical site with the client Taking measures to ensure the client's comfort Applying a grounding device to the client Preparing the medications to be given in the OR

Correct response: Establishing an IV line Verifying the surgical site with the client Taking measures to ensure the client's comfort Explanation: In the holding area, the nurse reviews charts, identifies clients, verifies surgical site and marks site per institutional policy, establishes IV lines, administers medications, if prescribed, and takes measures to ensure each client's comfort. A nurse in the preoperative holding area does not prepare medications to be given by anyone else. A grounding device is applied in the OR. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 17: Preoperative Nursing Management, Chart 17-1, p. 420.

A nurse is teaching a 53-year-old man about prostate cancer, given the fact that he has a family history of the disease. What information should the nurse provide to best facilitate the early identification of prostate cancer? Have a digital rectal examination and prostate-specific antigen (PSA) test done as recommended. Have a transrectal ultrasound every 5 years. Perform monthly testicular self-examinations, especially after age 60. Have a complete blood count (CBC), blood urea nitrogen (BUN), and creatinine assessment performed annually.

Correct response: Have a digital rectal examination and prostate-specific antigen (PSA) test done as recommended. Explanation: The incidence of prostate cancer increases after age 50. The digital rectal examination, which identifies enlargement or irregularity of the prostate, and the PSA test, a tumor marker for prostate cancer, are effective diagnostic measures that are especially relevant when a client has a family history. Testicular self-examinations won't identify changes in the prostate gland due to its location in the body. A transrectal ultrasound and CBC with BUN and creatinine assessment are usually done after diagnosis to identify the extent of disease and potential metastases. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 59: Assessment and Management of Patients with Male Reproductive Disorders, Prostate-Specific Antigen Test, p. 1756.

What neurologic assessment should the nurse perform to gauge the client's function of cranial nerve I? Have the client identify familiar odors with the eyes closed. Assess papillary reflex. Utilize the Snellen chart. Test for air and bone conduction (Rinne test).

Correct response: Have the client identify familiar odors with the eyes closed. Explanation: Cranial nerve I is the olfactory nerve. The client's sense of smell could be assessed by asking him or her to identify common odors. Assessment of papillary reflex does not address the olfactory function of cranial nerve I. The Snellen chart would be used to assess cranial nerve II (optic). Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Table 65-2, p. 1952.

When teaching clients about the risk factors of cervical cancer, what would the nurse identify as the most important risk factor? Late childbearing Human papillomavirus (HPV) Postmenopausal bleeding Tobacco use

Correct response: Human papillomavirus (HPV) Explanation: HPV is the most salient risk factor for cervical cancer, exceeding the risks posed by smoking, late childbearing, and postmenopausal bleeding. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 57: Management of Patients With Female Reproductive Disorders, Pathophysiology, p. 1691.

A client is 24 hours postoperative following prostatectomy and the urologist has ordered continuous bladder irrigation. What color of output should the nurse expect to find in the drainage bag? Red wine colored Tea colored Amber Light pink

Correct response: Light pink Explanation: The urine drainage following prostatectomy usually begins as a reddish pink, then clears to a light pink color 24 hours after surgery. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 59: Assessment and Management of Patients with Male Reproductive Disorders, Hemorrhage, p. 1775.

A geriatric nurse practitioner is assessing older adults. The nurse practitioner knows that older adults sometimes have difficulty following directions during a neurologic examination or diagnostic procedure. What strategies can the nurse practitioner use to examine older clients? Offer incentives such as sweets Provide brief instructions, one step at a time Spread the examination over 2 or 3 days Suggest a nurse or an examiner who is of their age

Correct response: Provide brief instructions, one step at a time Explanation: Older adults who have difficulty following directions during a neurologic examination or diagnostic procedure need brief instructions given one step at a time during the examination or procedure. In addition, diseases that are more common in older adults, such as dementia, often make it difficult to perform a neurologic assessment. The nurse should not offer incentives to them. In addition, spreading the examination over a couple of days or suggesting an examiner of their age may not help in examining older adults. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Nursing Implications, p. 1965.

A client who is scheduled for a skin test informs the nurse that he has been taking corticosteroids to help control his allergy symptoms. What nursing intervention should the nurse implement? The client should only be tested for grass, mold, and dust initially. The client should take his corticosteroids regularly prior to testing. The client's test should be cancelled until he is off his corticosteroids. The nurse should have an emergency cart available in case of anaphylaxis during the test.

Correct response: The client's test should be cancelled until he is off his corticosteroids. Explanation: Corticosteroids and antihistamines, including over-the-counter (OTC) allergy medications, suppress skin test reactivity and should be stopped 48 to 96 hours before testing, depending on the duration of their activity. Emergency equipment must be at hand during allergy testing, but the test would be postponed. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 37: Assessment and Management of Patients With Allergic Disorders, Interpretation of Skin Test Results, p. 1063.

The home health nurse is assessing a client who is immunosuppressed. What is the most essential teaching for this client and the family? The need to report any slight changes in the client's health status How to choose antibiotics based on the client's symptoms How to promote immune function through nutrition The importance of maintaining the client's vaccination status

Correct response: The need to report any slight changes in the client's health status Explanation: They must be informed of the need for continuous monitoring for subtle changes in the client's physical health status and of the importance of seeking immediate health care if changes are detected. Nutrition is important, but infection control is the priority. Clients and families do not choose antibiotics independently. Vaccinations are often contraindicated in immunocompromised clients. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 36: Management of Patients With Immune Deficiency Disorders, Chart 36-12, p. 1052.

A 35-year-old father of three tells the nurse that he wants information on a vasectomy. What would the nurse tell him about ejaculate after a vasectomy? There will be no ejaculate after a vasectomy, though the client's potential for orgasm is unaffected. There is no noticeable decrease in the amount of ejaculate even though it contains no sperm. There is a marked decrease in the amount of ejaculate after vasectomy, though this does not affect sexual satisfaction. There is no change in the quantity of ejaculate after vasectomy, but the viscosity is somewhat increased.

Correct response: There is no noticeable decrease in the amount of ejaculate even though it contains no sperm. Explanation: Seminal fluid is manufactured predominantly in the seminal vesicles and prostate gland, which are unaffected by vasectomy, thus no noticeable decrease in the amount of ejaculate occurs (volume decreases approximately 3%), even though it contains no spermatozoa. The viscosity of ejaculate does not change. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 59: Assessment and Management of Patients with Male Reproductive Disorders, Vasectomy, p. 1783.

The nurse is preparing to assess a client with neurologic dysfunction. What does accurate and appropriate assessment require? Select all that apply. The ability to select basic medications for the neurologic dysfunction Understanding of the tests used to diagnose neurologic disorders Knowledge of nursing interventions related to assessment and diagnostic testing Knowledge of the anatomy of the nervous system The ability to interpret the results of diagnostic tests

Correct response: Understanding of the tests used to diagnose neurologic disorders Knowledge of nursing interventions related to assessment and diagnostic testing Knowledge of the anatomy of the nervous system Explanation: Assessment requires knowledge of the anatomy and physiology of the nervous system and an understanding of the array of tests and procedures used to diagnose neurologic disorders. Knowledge about the nursing implications and interventions related to assessment and diagnostic testing is also essential. Selecting medications and interpreting diagnostic tests are beyond the normal scope of the nurse. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Introduction, p. 1946.

A client has been scheduled for a bone marrow biopsy and admits to the nurse that she is worried about the pain involved with the procedure. What client education is most accurate? "You'll feel some pain when the needle enters your skin, but none when the needle enters the bone because of the absence of nerves in bone." "You'll be given painkillers before the test, so there won't likely be any pain?" "I'll be there with you, and I'll try to help you keep your mind off the pain." "Most people feel some brief, sharp pain when the needle enters the bone."

Correct response: "Most people feel some brief, sharp pain when the needle enters the bone." Explanation: Clients typically feel a pressure sensation as the needle is advanced into position. The actual aspiration always causes sharp, brief pain, resulting from the suction exerted as the marrow is aspirated into the syringe; the client should be warned about this. Stating, "I'll try to help you keep your mind off the pain" may increase the client's fears of pain, because this does not help the client know what to expect Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 32: Assessment of Hematologic Function and Treatment Modalities, Bone Marrow Aspiration and Biopsy, p. 910.

The nurse is caring for a client who is rapidly progressing toward brain death. The nurse should be aware of what cardinal signs of brain death? Select all that apply. Absence of pain response Apnea Coma Absence of brain stem reflexes Absence of deep tendon reflexes

Correct response: Apnea Coma Absence of brain stem reflexes Explanation: The three cardinal signs of brain death upon clinical examination are coma, the absence of brain stem reflexes, and apnea. Absences of pain response and deep tendon reflexes are not necessarily indicative of brain death. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 68: Management of Patients With Neurologic Trauma, Brain Death, p. 2038.

The nurse is preparing a client for surgery prior to her hysterectomy without oophorectomy. The nurse is witnessing the client's signature on a consent form. Which comment by the client would best indicate informed consent? "I know I'll be fine because the physician said he has done this procedure hundreds of times." "I know I'll have pain after the surgery but they'll do their best to keep it to a minimum." "The physician is going to remove my uterus and told me about the risk of bleeding." "Because the physician isn't taking my ovaries, I'll still be able to have children."

Correct response: "The physician is going to remove my uterus and told me about the risk of bleeding." Explanation: The surgeon must inform the client of the benefits, alternatives, possible risks, complications, disfigurement, disability, and removal of body parts as well as what to expect in the early and late postoperative periods. The nurse clarifies the information provided, and, if the client requests additional information, the nurse notifies the physician. In the correct response, the client is able to tell the nurse what will occur during the procedure and the associated risks. This indicates the client has a sufficient understanding of the procedure to provide informed consent. Clarification of information given may be necessary, but no additional information should be given. The other listed statements do not reflect an understanding of the surgery to be performed. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 17: Preoperative Nursing Management, Informed Consent, p. 422.

An elderly client is being discharged home. The client lives alone and has atrophy of his olfactory organs. The nurse tells the client's family that it is essential that the client have what installed in the home? Grab bars Nonslip mats Baseboard heaters A smoke detector

Correct response: A smoke detector Explanation: The sense of smell deteriorates with age. The olfactory organs are responsible for smell. This may present a safety hazard for the client because he or she may not smell smoke or gas leaks. Smoke detectors are universally necessary, but especially for this client. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Sensory Alterations, p. 1964.

A 69-year-old client is brought to the ED by ambulance because a family member found him lying on the floor disoriented and lethargic. The health care provider suspects bacterial meningitis and admits the client to the ICU. What interventions should the nurse perform? Select all that apply. Obtain a blood type and cross-match Administer antipyretics as prescribed Perform frequent neurologic assessments Monitor pain levels and administer analgesics Place the client in positive pressure isolation

Correct response: Administer antipyretics as prescribed Perform frequent neurologic assessments Monitor pain levels and administer analgesics Explanation: Clients with meningitis require antipyretics and analgesia to treat fever and pain. As well, their neurologic status must be monitored closely. Transfusions are not anticipated. Infection control precautions are implemented, but positive pressure isolation is not necessary because the client is not immunocompromised. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies, Nursing Management, p. 2068.

An office worker takes a cookie that contains peanut butter. The worker begins wheezing, with an inspiratory stridor and air hunger and the occupational health nurse is called to the office. The nurse should recognize that the worker is likely suffering from which type of hypersensitivity? Cytotoxic (type II) Immune complex (type III) Delayed-type (type IV) Anaphylactic (type 1)

Correct response: Anaphylactic (type 1) Explanation: The most severe form of a hypersensitivity reaction is anaphylaxis. An unanticipated severe allergic reaction that is often explosive in onset, anaphylaxis is characterized by edema in many tissues, including the larynx, and is often accompanied by hypotension, bronchospasm, and cardiovascular collapse in severe cases. Type II, or cytotoxic, hypersensitivity occurs when the system mistakenly identifies a normal constituent of the body as foreign. Immune complex (type III) hypersensitivity involves immune complexes formed when antigens bind to antibodies. Type III is associated with systemic lupus erythematosus, rheumatoid arthritis, certain types of nephritis, and bacterial endocarditis. Delayed-type (type IV), also known as cellular hypersensitivity, occurs 24 to 72 hours after exposure to an allergen. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 37: Assessment and Management of Patients With Allergic Disorders, Anaphylactic (Type I) Hypersensitivity, p. 1061.

A client's health history reveals daily consumption of two to three bottles of wine. The nurse should plan assessments and interventions in light of the client's increased risk for what hematologic disorder? Anemia Lymphoma Thrombocytopenia Leukemia

Correct response: Anemia Explanation: Heavy alcohol use is associated with numerous health problems, including anemia. Leukemia and lymphoma are not associated with alcohol use; RBC levels are typically affected more than platelet levels. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 32: Assessment of Hematologic Function and Treatment Modalities, Table 32-2, p. 911.

A nurse is educating a client about the role of B lymphocytes. The nurse's description will include which of the following physiologic processes? Phagocytosis Stem cell differentiation Antibody production Cytokine production

Correct response: Antibody production Explanation: B lymphocytes are capable of differentiating into plasma cells. Plasma cells, in turn, produce antibodies. Cytokines are produced by NK cells. Stem cell differentiation greatly precedes B lymphocyte production. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 32: Assessment of Hematologic Function and Treatment Modalities, Function of Leukocytes, p. 907.

A client is admitted to the hospital with pernicious anemia. The nurse should prepare to administer which of the following medications? Folic acid Vitamin B12 Lactulose Magnesium sulfate

Correct response: Vitamin B12 Explanation: Pernicious anemia is characterized by vitamin B12 deficiency. Magnesium sulfate, lactulose, and folic acid do not address the pathology of this type of anemia. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 33: Management of Patients With Nonmalignant Hematologic Disorders, Medical Management, p. 934.

A client diagnosed with Bell palsy is being cared for on an outpatient basis. During health education, the nurse should promote which of the following actions? Applying a protective eye shield at night Chewing on the affected side to prevent unilateral neglect Avoiding the use of analgesics whenever possible Avoiding brushing the teeth

Correct response: Applying a protective eye shield at night Explanation: Corneal irritation and ulceration may occur if the eye is unprotected. While paralysis lasts, the involved eye must be protected. The client should be encouraged to eat on the unaffected side, due to swallowing difficulties. Analgesics are used to control the facial pain. The client should continue to provide self-care including oral hygiene. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies, Nursing Management, p. 2089.

A client with spinal cord injury has a nursing diagnosis of altered mobility and the nurse recognizes the increased the risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent a DVT from occurring? Placing the client on a fluid restriction as ordered Applying thigh-high elastic stockings Administering an antifibrinolytic agent Assisting the client with passive range-of-motion (PROM) exercises

Correct response: Applying thigh-high elastic stockings Explanation: It is important to promote venous return to the heart and prevent venous stasis in a client with altered mobility. Applying elastic stockings will aid in the prevention of a DVT. The client should not be placed on fluid restriction because a dehydrated state will increase the risk of clotting throughout the body. Antifibrinolytic agents cause the blood to clot, which is absolutely contraindicated in this situation. PROM exercises are not an effective protection against the development of DVT. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 68: Management of Patients With Neurologic Trauma, Venous Thromboembolism, p. 2054.

A client in her 30s has two young children and has just had a modified radical mastectomy with immediate reconstruction. The client shares with the nurse that she is somewhat worried about her future, but she appears to be adjusting well overall to her diagnosis and surgery. What nursing intervention is most appropriate to support this client's coping? Encourage the client's spouse or partner to be supportive while she recovers. Encourage the client to proceed with the next phase of treatment. Recommend that the client remain optimistic for the sake of her children. Arrange a referral to a community-based support program.

Correct response: Arrange a referral to a community-based support program. Explanation: The client is not exhibiting clear signs of anxiety or depression. Therefore, the nurse can probably safely approach her about talking with others who have had similar experiences. The nurse may educate the client's spouse or partner to listen for concerns, but the nurse should not tell the client's spouse what to do. The client must consult with her physician and make her own decisions about further treatment. The client needs to express her sadness, frustration, and fear. She cannot be expected to be optimistic at all times. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 58: Assessment and Management of Patients With Breast Disorders, Reducing Fear and Anxiety and Improving Coping Ability, p. 1735.

The nurse is aware that burr holes may be used in neurosurgical procedures. Which of the following is a reason why a neurosurgeon may choose to create a burr hole in a patient? Visualization of a hemorrhage Aspiration of a brain abscess Access for intravenous (IV) fluids To assess visual acuity

Correct response: Aspiration of a brain abscess Explanation: Burr holes may be used in neurosurgical procedures to make a bone flap in the skull, to aspirate a brain abscess, or to evacuate a hematoma. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 66: Management of Patients With Neurologic Dysfunction, Intracranial Surgery, p. 1989.

A school nurse is caring for a child who appears to be having an allergic response. What should be the initial action of the school nurse? Assess for signs and symptoms of anaphylaxis. Assess for erythema and urticaria. Administer an over-the-counter (OTC) antihistamine. Administer epinephrine.

Correct response: Assess for signs and symptoms of anaphylaxis. Explanation: If a client is experiencing an allergic response, the nurse's initial action is to assess the client for signs and symptoms of anaphylaxis. Erythema and urticaria may be present, but these are not the most significant or most common signs of anaphylaxis. Assessment must precede interventions, such as administering an antihistamine. Epinephrine is indicated in the treatment of anaphylaxis, not for every allergic reaction. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 37: Assessment and Management of Patients With Allergic Disorders, Nursing Management, p. 1066.

A client with a diagnosis of primary immunodeficiency disease informs the nurse that he has been experiencing a new onset of a dry cough and occasional shortness of breath. After determining that the client's vital signs are within reference ranges, what action should the nurse take? Perform oral suctioning. Assess the client for signs and symptoms of infection. Administer a nebulized bronchodilator. Teach the client deep breathing and coughing exercises.

Correct response: Assess the client for signs and symptoms of infection. Explanation: Dyspnea and cough are among the varied signs and symptoms that may suggest infection in an immunocompromised client. There is no indication for suctioning or the use of nebulizers. Deep breathing and coughing exercises do not address the client's complaints or the likely etiology. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 36: Management of Patients With Immune Deficiency Disorders, Nursing Management, p. 1023.

When teaching a client with sickle cell disease about strategies to prevent crises, what measures should the nurse recommend? Maximizing physical activity and taking OTC iron supplements Avoiding cold temperatures and ensuring sufficient hydration Using prophylactic antibiotics and performing meticulous hygiene Limiting psychosocial stress and eating a high-protein diet

Correct response: Avoiding cold temperatures and ensuring sufficient hydration Explanation: Keeping warm and providing adequate hydration can be effective in diminishing the occurrence and severity of attacks. Hygiene, antibiotics, and high protein intake do not prevent crises. Maximizing activity may exacerbate pain and be unrealistic. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 33: Management of Patients With Nonmalignant Hematologic Disorders, Minimizing Deficient Knowledge, p. 940.

The ED nurse is caring for a client who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding is suggestive of a basilar skull fracture? Epistaxis Periorbital edema Bruising over the mastoid Unilateral facial numbness

Correct response: Bruising over the mastoid Explanation: An area of ecchymosis (bruising) may be seen over the mastoid (Battle sign) in a basilar skull fracture. Numbness, edema, and epistaxis are not directly associated with a basilar skull fracture. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 68: Management of Patients With Neurologic Trauma, Clinical Manifestations, p. 2035.

A nurse is assessing reflexes in a client with hyperactive reflexes. When the client's foot is abruptly dorsiflexed, it continues to "beat" two to three times before settling into a resting position. How should the nurse document this finding? Rigidity Flaccidity Clonus Ataxia

Correct response: Clonus Explanation: When reflexes are very hyperactive, a phenomenon called clonus may be elicited. If the foot is abruptly dorsiflexed, it may continue to "beat" two to three times before it settles into a position of rest. Rigidity is an increase in muscle tone at rest characterized by increased resistance to passive stretch. Flaccidity is lack of muscle tone. Ataxia is the inability to coordinate muscle movements, resulting in difficulty walking, talking, and performing self-care activities. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Clonus, p. 1964.

A nurse is preparing a client for allergy skin testing. What precautionary step is most important for the nurse to follow? Emergency equipment should be readily available. Prophylactic epinephrine should be given before the test. The client must not have received an immunization within 7 days. The nurse should administer albuterol 30 to 45 minutes prior to the test.

Correct response: Emergency equipment should be readily available. Explanation: Emergency equipment must be readily available during testing to treat anaphylaxis. Immunizations do not contraindicate testing. Neither epinephrine nor albuterol is given prior to testing. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 37: Assessment and Management of Patients With Allergic Disorders, Skin Tests, p. 1062.

A home health nurse is caring for a client who has an immunodeficiency. What is the nurse's priority action to help ensure successful outcomes and a favorable prognosis? Make sure that the client and family understand the importance of monitoring fluid balance. Encourage the client and family to be active partners in the management of the immunodeficiency. Make sure that the client and family know how to adjust dosages of the medications used in treatment. Encourage the client and family to manage the client's activity level and activities of daily living effectively.

Correct response: Encourage the client and family to be active partners in the management of the immunodeficiency. Explanation: Encouraging the client and family to be active partners in the management of the immunodeficiency is the key to successful outcomes and a favorable prognosis. This transcends the client's activity and functional status. Medications should not be adjusted without consultation from the primary provider. Fluid balance is not normally a central concern. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 36: Management of Patients With Immune Deficiency Disorders, Nursing Management, p. 1023.

A 25-year-old female client with brain metastases is considering her life expectancy after her most recent meeting with her oncologist. Based on the fact that the client is not receiving treatment for her brain metastases, what is the nurse's most appropriate action? Promoting the client's functional status and ADLs Ensuring that the client receives adequate palliative care Ensuring that the family does not tell the client that her condition is terminal Promoting adherence to the prescribed medication regimen

Correct response: Ensuring that the client receives adequate palliative care Explanation: Clients with intracerebral metastases who are not treated have a steady downhill course with a limited survival time, whereas those who are treated may survive for slightly longer periods, but for most cure is not possible. Palliative care is thus necessary. This is a priority over promotion of function and the family should not normally withhold information from the client. Adherence to medications such as analgesics is important, but palliative care is a high priority. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 70: Management of Patients With Oncologic or Degenerative Neurologic Disorders, Medical Management, p. 2097.

During the nurse's assessment of a female client, the client reveals that she experienced sexual abuse when she was a young woman. What is the nurse's most appropriate response to this disclosure? Reassure her that this information will be kept a secret. Begin the process of intensive psychotherapy. Encourage the client to phone 911. Facilitate appropriate resources and referrals.

Correct response: Facilitate appropriate resources and referrals. Explanation: The nurse's primary roles in light of this disclosure are to provide empathy and to arrange for appropriate resources and referrals. There is no need to phone 911 because there is no immediate threat and psychotherapy is beyond the nurse's scope of practice. The client's confidentiality will be respected, but this does not mean that the nurse can promise to keep it a secret. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 56: Assessment and Management of Patients with Female Physiologic Processes, Incest and Childhood Sexual Abuse, p. 1657.

The nurse is planning the care of a client who has been recently diagnosed with a cerebellar tumor. Due to the location of this client's tumor, the nurse should implement measures to prevent what complication? Falls Audio hallucinations Respiratory depression Labile BP

Correct response: Falls Explanation: A cerebellar tumor causes dizziness, an ataxic or staggering gait with a tendency to fall toward the side of the lesion, and marked muscle incoordination. Because of this, the client faces a high risk of falls. Hallucinations and unstable vital signs are not closely associated with cerebellar tumors. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 70: Management of Patients With Oncologic or Degenerative Neurologic Disorders, Localized Symptoms, p. 2094.

Since the emergence of HIV/AIDS, there have been significant changes in epidemiologic trends. At present, members of what group are most affected by new cases of HIV? Recreational drug users Gay, bisexual, and other men who have sex with men Health care providers Blood transfusion recipients

Correct response: Gay, bisexual, and other men who have sex with men Explanation: Gay, bisexual, and other men who have sex with men remain the population most affected by HIV and account for 4% of the male population but 63% of the new infections. This exceeds the incidence among drug users, health care workers, and transfusion recipients. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 36: Management of Patients With Immune Deficiency Disorders, Epidemiology, p. 1025.

A client has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize? Unclassified seizure Absence seizure Generalized seizure Focal seizure

Correct response: Generalized seizure Explanation: Generalized seizures often involve both hemispheres of the brain, causing both sides of the body to react. Intense rigidity of the entire body may occur, followed by alternating muscle relaxation and contraction (generalized tonic-clonic contraction). This pattern of rigidity does not occur in clients who experience unclassified, absence, or focal seizures. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 66: Management of Patients With Neurologic Dysfunction, Generalized Seizures, p. 644.

A clinic nurse is caring for a client admitted with AIDS. The nurse has assessed that the client is experiencing a progressive decline in cognitive, behavioral, and motor functions. The nurse recognizes that these symptoms are most likely related to the onset of what complication? Kaposi's sarcoma B-cell lymphoma Wasting syndrome HIV encephalopathy

Correct response: HIV encephalopathy Explanation: HIV encephalopathy is a clinical syndrome characterized by a progressive decline in cognitive, behavioral, and motor functions. The other listed complications do not normally have cognitive and behavioral manifestations. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 36: Management of Patients With Immune Deficiency Disorders, HIV Encephalopathy, p. 1040.

The nurse educating a client with anemia is describing the process of RBC production. When the client's kidneys sense a low level of oxygen in circulating blood, what physiologic response is initiated? Decreased respiratory rate Increased stem cell synthesis Increased production of erythropoietin Arterial vasoconstriction

Correct response: Increased production of erythropoietin Explanation: If the kidney detects low levels of oxygen, as occurs when fewer red cells are available to bind oxygen (i.e., anemia), erythropoietin levels increase. The body does not compensate with vasoconstriction, decreased respiration, or increased stem cell activity. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 32: Assessment of Hematologic Function and Treatment Modalities, Erythropoiesis, p. 905.

The nurse is performing a preoperative assessment on a client going to surgery. The client informs the nurse that he drinks approximately two bottles of wine each day and has for the last several years. What postoperative difficulties should the nurse anticipate for this client? Nonadherence to prescribed treatment after surgery following surgery Increased risk for postoperative complications Alcohol withdrawal syndrome upon administration of general anesthesia Increased risk for allergic reactions

Correct response: Increased risk for postoperative complications Explanation: Alcohol use increases the risk of complications. Withdrawal does not occur immediately upon administration of anesthesia. Alcohol does not increase the risk of allergies and is not necessarily a risk factor for nonadherence. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 17: Preoperative Nursing Management, Drug or Alcohol Use, p. 424.

A nurse is planning the care of a client with a diagnosis of sickle cell disease who has been admitted for the treatment of an acute vaso-occlusive crisis. What nursing diagnosis should the nurse prioritize in the client's plan of care? Ineffective tissue perfusion related to thrombosis Risk for disuse syndrome related to ineffective peripheral circulation Ineffective thermoregulation related to hypothalamic dysfunction Functional urinary incontinence related to urethral occlusion

Correct response: Ineffective tissue perfusion related to thrombosis Explanation: There are multiple potential complications of sickle cell disease and sickle cell crises. Central among these, however, is the risk of thrombosis and consequent lack of tissue perfusion. Sickle cell crises are not normally accompanied by impaired thermoregulation or genitourinary complications. Risk for disuse syndrome is not associated with the effects of acute vaso-occlusive crisis. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 33: Management of Patients With Nonmalignant Hematologic Disorders, Sickle Cell Crisis, p. 935.

An immunocompromised client is being treated in the hospital. The nurse's assessment reveals that the client's submandibular lymph nodes are swollen, a finding that represents a change from the previous day. What is the nurse's most appropriate action? Administer a PRN dose of acetaminophen as ordered. Inform the client's primary care provider of this finding. Monitor the client's vital signs q2h for the next 24 hours. Implement standard precautions in the client's care.

Correct response: Inform the client's primary care provider of this finding. Explanation: Swollen lymph nodes are suggestive of infection and warrant prompt medical assessment and treatment. Acetaminophen is an ineffective response. The nurse should monitor the client's vital signs closely, but the physician should also be informed. Standard precautions should be in place regardless of the client's status. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 36: Management of Patients With Immune Deficiency Disorders, Nursing Management, p. 1023.

A family member of a client diagnosed with Huntington disease calls you at the clinic. She is requesting help from the Huntington's Disease Society of America. What kind of help can this client and family receive from this organization? Select all that apply. Information about this disease Referrals Public education Individual assessments Appraisals of research studies

Correct response: Information about this disease Referrals Public education Explanation: The Huntington's Disease Society of America helps clients and families by providing information, referrals, family and public education, and support for research. It does not provide individual assessments or appraisals of individual research studies. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 70: Management of Patients With Oncologic or Degenerative Neurologic Disorders, Continuing and Transitional Care, p. 2109.

A client is admitted to the neurologic ICU with a spinal cord injury. In writing the client's care plan, the nurse specifies that contractures can best be prevented by what action? Repositioning the client every 2 hours Initiating range-of-motion exercises (ROM) as soon as the client initiates Initiating (ROM) exercises as soon as possible after the injury Performing ROM exercises once a day

Correct response: Initiating (ROM) exercises as soon as possible after the injury Explanation: Passive ROM exercises should be implemented as soon as possible after injury. It would be inappropriate to wait for the client to first initiate exercises. Toes, metatarsals, ankles, knees, and hips should be put through a full ROM at least four, and ideally five, times daily. Repositioning alone will not prevent contractures. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 68: Management of Patients With Neurologic Trauma, Improving Mobility, p. 2055.

A client has come to the OB/GYN clinic due to recent heavy menstrual flow. Because of the client's consequent increase in red cell production, the nurse should recommend the client increase her daily intake of what substance? Vitamin D Magnesium Vitamin E Iron

Correct response: Iron Explanation: To replace blood loss, the rate of red cell production increases. Iron is incorporated into hemoglobin. Vitamins E and D and magnesium do not need to be increased when RBC production is increased. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 32: Assessment of Hematologic Function and Treatment Modalities, Iron Stores and Metabolism, p. 906.

A client comes to the clinic reporting fatigue and the health interview is suggestive of pica. Laboratory findings reveal a low serum iron level and a low ferritin level. With what would the nurse suspect that the client will be diagnosed? Iron deficiency anemia Hemolytic anemia Sickle cell disease Pernicious anemia

Correct response: Iron deficiency anemia Explanation: A low serum iron level, a low ferritin level, and symptoms of pica are associated with iron deficiency anemia. TIBC may also be elevated. None of the other anemias are associated with pica. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 33: Management of Patients With Nonmalignant Hematologic Disorders, Clinical Manifestations, p. 930.

A nurse is providing education to a client with iron deficiency anemia who has been prescribed iron supplements. What should the nurse include in health education? Take the iron with dairy products to enhance absorption. Limit foods high in fiber due to the risk for diarrhea. Increase the intake of vitamin E to enhance absorption. Iron will cause the stools to darken in color.

Correct response: Iron will cause the stools to darken in color. Explanation: The nurse will inform the client that iron will cause the stools to become dark in color. Iron should be taken on an empty stomach, as its absorption is affected by food, especially dairy products. Clients should be instructed to increase their intake of vitamin C to enhance iron absorption. Foods high in fiber should be consumed to minimize problems with constipation, a common side effect associated with iron therapy. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 33: Management of Patients With Nonmalignant Hematologic Disorders, Chart 33-3, p. 931.

A nurse is assessing a client with an acoustic neuroma who has been recently admitted to an oncology unit. What symptoms is the nurse likely to find during the initial assessment? Loss of hearing, tinnitus, and vertigo Loss of vision, change in mental status, and hyperthermia Loss of hearing, increased sodium retention, and hypertension Loss of vision, headache, and tachycardia

Correct response: Loss of hearing, tinnitus, and vertigo Explanation: An acoustic neuroma is a tumor of the eighth cranial nerve, the cranial nerve most responsible for hearing and balance. The client with an acoustic neuroma usually experiences loss of hearing, tinnitus, and episodes of vertigo and staggering gait. Acoustic neuromas do not cause loss of vision, increased sodium retention, or tachycardia. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 70: Management of Patients With Oncologic or Degenerative Neurologic Disorders, Acoustic Neuromas, p. 2092.

The neurologic ICU nurse is admitting a client with increased intracranial pressure. How should the nurse best position the client? Position the client supine. Maintain head of bed (HOB) elevated at 30 to 45 degrees. Position client in prone position. Maintain bed in Trendelenburg position.

Correct response: Maintain head of bed (HOB) elevated at 30 to 45 degrees. Explanation: The client with increased ICP should be placed with the HOB elevated 30 to 45 degrees, with the neck in neutral alignment. Each of the other listed positions would cause a dangerous elevation in ICP. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 66: Management of Patients With Neurologic Dysfunction, Optimizing Cerebral Tissue Perfusion, p. 1984.

A client is brought to the ED by her family after falling off the roof. The care team suspects an epidural hematoma, prompting the nurse to prepare for which priority intervention? Insertion of an intracranial monitoring device Treatment with antihypertensives Making openings in the skull Administration of anticoagulant therapy

Correct response: Making openings in the skull Explanation: An epidural hematoma is considered an extreme emergency. Marked neurologic deficit or respiratory arrest can occur within minutes. Treatment consists of making an opening through the skull to decrease ICP emergently, remove the clot, and control the bleeding. Antihypertensive medications would not be a priority. Anticoagulant therapy should not be prescribed for a client who has a cranial bleed. This could further increase bleeding activity. Insertion of an intracranial monitoring device may be done during the surgery, but is not priority for this client. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 68: Management of Patients With Neurologic Trauma, Epidural Hematoma, p. 2036.

The nurse is assessing a new client with complaints of acute fatigue and a sore tongue that is visibly smooth and beefy red. This client is demonstrating signs and symptoms associated with what form of hematologic disorder? Thrombocytopenia Megaloblastic anemia Hemophilia Sickle cell disease

Correct response: Megaloblastic anemia Explanation: A red, smooth, sore tongue is a symptom associated with megaloblastic anemia. Sickle cell disease, hemophilia, and thrombocytopenia do not have symptoms involving the tongue. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 33: Management of Patients With Nonmalignant Hematologic Disorders, Assessment, p. 928.

A client with increased ICP has a ventriculostomy for monitoring ICP. The nurse's most recent assessment reveals that the client is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the presence of what complication? Encephalitis CSF leak Meningitis Catheter occlusion

Correct response: Meningitis Explanation: Complications of a ventriculostomy include ventricular infectious meningitis and problems with the monitoring system. Nuchal rigidity and photophobia are clinical manifestations of meningitis, but are not suggestive of encephalitis, a CSF leak, or an occluded catheter. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 66: Management of Patients With Neurologic Dysfunction, Preventing Infection, p. 1988.

An ED nurse has just received a call from EMS that they are transporting a 17-year-old man who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what? Syncope (fainting) Suicide attempts Workplace injuries Motor vehicle accidents

Correct response: Motor vehicle accidents Explanation: The most common causes of SCIs are motor vehicle crashes, falls, violence, and sports. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 68: Management of Patients With Neurologic Trauma, Spinal Cord Injury, p. 2048.

Following a spinal cord injury a client is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action? Complete the pin site care to decrease risk of infection. Notify the neurosurgeon of the occurrence. Stabilize the head in a lateral position. Reattach the pin to prevent further head trauma.

Correct response: Notify the neurosurgeon of the occurrence. Explanation: If one of the pins became detached, the head is stabilized in neutral position by one person while another notifies the neurosurgeon. Reattaching the pin as a nursing intervention would not be done due to risk of increased injury. Pin site care would not be a priority in this instance. Prevention of neurologic injury is the priority. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 68: Management of Patients With Neurologic Trauma, Providing Comfort Measures: The Patient in Traction With Tongs or Halo Vest, p. 2056.

A 45-year-old woman comes into the health clinic for her annual checkup. She mentions to the nurse that she has noticed dimpling of the right breast that has occurred over a few months. What assessment would be most appropriate for the nurse to make? Palpate the client's breasts for tenderness and assess for infection. Palpate the area for a breast mass. Assess the client's knowledge of breast cancer. Assure the client that this is likely an age-related change.

Correct response: Palpate the area for a breast mass. Explanation: It would be most important for the nurse to palpate the breast to determine the presence of a mass and to refer the client to her primary provider. Edema and pitting of the skin may result from a neoplasm blocking lymphatic drainage, giving the skin an orange-peel appearance (peau d'orange), a classic sign of advanced breast cancer. The client's knowledge of breast cancer is relevant, but is not a time-dependent priority. This finding is not an age-related change. Assessment for signs of malignancy is a priority over infection, which is unlikely to cause these changes. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 58: Assessment and Management of Patients With Breast Disorders, Inspection, p. 1721.

The nurse is caring for a client in the ICU who has a brain stem herniation and who is exhibiting an altered level of consciousness. Monitoring reveals that the client's mean arterial pressure (MAP) is 60 mm Hg with an intracranial pressure (ICP) reading of 5 mm Hg. What is the nurse's most appropriate action? Position the client the high Fowler position as tolerated. Administer osmotic diuretics as prescribed. Participate in interventions to increase cerebral perfusion pressure (CPP). Prepare the client for craniotomy.

Correct response: Participate in interventions to increase cerebral perfusion pressure (CPP). Explanation: The CPP is 55 mm Hg, which is considered low. The normal CPP is 70 to 100 mm Hg. Clients with a CPP of less than 50 mm Hg experience irreversible neurologic damage. As a result, interventions are necessary. A craniotomy is not directly indicated. Diuretics and increased height of bed would exacerbate the client's condition. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 66: Management of Patients With Neurologic Dysfunction, Cerebral Response to Increased Intracranial Pressure, p. 1980.

A nurse is caring for a client with severe anemia. The client is tachycardic and reports dizziness and exertional dyspnea. What signs and symptoms might develop if this client goes into heart failure? Migraine Peripheral edema Fever Nausea and vomiting

Correct response: Peripheral edema Explanation: Cardiac status should be carefully assessed in clients with anemia. When the hemoglobin level is low, the heart attempts to compensate by pumping faster and harder in an effort to deliver more blood to hypoxic tissue. This increased cardiac workload can result in such symptoms such as tachycardia, palpitations, dyspnea, dizziness, orthopnea, and exertional dyspnea. Heart failure may eventually develop, as evidenced by an enlarged heart (cardiomegaly) and liver (hepatomegaly), and by peripheral edema. Nausea, migraine, and fever are not associated with heart failure. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 33: Management of Patients With Nonmalignant Hematologic Disorders, Assessment, p. 928.

The client in the ED has just had a diagnostic lumbar puncture. To reduce the incidence of a post-lumbar puncture headache, what is the nurse's most appropriate action? Position the client prone. Position the client supine with the head of bed flat. Position the client left side-lying. Administer acetaminophen as ordered.

Correct response: Position the client prone. Explanation: The lumbar puncture headache may be avoided if a small-gauge needle is used and if the client remains prone after the procedure. Acetaminophen is not given as a preventative measure for post-lumbar puncture headaches. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Chart 65-4, p. 1970.

A male client presents to the clinic reporting a headache. The nurse notes that the client is guarding his neck and tells the nurse that he has stiffness in the neck area. The nurse suspects the client may have meningitis. What is another well-recognized sign of this infection? Negative Brudzinski sign Positive Kernig sign Hyperpatellar reflex Sluggish pupil reaction

Correct response: Positive Kernig sign Explanation: Meningeal irritation results in a number of well-recognized signs commonly seen in meningitis, such as a positive Kernig sign, a positive Brudzinski sign, and photophobia. Hyperpatellar reflex and a sluggish pupil reaction are not commonly recognized signs of meningitis. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies, Clinical Manifestations, p. 2066.

A nurse conducts the Romberg test by asking the client to stand with the feet close together and the eyes closed. As a result of this posture, the client suddenly sways to one side and is about to fall when the nurse intervenes and prevents the client from being injured. In which way should the nurse interpret the client's result? Positive Romberg test, indicating a problem with level of consciousness Negative Romberg test, indicating a problem with body mass Negative Romberg test, indicating a problem with vision Positive Romberg test, indicating a problem with equilibrium

Correct response: Positive Romberg test, indicating a problem with equilibrium Explanation: If the client sways and starts to fall during the Romberg test, it indicates a positive result. This means the client has a problem with equilibrium. The examiner or the nurse stands fairly close to the client during the test to prevent the client from falling. The Romberg test is used to assess the client's motor function, including muscle movement, size, tone, strength, and coordination. However, the Romberg test is not used to assess the client's level of consciousness, body mass, or vision. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, p. 1961.

A nurse conducts the Romberg test on a client by asking the client to stand with the feet close together and the eyes closed. As a result of this posture, the client suddenly sways to one side and is about to fall when the nurse intervenes and saves the client from being injured. How should the nurse interpret the client's result? Positive Romberg test, indicating a problem with level of consciousness Negative Romberg test, indicating a problem with body mass Negative Romberg test, indicating a problem with vision Positive Romberg test, indicating a problem with equilibrium

Correct response: Positive Romberg test, indicating a problem with equilibrium Explanation: If the client sways and starts to fall during the Romberg test, it indicates a positive result. This means the client has a problem with equilibrium. The examiner or the nurse stands fairly close to the client during the test to prevent the client from falling. The Romberg test is used to assess the client's motor function, including muscle movement, size, tone, strength, and coordination. However, the Romberg test is not used to assess the client's level of consciousness, body mass, or vision. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, p. 1961.

A public health nurse is participating in a campaign aimed at preventing cervical cancer. What strategies should the nurse include is this campaign? Select all that apply. Promotion of HPV immunization Encouraging young women to delay first intercourse Smoking cessation Vitamin D and calcium supplementation Using safer sex practices

Correct response: Promotion of HPV immunization Encouraging young women to delay first intercourse Smoking cessation Using safer sex practices Explanation: Preventive measures relevant to cervical cancer include regular pelvic examinations and Pap tests for all women, especially older women past childbearing age. Preventive counseling should encourage delaying first intercourse, avoiding HPV infection, participating in safer sex only, smoking cessation, and receiving HPV immunization. Calcium and vitamin D supplementation are not relevant. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 57: Management of Patients With Female Reproductive Disorders, Cancer of the Cervix, p. 1706.

The nurse is caring for a client who has just been told that her ovarian cancer is terminal and that no curative options remain. What would be the priority nursing care for this client at this time? Provide emotional support to the client and her family. Implement distraction and relaxation techniques. Offer to inform the client's family of this diagnosis. Teach the client about the importance of maintaining a positive attitude.

Correct response: Provide emotional support to the client and her family. Explanation: Emotional support is an integral part of nursing care at this point in the disease progression. It is not normally appropriate for the nurse to inform the family of the client's diagnosis. It may be inappropriate and simplistic to focus on distraction, relaxation, and positive thinking. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 57: Management of Patients With Female Reproductive Disorders, Nursing Management, p. 1677.

A client's diagnosis of atrial fibrillation has prompted the primary care provider to prescribe warfarin, an anticoagulant. When assessing the therapeutic response to this medication, what is the nurse's most appropriate action? Assess the client's capillary refill time. Review the client's platelet level. Assess for signs of myelosuppression. Review the client's international normalized ratio (INR).

Correct response: Review the client's international normalized ratio (INR). Explanation: The INR and aPTT serve as useful screening tools for evaluating a client's clotting ability and to monitor the therapeutic effectiveness of anticoagulant medications. The client's platelet level is not normally used as a short-term indicator of anticoagulation effectiveness. Assessing the client for signs of myelosuppression and capillary refill time does not address the effectiveness of anticoagulants. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 32: Assessment of Hematologic Function and Treatment Modalities, Hematologic Studies, p. 909.

A client suffers a leg wound which causes minor blood loss. As a result of bleeding, the process of primary hemostasis is activated. What will occur during this process? Thromboplastin is released. Fibrin is lysed. Severed blood vessels constrict. Prothrombin is converted to thrombin.

Correct response: Severed blood vessels constrict. Explanation: Primary hemostasis involves the severed vessel constricting and platelets collecting at the injury site. Secondary hemostasis occurs when thromboplastin is released, prothrombin converts to thrombin, and fibrin is lysed. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 32: Assessment of Hematologic Function and Treatment Modalities, Hemostasis, p. 908.

After undergoing skin testing, a client returns to the clinic for evaluation of the reaction. The reaction was documented as negative. Which image best depicts this finding? *PICTURES* A. Small baby rash B. Slightly larger rash C. Even bigger rash D. Biggest rash

Correct response: Small baby rash picture Explanation: A negative reaction is identified by a soft wheal with minimal erythema, as shown in option A. A 1+ reaction is indicated by a wheal approximately 5 to 8 mm with erythema, as shown in option B. A 2+ reaction is indicated by a wheal that is 7 to 10 mm accompanied by erythema, as shown in option C. A 3+ reaction is indicated by a wheal that is 9 to 15 mm with slight pseudopodia and erythema. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 37: Assessment and Management of Patients With Allergic Disorders, Figure 37-4, p. 1064.

A patient has been taught how to perform breast self-examination. After standing in front of a mirror and checking both breasts for anything unusual, which of the following would the patient do next? *PICTURES* A. Laying down with one arm behind head, using opposite arm to feel opposite breast B. Standing up and bending forward C. Standing up with arms behind head D. Standing up with one arm up and opposite arm feeling opposite breast

Correct response: Standing up with arms behind head (C.) Explanation: After checking both breasts for anything unusual while looking in the mirror, the patient then clasps her hands behind the head and presses forward, noting any change in the contour of the breasts, as shown in option C. Next, the patient would press her hands firmly on her hips and bow slightly toward the mirror, noting any changes, as shown in option B. After, the patient would feel the breast firmly with the fingers of the opposite hand, as shown in option D. This palpation is repeated with the patient lying down, as shown in option A. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 58: Assessment and Management of Patients With Breast Disorders, Chart 58-2, p. 1724.

The nurse is performing a preadmission assessment of a client scheduled for a bilateral mastectomy. The nurse should be aware of what purpose of the preadmission assessment? Verifies completion of preoperative diagnostic testing Discusses and reviews client's financial status Determines the client's suitability as a surgical candidate Informs the client of need for postoperative transportation

Correct response: Verifies completion of preoperative diagnostic testing Explanation: Purposes of preadmission testing (PAT) include verifying completion of preoperative diagnostic testing. The nurse's role in PAT does not normally involve financial considerations or addressing transportation. The physician determines the client's suitability for surgery. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 17: Preoperative Nursing Management, Chart 17-1, p. 420.

By initiating an assessment about sexual concerns what information should the nurse convey to the client? Select all that apply. That sexual issues are valid health issues That it is safe to talk about sexual issues That sexual issues are a comparatively minor aspect of a person's identity That changes or problems in sexual functioning should be discussed That changes or problems in sexual functioning are highly atypical

Correct response: That sexual issues are valid health issues That it is safe to talk about sexual issues That changes or problems in sexual functioning should be discussed Explanation: By initiating an assessment about sexual concerns, the nurse communicates to the client that issues about changes or problems in sexual functioning are valid and significant health issues. The nurse communicates that it is safe to talk about sexual issues and that changes or challenges in sexual function are not unusual. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 56: Assessment and Management of Patients with Female Physiologic Processes, Sexual History, p. 1657.

In anticipation of a client's scheduled surgery, the nurse is teaching her to perform deep breathing and coughing to use postoperatively. What action should the nurse teach the client? The client should take three deep breaths and cough hard three times, at least every 15 minutes for the immediately postoperative period. The client should take three deep breaths and exhale forcefully and then take a quick short breath and cough from deep in the lungs. The client should take a deep breath in through the mouth and exhale through the mouth, take a short breath, and cough from deep in the lungs. The client should rapidly inhale, hold for 30 seconds or as long as possible, and exhale slowly.

Correct response: The client should take a deep breath in through the mouth and exhale through the mouth, take a short breath, and cough from deep in the lungs. Explanation: The client assumes a sitting position to enhance lung expansion. The nurse then demonstrates how to take a deep, slow breath and how to exhale slowly. After practicing deep breathing several times, the client is instructed to breathe deeply, exhale through the mouth, take a short breath, and cough from deep in the lungs. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 17: Preoperative Nursing Management, Deep Breathing, Coughing, and Incentive Spirometry, p. 429.

A nurse is collaborating with the interdisciplinary team to help manage a client's recurrent headaches. What aspect of the client's health history should the nurse identify as a potential contributor to the client's headaches? The client leads a sedentary lifestyle. The client takes vitamin D and calcium supplements. The client takes vasodilators for the treatment of angina. The client has a pattern of weight loss followed by weight gain.

Correct response: The client takes vasodilators for the treatment of angina. Explanation: Vasodilators are known to contribute to headaches. Weight fluctuations, sedentary lifestyle, and vitamin supplements are not known to have this effect. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 66: Management of Patients With Neurologic Dysfunction, Prevention, p. 2006.

A 13 year old was brought to the ED after being hit in the head by a baseball and is subsequently diagnosed with a concussion. What assessment finding would rule out discharging the client? The client reports a headache. The client reports pain at the site where the ball hits his head. The client is visibly fatigued. The client's speech is slightly slurred.

Correct response: The client's speech is slightly slurred. Explanation: Slurred speech would indicate a need for further assessment and observation due to the possibility of more serious trauma. Localized pain, a headache and fatigue are consistent with a concussion and do not necessarily require further intervention. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 68: Management of Patients With Neurologic Trauma, Concussion, p. 2037.

A client who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the client's current health status is most likely to have precipitated this event? The client received a blood transfusion. The client's analgesia regimen was recently changed. The client was not repositioned during the night shift. The client's urinary catheter became occluded.

Correct response: The client's urinary catheter became occluded. Explanation: A distended bladder is the most common cause of autonomic dysreflexia. Infrequent positioning is a less likely cause, although pressure ulcers or tactile stimulation can cause it. Changes in medications or blood transfusions are unlikely causes. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 68: Management of Patients With Neurologic Trauma, 207, p. 2057.

A client has been prescribed sildenafil. What should the nurse teach the client about this medication? Sexual stimulation is not needed to obtain an erection. The drug should be taken 1 hour prior to intercourse. Facial flushing or headache should be reported to the health care provider. The drug has the potential to cause permanent visual changes.

Correct response: The drug should be taken 1 hour prior to intercourse. Explanation: The client must have sexual stimulation to create the erection, and the drug should be taken 1 hour before intercourse. Facial flushing, mild headache, indigestion, and running nose are common side effects of Viagra and do not normally warrant reporting. Some visual disturbances may occur, but these are transient. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 59: Assessment and Management of Patients with Male Reproductive Disorders, Table 59-2, p. 1758.

The nurse is applying standard precautions in the care of a client who has an immunodeficiency. What are key elements of standard precautions? Select all that apply. Using safe injection practices Performing hand hygiene Placing clients in negative pressure isolation rooms Placing clients in positive pressure isolation rooms Using appropriate personal protective equipment

Correct response: Using appropriate personal protective equipment Using safe injection practices Performing hand hygiene Explanation: Some of the key elements of standard precautions include performing hand hygiene; using appropriate personal protective equipment, depending on the expected type of exposure; and using safe injection practices. Isolation is an infection control strategy but is not a component of standard precautions. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 36: Management of Patients With Immune Deficiency Disorders, Standard Precautions, p. 1029.