PCN 102 Final

36. Decreasing visual acuity is a sign of .

ANS: normal aging As an individual ages, the crystalline lens of the eye hardens and becomes too large for the eye muscles, thus causing a loss of accommodation, which often results in a need for bifocals or trifocals. REF: Pages 1842-1843, Life Span Considerations box TOP: Normal aging

3. The patient is a newly diagnosed diabetic. Until he has his diabetes under control, which test will furnish valuable immediate feedback information? a. BS b. HgbA1c c. OGTT d. Clinitest

ANS: A Diabetics should do a fingerstick blood glucose level test before each meal and at bedtime each day until their disease is under control. HgbA1c serum test reveals the effectiveness of diabetes therapy for preceding 8-12 weeks. REF: Page 1747, Box 51-2 TOP: Diabetes mellitus

38. is a medical term for blurred vision.

ANS: Astigmatism Astigmatism is a defect in the curvature of the eyeball surface, resulting in blurred vision. REF: Page 1847, Table 53-3 TOP: Visual acuity

29. The purpose of immunotherapy is .

ANS: desensitization The theory behind immunotherapy is to assist the individual to build a tolerance to the allergen without developing fever or increased signs and symptoms. Desensitization is another term used for immunotherapy. REF: Page 1960 TOP: Immunotherapy

18. A patient, age 76, is partially blind. His physician has diagnosed open-angle glaucoma. The goal of treatment in glaucoma is to a. decrease aqueous humor. b. increase aqueous humor. c. decrease discomfort. d. restore vision.

ANS: A A beta-blocker, such as Betoptic, will reduce intraocular pressure. Miotics such as pilocarpine constrict the pupil and draw the iris away from the cornea, allowing aqueous humor to drain out of the canal of Schlemm. REF: Page 1861, Table 53-5 TOP: Glaucoma Step: Planning

8. The priority nursing responsibility while caring for a patient with vertigo is a. safety. b. comfort. c. hygiene. d. quiet.

ANS: A A nursing diagnosis of Risk for injury related to disturbed sensory perception is the most important diagnosis for a patient with vertigo. REF: Pages 1875-1876, Patient Teaching boxes, NCP 53-2 TOP: Vertigo

9. A patient, age 42, develops a severe angioedema involving her face, hands, and feet, with burning and stinging of the lesions. During the assessment, which significant risk factor for allergies does the nurse recognize? a. Family history of allergies b. History of a recent fungal infection c. Use of OTC medications d. Recurrent respiratory infections

ANS: A A thorough history is the most important diagnostic tool. There is a genetic link to both well-developed immune systems and poorly developed or compromised immune systems. REF: Page 1961, Health Promotion box TOP: Allergic reaction

20. The correct nursing intervention for anaphylaxis would be a. assess respiratory status, including dyspnea. b. hypertension and elevated albumin levels. c. assess skin status, including erythema, urticaria, cyanosis, and pallor. d. assess GI status, including nausea, vomiting, diarrhea, incontinence.

ANS: A Anaphylaxis—If moderate to severe signs and symptoms occur, IV therapy may be initiated to prevent vascular collapse and the patient may be intubated to prevent airway obstruction. Nursing interventions and patient teaching—Assess respiratory status, including dyspnea, wheezing, and decreased breath sounds. REF: Page 1963 TOP: Anaphylaxis Step: Assessment

15. Astigmatism is a medical term meaning which visual disorder? a. Blurred vision b. Inability to detect colors c. Color blindness d. Farsightedness

ANS: A Astigmatism—blurred vision. REF: Page 1847, Table 53-2, Table 53-3 TOP: Visual acuity

29. Otitis media is more frequently seen in children 6 to 36 months because a. eustachian tubes in children are shorter and straighter. b. infection descends via the eustachian tube to the throat. c. children's eustachian tubes are more vertical and longer. d. otitis media is seen equally in both children and adults.

ANS: A Children's shorter and straighter eustachian tubes provide easier access of the organisms from the nasopharynx to travel to the middle ear. REF: Page 1872 TOP: Otitis media Step: Evaluation

14. Rapid onset of decreased vision, halos around lights, and severe eye pain are indications of a. closed-angle glaucoma. b. open-angle glaucoma. c. retinal detachment. d. diabetic retinopathy.

ANS: A Closed-angle glaucoma causes rapid vision loss and dramatic symptoms. Closed-angle (acute) glaucoma produces severe pain, decreased vision, and nausea and vomiting. The patient sees colored halos around lights. REF: Page 1860 TOP: Glaucoma

28. The most common cause of congenital hearing loss from birth or early infancy is: a. Anoxia or trauma b. Tumor c. Infection d. Occasional loud noise

ANS: A Congenital hearing loss is present from birth or early infancy. Anoxia or trauma during delivery may be causes. DIF: Cognitive Level: AnalysisREF: Page 1869, Health Promotion box OBJ: 19 TOP: Hearing loss Step: Evaluation

15. The delayed major process that leads to organ transplant rejection is a. hypersensitivity. b. cellular immunity. c. autoimmune factors. d. immunodeficiency.

ANS: A Delayed hypersensitivity reactions occurring 24 to 72 hours after exposure are mediated by T cells accompanied by release of lymphokines. Tissue transplant rejection is another example. REF: Page 1965 TOP: Transplant Step: Planning

8. In diabetes insipidus, clinical manifestations are caused by a deficiency of a. antidiuretic hormone (ADH). b. follicle-stimulating hormone (FSH). c. thyroid-stimulating hormone (TSH). d. adrenocorticotropic hormone (ACTH).

ANS: A Diabetes insipidus is a transient or permanent metabolic disorder of the posterior pituitary in which ADH is deficient. REF: Page 1728 TOP: Diabetes insipidus

23. Common early signs and symptoms of diabetic ketoacidosis include a. thirst and drowsiness. b. cold, clammy skin and anxiety. c. slow pulse and increased blood pressure. d. bulging of the eyeballs and carpopedal spasms.

ANS: A Diabetic ketoacidosis symptoms include dry mucous membranes and drowsiness leading to coma. REF: Page 1747, Table 51-5, Table 51-8 TOP: Diabetes mellitus complications

7. A hearing-impaired patient is having problems communicating with staff members. Which behaviors would continue to hinder communication? a. Overaccentuating words b. Facing the patient when speaking c. Speaking in conversational tones d. Speaking into the affected ear

ANS: A Do not overaccentuate words. Speak in a normal tone; do not shout or raise the pitch of voice. REF: Page 1869, Health Promotion box

25. The LPN/LVN has arrived at the patient's bedside with a unit of packed cells to be connected to an IV that is infusing. When the RN arrives, what is the first thing the nurses must do? a. Do the checks to ensure that the donor and recipient numbers match according to policy. b. Leave the packed cells at the bedside until the saline is infused. c. Immediately hang the packed cells to get the infusion started. d. Check the patients ID bracelet and then hang the packed cells.

ANS: A Donor and recipient numbers are specific and must be thoroughly checked and the patient identified with an armband. REF: Page 1965 TOP: Blood transfusion

5. Sjögren's syndrome is associated with which eye disorder? a. Keratoconjunctivitis sicca b. Conjunctivitis c. Blepharitis d. Opaque lens disorder

ANS: A If the patient with keratoconjunctivitis sicca has associated dry mouth, the patient has Sjögren's syndrome (an immunologic disorder characterized by deficient fluid production by the lacrimal, salivary, and other glands, resulting in abnormal dryness of the mouth, eyes, and other mucous membranes). Complaints of dry eye are caused by a variety of ocular disorders characterized by decreased tear secretion or increased tear film evaporation. REF: Pages 1851-1852 TOP: Dry eye disorders

28. A patient has experienced an anaphylaxis reaction and is being monitored to ensure she is stable. A nursing diagnosis for her will be a. Decreased cardiac output. b. Impaired skin integrity. c. Imbalanced nutrition: less than required. d. Feeding self-care deficit.

ANS: A In a patient suffering an anaphylaxis reaction, a nursing diagnosis is Decreased cardiac output. REF: Pages 1963-1964, Nursing Diagnoses box TOP: Anaphylactic reaction

29. To prevent lipodystrophy, the nurse should administer insulin a. at room temperature. b. at body temperature. c. straight from the refrigerator. d. at any convenient temperature.

ANS: A In fact, it is now believed that insulin should be administered at room temperature, not straight from the refrigerator, to help prevent insulin lipodystrophy. REF: Page 1753 TOP: Diabetes mellitus

15. A patient is depressed about the changes in her personal appearance related to Cushing's disease. She is particularly likely to exhibit which change? a. Weight gain, moonface, and increased facial hair b. Hand tremors and nervousness c. Retracted eyelids and increased skin pigmentation d. Muscle atrophy, bruising, and weight loss

ANS: A In patients with Cushing's disease, there is usually weight gain and hirsutism (excessive body hair in a masculine distribution). This overabundance of hormones produces many signs and symptoms, including moonface. REF: Pages 1740, 1743 TOP: Cushing's disease

18. Chvostek's sign and Trousseau's sign are tests to determine: a. low levels of blood calcium. b. high levels of blood calcium. c. low levels of blood sodium. d. high levels of blood sodium.

ANS: A Low levels of blood calcium may be determined by the use of Chvostek's sign and Trousseau's sign. REF: Page 1734 TOP: Thyroidectomy

22. The patient, age 42, has chronic otitis media. Otoscopic examination reveals a central perforation of the eardrum with purulent drainage into the ear canal. A CT scan confirms the presence of a cholesteatoma in the middle ear, and he is scheduled for a tympanoplasty. Which postoperative activity does the nurse teach him about preoperatively? a. Elevation of head of bed with operative side facing upward b. Enforce bed rest for 72 hours c. Frequent turning, coughing, and deep breathing d. Continuous irrigation of the ear canal with antibiotic solutions

ANS: A Postoperative management for patients who have had a tympanoplasty consists of bed rest until the next morning. The head of the bed is elevated 40 degrees, and the operative side faces upward. REF: Page 1880, Nursing Diagnoses box TOP: Otitis media

1. The amount of hormone released by any gland is controlled by a. a negative feedback system. b. a positive feedback system. c. exogenous stimuli. d. the nervous system.

ANS: A The amount of hormone released is controlled by a negative feedback system. REF: Page 1721 TOP: Anatomy

4. A 63-year-old patient on the medical floor has a diagnosis of adrenal hyperfunction (Cushing's syndrome). She will probably have to adhere to a diet that contains a. less sodium. b. more calories. c. less potassium. d. more carbohydrates.

ANS: A The diet should be lower in sodium to help decrease edema. REF: Page 1741 TOP: Cushing's syndrome Step: Planning

17. During a patient history, the nurse notices that the patient has had five upper respiratory infections in the past 18 months. The nurse begins to suspect that the patient may have an immunodeficiency disease because the first evidence of this disease is a. an increased susceptibility to infection. b. an increased coagulation problem. c. a problem with hemostasis. d. localized edema, raised wheals.

ANS: A The first evidence of immunodeficiency disease (an abnormal condition of the immune system in which cellular or humoral immunity is inadequate and resistance to infection is decreased) is an increased susceptibility to infection. REF: Page 1966 TOP: Immunodeficiency

24. A patient, age 28, has sought medical attention because her hands and feet have become enlarged. She also has noticed amenorrhea and increased hair growth. These symptoms most likely indicate problems with the a. pituitary gland. b. adrenal glands. c. thyroid gland. d. pancreas.

ANS: A The pituitary gland may produce an overabundance of growth hormone. This overproduction of hormones may cause changes throughout the patient's body, including enlargement of the pituitary gland and hands and feet. Female patients may develop a deepened voice, increased facial hair growth, and amenorrhea. REF: Page 1725 TOP: Acromegaly

4. A 72-year-old female patient is admitted with a diagnosis of immunodeficiency disease. The primary nursing goal would be to a. reduce the risk of her developing an infection. b. encourage her to provide self-care. c. plan nutritious meals to provide adequate intake. d. encourage her to interact with other patients.

ANS: A Unusually severe infections with complications or incomplete clearing of an infection may also indicate an underlying immunodeficiency. REF: Pages 1966-1967 TOP: Immunodeficiency diseases Step: Planning

34. What factors must the nurse consider when assessing readiness to learn when teaching health promotion practices for the visually and hearing impaired? (Select all that apply.) a. Cultural beliefs b. Values c. Habits d. Income e. Occupation

ANS: A, B, C The nurse also assesses readiness to learn and teaches health promotion practices (see Patient Teaching boxes). The nurse must consider the patient's culture, beliefs, values, and habits (Cultural Considerations 13-2), as well as the special needs of the older adult (Older Adult Considerations 13-1). REF: Page 1882 TOP: Health promotion

33. Which may contribute to otitis media? (Select all that apply.) a. Exposure to cigarette smoke b. Allergies c. Upper respiratory infections d. Lower respiratory infections e. Trauma f. Prolonged exposure to loud noise

ANS: A, B, C Otitis media is usually caused by gram-negative bacteria, such as Proteus, Klebsiella, and Pseudomonas. In addition, allergy, exposure to cigarette smoke, mycoplasma, and several viruses may be factors. REF: Page 1872 TOP: Otitis media

35. What are the major senses? (Select all that apply.) a. Taste b. Touch c. Smell d. Sight e. Hearing/Balance

ANS: A, B, C, D, E The five major senses are taste, touch, smell, sight, and hearing/balance. REF: Page 1838 TOP: Health promotion

32. Select all the conditions that may cause conductive hearing loss. a. Buildup of cerumen b. Foreign bodies c. Otosclerosis of external auditory canal d. Trauma e. Exposure to ototoxic drugs f. Otitis media with effusion

ANS: A, B, C, F Common causes of conductive hearing loss are buildup of cerumen and otitis media with effusion (escape of effusion). Other conditions that may result in conductive hearing loss are foreign bodies, otosclerosis, and stenosis of the external auditory canal. Sensorineural hearing loss is usually due to trauma, infectious processes, or exposure to ototoxic drugs. REF: Page 1869 TOP: Hearing loss

32. Which are autoimmune diseases? (Select all that apply.) a. Lupus erythematosus b. Glomerulonephritis c. Polio d. Rheumatoid arthritis e. Thrombocytopenic purpura f. Osteoarthritis

ANS: A, B, D, E Autoimmune diseases such as systemic lupus erythematosus, glomerulonephritis, myasthenia gravis, thrombocytopenic purpura, rheumatoid arthritis, and Guillain-Barré syndrome are treated with plasmapheresis. REF: Pages 1966-1967 TOP: Autoimmune disorders

31. The first line of defense is innate (natural) immunity. Which is part of that protective mechanism against the external environment? (Select all that apply.) a. Skin and mucous membranes b. Lungs c. Heart d. Tears and saliva e. Natural intestinal and vaginal flora f. Stomach acid

ANS: A, D, E, F The innate system is composed of the skin and mucous membranes, cilia, stomach acid, tears, saliva, sebaceous glands, and secretions and flora of the intestine and vagina. These organs, tissues, and secretions provide biochemical and physical barriers to disease. REF: Page 1956 TOP: Natural immunity

27. A 27-year-old patient with hypothyroidism is referred to the dietitian for dietary consultation. Nutritional interventions should include a. frequent small meals high in carbohydrates. b. calorie-restricted meals. c. caffeine-rich beverages. d. fluid restrictions.

ANS: B A high-protein, high-fiber, lower calorie diet is given. REF: Page 1736 TOP: Hypothyroid Step: Planning

27. A patient, age 23, has been diagnosed with external otitis on return from vacation at the beach. The physician places an ear wick in the external ear canal and prescribes antibiotic otic drops. Before the patient leaves the clinic, the nurse reviews the management of the disorder with her. Which statement by her indicates the need for further instruction? a. "I may use aspirin for the pain." b. "I should remove the wick tomorrow." c. "I should apply the ear drops to the cotton wick placed in my ear canal." d. "I may use warm compresses to the outside of my ear for comfort."

ANS: B A wick is inserted into the ear canal to prevent loss of medication from the canal and to maintain continuous absorption of the medication. REF: Page 1871 TOP: External otitis Step: Evaluation

24. Once blood is removed from refrigeration, what is the length of time allotted for the blood to be transfused? a. 2 hours b. 4 hours c. 6 hours d. 3 hours

ANS: B Blood must be administered within 4 hours of refrigeration, and blood components within 6 hours of refrigeration. REF: Page 1965 TOP: Blood products Step: Planning

12. A patient has a family history of cataracts. He asks what symptom would be present if he begins to develop them. The nurse might respond that the first symptom of a cataract is usually a. pain in the eyes. b. blurring of vision. c. loss of peripheral vision. d. dry eyes.

ANS: B Blurring of vision is often the first subjective symptom reported by a patient who has cataracts. REF: Page 1853 TOP: Cataracts

13. The nurse has held a unit conference on the specific immune response. Which statement by a colleague indicates an understanding of cell-mediated immune response? "Cell-mediated responses are a. directed from humorally mediated B cells." b. the direct attack of activated T-cell lymphocytes." c. from cells matured in the bone marrow." d. characterized by antigen-specific immunoglobulins."

ANS: B Cell-mediated immunity (the mechanism of acquired immunity characterized by the dominant role of small T cells) results when T cells are activated by an antigen. REF: Page 1958 TOP: Immune response

22. When assessing the patient for hypersensitivity, the nurse should a. review the immunization history. b. discuss seasonal occurrence of signs and symptoms. c. evaluate nutritional status. d. observe the range of joint mobility.

ANS: B Common offenders include pollens, spores, dusts, food, drugs, and insect venoms. Many, but not all, offenders are seasonal in nature. REF: Page 1960, Box 55-4 TOP: Hypersensitivity

18. A cancer patient who has been receiving cytotoxic drugs has been having frequent sinus infections. During planning of his care, the nurse must remember that this frequency of infections is an indication of possible a. immunotherapy. b. drug-induced immunosuppression. c. delayed hypersensitivity. d. autoimmune disorder.

ANS: B Drug-induced immunosuppression is the most common type of secondary immunodeficiency disorder. Immunosuppression is a serious side effect of cytotoxic drugs used in cancer chemotherapy. REF: Page 1966 TOP: Immunosuppression Step: Planning

2. A patient comes to the emergency department with dyspnea, wheezing, and urticaria over the arms and face after being stung by a bee. The nurse would begin immediate care for this patient because he or she is having a(n) a. asthma attack. b. anaphylactic reaction. c. pulmonary embolism. d. acute psychotic episode.

ANS: B Fatal reactions are associated with a fall in blood pressure, laryngeal edema, and bronchospasm, leading to cardiovascular collapse, myocardial infarction, and respiratory failure. Early recognition of signs and symptoms and early treatment may prevent severe reactions and even death. REF: Page 1963 TOP: Anaphylactic reaction

16. Most patients with Ménière's disease are treated with a. surgery. b. diuretics. c. hearing aids. d. analgesics.

ANS: B Fluid restriction, diuretics, and a low-salt diet are prescribed in an attempt to decrease fluid pressure. REF: Page 1877 TOP: Ménière's disease

7. A liver transplant patient is receiving azathioprine (Imuran). What nursing goal is critical for this patient? a. Maintain bed rest with minimal exertion. b. Minimize his risk for infection. c. Allow several visitors. d. Monitor vital signs every 15 minutes.

ANS: B Graft rejection is slowed through the use of chemical agents that interfere with the immune response process. Included are corticosteroids, cyclosporine (Neoral, Sandimmune), and azathioprine (Imuran). This chemical therapy is referred to as immunosuppressive (the administration of agents that significantly interfere with the ability of the immune system to respond to antigenic stimulation by inhibition of cellular and humoral immunity) therapy. REF: Page 1966 TOP: Transplant Step: Planning

6. A long-term complication of diabetes mellitus is a. Cushing's disease. b. renal failure. c. hypothyroidism. d. hyperglycemia.

ANS: B Long-term complications of diabetes include blindness, cardiovascular problems, and renal failure. REF: Page 1762 TOP: Diabetes mellitus

4. The patient, age 42, notices that she is having difficulty reading typed print. The nurse would explain that the decreased ability to accommodate for near vision is called a. senility. b. presbyopia. c. myopia. d. refraction.

ANS: B Measurement of visual acuity can determine refractory errors such as presbyopia, the inability to focus on close objects. DIF: Cognitive Level: ApplicationREF: Page 1843, Table 53-2 OBJ: 6 TOP: Vision

27. Which sign and symptom is a sign of a mild reaction as a result of a blood transfusion? a. Vomiting b. Urticaria c. Diaphoresis d. Sore throat

ANS: B Mild transfusion reaction signs and symptoms include dermatitis, diarrhea, fever, chills, urticaria, cough, and orthopnea. REF: Page 1965 TOP: Blood transfusion

9. A patient is prescribed eyedrops that constrict the pupil, permitting aqueous humor to flow. The nurse would reinforce the teaching by referring to the drops as a. mydriatics. b. miotics. c. osmotics. d. inhibitors.

ANS: B Miotics are agents that cause the pupil to contract or constrict. REF: Page 1861 TOP: Medication

19. A patient with rheumatoid arthritis is scheduled for plasmapheresis. She asks the nurse why they are going to do this procedure. In forming an answer the nurse must remember that the purpose of plasmapheresis is to a. add medication to relieve pain symptoms. b. remove plasma-containing components that may be causing the disease. c. remove waste products such as urea. d. add saline or albumin that lubricates joints.

ANS: B Plasmapheresis is the removal of plasma-containing components causing or thought to cause disease. REF: Page 1967 TOP: Plasmapheresis Step: Planning

13. A patient is admitted with a subtotal thyroidectomy. She is returned to the surgical unit after a short stay in the postanesthesia care unit. She is receiving fluids intravenously. When this patient has completely recovered from anesthesia, and her vital signs are stable, which position would be most appropriate for her? a. Prone b. Semi-Fowler's c. Trendelenburg d. Supine

ANS: B Postoperative management of this patient includes keeping the bed in semi-Fowler's position, with pillows supporting the head and shoulders. There should be a suction apparatus and tracheotomy tray available for emergency use. REF: Page 1733 TOP: Thyroidectomy

30. The best prevention of serious complications of ear disorders like infections, mastoiditis and brain abscesses is: a. Strong antibiotics and isolation b. Early detection and treatment c. Surgery and rehabilitation d. Bed rest and early speech reading techniques

ANS: B Prevention of serious complications of ear disorders—such as infections, mastoiditis, and brain abscess—requires early detection and treatment. REF: Page 1883, Key Points TOP: Health promotion

25. A patient, age 61, has had type II diabetes for 20 years. He has symmetrical peripheral polyneuropathy of his feet and legs with almost total loss of sensitivity to touch and temperature. He also has peripheral vascular disease evidenced by decreased peripheral pulses and dependent rubor. To prevent injury and infection to this patient's feet and legs, which instruction does the nurse include in teaching? a. He should soak his feet in warm water every day. b. He should not go barefoot and should always wear shoes with soles. c. The use of commercial keratolytic agents to remove corns and calluses is preferred to cutting off corns and calluses. d. He should use a heating pad to warm his feet when they feel cool to the touch.

ANS: B Sturdy, properly fitting shoes should be worn. REF: Page 1758 TOP: Diabetes mellitus complications

11. A patient, age 28, is treated at the clinic with an injection of long-acting penicillin for a streptococcal throat infection. Her history reveals that she has received penicillin before with no allergic responses. When the penicillin injection is administered, which information should be given to the patient by the nurse? a. Because she has taken penicillin before without problems, she can safely take it now. b. She must wait in the clinic area for 20 minutes before she is discharged. c. She would have immediate symptoms if she had developed an allergy to penicillin. d. She should monitor for fever and skin rash typical of serum sickness after taking penicillin.

ANS: B The patient must always be observed for at least 20 minutes after administration, because hypersensitivity reaction or anaphylaxis may occur. REF: Page 1960 TOP: Medication

17. A patient has asked why she needs to exercise. The nurse tells her that if the diabetic patient exercises, then the insulin requirement a. increases. b. decreases. c. remains unchanged. d. is changed to regular insulin.

ANS: B The patient with diabetes should exercise regularly. Exercise can reduce insulin resistance and increase glucose uptake for as long as 72 hours as well as reducing blood pressure and lipid levels. However, exercise can carry some risks for patients with diabetes, including hypoglycemia. REF: Page 1750 TOP: Diabetes mellitus

25. The nurse answers the call light of a newly admitted patient. The patient tells the nurse she is blind and asks the nurse to assist her to the bathroom. Which action by the nurse is most appropriate? a. Take the patient by the arm and lead her slowly to the bathroom. b. Walk slightly ahead of the patient and allow the patient to hold the nurse's elbow. c. Give the patient exact descriptive directions to the bathroom so that she can walk there independently. d. Lead the patient to the bathroom by the hand, describing the location and providing verbal clues.

ANS: B The walking companion should precede the patient by about 1 foot, and the patient's hand should be on the companion's elbow to provide security. REF: Page 1846, Figure 53-5 TOP: Blindness Step: Planning

14. What would be most necessary to place postoperatively at the bedside of the patient with a subtotal thyroidectomy? a. Suction tray b. Tracheotomy tray c. Incentive spirometer d. Water sealed drainage system

ANS: B There should be a suction apparatus and tracheotomy tray available for emergency use. REF: Page 1740 TOP: Thyroidectomy Step: Planning

30. If a nurse is sensitive to latex gloves, what potential food sensitivities might the nurse develop? (Select all that apply.) a. Peanuts b. Avocados c. Milk d. Bananas e. Tomatoes f. Potatoes

ANS: B, D, E, F A person sensitive to latex may also be sensitive to certain foods, including avocados, kiwi, guava, bananas, water chestnuts, hazelnuts, tomatoes, potatoes, peaches, grapes, and apricots. REF: Page 1964 TOP: Latex allergy

1. A patient visits the physician for a routine physical examination that involves testing distance vision. As she faces the Snellen chart, the nurse is to instruct the patient to a. use both eyes to read the chart. b. read the chart from right to left. c. cover one eye while testing the other. d. use any one eye since they will be the same.

ANS: C A major diagnostic eye test is the Snellen test. While instructing a patient to perform this test, the nurse will have the patient stand or sit 20 feet from the chart and cover one eye to read the letters on the chart. REF: Page 1844, Table 53-2 TOP: Physical examination

23. A 25-year-old male patient with severe rhinitis asks the nurse what is causing his nose to run. The symptoms are caused by a reaction to a substance, usually a protein, that causes the formation of an antibody and reacts specifically with an antibody called a(n) a. proliferation. b. complement. c. antigen. d. lymphokine.

ANS: C An antigen is referred to as an allergen (a substance that can produce hypersensitive reaction in the body but is not necessarily inherently harmful) when symptoms of allergy occur. REF: Page 1958 TOP: Allergic reaction

10. A patient, age 47, is undergoing skin testing with intracutaneous injections on the forearm to identify allergens to which she is sensitive. Immediately after the nurse administers one of the injections, the patient complains of itching at the site, weakness, and dizziness. Which action by the nurse is most appropriate initially? a. Elevate the arm above the shoulder. b. Administer subcutaneous epinephrine. c. Give 0.2 to 0.5 mL of epinephrine 1:1,000 subcutaneously. d. Apply a local anti-inflammatory cream to the site.

ANS: C At the first sign of reaction, 0.2 to 0.5 mL of epinephrine 1:1,000 is given subcutaneously. REF: Page 1963 TOP: Anaphylactic reaction

3. A patient is cleaning the garage and splashes a chemical in his eyes. The initial priority after the chemical burn is to a. transport to a physician immediately. b. cover the eyes with a sterile gauze. c. irrigate with H2O for 15 minutes or longer. d. irrigate with normal saline solution for 1 to 5 minutes.

ANS: C Burns are medically treated with a prolonged, 15- to 20-minute or longer tap-water flush immediately after burn exposure. REF: Page 1864 TOP: Trauma Step: Planning

20. A 69-year-old patient with diabetes mellitus is admitted with cellulitis of the right foot. In applying moist packs to his ulcerated foot, the nurse should use aseptic techniques to a. destroy bacteria on the skin. b. inhibit the growth of pathogens. c. prevent the introduction of additional microorganisms. d. minimize the risk of spreading infection to others.

ANS: C Compromised skin integrity makes a diabetic more susceptible to infection. REF: Page 1758 TOP: Diabetes mellitus

19. A male patient brings home a note from the occupational nurse that states, "You have acute bacterial conjunctivitis." This condition is more commonly called a. infection. b. tearing. c. pink eye. d. color blindness.

ANS: C Conjunctivitis is an inflammation of the conjunctiva caused by bacterial or viral infection, allergy, or environmental factors. It is commonly called pink eye. REF: Page 1850 TOP: Conjunctivitis

19. A patient has undergone tests that indicate a deficiency of the parathormone secretion. She should be informed of which potential complication? a. Osteoporosis b. Lethargy c. Laryngeal spasms d. Kidney stones

ANS: C Decreased parathyroid hormone levels in the bloodstream causes a decreased calcium level. Severe hypocalcemia may result in laryngeal spasm, stridor, cyanosis, and increased possibility of asphyxia. REF: Page 1722 TOP: Hypoparathormonism

2. Which diagnostic test for diabetes mellitus provides a measure of glucose levels for the previous 8 to 12 weeks? a. Fasting blood sugar (FBS) b. Oral glucose tolerance test c. Glycosylated hemoglobin (HbA1c) d. Postprandial glucose test

ANS: C Glycosylated hemoglobin (HbA1c)—This blood test measures the amount of glucose that has become incorporated into the hemoglobin within an erythrocyte. Because glycosylation occurs constantly during the 120-day life span of the erythrocyte, this test reveals the effectiveness of diabetes therapy for the preceding 8 to 12 weeks. REF: Page 1748, Box 51-2 TOP: Glucose monitoring

16. The human insulin whose onset of action occurs within minutes is Humalog (Lispro). a. 30 b. 60 c. 15 d. 45

ANS: C Humalog begins to take effect in less than half the time of regular, fast-acting insulin. The new formula can be injected 15 minutes before a meal. REF: Page 1751, Table 51-5 TOP: Insulin Step: Planning

21. The physician orders an 1,800-calorie diabetic diet and 40 units of (Humulin N) insulin U-100 subcutaneously daily for a patient with diabetes mellitus. A mid- afternoon snack of milk and crackers is given to a. improve nutrition. b. improve carbohydrate metabolism. c. prevent an insulin reaction. d. prevent diabetic coma.

ANS: C Humulin N insulin starts to peak in 4 hours. The nurse should be alert for signs of hypoglycemia (a less-than-normal amount of glucose in the blood, usually caused by administration of too much insulin, excessive secretion of insulin by the islet cells of the pancreas, or dietary deficiency) at the peak of action of whatever type of insulin the patient is taking. REF: Page 1750, Box 51-3, Table 51-5 TOP: Diabetes mellitus

17. A 32-year-old construction worker has suffered a penetrating wound to his right eye. The best intervention for anyone to perform at the scene while waiting to be transported to the hospital is to a. gently remove the object. b. wipe away the blood and tears. c. cover both eyes with a paper cup and tape. d. do nothing; rush to the hospital.

ANS: C Immediately after a penetrating wound injury, both eyes should be covered while transporting the patient to the hospital because both eyes work in synchrony. A Styrofoam cup provides adequate coverage and is readily available. REF: Page 1865, Safety Alert! TOP: Trauma

30. A patient with a history of Graves' disease is admitted to the unit with shortness of breath. The nurse notes the patient's vital signs: T 103° F, P 160, R 24, BP 160/80. The nurse also notes distended neck veins. The nurse suspects the patient has which medical emergency? a. Pulmonary embolism b. Hypertensive crisis c. Thyroid storm d. Cushing crisis

ANS: C In a thyroid crisis, all the signs and symptoms of hyperthyroidism are exaggerated. Additionally, the patient may develop nausea, vomiting, severe tachycardia, severe hypertension, and occasionally hyperthermia up to 41° C (106° F). Extreme restlessness, cardiac dysrhythmia, and delirium may also occur. The patient may develop heart failure and may die. REF: Page 1834 TOP: Hyperthyroid

6. A patient comes to the clinic for his weekly "allergy shot." He missed his appointment the week before because of a family emergency. Which action by the nurse is appropriate in administering his injection? a. Administer the usual dosage of the allergen. b. Double the dosage to account for the missed injection the previous week. c. Consult with the physician about decreasing the dosage for this injection. d. Reevaluate his sensitivity to the allergen with a skin test.

ANS: C Interrupted regimens may place the patient at risk for reaction. REF: Page 1960 TOP: Allergies Step: Planning

23. During a nursing history related to a patient's activity-exercise functional health pattern, the patient comments that he cannot bend over and lift an object without becoming dizzy and that he frequently has to stop physical activities because of dizziness and nausea. Which structure of this patient's ear is most likely to have a dysfunction causing his symptoms? a. Middle ear b. Organ of Corti c. Semicircular canals d. Cochlea

ANS: C Labyrinthitis is an inflammation of the labyrinthine canals of the inner ear. REF: Page 1841 TOP: Aging

31. The aging process can be a factor in the patient's smell and taste. Which may contribute to altered nutrition for the elderly? a. Increase in the receptors in the nasal cavities b. Increase in papillae of the tongue c. Medications d. Myopia

ANS: C Medications often affect the taste of food and can contribute to altered nutrition. A decreased number of receptors in the nasal cavities and papillae of the tongue results in changes in smell and taste. Most affected are the sweet and salty tastes. DIF: Cognitive Level: Knowledge REF: Page 1843, Life Span Considerations box TOP: Health promotion

10. Myopia is a medical term meaning which visual disorder? a. Farsightedness b. Blurred vision c. Nearsightedness d. Halos around lights

ANS: C Myopia—nearsightedness. REF: Pages 1844, 1848, Table 53-3 TOP: Visual acuity

10. Which nursing diagnosis is appropriate for a patient diagnosed with hypothyroidism as the result of a newly developed goiter? a. Diarrhea b. Hyperthermia c. Disturbed body image d. Increased cardiac output

ANS: C Nursing diagnosis and interventions for the patient with simple (colloid) goiter include Body image, disturbed, risk for, related to altered physical appearance. REF: Page 1737, Nursing Diagnosis TOP: Hypothyroidism

9. A patient has recently been diagnosed with acromegaly. Using Maslow's hierarchy, which of the nursing diagnoses listed below should be of the highest priority in caring for him? a. Ineffective coping b. Activity intolerance c. Risk for trauma d. Chronic low self-esteem

ANS: C Nursing interventions are mainly supportive. The presence of muscle weakness, joint pain, or stiffness warrants assessment of the ability to perform activities of daily living (ADLs). REF: Pages 1725, 1727, Nursing Diagnoses box TOP: Acromegaly Step: Planning

26. The physician prescribes glyburide (Micronase, DiaBeta, Glynase) for a patient, age 57, when diet and exercise have not been able to control her type 2 diabetes. Which information does the nurse include when teaching her about the glyburide? a. Glyburide is a substitute for insulin and acts by directly stimulating glucose uptake into the cell. b. Glyburide, like all oral hypoglycemic agents, does not cause the hypoglycemic reactions that may occur with insulin use. c. Glyburide and other hypoglycemic agents are thought to stimulate insulin production and increase sensitivity to insulin at receptor sites. d. Glyburide and other sulfonylureas lower blood sugar by inhibiting glucagon release from the liver, preventing gluconeogenesis.

ANS: C Oral hypoglycemics are compounds that stimulate the beta cells in the pancreas to increase insulin release. REF: Page 1756, Table 51-6 TOP: Medication Step: Planning

16. A patient is undergoing immunotherapy on a perennial basis. With this form of treatment, she receives a. larger doses each week. b. higher concentrations each week. c. increased amounts and concentrations in 6-week cycles. d. the same amount and concentration each visit.

ANS: C Perennial therapy is most widely accepted, because it allows for a higher cumulative dose, which produces a better effect. Perennial therapy usually begins with 0.05 mL of 1:10,000 dilution and increases to 0.5 mL in a 6-week period. REF: Pages 1960-1961 TOP: Immunotherapy

11. A patient, age 40, is having a diagnostic workup because of a possible disorder of the thyroid gland. The nurse noting the physician's orders recalls that there are several diagnostic tests to determine thyroid disorders. The test that employs radioactive iodine and use of a scintillation camera is called the a. positron emission tomography (PET). b. thyroid scan. c. radioactive iodine uptake test (RAIU). d. T3.

ANS: C RAIU: radioactive iodine is given by mouth; a scintillator is held over the thyroid to measure how much isotope has been removed from the bloodstream. REF: Page 1732, Box 51-1 TOP: Thyroid disorders

1. A patient has a history of allergic reactions to bee stings. Which actions should the nurse teach to avoid an anaphylactic reaction to bee stings? a. Limit intake of sweets to reduce attraction of bees. b. Carry a dose of aminophylline at all times. c. Take extra precautionary actions when outdoors where bees may be present. d. Wear a Medic-Alert tag that states the patient is allergic to bee stings.

ANS: C Teach the patient avoidance of allergens. REF: Page 1962 TOP: Anaphylactic reaction

21. Which is a factor that contributes to the extent of an allergic response to an allergen? a. The integrity of the skin b. The time of year in which one is exposed c. The amount of exposure d. Exposure to one's clothing

ANS: C The five factors influencing hypersensitivity response include host response to allergen, exposure amount, nature of the allergen, route of allergen entry, and repeated exposure. REF: Page 1961, Box 55-3 TOP: Hypersensitivity

6. A patient is scheduled for a stapedectomy. Appropriate postoperative teaching should include: a. Hourly changing cotton from external ear canal b. Gently blowing both nares simultaneously c. Teaching patient to open mouth when sneezing or coughing d. Limiting activities for 3 weeks

ANS: C The nurse must include patient teaching about opening the mouth when sneezing or coughing or blowing the nose gently on one side at a time for 1 week. REF: Page 1880, Patient Teaching box TOP: Stapedectomy

13. A patient has been blind for the past 10 years. He is hospitalized with congestive heart failure (CHF). In the care of a long-term blind individual, it is important to a. speak loudly to get the patient's attention. b. schedule a consultation with an occupational therapist to teach activities of daily living. c. announce when you enter and leave the room. d. initiate a referral to the Department of Health and Human Services.

ANS: C The nurse should announce when entering or leaving the room, so that a blind person is not put in the position of talking to someone who is no longer there. REF: Page 1846, Box 53-1 TOP: Blindness Step: Planning

5. What precautionary safety measure should the nurse take for a patient who is receiving first-time intradermal injections for allergy testing? a. Take vital signs every 15 minutes for 1 hour after the patient receives the injection. b. Remind the patient to call the physician if a rash develops. c. Have the patient remain for 20 minutes after the injection. d. Instruct the patient to take epinephrine if an allergic reaction occurs.

ANS: C The patient must always be observed for at least 20 minutes after administration, because hypersensitivity reaction or anaphylaxis may occur. REF: Page 1960 TOP: Medication

24. During examination of his external ear, the patient tells the nurse that his ear is very painful when touched. The nurse recognizes that this finding is commonly associated with a. a ruptured tympanic membrane. b. a blocked eustachian tube. c. infection of the mastoid bone. d. inflammation of the ear canal.

ANS: D The acute inflammatory or infectious process produces pain with movement of the auricle or chewing, and often the entire side of the headaches. REF: Page 1871 TOP: Infectious/inflammatory disorders

8. A patient who has suffered an allergic reaction to a bee sting is stabilized and prepared for discharge from the clinic. During discussion of prevention and management of further allergic reactions, the nurse identifies a need for additional teaching based on which comment? a. "I need to think about a change in my occupation." b. "I will learn to administer epinephrine so that I will be prepared if I am stung again." c. "I should wear a Medic-Alert bracelet indicating my allergy to insect stings." d. "I will need to take maintenance doses of corticosteroids to prevent reactions to further stings."

ANS: D The nurse's responsibilities in patient education are as follows: Teach the patient preparation and administration of epinephrine subcutaneously. There is no need for the patient to take maintenance dosages of corticosteroids because this was a short, rapid reaction. REF: Pages 1964-1965 TOP: Allergic reaction Step: Evaluation

2. The patient tells the nurse that he is legally blind. This information provides the nurse with which information to use in planning care? a. No vision enhancement techniques would be appropriate for this patient, because he is totally blind. b. This patient probably has some light perception, but no usable vision. c. This patient has some usable vision, which enables him to function at an acceptable level. d. Further questioning is needed to determine how this patient's visual impairment affects his normal functioning.

ANS: D "Legal blindness" refers to individuals with a maximum visual acuity of 20/200 with corrective eyewear and/or visual field sight capacity reduced by 20 degrees. Categories have been established to help determine the exact extent of the vision loss and what assistive measures are appropriate for the individual. The nurse will need more information as to the exact extent of the vision loss for this patient. REF: Page 1845 TOP: Blindness Step: Planning

11. A patient has an infectious/inflammatory process of the eyelid. The primary goal of nursing intervention is a. administering antibiotics. b. flushing the eye with sterile ophthalmic solution. c. maintaining bed rest. d. preventing further infection.

ANS: D A primary objective of nursing care for the patient with an infectious or inflammatory process of the eyelids is prevention of the spread of infection. Hand hygiene is essential before contact with the eye. REF: Page 1850 TOP: Infectious/inflammatory disorders Step: Planning

21. When the eye adjusts to seeing objects at various distances, it is called a. PERRLA. b. refraction. c. focusing. d. accommodation.

ANS: D Accommodation: The eye is able to focus on objects at various distances. REF: Page 1840 TOP: Aging

14. After a bee sting, a patient's face becomes edematous and she begins to wheeze. Based on this assessment, the nurse would be prepared to administer: a. aminophylline. b. diphenhydramine (Benadryl). c. diazepam (Valium). d. epinephrine.

ANS: D At the first sign of reaction, 0.2 to 0.5 mL of epinephrine 1:1,000 is given subcutaneously. REF: Pages 1960, 1963 TOP: Allergic reaction

3. A patient has been admitted with pernicious anemia and has asked the nurse to tell him what type of disorder pernicious anemia is. The nurse tells him that it is an immune disorder that results from failures of the tolerance to one's "self." Responding immunologically to one's own antigens is called a(n) a. immunodeficiency disorder. b. hypersensitivity disorder. c. desensitization disorder. d. autoimmune disorder.

ANS: D Autoimmune disorders are failures of the tolerance to "self." Autoimmune disorders may be described as an immune attack on the self and result from the failure to distinguish "self" protein from "foreign" protein. REF: Pages 1966-1967 TOP: Autoimmune disorders

5. The patient is a 20-year-old college student who has type 1 diabetes and normally walks each evening as part of her exercise regimen. She now plans to enroll in a swimming class to meet her physical education requirement. Which adjustment in her treatment plan will the nurse help this patient make? a. Time her morning insulin injection so that the peak action will occur during her swimming class. b. Delete her normal walks on days she has swimming class. c. Delay the meal before the swimming class until the session is over. d. Monitor her glucose level before, during, and after swimming to determine the need for alterations in food or insulin.

ANS: D Exercise can reduce insulin resistance and increase glucose uptake for as long as 72 hours as well as reducing blood pressure and lipid levels. However, exercise can carry some risks for patients with diabetes, including hypoglycemia. REF: Page 1748 TOP: Diabetes mellitus Step: Planning

7. A patient has returned to his room after a thyroidectomy. He is presenting with signs and symptoms of thyroid crisis. During thyroid crisis, exaggerated hyperthyroid manifestations may lead to the development of the potentially lethal complication of a. severe nausea and vomiting. b. bradycardia. c. delirium with restlessness. d. congestive heart failure.

ANS: D In thyroid crisis, all the signs and symptoms of hyperthyroidism are exaggerated. The patient may develop congestive heart failure and die. Additionally, the patient may develop nausea, vomiting, severe tachycardia, severe hypertension, and occasionally hyperthermia up to 41° C (106° F). Extreme restlessness, cardiac dysrhythmia, and delirium may also occur. REF: Page 1734 TOP: Thyroidectomy

20. The patient, age 71, has severe vertigo. A nursing action to help him reduce the symptoms is: a. Avoid sudden movements until the vertigo lessens. b. Avoid noises until the vertigo lessens. c. Encourage fluid intake. d. Lie immobile and hold the head in one position until the vertigo lessens.

ANS: D Lie immobile and hold the head in one position until the vertigo lessens. REF: Page 1876, Patient Teaching box TOP: Vertigo Step: Planning

12. A patient is diagnosed with hyperthyroidism. In the treatment of hyperthyroidism, which one of these medications is likely to be prescribed to decrease the activity of her thyroid gland? a. Diazepam (Valium) b. Liothyronine sodium (Cytomel) c. Prednisone d. Propylthiouracil

ANS: D Medical management for hyperthyroidism may include administration of drugs that block the production of thyroid hormones, such as propylthiouracil. REF: Page 1732, Table 51-2 TOP: Hyperthyroid

26. The nurse arrives at the bedside of a patient who has had a unit of packed cells infusing in his right arm for 35 minutes. He is complaining of chills, itching, and shortness of breath. The next action for the nurse would be to a. leave and get help. b. take the patient's temperature. c. give him his nose spray. d. stop the transfusion and IV administer saline.

ANS: D Mild transfusion reactions signs and symptoms include dermatitis, diarrhea, fever, chills, urticaria, cough, and orthopnea. Treatment includes stopping the transfusion and administering saline. REF: Page 1965 TOP: Blood transfusion

26. The patient, age 62, has had insulin-dependent diabetes mellitus for 20 years and has symptoms of proliferate diabetic retinopathy. He is scheduled for his first panretinal photocoagulation treatment. The nurse explains to him that the purpose of this procedure is to a. destroy the retina, which is not getting enough blood supply. b. reduce edema in the macula of the eye. c. vaporize fatty deposits that appear in the retina. d. destroy new blood vessels, seal leaking vessels, and help prevent retinal edema.

ANS: D Photocoagulation is useful in diabetic retinopathy to cauterize hemorrhaging vessels. REF: Page 1856 TOP: Diabetic retinopathy

28. A 47-year-old patient with hypothyroidism is being given discharge instructions that should include a. taking his medication whenever symptoms cause discomfort. b. decreasing fluid and fiber intake. c. consuming foods rich in iron. d. seeing his physician regularly for follow-up care.

ANS: D Regular checkups are essential, because drug dosage may have to be adjusted from time to time. REF: Page 1736 TOP: Hypothyroid Step: Planning

22. A patient has type 1 diabetes (IDDM). The nurse is teaching her early signs and symptoms of insulin reaction, which include a. abdominal pain and nausea. b. dyspnea and pallor. c. flushing of the skin and headache. d. perspiration and a trembling sensation.

ANS: D The patient should be instructed to notify a member of the nursing staff if any signs of hypoglycemic (low insulin) reaction occur: excessive perspiration or trembling. REF: Page 1750, Table 51-8 TOP: Diabetes mellitus

12. A patient is recovering from a kidney transplant. He is receiving cyclosporine after surgery. The purpose of this drug is to a. promote diuresis. b. prevent infection. c. manage pain. d. suppress the immune response.

ANS: D Tissue reaction does not occur immediately after transplantation. It takes several days for vascularization to occur. Seven to ten days after blood supply is adequately established, sensitized lymphocytes appear in sufficient numbers for sloughing to occur at the site. Graft rejection is slowed through the use of chemical agents that interfere with the immune response process. REF: Pages 1965-1966 TOP: Transplant

37. Schiötz tonometry is a diagnostic test for .

ANS: glaucoma REF: Page 1860, Figure 53-11 TOP: Diagnostic tests