Med surg 4 test 1 pain
15. To help with pain control, the nurse plans distraction activities for a patient to be timed to
a. coincide with mealtimes. b. bridge the time between administration and onset. c. be just previous to bedtime. d. diminish drowsiness and sleep. ANS: B Distraction is helpful with pain control between administration of the analgesia and its onset. Mealtimes, bedtime, and sleep should not be interrupted with distraction activities.
8. When the nurse is assessing a bed-bound resident, a reddened area over the coccyx that does not blanch is discovered. The best intervention to prevent further skin damage is to:
a. cover with a transparent film dressing. b. apply warm compress. c. turn the patient every 2 hours. d. continue to monitor the area. ANS: A Since this appears to be a stage 1 pressure area, the transparent film ensures the proper amount of moisture is present for healing while allowing monitoring of the area. A warm compress is not warranted. This patient will need to be turned every hour. Monitoring of the area should continue but does not meet the immediate need.
2. The 26-year-old patient with a malignant neoplasm has experienced a 10-pound weight loss in 3 weeks. The nurse takes into consideration that the rapid weight loss is most likely related to:
a. disinterest in eating food in general. b. a fitness and weight-training exercise program. c. the malignancy's high nutritional demand. d. a self-imposed rigid diet regimen. ANS: C Rapid cell growth of the malignancy robs nutrients from normal cells and results in weight loss
10. While bathing the patient, the nurse notes that a transdermal patch that was meant to be on the patient for 3 days is now gone on the second day. The nurse should:
a. document the loss and apply a fresh patch to be replaced in 3 days. b. report the loss to the charge nurse. c. document the loss, replace the patch, and continue with the original schedule for replacement. d. remind the patient that, until the patch is replaced in 24 hours, oral pain relief will be available. ANS: A The patch should be replaced after the loss is documented, and the schedule should be changed. There is no need for the patient to wait for a new patch to be applied in 24 hours.
9. The nurse reminds the 40-year-old female patient that the American Cancer Society (ACS) recommendations for early detection of cancer include that she should
a. get a Pap smear every year. b. get an annual fecal occult blood exam. c. plan a sigmoidoscopy every 5 years. d. have a mammogram done every year. ANS: D The ACS recommends that 40-year-old women have an annual mammogram and a Pap smear every 2 to 3 years. Yearly fecal occult blood studies and sigmoidoscopy are recommended beginning at age 50.
27. Pain receptors in the skin, connective tissue, bone, joints, and muscles are classified as __________.
nociceptors Pain receptors in the skin, connective tissue, bone, joints, and muscles are nociceptors
22. Which patient statement indicates understanding of patient teaching regarding cancer diagnostic exams?
a. "I will have less scarring if my surgeon uses an incision to biopsy my breast." b. "My CEA level will be low if my pancreatic cancer returns." c. "The doctor will monitor my ovarian cancer remission with the CA-125 test." d. "My colonoscopy results were great, so I won't need another one for 5 years." ANS: C The CA-125 is one of the tests the physician will monitor to detect the presence of ovarian cancer or recurrence of ovarian cancer after therapy. Fine-needle biopsy causes the least amount of scarring during breast cancer biopsy. The patient's CEA level will rise if pancreatic cancer is present. Recommendations suggest a colonoscopy every 10 years if the exam is negative and there is no family history of colon cancer.
In order to provide the optimum nursing care, it is important for the nurse to know that the standard of pain and pain control is best determined by which person?
a. Physician b. Nurse c. Patient's family d. Patient ANS: D Only the patient knows when pain occurs and what remedy relieves it.
23. The wife of a terminally ill cancer patient who is receiving palliative care asks the hospice nurse how her husband's pain will be controlled as he nears death. The nurse's best response is:
a. "Most of the time we can manage the pain with oral morphine and transdermal pain medication." b. "We will probably have to start an IV to administer morphine to control the intense pain he may be experiencing." c. "Dying patients typically do not have any pain, so this will not be an issue." d. "I will have to check with your husband's physician to see how he wants us to handle pain control." ANS: A Oral and transdermal pain control methods are most often used for the terminally ill patient near death. An IV is not typically started on a patient near death who is receiving palliative care. Dying patients do experience pain. The plan of care should be in place for the patient receiving palliative care, so the physician would not be contacted for pain medication orders.
7. The patient who had abdominal surgery this morning refuses the opioid pain medication for fear of addiction. The most informative response by the nurse is:
a. "Opioids are addictive, whereas nonsteroidal anti-inflammatory drugs (NSAIDs) are not." b. "Addiction is mainly a matter of attitude." c. "Fewer than 3% of people become addicted to drugs used for pain relief." d. "Although addiction does occur, it is quickly reversed." ANS: C This patient is not experiencing chronic pain that will require ongoing pain medication, and addiction occurs in fewer than 3% of people who take pain medication. Any medication can be addictive. Addiction is often not merely a matter of attitude. Finally, addictions typically require long-term therapy.
22. The nurse anticipates the needs of several patients being cared for. The nurse is correct in anticipating that the patient who may experience the highest level of pain is a:
a. 23 year old experiencing pain related to a broken femur. b. 45 year old experiencing pain following a laparoscopic cholecystectomy. c. 67 year old experiencing chronic back pain. d. 89 year old experiencing pain related to osteoarthritis. ANS: D While pain is always dependent on the individual patient's perception, the older adult tends to be less tolerant to pain due to factors such as having more than one chronic ailment and having fewer resources for tolerating pain.
4. In assessing several patients in the outpatient clinic, the nurse identifies the patient who is at the greatest risk for cancer as the:
a. 23-year-old car repairman who repaints cars. b. 30-year-old overweight CPA in New York who has smoked for 10 years and rarely exercises. c. 45-year-old farmer from Texas who has worked on his family's cotton farm since the age of 12. d. 60-year-old ski instructor in Colorado. ANS: C The cotton farmer in Texas has the most exposure to carcinogens. Chemicals, pesticides, and sun are the carcinogens that this farmer has been exposed to for at least 33 years.
13. The home health nurse cautions the 75-year-old patient that the warm compresses that are used on his swollen elbow should be left in place only for _____ minutes.
a. 5 to 10 b. 15 to 20 c. 25 to 30 d. 35 to 40 ANS: B Applications of heat should only be left in place for 15 to 20 minutes
21. The student nurse demonstrates an understanding of cancer risk factors by identifying which patient as being at the highest risk for developing colorectal cancer?
a. 50-year-old male who has been exposed to arsenic in the workplace b. 45-year-old female with a doctorate degree in psychology who smokes occasionally c. 38-year-old female who had her first child one year ago d. 29-year-old male who has had Crohn's disease since the age of 13 ANS: D Inflammatory diseases of the colon increase the risk of colorectal cancer. Arsenic exposure places the patient at risk for lung cancer. Women with a high level of education have been found to fall into the high risk category for developing breast cancer, as well as having the first child after the age of 30.
4. The nurse is caring for a patient who is having constant nociceptor pain. The nurse can best address the patient's pain during the perception phase of pain with which intervention?
a. Administer nonsteroidal anti-inflammatory drugs (NSAIDs) for moderate pain. b. Ask the physician if an opioid could be ordered to treat the patient's pain when severe. c. Engage the patient in conversation regarding his family, hobbies, and plans following discharge from the facility. d. Determine if the patient typically takes a neurotransmitter uptake blocker medication for pain control. ANS: C Nonpharmacologic interventions such as distraction and guided imagery are effective for pain relief during the perception phase. NSAIDs are most effective during the transduction phase of pain, opioids are most effective during the transmission phase, and drugs that block neurotransmitter uptake work best during the modulation phase.
6. The nurse assessing an 85-year-old patient who has been on bed rest for a fractured hip finds the patient flushed with a temperature of 100° F, pulse of 100, and respiration rate of 24. The next intervention should be to assess:
a. BP. b. breath sounds. c. abdominal distention. d. amount of urinary output. ANS: B
17. The 32-year-old mother who is undergoing radiation from a sealed-source modality and has been isolated in a private room for 3 days is preparing to be visited by her 8-year-old twins. The nurse should include what in the preparations?
a. Instruct the children to visit at the bedside one at a time. b. Inform family that children cannot visit patients undergoing radiation. c. Put chairs in the hall for "long-distance" visitation. d. Allow visitation of only 3 minutes without any physical contact. ANS: C Children and pregnant people should not visit at the bedside, but a visit from a safe distance or by phone helps relieve the boredom of isolation.
4. When the nurse assesses reddened heels on the bed-bound stroke patient, the nurse modifies the care plan to include which intervention?
a. Massage heels briskly. b. Apply socks to feet. c. Swab heels with alcohol. d. Elevate feet on pillows. ANS: D Elevation of the feet gets the weight off the heels and will allow them to heal. All other options are not helpful to damaged skin. Brisk massage may promote damage to the skin. Alcohol can be irritating and may further damage heel skin.
5. The patient is experiencing phantom pain following the amputation of her foot. Which type of pain is most associated with phantom pain?
a. Nociceptive b. Mild c. Uncontrollable d. Neuropathic ANS: D Neuropathic pain is associated with a dysfunction of the nervous system that involves an abnormality in the processing of sensations such as phantom pain. Nociceptive pain is associated with pain stimuli from either somatic(body tissue) or visceral (organs) structures. Mild and uncontrollable refer to severity rather than classifications of pain.
8. The student nurse understands proper documentation of a pain assessment as evidenced by which note in the patient's record?
a. Pt. complains of local sharp pain (4/5) in lower abdomen upon standing. b. Pt. complains of stomach pain after eating (3/5). c. Pt. reports standing makes his stomach hurt. d. Pt. reports sharp pain in stomach. ANS: A The recorded assessment should include location, characteristics, quantity, severity based on a pain scale, and pattern.
7. The nurse outlines a diet that would be helpful in the prevention of cancer. This diet includes:
a. adequate nitrites. b. no more than 40% fats. c. vitamin B complex. d. citrus fruits. ANS: D Vitamin C helps combat the effects of nitrites; fats should be no more than 30%, and vitamin B has not been proven effective for cancer prevention.
25. The nurse explains to the patient with neuropathic pain that the most effective pain control will be achieved through the use of: (Select all that apply.)
a. analgesics. b. opioids. c. antidepressants. d. anti-inflammatory agents. e. anticonvulsants. ANS: C, D, E Neuropathic pain is best relieved by antidepressants, anti-inflammatory agents, and anticonvulsants. Analgesics and opioids generally do not alleviate neuropathic pain.
21. The nurse is caring for a patient who is 1-day postoperative following a colon resection. The patient has degenerative joint disease and uses a pain medication patch to control this chronic pain. When planning care for this patient, the nurse
a. anticipates that the pain medication patch will control the postoperative pain. b. knows that this patient will most likely require more pain medication than most patients undergoing a colon resection. c. realizes that the patient will be afraid to ask for additional pain medication for fear of being viewed as addicted to pain medicine. d. expects the patient to forget about the pain caused from the degenerated joint disease. ANS: B Patients who are being treated for chronic pain often require higher doses of pain medication to treat postoperative pain. The patient's pain medication patch will not likely treat the postoperative pain. There is no indication that the patient will be afraid to ask for additional pain medication, and the patient is not likely to forget about the postoperative pain.
1. The 40-year-old female who was diagnosed with a benign growth in her colon is concerned about the growth spreading. The nurse can allay her anxiety by explaining that benign neoplasms:
a. arrest their growth on their own. b. never interfere with normal structures or functions. c. are easily controlled with radiation. d. are surrounded by fibrous tissue that prevents spread. ANS: D Benign neoplasms are encapsulated with a fibrous membrane that interferes with their spreading. They do not self-limit their growth and may obstruct passages or impinge on an organ. They are not treated with radiation.
5. The nurse cautions the 70-year-old patient who just had the cast removed from a broken arm that the immobility during the time he was in a cast can cause:
a. arthritis. b. phlebitis. c. frozen shoulder. d. painful swelling. ANS: C Immobility can cause loss of strength and flexibility in the older adult.
9. The nurse stresses to the home health patient that the acetaminophen pain medication should be taken:
a. as frequently as needed. b. before pain is severe. c. when pain becomes unbearable. d. sparingly and with caution. ANS: B Taking medication before pain becomes severe controls pain best. Once taken, the medication should be taken on the prescribed schedule until pain is well controlled.
19. Following a visit from his family, the 55-year-old male patient with terminal cancer tearfully says, "I am so afraid" and begins to cry. The nurse's most supportive response is to:
a. ask, "Would you like to have your pain medication now?" b. sit down and say, "Let's talk about what you are afraid of." c. offer to call the hospital chaplain. d. darken the room and leave to give the patient privacy. ANS: B Verbalizing fears to a caring nurse is comforting. Offering medications, chaplains, and privacy is not helpful or supportive as a first nursing response in this situation
11. In planning care for the patient who is on a protocol of bleomycin, an antitumor antibiotic, the nurse will add to the care plan an intervention to:
a. assess hearing acuity. b. measure urinary output. c. weigh daily to assess fluid retention. d. monitor cardiac arrhythmias. ANS: D Bleomycin is cardiotoxic and can cause cardiac arrhythmias; therefore, this would be the highest priority intervention. Chemotherapies that are ototoxic would warrant a hearing test; urinary output and fluid retention should be assessed with most chemotherapy drugs, and especially for those that are nephrotoxic.
3. When giving care to a 30-year-old Hispanic male, the nurse is aware that the young man will most likely:
a. be stoic about pain. b. prefer a pill to an injection. c. ignore somatic interventions such as heat and massage. d. confess to pain, but refuse pain medication. ANS: A Hispanic males are frequently stoic regarding pain. They prefer injections to pills but may elect to use prayer, heat, or herbal remedies for pain relief.
6. The x-ray technician wears a badge that is monitored frequently to measure the amount of radiation he has absorbed. Such occupational exposure to radiation frequently results in a specific cancer, which is:
a. bladder cancer. b. leukemia. c. melanoma. d. lung cancer. ANS: B The blood cancer leukemia is associated with radiation exposure. Bladder, melanoma, and lung cancer are associated with other carcinogens.
13. The nurse includes in the instructions to a 50-year-old male patient taking estrogens as treatment of prostate cancer that he may develop:
a. blurred vision. b. gynecomastia. c. enlarged gonads. d. acne. ANS: B Men taking estrogen experience a redistribution of fat and develop enlarged breasts (gynecomastia).
15. The patient on radiation therapy has developed diarrhea. The nurse suggests foods that would decrease diarrhea, such as:
a. broccoli. b. cauliflower. c. cheese and crackers. d. apples and pears. ANS: C Food low in fiber, such as cheese and crackers, will help slow diarrhea. All other options are high-fiber foods that stimulate bowel evacuation.
25. The classifications of malignant neoplasms are: (Select all that apply.)
a. carcinomas. b. lymphomas. c. fibromas. d. lipomas. e. sarcomas. ANS: A, B, E The categories of malignancy are sarcomas, carcinomas, leukemias, and lymphomas. Fibromas and lipomas are benign.
. The obese resident who lies on her back because it is difficult to turn due to her weight has a pressure ulcer on her coccyx that is covered with a dressing. The most effective intervention to encourage independence is:
a. have staff turn the resident every 2 hours. b. turn the patient on her side and use pillows to stabilize her. c. arrange for short side rails to be used for positioning. d. arrange for a trapeze so the patient can assist with positioning. ANS: D The trapeze allows for self-positioning and is less confining than are bed rails. The other options do not foster independence.
10. In assessing a man who is to have a prostate-specific antigen (PSA) test done, the nurse identifies the situation that will delay the test, which is:
a. having eaten shellfish 48 hours previously. b. identification of an enlarged prostate. c. recent urinary tract infection. d. temperature of 100° F. ANS: C The PSA would be delayed in the event of a recent urinary tract infection.
19. The nurse instructing a family member in the technique of massage will stress that he should use:
a. heat and a mild menthol cream for comfort. b. progressively intense pounding with sides of the hands. c. gentle massage of areas of inflammation. d. long, firm strokes. ANS: D Long, firm, smooth strokes on areas that are not inflamed will direct the patient's attention away from the painful area. Heat and menthol cream used together may cause a burn.
12. Because of the threat of lowering the seizure threshold, the home health nurse would suggest that the 85-year-old patient limit the use of the pain medication:
a. ibuprofen (Motrin). b. naproxen (Aleve). c. tramadol (Ultram). d. acetaminophen (Tylenol). ANS: D Tramadol (Ultram) is associated with a lowered seizure threshold in the older adult
1. The rehabilitation nurse describes a patient who is blind, works full time as a Spanish interpreter, and lives with his wife in a downtown apartment. The nurse classifies this person as:
a. impaired. b. disabled. c. handicapped. d. dependent. ANS: A
14. The nurse instructs a patient who is on a biologic response modifier (BMR) colony-stimulating drug that the effect of this type of drug is to:
a. increase appetite. b. seek out and kill specific colonies of neoplasms. c. enhance recovery of bone marrow. d. reduce pain. ANS: C BMRs enhance and support the recovery of suppressed bone marrow resulting from radiation and chemotherapy.
26. Although the patient with a kidney stone denies pain, the nurse assesses cues that indicate that pain is perceived. These cues include: (Select all that apply.)
a. increased pulse rate. b. decreased respiratory rate. c. sweating. d. muscle tension. e. nausea. ANS: A, C, D, E The respiratory rate increases in patients in acute pain
24. The functions of endorphins are believed to be: (Select all that apply.)
a. inhibition of unpleasant stimuli. b. diminished anxiety. c. relief of pain. d. feeling of euphoria. e. increased blood pressure. ANS: A, B, C, D Endorphins are thought to diminish unpleasant stimuli and pain, reduce anxiety, and give feelings of euphoria.
2. A resident with advanced Parkinson's disease stays in his wheelchair all day because it is too tiring to walk and he is fearful of falling. In order to increase mobility, the best intervention would be to:
a. instruct the resident in crutch walking. b. assist the resident to walk in the hallway with a gait belt. c. encourage the resident to rock back and forth in his wheelchair to off load weight. d. arrange for a walking cane.
28. The biologic response modifier drugs include: (Select all that apply.)
a. interleukins. b. colony-stimulating factors. c. monoclonal antibodies. d. cyclosporines. e. gene therapies. ANS: A, B, C, E Cyclosporines are drugs that are used to prevent tissue transplant rejection and are considered a carcinogen for non-Hodgkin's lymphoma. In addition to the biologic response modifiers (BRM) listed, vaccines are also a BRM.
5. The nurse recognizes a "promoter" that, although not a carcinogen itself, allows cancer to occur faster in the patient that:
a. is more than 25 pounds overweight. b. works in a hospital lab. c. abuses cocaine. d. drinks heavily. ANS: D Alcohol and smoking are "promoters" that facilitate the occurrence of cancer. Being overweight, working in a hospital lab, and abusing cocaine are not considered "promoters" in regard to cancer risk.
18. The nurse evaluated that the 50-year-old male recently diagnosed with early stage cancer of the prostate has begun to accept his diagnosis when he:
a. jokes, "Well, I guess this just about cancels any plans for a second honeymoon." b. calls his lawyer to update his will. c. requests current information on prostate cancer. d. asks his wife to call their children home from college to visit. ANS: C Well-adjusted patients should seek information on the disease and varied treatments. Joking is a form of denial. Gathering family and making final arrangements reflect loss of hope and do not coincide with the prognosis of early stage prostate cancer. Humor is a positive coping strategy, but requesting information about the disease is more indicative of acceptance.
27. The nurse explains that viruses are responsible for some specific cancers, such as: (Select all that apply.)
a. liver cancer from hepatitis B virus. b. Burkitt's lymphoma from Epstein-Barr virus. c. cervical cancer from human papillomavirus. d. lung cancer from measles virus. e. Kaposi sarcoma from human immunodeficiency virus. ANS: A, B, C, E Measles do not cause lung cancer. All other options are examples of cancer caused by a virus.
9. The LPN/LVN making care assignments to nursing assistants would not assign a patient who has:
a. manipulative behavior. b. an unstable condition. c. a draining wound. d. a communicable disease. ANS: B Nursing assistants are not assigned to patients who have an unstable condition. Care of an unstable patient does not fall into the scope of practice of the unlicensed personnel.
23. The nurse using the gate theory as a guide to pain management will offer: (Select all that apply.)
a. massage. b. social activities. c. music. d. interactive distraction. e. a quiet environment. ANS: A, B, D Music is not effective as a gate closer. High levels of sensory stimulation are more effective for decreasing pain according to the gate theory.
20. The nurse explains that acupressure and acupuncture are effective pain relief modalities that focus on specific body areas called:
a. triangulation. b. hot spots. c. meridians. d. zones. ANS: C The Asian therapies of acupuncture and acupressure use body areas called meridians
20. The family becomes distressed when the dying 85-year-old patient becomes delirious and laughs and talks with old friends who have long since died. The nurse's best intervention would be to:
a. medicate the patient with the prescribed sedative. b. encourage a family member to talk to the patient calmly. c. stimulate and reorient the patient. d. suggest the family leave the patient for while. ANS: B Delirious patients can still hear. A familiar voice is comforting. Medicating the patient with a sedative is not appropriate. Stimulating and trying to reorient the patient may cause the patient to become irritated. The family should remain with the patient.
14. The hospitalized postsurgical patient is reluctant to take the opioid pain medication because of drowsiness. The most informative response made by the nurse would be that:
a. mental stimulation after the medication will keep the patient more alert. b. sleep and analgesia promote healing. c. drowsiness is an undesirable side effect. d. the medication should be taken only before bedtime. ANS: B Effective analgesia and adequate rest and sleep promote healing. Mental stimulation after taking an opioid will most likely not be effective for keeping the patient alert; drowsiness is an expected effect; and the medication should be taken as prescribed, not just before bedtime.
17. The nurse takes into consideration that the 45-year-old male Arab patient who is in pain will probably:
a. not request pain medication. b. call for pain relief to control pain. c. become irritable and demanding. d. hide pain from his family. ANS: B Individuals of Arab descent generally view pain as something to be controlled and will probably call for pain remedy frequently and expect prompt response. Arabs will express pain to their family.
11. The patient on frequent doses of meperidine (Demerol) complains of constipation. The initial intervention the nurse should make is:
a. offer fruit such as prunes or apricots. b. request an order for an enema. c. report the condition to the charge nurse. d. increase oral fluid intake. ANS: D Increasing fluid intake is the best initial approach because additional fluid allows the body to correct the problem naturally. Fruits can be offered, but increasing the fluid intake is the most effective and priority intervention. An enema is invasive and is not an early intervention for constipation. The nurse should be able to implement proper care without reporting the constipation to the charge nurse.
10. The chief goal of a long-term care facility is to:
a. offer restorative services. b. promote individual independence. c. facilitate achievement of complete autonomy. d. manage medication protocols.
2. The nurse clarifies the basics of the gate theory of pain control as:
a. pain is perceived as opening a "gate" to pain symptoms. b. the "gate" can be closed to pain by the use of nonpainful stimuli. c. the "gate" swings back and forth, first allowing pain, then blocking it. d. the patient can be trained to close the "gate" to pain. ANS: B The sensorineural "gate" can be closed by applying a number of nonpharmacologic stimuli so that the pain is not perceived
6. The nurse explains that the pain threshold and pain tolerance are different in that the pain threshold is the point at which:
a. pain is perceived. b. the person responds to pain. c. pharmacologic intervention is required. d. signs such as grimacing or groaning are observed. ANS: A The pain threshold is the point at which the pain is perceived.
16. The nurse instructing fatigue management to the patient who is taking radiation will include information about:
a. prioritizing activities. b. planning 4 to 5 hours of daytime bed rest. c. decreasing fluid intake. d. avoiding between-meal snacks. ANS: A Prioritizing activities is essential to balance energy with expenditure. These patients should not spend long periods of daytime in bed, and they should increase fluids and plan between-meal snacks to keep energy up.
18. When the patient receiving morphine sulfate intravenously breaks out in hives and begins to itch, the nurse should initially:
a. slow the flow rate of the morphine. b. stop the IV drip. c. report the condition to the charge nurse. d. give prescribed antihistamine. ANS: B The drug should be stopped immediately. Reporting the condition to the charge nurse and administering prescribed antihistamine are additional interventions that may be initiated after the morphine infusion has been discontinued.
3. The nurse recognizes the staging T3, N2, M2 of the patient's cancer to mean that there is a:
a. small tumor with fewer than two lymph nodes involved. b. large tumor that is localized. c. small tumor with adjacent nodes involved. d. large tumor with extensive lymph node involvement. ANS: D The staging means a large tumor (T3) with involvement in regional lymph nodes (N2) and metastasis to distant lymph nodes (M2).
8. The young college student who wants a tan before spring break asks the nurse what the safest method would be. The nurse's best response is:
a. take advantage of morning sun while using sunscreen with an SPF of 30. b. use a spray-on tanning solution. c. use a sun lamp for only 20 minutes a day. d. use a tanning salon for no more than 10 minutes per visit. ANS: B Spray-on tanning solution is the safest. All other options increase ultraviolet exposure, even with the use of sunscreen.
7. The 76-year-old stroke patient in a long-term care facility has sent his food tray back to the kitchen untouched for the second time today. The most effective intervention to increase nutrition would be to:
a. take the tray back and offer to feed the patient. b. request the dietitian to talk with the patient about food preferences. c. take a high-protein drink to the patient. d. sit with the patient during meals. ANS: C
12. When caring for a patient with cancer who is receiving vincristine, a vesicant, the nurse is especially careful to avoid:
a. the patient getting chilled. b. the drug extravasating. c. an infusion time greater than 2 hours. d. feeding the patient during the infusion. ANS: B A vesicant such as vincristine can cause tissue damage if it extravasates. The degree of damage is based on the amount of drug that has leaked and the length of time it was in the tissue.
26. The nurse explains that metastasis from the original site to a new site is accomplished by malignant cells via: (Select all that apply.)
a. traveling through tissues. b. "transplantation" via surgical instruments during surgery. c. entering a body cavity and attaching to an organ. d. traveling through the lymphatic system. e. "relocation" from contaminated gloves during surgery. ANS: B, C, D, E
24. The nurse uses a visual aid to demonstrate the characteristics of a malignant neoplasm, which are: (Select all that apply.)
a. very small nuclei. b. disorganization. c. altered DNA. d. invasion of nearby organs. e. travel through body fluid. ANS: B, C, D, E Malignant neoplasms have large rather than small nuclei. Disorganization, altered DNA, invasion of nearby organs, and the ability to travel through body fluid are all characteristics of malignancies.
16. When a patient reports pain relief after having received a placebo, the nurse concludes that the patient:
a. was not experiencing pain. b. is relieved of the anxiety that there is no ready source of pain remedy. c. is demonstrating "attention-seeking" behavior. d. is being manipulative. ANS: B Much pain is associated with anxiety that there will be no pain remedy available. The delivery of a placebo relieves pain as it relieves the anxiety.
4. The parents of a hospitalized toddler are upset because she seems more interested in her toys when they come to visit her. In which stage of separation anxiety is the toddler?
a. Protest b. Despair c. Denial d. Attachment ANS: C In the stage of denial or detachment, the child appears to deny the need for the parents and becomes uninterested in their visits.
29. The nurse cautions that stress over a long period of time can contribute to the risk for cancer as prolonged stress suppresses the ____________.
immune system
