Patho/Pharm 3 Week 5 & 6 combined

A 9 year old child will be receiving carbamazepine (Tegretol) suspension, 200 mg twice daily. The medication is available in a strength of 100 mg/5mL. Identify how many milliliters the nurse will give to the patient for each dose.

10 mL

Fever if unknown origin (FUO) is characterized by a fever of ___*F or greater.

101

A patient is about to receive pentobarbital (Nembutal) 100 mg IV as preoperative sedation. The medication is available in a concentration of 50mg/mL. How many milliliters will the patient receive for this dose?

2 mL 50mg:1mL::100mg:x mL (50 x X)=(1 x 100); 50x=100; x=2mL

A patient who is having an acute exacerbation of multiple sclerosis has a prescription for methylpredisolone 150 mg IV. The label on the vial reads: methylprednisolone 125 mg in 2 mL. How man mL should the nurse administer?

2.4

A patient with a Pseudomonas species urinary infection will be receiving amikacin (Amikin) 15 mg/kg once daily via intravenous infusion. The patient weighs 198 pounds, and the medication is available in an injection solution strength of 250 mg/mL. Identify how many milliliters of medication will be drawn up for this injection. (record answer using one decimal place) _______

5.4 mL Patients weight in Kg= 198/2.2 = 90 Kg mg/kg dose = 15 x 90 = 1350 mg/dose mL needed for this dose: 1350 divided by 250= 5.4 mL

A nurse is conducting community education classes on skin cancer. One participant says to the nurse: "I read that most melanomas occur on the face and arms in fair-skinned women. Is this true?" The nurse's most helpful response would be which of the following?a."That is not correct. Melanoma is more commonly found on the torso or the lower legs of women."b."That is correct, because the face and arms are exposed more often to the sun."c."That is not correct. Melanoma occurs on the top of the head in men but is rare in women."d."That is incorrect. Melanoma is most commonly seen in dark-skinned individuals."

A

A patient is receiving aminoglycoside therapy and will be receiving a beta-lactam antibiotic as well. The patient asks why two antibiotics have been ordered. What is the nurse's best response? a. "The combined effect of both antibiotics is greater than each of them alone." b. "One antibiotic is not strong enough to fight the infection." c. "We have not yet isolated the bacteria, so the two antibiotics are given to cover a wide range of microorganisms." d. "We can give a reduced amount of each one if we give them together."

A Aminoglycosides are often used in combination with other antibiotics, such as beta-lactams or vancomycin, in the treatment of various infections because the combined effect of the two antibiotics is greater than that of either drug alone.

A patient who has received some traumatic news is panicking and asks for some medication to help settle down. The nurse anticipates giving which drug that is most appropriate for this situation? a. Diazepam (Valium) b. Zolpidem (Ambien) c. Phenobarbital d. Cyclobenzaprine (Flexeril)

A Benzodiazepines such as diazepam are used as anxiolytics, or sedatives. Zolpidem is used as a hypnotic for sleep. Phenobarbital is not used as an anxiolytic but is used for seizure control. Cyclobenzaprine is a muscle relaxant and is not used to reduce anxiety.

The nurse notes in the patient's medication history that the patient is taking cyclobenzaprine (Flexeril). Based on this finding, the nurse interprets that the patient has which disorder? a. A musculoskeletal injury b. Insomnia c. Epilepsy d. Agitation

A Cyclobenzaprine (Flexeril) is the muscle relaxant most commonly used to reduce spasms following musculoskeletal injuries. It is not appropriate for insomnia, epilepsy, or agitation.

A patient is recovering from a minor automobile accident that occurred 1 week ago. He is taking cyclobenzaprine (Flexeril) for muscular pain and goes to physical therapy three times a week. Which nursing diagnosis would be appropriate for him? a. Risk for injury related to decreased sensorium b. Risk for addiction related to psychologic dependency c. Decreased fluid volume related to potential adverse effects d. Disturbed sleep pattern related to the drug's interference with REM sleep

A Musculoskeletal relaxants have a depressant effect on the CNS; thus, the patient needs to be taught the importance of taking measures to minimize self-injury and falls related to decreased sensorium. "Risk for addiction" is not a NANDA nursing diagnosis. The other nursing diagnoses are not appropriate for this situation.

A patient is taking flurazepam (Dalmane) three to four nights a week for sleeplessness. She is concerned that she cannot get to sleep without taking the medication. What nonpharmacologic measures should the nurse suggest to promote sleep for this patient? a. Providing a quiet environment b. Exercising before bedtime to become tired c. Consuming heavy meals in the evening to promote sleepiness d. Drinking hot tea or coffee just before bedtime

A Nonpharmacologic approaches to induce sleep include providing a quiet environment, avoiding heavy exercise before bedtime, avoiding heavy meals late in the evening, and drinking warm decaffeinated drinks, such as warm milk, before bedtime.

The barbiturate phenobarbital is prescribed for a patient with epilepsy. While assessing the patient's current medications, the nurse recognizes that interactions may occur with which drugs? (Select all that apply.) a. Antihistamines b. Opioids c. Diuretics d. Anticoagulants e. Oral contraceptives f. Insulin

A, B, D, E The co-administration of barbiturates and alcohol, antihistamines, benzodiazepines, opioids, and tranquilizers may result in additive CNS depression. Co-administration of anticoagulants and barbiturates can result in decreased anticoagulation response and possible clot formation. Coadministration of barbiturates and oral contraceptives can result in accelerated metabolism of the contraceptive drug and possible unintended pregnancy. There are no interactions with diuretics and insulin

The nurse is administering intravenous vancomycin (Vancocin) to a patient who has had gastrointestinal surgery. Which nursing measures are appropriate? (Select all that apply.) a. Monitoring serum creatinine levels b. Restricting fluids while the patient is on this medication c. Warning the patient that a flushed feeling or facial itching may occur d. Instructing the patient to report dizziness or a feeling of fullness in the ears e. Reporting a trough drug level of 11 mcg/mL and holding the drug f. Reporting a trough drug level of 24 mcg/mL and holding the drug

A, C, D, F Constant monitoring for drug-related neurotoxicity, nephrotoxicity, ototoxicity, and superinfection remain critical to patient safety. Monitor for nephrotoxicity by monitoring serum creatinine levels. Ototoxicity may be indicated if the patient experiences dizziness or a feeling of fullness in the ears, and these symptoms must be reported immediately. Vancomycin infusions may cause red man syndrome, which is characterized by flushing of the neck and face and a decrease in blood pressure. In addition, adequate hydration (at least 2 L of fluids every 24 hours unless contraindicated) is most important to prevent nephrotoxicity. Optimal trough blood levels of vancomycin are 10 to 20 mcg/mL; therefore, the drug should not be administered when there is a trough level of 24 mcg/mL.

A patient will be receiving nitrofurantoin (Macrodantin) treatment for a urinary tract infection. The nurse is reviewing the patient's history and will question the nitrofurantoin order if which disorder is present in the history? (Select all that apply.) a. Liver disease b. Coronary artery disease c. Hyperthyroidism d. Type 1 diabetes mellitus e. Chronic renal disease

A, E Nitrofurantoin is contraindicated in cases of known drug allergy and also in cases of significant renal function impairment, because the drug concentrates in the urine. Because adverse effects include hepatotoxicity, which is rare but often fatal, the nurse should also question the order if liver disease is present. The other options are not contraindications.

The nurse practitioner orders a wet-to-dry normal saline solution (NSS) dressing for a patient who has a stage III pressure ulcer on the sacral area. The patient's daughter will be dressing the wound at home. Which of the following steps should the nurse include in the teaching plan?Select all that apply.a) Cleansing the woundb) Managing painc) Applying a dry sterile dressingd) Using cold water in the bath

AB

The nurse would explain to a patient that effective treatments for atopic pruritus include which treatments?Select all that apply.a) Oral steroidsb) Topical steroidsc) Oral antihistaminesd) Topical antihistaminese) Topical petroleum ointment

AB

The nurse in the skilled nursing facility is very busy and unable to answer the call bell lights. Which tasks related to skin care can the nurse delegate to the nursing assistant?Select all that apply.a) Applying over-the-counter lotions to skin that is not brokenb) Assisting the client with frequent turning to prevent pressure ulcersc) Covering the client who complains of being cold with more blanketsd) Placing a sterile gauze pad over broken skin to contain drainagee) Assessing a patient complaining of an itching rash

ABCD

To help decrease the threat of melanoma in a blonde-haired, fair-skinned patient at risk, which recommendations should the nurse provide? Select all that apply.a) Wear sunglasses.b) Drink plenty of water.c) Eat plenty of foods high in vitamin K.d) Apply sunscreen 30 minutes prior to exposure.e) Consume fish oil and vitamin E.

ADE

The nursery nurse should identify which newborn at significant risk for hypothermic alteration in thermoregulation? a. Large for gestational age b. Low birth weight c. Born at term d. Well nourished

ANS B

What is the most appropriate measure for a nurse to use in assessing core body temperature when there are suspected problems with thermoregulation? a. Oral thermometer b. Rectal thermometer c. Temporal thermometer scan d. Tympanic membrane sensor

ANS B

Which strategies should the nurse include in a community program for senior citizens related to dealing with cold winter temperatures? a. Avoiding hot beverages b. Shopping at an indoor mall c. Using a fan at low speed d. Walking slowly in the park

ANS B

During orientation to an emergency department, the nurse educator would be concerned if the new nurse listed which of the following as a risk factor for impaired thermoregulation? a. Impaired cognition b. Occupational exposure c. Physical agility d. Temperature extremes

ANS C

The nurse admitting a patient to the emergency department on a very hot summer day would suspect hyperthermia when the patient demonstrates which assessment finding? a. Decreased respirations b. Low pulse rate c. Red, sweaty skin d. Slow capillary refill

ANS C

A volunteer at the senior center asks the visiting nurse why the senior citizens always seem to be complaining about the temperature. What is the nurse's best response? a. Older people have a diminished ability to regulate body temperature because of active sweat glands. b. Older people have a diminished ability to regulate body temperature because of increased circulation. c. Older people have a diminished ability to regulate body temperature because of peripheral vasoconstriction. d. Older people have a diminished ability to regulate body temperature because of slower metabolic rates.

ANS D

The nurse planning care for a patient with hypothermia should consider what similar exemplar? a. Heat exhaustion b. Heat stroke c. Infection d. Prematurity

ANS D

What is the priority nursing action for a patient suspected to be hypothermic? a. Assess vital signs. b. Hydrate with intravenous (IV) fluids. c. Provide a warm blanket. d. Remove wet clothes.

ANS D

A patient is to receive prednisone 7.5 mg PO daily. The tablets are available in a 2.5- mg strength. Identify how many tablets will the patient receive. _______

ANS: 3 tablets

The prescriber writes this order, "Give amantadine (Symmetrel) 100 mg per PEG tube twice a day." The medication is available in a liquid form with a concentration 50 mg/5 mL. Identify how many milliliters will the nurse give with each dose. _______

ANS: 10 mL

A patient's temperature has been 101° F (38.3° C) for several days. The patient's normal caloric intake to meet nutritional needs is 2000 calories per day. Knowing that the metabolic rate increases 7% for each Fahrenheit degree above 100° in body temperature, how many total calories should the patient receive each day?

ANS: 2140 calories

A patient who has an infected abdominal wound develops a temperature of 104° F (40° C). All the following interventions are included in the patient's plan of care. In which order should the nurse perform the following actions? (Put a comma and a space between each answer choice [A, B, C, D]). a. Administer IV antibiotics. b. Sponge patient with cool water. c. Perform wet-to-dry dressing change. d. Administer acetaminophen (Tylenol).

ANS: A, D, B, C The first action should be to administer the antibiotic because treating the infection that has caused the fever is the most important aspect of fever management. The next priority is to lower the high fever, so the nurse should administer acetaminophen to lower the temperature set point. A cool sponge bath should be done after the acetaminophen is given to lower the temperature further. The wet-to-dry dressing change will not have an immediate impact on the infection or fever and should be done last

A nurse is monitoring intracranial pressure. A nurse recalls the normal upper limit of intracranial pressure is _______ mm Hg.

ANS: 14

When a patient wants to know how many vertebrae make up the vertebral column, the nurse responds with _____.

ANS: 33

A hospitalized patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first? a. Start the prescribed PRN O2 at 6 L/min. b. Put a moist hot pack on the patient's neck. c. Give the ordered PRN acetaminophen (Tylenol). d. Notify the patient's health care provider immediately.

ANS: A Acute treatment for cluster headache is administration of 100% O2 at 6 to 8 L/min. If the patient obtains relief with the O2, there is no immediate need to notify the health care provider. Cluster headaches last only 60 to 90 minutes, so oral pain medications have minimal effect. Hot packs are helpful for tension headaches but are not as likely to reduce pain associated with a cluster headache.

The nurse working in the dermatology clinic assesses a young adult female patient who has severe cystic acne. Which assessment finding is of concern related to the patient's prescribed isotretinoin? a. the patient recently had an IUD removed b. the patient already has some acne scarring on her forehead c. the patient has also used topical antibiotics to treat the acne d. the patient has a strong family history of rheumatoid arthritis

ANS: A Because isotretinoin is teratogenic, contraception is required for women who are using this medication

A patient in the dermatology clinic has a thin, scaly erythematous plaque on the right cheek. Which action should the nurse take? a. prepare the patient for a skin biopsy b. teach the use of corticosteroid cream c. explain how to apply tretinoin to the face d. discuss the need for topical application of antibiotics

ANS: A Because the appearance of the lesion is suggestive of actinic keratosis or possible squamous cell carcinoma, the appropriate treatment would be excision and biopsy

A patient is experiencing status epilepticus. The nurse prepares to give which drug of choice for the treatment of this condition? a.diazepam (Valium) b.midazolam (Versed) c.valproic acid (Depakote) d.carbamazepine (Tegretol)

ANS: A Diazepam (Valium) is considered by many to be the drug of choice for status epilepticus. Other drugs that are used are listed in Table 14-3 and do not include the drugs listed in the other options.

Which statement indicates a correct understanding of antibodies? The most abundant class of antibody in the serum is: a. IgG. b. IgM. c. IgA. d. IgE.

ANS: A IgG is the most abundant class of immunoglobulins, constituting 80-85% of the immunoglobulins in the blood.

A patient is taking gabapentin (Neurontin), and the nurse notes that there is no history of seizures on his medical record. What is the best possible rationale for this medication order? a.The medication is used for the treatment of neuropathic pain. b.The medication is helpful for the treatment of multiple sclerosis. c.The medication is used to reduce the symptoms of Parkinson's disease. d.The medical record is missing the correct information about the patient's history of seizures.

ANS: A Gabapentin (Neurontin) is commonly used to treat neuropathic pain. The other options are incorrect.

Phenytoin (Dilantin) has a narrow therapeutic index. The nurse recognizes that this characteristic means that a.the safe and the toxic plasma levels of the drug are very close to each other. b.phenytoin has a low chance of being effective. c.there is no difference between safe and toxic plasma levels. d.a very small dosage can result in the desired therapeutic effect.

ANS: A Having a "narrow therapeutic index" means that there is a small difference between safe and toxic drug levels. These drugs require monitoring of therapeutic plasma levels. The other options are incorrect.

The U.S. Food and Drug Administration has issued a warning for users of antiepileptic drugs. Based on this report, the nurse will monitor for which potential problems with this class of drugs? a.Increased risk of suicidal thoughts and behaviors b.Signs of bone marrow depression c.Indications of drug addiction and dependency d.Increased risk of cardiovascular events, such as strokes

ANS: A In December 2008, the U.S. Food and Drug Administration (FDA) required black box warnings on all antiepileptic drugs regarding the risk of suicidal thoughts and behaviors. Patients being treated with antiepileptic drugs for any indication need to be monitored for the emergence or worsening of depression, suicidal thoughts or behavior, or any unusual changes in mood or behavior. The other options are incorrect.

The nurse has given medication instructions to a patient receiving phenytoin (Dilantin). Which statement by the patient indicates that the patient has an adequate understanding? a."I will need to take extra care of my teeth and gums while on this medication." b."I can go out for a beer while on this medication." c."I can skip doses if the side effects bother me." d."I will be able to stop taking this drug once the seizures stop."

ANS: A Scrupulous dental care is necessary to prevent gingival hypertrophy during therapy with phenytoin. Alcohol and other central nervous system depressants may cause severe sedation. Consistent dosing is important to maintain therapeutic drug levels. Therapy with AEDs usually must continue for life and must not be stopped once seizures stop.

The nurse notes white lesions that resemble milk curds in the back of the patient's throat. Which question by the nurse is appropriate at this time? a. "Are you taking any medications?" b. "Do you have a productive cough?" c. "How often do you brush your teeth?" d. "Have you had an oral herpes infection?"

ANS: A The appearance of the lesions is consistent with an oral candidiasis infection, which can occur in patients who are taking medications such as immunosuppressants or antibiotics

A patient with a new prescription for a diuretic has just reviewed with the nurse how to include more potassium in her diet. This reflects learning in which domain? a. Cognitive b. Affective c. Physical d. Psychomotor

ANS: A The cognitive domain refers to problem-solving abilities and may involve recall and knowledge of facts. The affective domain refers to values and beliefs. The term physical does not refer to one of the learning domains. The psychomotor domain involves behaviors such as learning how to perform a procedure.

Which information should the nurse include when teaching a patient who has just received a prescription for ciprofloxacin to treat a urinary tract infection? a. use a sunscreen with a high SPF when exposed to the sun b. sun exposure may decrease the effectiveness of the medication c. photosensitivity may result in an artificial-looking tan appearance d. wear sunglasses to avoid eye damage while taking this medication

ANS: A The patient should stay out of the sun

Which instructions should the nurse include in the teaching plan for a patient with impetigo? a. clean the crusted areas with soap and water b. spread alcohol-based cleansers on the lesions c. avoid use of antibiotic ointments on the lesions d. use petroleum jelly to soften the crusty areas

ANS: A The treatment for impetigo includes the softening of the crusts with warm saline soaks and then soap-and-water removal

A patient with atopic dermatitis has been using a high-potency topical corticosteroid ointment for several weeks. The nurse should assess for which adverse effect? a. thinning of the affected area b. alopecia of the affected area c. dryness and scaling in the area d. reddish-brown skin discoloration

ANS: A Thinning of the skin indicates atrophy, a possible adverse effect of topical corticosteroids

An 8-year-old female presents with edema of the cutaneous and mucosal tissue layers. Her mother reports that the condition is recurrent and seems to occur more often during stressful situations. The child is diagnosed with hereditary angioedema. Which of the following is deficient in this child? a. C1 esterase inhibitor b. Carboxypeptidase c. Neutrophils d. Plasmin

ANS: A A genetic defect in C1 esterase inhibitor (C1 INH deficiency) results in hereditary angioedema. Hereditary angioedema is due to C1 esterase inhibitor. Carboxypeptidase degrades kinins. Hereditary angioedema is due to C1 esterase inhibitor, not a disorder of neutrophils. Plasmin is not associated with hereditary angioedema, but is associated with clots.

When planning to evaluate a patient's satisfaction with a teaching activity, the most appropriate strategy would be to a. include a survey instrument. b. observe for level of skill mastery. c. present information more than one time. d. provide for a return demonstration.

ANS: A A survey or questionnaires can be used to measure affective behavior change as well as patient satisfaction with the teaching experience. Observing for level of skill mastery would evaluate achievement of a psychomotor goal rather than satisfaction with the experience. Repeating information more than one time or in more than one way may be appropriate strategies to include in the teaching plan but would provide no evaluation data. Providing for a return demonstration would help in evaluating achievement of a psychomotor goal, not satisfaction with the activity.

Which patient will develop active immunity? A patient who: a. has natural exposure to an antigen or receives an immunization. b. receives preformed antibodies or T cells from a donor. c. has T cells that become B cells. d. receives immunoglobulin.

ANS: A Active immunity occurs either after natural exposure to an antigen or after immunization, not with preformed antibodies or the transformation of T cells into B cells or as a result of receiving immunoglobulin.

A patient is admitted to the hospital with acute rejection of a kidney transplant. Which intervention will the nurse prepare for this patient? a. Administration of immunosuppressant medications b. Insertion of an arteriovenous graft for hemodialysis c. Placement of the patient on the transplant waiting list d. A blood draw for human leukocyte antigen (HLA) matching

ANS: A Acute rejection is treated with the administration of additional immunosuppressant drugs such as corticosteroids. Because acute rejection is potentially reversible, there is no indication that the patient will require another transplant or hemodialysis. There is no indication for repeat HLA testing.

A nurse notes that a patient walks with the leg extended and held stiff, causing a scraping over the floor surface. What type of gait is the patient experiencing? a. Spastic gait b. Cerebellar gait c. Basal ganglion gait d. Scissors gait

ANS: A An individual who walks with the leg extended and held stiff, causing a scraping over the floor surface, is experiencing a spastic gait. A cerebellar gait is wide based with the feet apart and often turned outward or inward for greater stability. A basal ganglion gait occurs when the person walks with small steps and a decreased arm swing. A scissors gait is associated with bilateral injury and spasticity. The legs are abducted so they touch each other. REF: p. 385

A 6-year-old female is diagnosed with a bacterial infection of the respiratory system. Which of the following will most likely try to fight the antigen? a. Antibodies b. Cytotoxic T cells c. Self-antigens d. Helper T cells

ANS: A Antibodies are produced by plasma cells that mature from lymphocytes, called B lymphocytes (B cells), in response to an antigen. Cytotoxic T cells do not respond to antigens. Self-antigens do not respond to antigens. Helper T cells do not respond to antigens.

Blockage of which of the following would cause hydrocephalus? a. Cerebral aqueduct b. Inferior colliculi c. Red nucleus d. Tegmentum

ANS: A Blockage of the cerebral aqueduct leads to hydrocephalus. Hydrocephalus is not a result of dysfunction of the inferior colliculi, red nucleus, or tegmentum.

When phagocytes begin to stick avidly to capillary walls, which process is occurring? a. Margination b. Exudation c. Integration d. Emigration

ANS: A Both leukocytes and endothelial cells secrete substances that increase adhesion, or stickiness, causing the leukocytes to adhere more avidly to the endothelial cells in the walls of the capillaries and venules in a process called margination. Exudation is the process of pus formation and does not result in stickiness. Integration occurs in cells but is not a major function and does not lead to stickiness. Emigration is similar to diapedesis and is not associated with increased stickiness.

A patient has researched bradykinin on the Internet. Which information indicates the patient understands the functions of bradykinin? Bradykinin is involved in: a. Increasing vascular permeability b. Vasoconstricting blood vessels c. Stimulating the clotting system d. Increasing degradation of prostaglandins

ANS: A Bradykinin increases vascular permeability. Bradykinin increases vascular permeability; it does not promote vasoconstriction. Bradykinin increases vascular permeability; it does not stimulate clotting. Bradykinin promotes pain; thus, it does not degrade prostaglandins but supports them.

For legal purposes, brain death is defined as: a. cessation of entire brain function. b. lack of cortical function. c. a consistent vegetative state (VS). d. death of the brainstem.

ANS: A Brain death occurs when there is cessation of function of the entire brain, including the brainstem and cerebellum. Lack of cortical function or brainstem death is not enough to define brain death. A VS is complete unawareness of the self or surrounding environment and complete loss of cognitive function. REF: p. 364

The patient is experiencing an increase in intracranial pressure. This increase results in: a. brain tissue hypoxia. b. intracranial hypotension. c. ventricular swelling. d. expansion of the cranial vault.

ANS: A Brain tissue hypoxia occurs as a result of increased intracranial pressure as it places pressure on the brain. Increased intracranial pressure leads to intracranial hypertension. Ventricular swelling may lead to increased intracranial pressure, but increased pressure does not lead to either ventricular swelling or the expansion of the cranial vault. REF: p. 374

A patient taking entacapone (Comtan) for the first time calls the clinic to report a dark discoloration of his urine. After listening to the patient, the nurse realizes that what is happening in this situation? a. This is a harmless effect of the drug. b. The patient has taken this drug along with red wine or cheese. c. The patient is having an allergic reaction to the drug. d. The ordered dose is too high for this patient.

ANS: A COMT inhibitors, including entacapone, may darken a patient's urine and sweat.

Cerebrospinal fluid (CSF) can accumulate around the brain when there is injury to the sites of CSF reabsorption, which are called the: a. arachnoid villi. b. epidural foramina. c. lateral apertures. d. choroid plexuses.

ANS: A CSF is reabsorbed through a pressure gradient between the arachnoid villi and the cerebral venous sinuses. CSF absorption does not occur in the epidural foramina, the lateral apertures, or the choroid plexuses.

The directional migration of leukocytes along a chemical gradient is termed: a. Chemotaxis b. Endocytosis c. Margination d. Diapedesis

ANS: A Chemotaxis is the process by which leukocytes undergo directed migration. Endocytosis is a form of engulfment and a part of phagocytosis. Margination occurs when leukocytes adhere to endothelial cells in the walls of vessels. Diapedesis is the emigration of the cells through cell junctions that have loosened in response to inflammatory mediators.

The breathing pattern that reflects respirations based primarily on carbon dioxide (CO2) levels in the blood is: a. Cheyne-Stokes. b. ataxic. c. central neurogenic. d. normal.

ANS: A Cheyne-Stokes respirations occur as a result of CO2 levels in the blood. Ataxic breathing occurs as a result of dysfunction of the medullary neurons. Central neurogenic patterns occur as a result of uncal herniation. Normal respirations are based on the levels of oxygen (O2) in the blood. REF: p. 361

A 3-year-old is making play cakes in a sandbox and is eating the play cakes. The sand was also being used by cats as a litter box and was contaminated with toxoplasmosis. Which of the following would most likely also be present? a. Granuloma formation b. Degranulation c. Blood clots d. Exudate production

ANS: A Infections caused by bacteria such as toxoplasmosis can result in granuloma formation. Degranulation is a part of mast cell destruction. Blood clots are not expected with chronic inflammation. Exudate production is pus formation.

When admitting a patient with stage III pressure ulcers on both heels, which information obtained by the nurse will have the most impact on wound healing? a. The patient takes insulin daily. b. The patient states that the ulcers are very painful. c. The patient has had the heel ulcers for the last 6 months. d. The patient has several old incisions that have formed keloids.

ANS: A Chronic insulin use indicates diabetes, which can interfere with wound healing. The persistence of the ulcers over the last 6 months is a concern, but changes in care may be effective in promoting healing. Keloids are not disabling or painful, although the cosmetic effects may be distressing for some patients. Actions to reduce the patient's pain will be implemented, but pain does not directly affect wound healing

A nursing instructor assigns their clinical group the task of writing a journal depicting the student's clinical day. What is the most likely rationale for this assignment? a. Journaling allows reflection, an important critical thinking skill. b. Journaling gives you time to review what happened in your clinical. c. Journaling is a way to organize your thoughts about your experiences. d. Journaling teaches open-mindedness, a critical thinking disposition.

ANS: A Critical thinking requires reflection on what occurred, how data were processed, and how decisions were made. Journaling is one method of developing critical thinking skills. Journaling does give nurses time to review what happened in their clinical, but this statement does not go far enough in explaining the importance of the journal-writing process. Journaling may be a way to organize thoughts about one's experiences, but this statement is too narrow an explanation and does not account for the critical aspect of reflection. Open-mindedness is a critical thinking disposition that allows one to be tolerant of divergent views. Journaling can assist with developing this disposition, but only if what is written reflects that specific topic.

The nurse teaches a patient about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions? a. "After a couple of years, it is likely that I will be able to stop taking the cyclosporine." b. "If I develop an acute rejection episode, I will need to have other types of drugs given IV." c. "I need to be monitored closely because I have a greater chance of developing malignant tumors." d. "The drugs are given in combination because they inhibit different ways the kidney can be rejected."

ANS: A Cyclosporine, a calcineurin inhibitor, will need to be continued for life. The other patient statements are accurate and indicate that no further teaching is necessary about those topics.

A patient with an addiction to alcohol checked into a rehabilitation center as a result of experiencing delirium, inability to concentrate, and being easily distracted. What term would be used to document this state? a. Acute confusional state b. Echolalia c. Dementia d. Dysphagia

ANS: A Delirium and the inability to concentrate are characteristics of acute confusional state. Echolalia is the repeating of words and phrases. Dementia is characterized by loss of recent and remote memory. Dysphagia is difficulty speaking. REF: p. 367, Box 15-3

A home care nurse receives a physician order for a medication that the patient does not want to take because the patient has a history of side effects from this medication. The nurse carefully listens to the patient, considers it in light of the patient's condition, questions its appropriateness, and examines alternative treatments. This nurse would most likely a. call the physician, explain rationale, and suggest a different medication. b. consult an experienced nurse on whether there are other similar treatments. c. hold the drug until the physician returns to the unit and can be questioned. d. question other staff as to the physician's acceptance of nursing input.

ANS: A Determining how best to proceed on behalf of a patient's best health care outcomes may require clinical judgment. At the committed level of critical thinking, the nurse chooses an action after all possibilities have been examined. A home care nurse who is using good clinical judgment techniques should have confidence in their decision and may not have another nurse available as this is an autonomous setting. Holding the drug might jeopardize the patient's health, so this is not the best solution. The nurse working at this level of critical thinking makes choices based on careful examination of situations and alternatives; whether or not the physician is open to nursing input is not relevant.

A patient who has diabetes is admitted for an exploratory laparotomy for abdominal pain. When planning interventions to promote wound healing, what is the nurse's highest priority? a. Maintaining the patient's blood glucose within a normal range b. Ensuring that the patient has an adequate dietary protein intake c. Giving antipyretics to keep the temperature less than 102° F (38.9° C) d. Redressing the surgical incision with a dry, sterile dressing twice daily

ANS: A Elevated blood glucose will have an impact on multiple factors involved in wound healing. Ensuring adequate nutrition also is important for the postoperative patient, but a higher priority is blood glucose control. A temperature of 102° F will not impact adversely on wound healing, although the nurse may administer antipyretics if the patient is uncomfortable. Application of a dry, sterile dressing daily may be ordered, but frequent dressing changes for a wound healing by primary intention is not necessary to promote wound healing

An immunologist is discussing endotoxin production. Which information should the immunologist include? Endotoxins are produced by: a. gram-negative bacteria. b. gram-positive bacteria. c. gram-negative fungi. d. gram-positive fungi.

ANS: A Endotoxins are produced by gram-negative bacteria. They are not produced by gram-positive bacteria or any type of fungi.

On admission to the clinic, the nurse notes a moderate amount of serous exudate leaking from the patient's wound. The nurse realizes that this fluid a. contains the materials used by the body in the initial inflammatory response. b. indicates that the patient has an infection at the site of the wound. c. is destroying healthy tissue. d. results from ineffective cleansing of the wound area.

ANS: A Exudate is fluid moved from the vascular spaces to the area around a wound. It contains the proteins, fluid, and white blood cells (WBCs) needed to contain possible pathogens at the site of injury. Exudate appears as part of all inflammatory responses and does not mean an infection is present. Exudate is part of normal inflammatory responses which contain self-monitoring mechanisms to help prevent damage to healthy tissue. Exudate appears at wound sites regardless of cleaning done to the area of injury.

An immunology nurse is caring for a patient. While planning care, which principle will the nurse remember? The primary role of IgA1 is to prevent infections in the: a. blood. b. kidneys. c. lungs. d. mucous membranes.

ANS: A IgA1 is found predominantly in the blood.

An infant develops a fever secondary to a bacterial infection. Which of the following most likely triggered the fever? a. Interleukin-1 b. Interleukin-6 c. Interleukin-10 d. Interferons (INFs)

ANS: A Interleukin-1 is responsible for fever production. Interleukin-6 stimulates growth and differentiation of blood cells. Interleukin-10 helps decrease the immune response. INFs are members of a family of cytokines that protect against viral infections.

A new graduate nurse (GN) is working with an experienced nurse to chart assessment findings. The GN notes that the physical therapist wrote on the chart that the patient is lazy and did not want to participate in assigned therapies this AM. The experienced nurse asks the GN what may be going on here. What is the best explanation for this statement? a. Data on the chart can sometimes be documented in a biased manner. b. Data on the chart changes as the patient's condition changes. c. Data on the chart is usually accurate and can be verified from the patient. d. Reading the chart is not a wise use of time as this can be time consuming and tedious.

ANS: A It is important that the nurse records only what is assessed, without adding judgments or interpretations to the record. Data do indeed change (and need to be charted) as the patient's condition changes, but this would not be the best answer to this question. Assessment data may at times be difficult to obtain, but that would not occur often enough to warrant a warning about the difficulty in charting it. Also, obtaining data is clearly a different activity from charting it. Charting can be time consuming and tedious, but this is not the most complete answer to this question.

When a student asks in which region of the neuron do nerve impulses travel the fastest, how should the nurse respond? The: a. large axon. b. axon hillock. c. cell body. d. dendrites.

ANS: A Large axons transmit impulses at a faster rate than cell bodies. The axon hillock has a low threshold level. The dendrites carry impulses toward the cell body, but not as quickly as large axons.

A student nurse is studying clinical judgment theories and is working with Tanner's Model of Clinical Judgment. The student nurse can generalize the process as a. a reflective process where the nurse notices, interprets, responds, and reflects in action. b. one conceptual mechanism for critiquing ideas and establishing goal-oriented care. c. researching best practice literature to create care pathways for certain populations. d. assessing, diagnosing, implementing, and evaluating the nursing care plans.

ANS: A Looking across theories and definitions of clinical judgment, they all have in common the ability to reflect on data and choose actions. Reflection also considers evaluating the result of the actions to determine whether they were effective. Although critiquing ideas and establishing goal-oriented care could be considered part of a generalized statement of critical thinking, this is not broad enough without the reflection and evaluation. Clinical judgment would most likely be used to create care paths derived from the evidence; however, this is not the cornerstone of the Tanner Model. Clinical judgment is used when engaging in the nursing process, but this is too narrow in focus to capture the essence of critical thinking definitions and theories. Critical thinking is not synonymous with the nursing process.

For evaporation to function effectively as a means of dissipating excess body heat, which one of the following conditions must be present? a. Moisture b. Fever c. Pyrogens d. Trauma

ANS: A Moisture must be present because heat is lost through evaporation from the surface of skin and lining of mucous membranes, a major source of heat reduction connected with increased sweating in warmer surroundings. Fever is not required for evaporation to occur, but moisture is. Pyrogens are heat producers and do not assist with evaporation, but moisture is required. Trauma is not a portion of the evaporative process of heat loss. REF: p. 343, Table 14-5

Neurotransmitters interact with the postsynaptic membrane by binding to which structure? a. Receptor b. Nissl body c. Glial cell d. Neurofibril

ANS: A Neurotransmitters bind to a receptor. The Nissl body is involved in protein synthesis. Neurotransmitters do not bind to glial cells. Neurofibrils provide support for the neuron.

A patient is admitted to the neurological critical care unit with a severe closed head injury. When an intraventricular catheter is inserted, the intracranial pressure (ICP) is recorded at 24 mm Hg. How should the nurse interpret this reading? a. Higher than normal b. Lower than normal c. Normal d. Borderline

ANS: A Normal ICP is 1-15 mm Hg; at 24 mm Hg, the patient's ICP is higher than normal. REF: p. 374, Box, 15-4

A nurse has committed a serious medication error and has reported their error to the hospital's adverse medication error hotline as well as to the unit manager. The manager is a firm believer in developing critical thinking skills. From this standpoint, what action by the manager would best nurture this ability in the nurse who made the error? a. Have the nurse present an in-service related to the cause of the error. b. Instruct the nurse to write a paper on how to avoid this type of error. c. Let the nurse work with more experienced nurses when giving medications. d. Send the nurse to refresher courses on medication administration.

ANS: A Nurturing critical thinking skills is done in part by turning errors into learning opportunities. If the nurse presents an in-service on the cause and prevention of the type of error committed, not only will the nurse learn something but many others nurses on the unit will learn from it to. This is the best example of developing critical thinking skills. This option would allow the nurse to learn from the mistake, which is a method of developing critical thinking skills, but the paper would benefit only the nurse, so this option is not the best choice. Letting the nurse work with more experienced nurses might be a good option in a very limited setting, for example, if the nurse is relatively new and the manager discovers a deficiency in the nurse's orientation or training on giving medications in that system. Otherwise, this option would not really be beneficial. Sending the nurse to refresher courses might be a solution, but it is directed at the nurse's learning, not critical thinking. The nurse might feel resentful at having to attend such classes, but even if they were helpful, only this one nurse is learning. Going to generic classes also does not address the specific reason this error occurred, and thus might be irrelevant. Critical thinking and learning can be enhanced by a presentation to the staff on the causes of the error.

A patient has paralysis of both legs. What type of paralysis does the patient have? a. Paraplegia b. Quadriplegia c. Infraparaplegia d. Paresthesia

ANS: A Paraplegia is the paralysis of both legs. Quadriplegia is the paralysis of all four extremities. Infraparaplegia is not a description of paralysis. Paresthesia is a loss of sensation, not paralysis. REF: p. 382, Box 15-6

Which are appropriate considerations when the nurse is assessing the learning needs of a patient? (Select all that apply.) a. Cultural background b. Family history c. Level of education d. Readiness to learn e. Health beliefs

ANS: A, C, D, E Family history is not a part of what the nurse considers when assessing learning needs. The other options are appropriate to consider when the nurse is assessing learning needs.

A GN appears to be second-guessing herself and is constantly calling on the other nurses to double-check their plan of care or rehearse what they will say to the doctor before she call on the patient's behalf. This seems to be annoying some of the nurse's coworkers. The nurse manager's best response to this situation is to a. explain to coworkers that this is a characteristic of critical thinking and is important for the GN to improve reasoning skills. b. agree with the staff and have someone follow and work more closely with a preceptor. c. have a talk with the nurse and suggest asking fewer questions. d. tell the staff that all new nurses go through this phase, and ignore their behavior.

ANS: A Reflection-on-action is critical for development of knowledge and improvement in reasoning. It is where learning from practice is incorporated into experience. Inquisitiveness is a characteristic of critical thinking and reflects a desire to learn even when the knowledge may not appear readily useful. The manager should promote this. Suggesting the nurse work more closely with a preceptor implies that the manager thinks the nurse needs to learn more and increase confidence. In reality, this nurse is demonstrating a characteristic of critical thinking. Suggesting that the nurse ask fewer questions would hamper the development of the nurse as a critical thinker. All new nurses do go through a phase of asking more questions at one time, but dismissing the nurse's behavior with this explanation is simplistic and will discourage critical thinking.

A patient is being evaluated for possible atopic dermatitis. The nurse expects elevation of which laboratory value? a. IgE b. IgA c. Basophils d. Neutrophils

ANS: A Serum IgE is elevated in an allergic response (type 1 hypersensitivity disorders). The eosinophil level will be elevated rather than neutrophil or basophil counts. IgA is located in body secretions and would not be tested when evaluating a patient who has symptoms of atopic dermatitis.

A patient arrives in the emergency department with a swollen ankle after an injury incurred while playing soccer. Which action by the nurse is most appropriate? a. Elevate the ankle above heart level. b. Apply a warm moist pack to the ankle. c. Assess the ankle's range of motion (ROM). d. Assess whether the patient can bear weight on the affected ankle.

ANS: A Soft tissue injuries are treated with rest, ice, compression, and elevation (RICE). Elevation of the ankle will decrease tissue swelling. Moving the ankle through the ROM will increase swelling and risk further injury. Cold packs should be applied the first 24 hours to reduce swelling. The nurse should not ask the patient to move or bear weight on the swollen ankle because immobilization of the inflamed or injured area promotes healing by decreasing metabolic needs of the tissues

A 25-year-old female has sexual relations with her boyfriend. Later she is told that the boyfriend is infected with Neisseria gonorrhoeae. Testing reveals that she does not have the disease. How is it possible that she did not contract the disease? a. Antibodies covered sites of attachment. b. She was vaccinated against it. c. Platelets provided protection. d. IgE was released.

ANS: A Some bacteria, such as Neisseria gonorrhoeae that causes gonorrhea, must attach to specific sites on urogenital epithelial cells. Antibodies may protect the host by covering sites on the microorganism that are needed for attachment, thereby preventing infection. Neither a vaccination, the protection of platelets, nor the release of IgE was relevant to the client's ability to avoid contracting this disease.

When a patient's vagus nerve is stimulated, what does the nurse expect to observe? a. Increased gastrointestinal activity b. Increased heart rate c. Pupil constriction d. Vasoconstriction

ANS: A Stimulation of the vagus nerve increases gastrointestinal activity. Stimulation of the vagus decreases heart rate, causes pupil dilation, and leads to vasodilation.

A nurse is preparing to teach about nerves. Which information should the nurse include? The axon leaves the cell body at the: a. axon hillock. b. Nissl body. c. node of Ranvier. d. myelin sheath.

ANS: A The axon hillock is the cone-shaped process where the axon leaves the cell body. The Nissl body is involved in protein synthesis. Axons branch at the node of Ranvier. The myelin sheath covers the entire membrane.

The complement, clotting, and kinin systems share which of the following characteristics? a. Activation of a series of proenzymes b. Phagocytosis initiation c. Granulocyte production d. Activated by interferon

ANS: A The complement system, the clotting system, and the kinin system are normally in inactive forms, but can activate in a series as proenzymes and are involved in the inflammatory process. The complement system, the clotting system, and the kinin system do not play a role in phagocytosis, but do play a role in the inflammatory response as proenzymes. The complement system, the clotting system, and tje kinin system do not play a role in granulocyte production, but they function as proenzymes in the inflammatory response. The complement system, the clotting system, and the kinin system are not activated by interferon, but are activated by enzymatic action.

A patient has an open surgical wound on the abdomen that contains deep pink granulation tissue. How would the nurse document this wound? a. Red wound b. Yellow wound c. Full-thickness wound d. Stage III pressure ulcer

ANS: A The description is consistent with a red wound. A stage III pressure ulcer would expose subcutaneous fat. A yellow wound would have creamy colored exudate. A full-thickness wound involves subcutaneous tissue, which is not indicated in the wound description

What term should the nurse use when talking about the outermost membrane surrounding the brain? a. Dura mater b. Arachnoid mater c. Pia mater d. Falx cerebri

ANS: A The dura mater is the outer layer of the brain. The arachnoid is a spongy, web-like structure that loosely follows the contours of the cerebral structures. The pia mater adheres to the contours of the brain. The falx cerebri dips between the two cerebral hemispheres along the longitudinal fissure.

A 20-year-old male received a knife wound to the arm during an altercation. Which of the following types of immunity was compromised? a. Innate immunity b. Inflammatory response c. Adaptive immunity d. Specific immunity

ANS: A The epithelial cells of the skin are a part of innate immunity. The inflammatory response is not a type of immunity. Adaptive immunity is represented by the normal flora of the bowel. Specific immunity is a type of adaptive immunity and is not associated with a break in skin integrity.

What term is used to describe an explosive, disorderly discharge of cortical neurons? a. Reflex b. Seizure c. Inattentiveness d. Brain death

ANS: B An explosive, disorderly discharge of cortical neurons is a seizure. A reflex is an expected response. Inattentiveness is a form of neglect. Brain death is a cessation of function. REF: p. 372

A patient with an open leg wound has a white blood cell (WBC) count of 13, 500/µL and a band count of 11%. What action should the nurse take first? a. Obtain wound cultures. b. Start antibiotic therapy. c. Redress the wound with wet-to-dry dressings. d. Continue to monitor the wound for purulent drainage.

ANS: A The increase in WBC count with the increased bands (shift to the left) indicates that the patient probably has a bacterial infection, and the nurse should obtain wound cultures. Antibiotic therapy and/or dressing changes may be started, but cultures should be done first. The nurse will continue to monitor the wound, but additional actions are needed as well

A patient who has received allergen testing using the cutaneous scratch method has developed itching and swelling at the skin site. Which action should the nurse take first? a. Administer epinephrine. b. Apply topical hydrocortisone. c. Monitor the patient for lower extremity edema. d. Ask the patient about exposure to any new lotions or soaps.

ANS: A The initial symptoms of anaphylaxis are itching and edema at the site of the exposure. Hypotension, tachycardia, dilated pupils, and wheezes occur later. Rapid administration of epinephrine when excessive itching or swelling at the skin site is observed can prevent the progression to anaphylaxis. Topical hydrocortisone would not deter an anaphylactic reaction. Exposure to lotions and soaps does not address the immediate concern of a possible anaphylactic reaction. The nurse should not wait and observe for edema. The nurse should act immediately in order to prevent progression to anaphylaxis.

A student nurse asks the nurse what controls reflex activities concerned with heart rate and blood pressure. What is the nurse's best response? These reflex activities are controlled by the: a. medulla oblongata. b. pons. c. midbrain. d. cerebrum.

ANS: A The medulla oblongata, not the pons, controls reflex activities, such as heart rate, respiration, blood pressure, coughing, sneezing, swallowing, and vomiting. The midbrain is primarily a relay center for motor and sensory tracts, as well as a center for auditory and visual reflexes. The cerebrum plays a role in the transfer of information.

Ten days after receiving a bone marrow transplant, a patient develops a skin rash. What would the nurse suspect is the cause of this patient's skin rash? a. The donor T cells are attacking the patient's skin cells. b. The patient's antibodies are rejecting the donor bone marrow. c. The patient is experiencing a delayed hypersensitivity reaction. d. The patient will need treatment to prevent hyperacute rejection.

ANS: A The patient's history and symptoms indicate that the patient is experiencing graft-versus-host disease, in which the donated T cells attack the patient's tissues. The history and symptoms are not consistent with rejection or delayed hypersensitivity

An older adult patient who is having an annual check-up tells the nurse, "I feel fine, and I don't want to pay for all these unnecessary cancer screening tests!" Which information should the nurse plan to teach this patient? a. Consequences of aging on cell-mediated immunity b. Decrease in antibody production associated with aging c. Impact of poor nutrition on immune function in older people d. Incidence of cancer-stimulating infections in older individuals

ANS: A The primary impact of aging on immune function is on T cells, which are important for immune surveillance and tumor immunity. Antibody function is not affected as much by aging. Poor nutrition can also contribute to decreased immunity, but there is no evidence that it is a contributing factor for this patient. Although some types of cancer are associated with specific infections, this patient does not have an active infection.

A nurse is discussing the membrane that separates the cerebellum from the cerebrum. What term should the nurse use to describe this membrane? a. Tentorium cerebelli b. Falx cerebri c. Arachnoid membrane d. Temporal lobe

ANS: A The tentorium cerebelli, a common landmark, is a membrane that separates the cerebellum below from the cerebral structures above. The cerebellum is not separated by the falx cerebri, the arachnoid membrane, or the temporal lobe.

Which finding is most important for the nurse to communicate to the health care provider when caring for a patient who is receiving negative pressure wound therapy? a. Low serum albumin level b. Serosanguineous drainage c. Deep red and moist wound bed d. Cobblestone appearance of wound

ANS: A With negative pressure therapy, serum protein levels may decrease, which will adversely affect wound healing. The other findings are expected with wound healing

A patient begins taking a new drug that causes pupil dilation, vasoconstriction, decreased gastrointestinal motility, and goose bumps. Which of the following receptors are activated? a. α1 b. Α2 c. β1 d. Β2

ANS: A α1 stimulation leads to pupil dilation. α2 stimulation leads to inhibition of intestinal secretions. β1 stimulation leads to miosis or pupillary constriction. β2 stimulation leads to pupillary constriction.

After change-of-shift report, which patient should the nurse assess first? a. Patient with myasthenia gravis who is reporting increased muscle weakness b. Patient with a bilateral headache described as "like a band around my head" c. Patient with seizures who is scheduled to receive a dose of phenytoin (Dilantin) d. Patient with Parkinson's disease who has developed cogwheel rigidity of the arms

ANS: A Because increased muscle weakness may indicate the onset of a myasthenic crisis, the nurse should assess this patient first.

A patient has been taking phenytoin (Dilantin) for 2 years. Which action will the nurse take when evaluating for adverse effects of the medication? a. Inspect the oral mucosa. b. Listen to the lung sounds. c. Auscultate the bowel sounds. d. Check pupil reaction to light.

ANS: A Phenytoin can cause gingival hyperplasia, but does not affect bowel sounds, lung sounds, or pupil reaction to light.

A patient tells the nurse about using acetaminophen (Tylenol) several times every day for recurrent bilateral headaches. Which action will the nurse plan to take first? a. Discuss the need to stop taking the acetaminophen. b. Suggest the use of biofeedback for headache control. c. Describe the use of botulism toxin (Botox) for headaches. d. Teach the patient about magnetic resonance imaging (MRI).

ANS: A The headache description suggests that the patient is experiencing medication overuse headache. The initial action will be withdrawal of the medication. The other actions may be needed if the headaches persist.

Which information will the nurse include when teaching an older patient about skin care? a. dry skin thoroughly before applying lotions b. bathe and wash hair daily with soap and shampoo c. use warm water and a moisturizing soap when bathing d. use antibacterial soaps when bathing to avoid infection

ANS: C Warm water and moisturizing soap will avoid over drying the skin

A patient reports feeling numbness and tingling of the left arm before experiencing a seizure. The nurse determines that this history is consistent with what type of seizure? a. Focal-onset b. Atonic c. Absence d. Myoclonic

ANS: A The initial symptoms of a focal seizure involve clinical manifestations that are localized to a particular part of the body or brain. Symptoms of an absence seizure are staring and a brief loss of consciousness. In an atonic seizure, the patient loses muscle tone and (typically) falls to the ground. Myoclonic seizures are characterized by a sudden jerk of the body or extremities.

A person is given an attenuated antigen as a vaccine. When the person asks what was given in the vaccine, how should the nurse respond? The antigen is: a. alive, but less infectious. b. mutated, but highly infectious. c. normal, but not infectious. d. inactive, but infectious

ANS: A Attenuated vaccines are alive, but less infectious. Attenuated vaccines are not mutated or highly infectious. Inactive infers the virus is killed

When a nurse cares for a patient with systemic lupus erythematosus (SLE), the nurse remembers this disease is an example of: a. autoimmunity. b. alloimmunity. c. homoimmunity. d. alleimmunity

ANS: A SLE is the most common, complex, and serious of the autoimmune disorders. SLE is not identified as alloimmune, homoimmune, or alleimmune.

A 22-year-old was recently diagnosed with acquired immunodeficiency syndrome (AIDS). Which decreased lab finding would be expected to accompany this virus? a. CD4+ T-helper b. CD8 T-helper c. CDC cells d. CDC10 cells

ANS: A The major immunologic finding in AIDS is the striking decrease in the number of CD4+ T cells. The change occurs in CD4 cells, not CD8. Neither CDC nor CDC 10 is a type of cell

MS While planning care for infants, which principles should the nurse remember? (select all that apply) Infants have problems with thermoregulation because they: a. cannot conserve heat. b. do not shiver. c. rarely sweat. d. have decreased metabolic rates. e. have excess subcutaneous fat.

ANS: A, B Infants cannot conserve heat; thus, they have a problem with thermoregulation because of their small size. Infants are unable to shiver, do have the ability to sweat, have an increased metabolic rate, and have little subcutaneous fat. REF: p. 342

Direct effects of antibodies include: (select all that apply) a. neutralization. b. agglutination. c. precipitation. d. phagocytosis. e. division.

ANS: A, B, C Directly, antibodies can affect infectious agents or their toxic products by neutralization (inactivating or blocking the binding of antigen to receptors), agglutination (clumping insoluble particles that are in suspension), or precipitation (making a soluble antigen into an insoluble precipitate). Indirectly, antibodies activate components of innate resistance, including complement and phagocytes. Antibodies are generally a mixed population of classes, specificities, and capacity to provide the functions listed above.

MULTIPLE RESPONSE 1. A nurse recalls that neural systems basic to cognitive functions include _____ systems. (select all that apply) a. attentional b. memory and language c. affective d. sensory and motor e. tactile

ANS: A, B, C The neural systems that are essential to cognitive function are: (i) attentional systems that provide arousal and maintenance of attention over time; (ii) memory and language systems by which information is communicated; and (iii) affective or emotive systems that mediate mood, emotion, and intention. The sensory, motor, and somatic systems are not involved. The tactile system is not involved in cognitive functioning. REF: p. 359

When a patient asks about secondary lymph organs, how should the nurse respond? Secondary lymph organs include: (select all that apply) a. the spleen. b. Peyer patches. c. adenoids. d. the liver. e. bone marrow. f. the appendix.

ANS: A, B, C, F The secondary lymphoid organs include the spleen, lymph nodes, adenoids, tonsils, Peyer patches (intestines), and appendix. The liver and bone marrow are not secondary lymph organs.

Which of the following is a neuroglial cell? (select all that apply) a. Astrocyte b. Oligodendrocyte c. Neuron d. Ependymal cell e. Melanocyte

ANS: A, B, D Neuroglial cells include astrocytes, oligodendrocytes, and ependymal cells. Neurons and melanocytes are not neuroglial cells.

A patient with Parkinson's disease is admitted to the hospital for treatment of pneumonia. Which nursing interventions will be included in the plan of care (select all that apply)? a. Provide an elevated toilet seat. b. Cut patient's food into small pieces. c. Serve high-protein foods at each meal. d. Place an armchair at the patient's bedside. e. Observe for sudden exacerbation of symptoms.

ANS: A, B, D Because the patient with Parkinson's disease has difficulty chewing, food should be cut into small pieces. An armchair should be used when the patient is seated so that the patient can use the arms to assist with getting up from the chair. An elevated toilet seat will facilitate getting on and off the toilet. High-protein foods will decrease the effectiveness of L-dopa. Parkinson's disease is a steadily progressive disease without acute exacerbations.

MULTIPLE RESPONSE The nurse is explaining clinical manifestations of alterations in the extrapyramidal system. The nurse would correctly include: (select all that apply) a. little or no paralysis of voluntary movement. b. normal or slightly increased tendon reflexes. c. positive (present) Babinski. d. presence of tremor. e. rigidity in muscle tone.

ANS: A, B, D, E The patient will experience little or no paralysis of voluntary movement. The patient will experience normal or slightly increased deep tendon reflexes. Babinski will be negative (absent). Tremor will be present. Rigidity of muscle tone occurs intermittently. REF: p. 386, Table 15-19

When assessing the medication history of a patient with a new diagnosis of Parkinson's disease, which conditions are contraindications for the patient who will be taking carbidopa-levodopa? (Select all that apply.) a. Angle-closure glaucoma b. History of malignant melanoma c. Hypertension d. Benign prostatic hyperplasia e. Concurrent use of monoamine oxidase inhibitors (MAOIs)

ANS: A, B, E Angle-closure glaucoma, a history of melanoma or other undiagnosed skin conditions, and concurrent use of MAOIs are contraindications to the use of carbidopa-levodopa. The other options are incorrect.

A 30-year-old female is diagnosed with systemic lupus erythematosus (SLE). Which symptoms are a result of a type II hypersensitivity? a. Anemia b. Seizures c. Lymphopenia d. Facial rash e. Photosensitivity

ANS: A, C The patient is experiencing type II hypersensitivity when experiencing anemia and lymphopenia. Seizures, facial rash, and photosensitivity are not associated with type II hypersensitivity reactions.

The nurse assesses the patient and notes all of the following. Select all of the findings that indicate the systemic manifestations of inflammation. a. Oral temperature 38.6° C/101.5° F b. Thick, green nasal discharge c. Patient complaint of pain at 6 on a 0 to 10 scale on palpation of frontal and maxillary sinuses d. WBC 20 ´ 109/L e. Patient reports, "I'm tired all the time. I haven't felt like myself in days."

ANS: A, D, E Systemic manifestations of inflammatory response include elevated temperature, leukocytosis, and malaise and fatigue. Purulent exudates and pain are both considered local manifestations of inflammation.

A patient has been taking an AED for several years as part of his treatment for partial seizures. His wife has called because he ran out of medication this morning and wonders if he can go without it for a week until she has a chance to go to the drugstore. What is the nurse's best response? a."He is taking another antiepileptic drug, so he can go without the medication for a week." b."Stopping this medication abruptly may cause withdrawal seizures. A refill is needed right away." c."He can temporarily increase the dosage of his other antiseizure medications until you get the refill." d."He can stop all medications because he has been treated for several years now."

ANS: B Abrupt discontinuation of antiepileptic drugs can lead to withdrawal seizures. The other options are incorrect. The nurse cannot change the dose or stop the medication without a prescriber's order.

During a nursing assessment, which question by the nurse allows for greater clarification and additional discussion with the patient? a. "Are you allergic to penicillin?" b. "What medications do you take?" c. "Have you had a reaction to this drug?" d. "Are you taking this medication with meals?"

ANS: B Asking "What medications do you take?" is an open-ended question that will encourage greater clarification and additional discussion with the patient. The other options are examples of closedended questions, which prompt only a "yes" or "no" answer and provide limited information.

A 35 yr old female patient states that she is using a topical fluorouracil to treat actinic keratoses on her face. Which additional assessment information will be most important for the nurse to obtain? a. history of sun exposure by the patient b. method of contraception used by the patient c. length of time the patient has used fluorouracil d. appearance of the treated areas on the patient's face

ANS: B Because fluorouracil is teratogenic, it is essential that the patient use a reliable method of birth control

A patient has the following risk factors for melanoma. Which risk factor should the nurse assign as the priority focus of patient teaching? a. the patient has multiple dysplastic nevi b. the patient uses a tanning booth weekly c. the patient is fair-skinned with blue eyes d. the patient's mother died of malignant melanoma

ANS: B Because the only risk factor that the patient can change is the use of a tanning booth, the nurse should focus teaching about melanoma prevention on this factor

The nurse is giving an intravenous dose of phenytoin (Dilantin). Which action is correct when administering this drug? a.Give the dose as a fast intravenous (IV) bolus. b.Mix the drug with normal saline, and give it as a slow IV push. c.Mix the drug with dextrose (D5W), and give it as a slow IV push. d.Mix the drug with any available solution as long as the administration rate is correct.

ANS: B Intravenous phenytoin is given only with normal saline solution to prevent precipitation formation caused by incompatibilities. The IV push dose must be given slowly (not exceeding 50 mg/min in adults), and the patient must be monitored for bradycardia and decreased blood pressure.

The nurse is reviewing the dosage schedule for several different antiepileptic drugs (AEDs). Which antiepileptic drug allows for once-a-day dosing? a.levetiracetam (Keppra) b.phenobarbital c.valproic acid (Depakote) d.gabapentin (Neurontin)

ANS: B Phenobarbital has the longest half-life of all standard AEDs, including those listed in the other options, so it allows for once-a-day dosing.

A patient with atopic dermatitis has a new prescription for pimecrolimus. After teaching the patient about the medication, which statement by the patient indicates that further teaching is needed? a. "After I apply the medication, I can get dressed as usual." b. "If the medication burns when I apply it, I will wipe it off." c. "I need to minimize time in the sun while using the medication." d. "I will rub the medication in gently every morning and night."

ANS: B The patient should be taught that transient burning at the application site is an expected effect of the medication and it should be left in place

The health care provider prescribes topical 5-FU for a patient with actinic keratosis in the left cheek. Which statement should the nurse include in the patient's instructions? a. "5-FU will shrink the lesion to prepare for surgical excision." b. "Your cheek area will be eroded and take several weeks to heal." c. "You may develop nausea and anorexia, but good nutrition is important during treatment." d. "You will need to avoid crowds because the risk of infection cause by chemotherapy."

ANS: B Topical 5-FU causes an initial reaction of erythema, itching, and erosion that lasts 4 wks after application of the medication is stopped

The nurse is monitoring a patient who has been taking carbamazepine (Tegretol) for 2 months. Which effects would indicate that autoinduction has started to occur? a.The drug levels for carbamazepine are higher than expected. b.The drug levels for carbamazepine are lower than expected. c.The patient is experiencing fewer seizures. d.The patient is experiencing toxic effects from the drug.

ANS: B With carbamazepine, autoinduction occurs and leads to lower-than-expected drug concentrations. Therefore, the dosage may have to be adjusted with time. The other options are incorrect.

Healing by secondary intention would occur in which of the following patients? A patient with a: a. Sutured surgical wound b. Stage IV pressure ulcer c. Paper cut d. Sunburn

ANS: B A patient with a stage IV pressure ulcer would heal by secondary intention. A patient with a surgical wound would heal by primary intention. A patient with a paper cut would heal by primary intention. A patient with a sunburn would heal without needing either primary or secondary intention.

A 65-year-old patient who recently suffered a cerebral vascular accident is now unable to recognize and identify objects by touch because of injury to the sensory cortex. How should the nurse document this finding? a. Hypomimesis b. Agnosia c. Dysphasia d. Echolalia

ANS: B Agnosia is the failure to recognize the form and nature of objects. Hypomimesis is a disorder of communication. Dysphasia is an impairment of comprehension of language. Echolalia is the ability to repeat. REF: p. 367

An infant is diagnosed with noncommunicating hydrocephalus. What is an immediate priority concern for this patient? a. Metabolic edema b. Interstitial edema c. Vasogenic edema d. Ischemic edema

ANS: B An immediate concern for the infant with noncommunicating hydrocephalus is interstitial edema. Neither metabolic, vasogenic, nor ischemic edema is observed as a result of noncommunicating hydrocephalus.

. Strategies to include in a teaching plan for an adult who has repeatedly not followed the written discharge instructions would include a. individualized handout. b. instructional videos. c. Internet resources. d. self-help books.

ANS: B An instructional video would provide a visual/auditory approach for discharge instructions. Repeatedly not following written instructions is a clue that the patient may not be able to read or understand the information. While assessing the literacy level of an adult patient can be challenging, the information that they have not been able to follow previous written instructions would suggest that the nurse use an alternate strategy that does not require a high degree of literacy. An individualized handout would be written, very similar to previous instructions, and would not address a concern about literacy. Internet resources generally require an individual to be able to read, and although videos are available through the Internet, this is not the best response. Self-help books would be appropriate for an individual who reads. There is a question about whether this patient is literate, so these would not be the best choice.

A patient is being treated with an antibiotic. The nurse explains to the patient that this medication is required for the reduction of inflammation at the injury site because this medication a. will decrease the pain at the site. b. helps to kill the infection causing the inflammation. c. inhibits cyclooxygenase. d. will reduce the patient's fever.

ANS: B Antimicrobials treat the underlying cause of the infection which leads to inflammation. Analgesics and nonsteroidal antiinflammatory drugs (NSAIDs) help to treat pain. NSAIDs and other antipyretics are cyclooxygenase inhibitors. Antipyretics help to reduce fever.

A patient has been taking selegiline (Eldepryl), 20 mg/day for 1 month. Today, during his office visit, he tells the nurse that he forgot and had a beer with dinner last evening, and "felt awful." What did the patient most likely experience? a. Hypotension b. Hypertension c. Urinary discomfort d. Gastrointestinal upset

ANS: B At doses that exceed 10 mg/day, selegiline becomes a nonselective monoamine oxidase inhibitor (MAOI), contributing to the development of the cheese effect, so-called because it interacts with tyramine-containing foods (cheese, red wine, beer, and yogurt) and can cause severe hypertension.

A patient comes to the clinic with a complaint of painful, itchy feet. On interview, the patient tells the nurse that he is a college student living in a dormitory apartment that he shares with five other students. The nurse plans to teach the patient to a. not eat with the other students. b. avoid sharing razors and other personal items. c. have his CBC checked monthly. d. disinfect showers and bathroom floors weekly after use.

ANS: B Avoidance of sharing personal items like razors and hairbrushes can decrease the spread of pathogens that cause inflammation and infection. Not eating with the others in his college apartment won't relieve or prevent the spread of infection. A CBC monthly will not treat or prevent inflammation. Showers should be disinfected before and after each use.

An experiment is designed to determine specific cell types involved in cell-mediated immune response. The experimenter is interested in finding cells that attack cells that have specific antigens. Which cells should be isolated? a. Lymphokine-producing cells b. T-cytotoxic cells c. Helper T cells d. Macrophages

ANS: B Cell-mediated immunity is driven by T-cytotoxic (Tc) cells that attack antigens directly and destroy cells that bear foreign antigens. Lymphokine-producing cells, helper T cells, and macrophages do not attack antigens directly and destroy cells that bear foreign antigens.

The nurse provides discharge instructions to a patient who has an immune deficiency involving the T lymphocytes. Which screening should the nurse include in the teaching plan for this patient? a. Screening for allergies b. Screening for malignancy c. Antibody deficiency screening d. Screening for autoimmune disorders

ANS: B Cell-mediated immunity is responsible for the recognition and destruction of cancer cells. Allergic reactions, autoimmune disorders, and antibody deficiencies are mediated primarily by B lymphocytes and humoral immunity.

Heat loss from the body via convection occurs by: a. evaporation of electromagnetic waves. b. transfer of heat through currents of liquids or gas. c. dilation of blood vessels bringing blood to skin surfaces. d. direct heat loss from molecule-to-molecule transfer.

ANS: B Convection occurs by transfer of heat through currents of gases or liquids, exchanging warmer air at the body's surface with cooler air in surrounding spaces. Convection does not involve electromagnetic waves, bringing blood to skin surfaces, or molecule-to-molecule transfer. REF: p. 343, Table 14-5

A patient suffers from head trauma that affects cranial nerve I. Which of the following symptoms would the nurse expect? a. Visual disturbances b. Loss of sense of smell c. Loss of ability to taste d. Hearing disturbances

ANS: B Cranial nerve I controls the sense of smell. Visual disturbances are associated with cranial nerve II. Cranial nerve VII is related to tasting. Cranial nerve VIII is related to hearing.

A 25-year-old female presents to her primary care provider reporting vaginal discharge of a white, viscous, and foul-smelling substance. She reports that she has been taking antibiotics for the past 6 months. Which finding will the nurse most likely see on the microorganism report? a. Clostridium difficile overgrowth b. Decreased Lactobacillus c. Streptococcus overgrowth d. Decreased Candida albicans

ANS: B Diminished colonization with Lactobacillus that occurs as a result of prolonged antibiotic treatment increases the risk for vaginal infections, such as vaginosis. Clostridium difficile occurs in the colon, not the vagina. Streptococcus overgrowth will occur in the mouth. Candida albicans occurs in the colon, not the vagina.

While a patient is receiving drug therapy for Parkinson's disease, the nurse monitors for dyskinesia, which is manifested by which finding? a. Rigid, tense muscles b. Difficulty in performing voluntary movements c. Limp extremities with weak muscle tone d. Confusion and altered mental status

ANS: B Dyskinesia is the difficulty in performing voluntary movements that is experienced by some patients with Parkinson's disease. The other options are incorrect.

A 10-year-old male is diagnosed with a parasite. Which lab result should the nurse check for a response to the parasite? a. Monocytes b. Eosinophils c. Neutrophils d. Macrophages

ANS: B Eosinophils serve as the body's primary defense against parasites. Monocytes are not the body's primary defense against parasite; eosinophils are. Monocytes are phagocytic. Neutrophils are phagocytic; they are not the body's defense against parasites. Macrophages are not active against parasites; they act as long-term defense against infections.

Exogenous pyrogens are: a. interleukins. b. endotoxins. c. prostaglandins. d. corticotropin-releasing factors.

ANS: B Exogenous pyrogens are endotoxins produced by pathogens. They are not interleukins, prostaglandins, or corticotropin-releasing factors. REF: p. 343

A 5-year-old male becomes ill with a severe cough. Histologic examination reveals a bacterial infection, and further laboratory testing reveals cell membrane damage and decreased protein synthesis. Which of the following is the most likely cause of this illness? a. Endotoxin b. Exotoxin c. Hemolysis d. Septicemia

ANS: B Exotoxins are enzymes that can damage the plasma membranes of host cells or can inactivate enzymes critical to protein synthesis, and endotoxins activate the inflammatory response and produce fever. Endotoxins released by blood-borne bacteria cause the release of vasoactive enzymes that increase the permeability of blood vessels. Hemolysis is the breakdown of red cells. Septicemia is the growth of bacteria in the blood.

If a neuron's membrane potential is held close to the threshold potential by excitatory postsynaptic potentials (EPSPs), the neuron is said to be: a. hyperpolarized. b. facilitated. c. integrated. d. inhibited.

ANS: B Facilitation refers to the effect of EPSP on the plasma membrane potential. The postsynaptic neuron's plasma membrane may be inhibited, which is called hyperpolarized. When the neuron's membrane potential is held close to the threshold potential, the neuron is facilitated, not integrated or inhibited.

A nurse has designed an individualized nursing care plan for a patient, but the patient is not meeting goals. Further assessment reveals that the patient is not following through on many items. Which action by the nurse would be best for determining the cause of the problem? a. Assess whether the actions were too hard for the patient. b. Determine whether the patient agrees with the care plan. c. Question the patient's reasons for not following through. d. Reevaluate data to ensure the diagnoses are sound.

ANS: B Having patient and/or family provide input to the care plan is vital in order to gain support for the plan of action. The actions may have been too difficult for the patient, but this is a very narrow item to focus on. The nurse might want to find out the rationale for the patient not following through, but instead of directly questioning the patient, which can sound accusatory, it would be best to offer some possible motives. Reevaluation should be an ongoing process, but the more likely cause of the patient's failure to follow through is that the patient did not participate in making the plan of care.

Hikers are attempting to cross the Arizona desert with a small supply of water. The temperatures cause them to sweat profusely and become dehydrated. The hikers are experiencing: a. heat cramping. b. heat exhaustion. c. heat stroke. d. malignant hyperthermia.

ANS: B Heat exhaustion results from prolonged high core or environmental temperatures, which cause profound vasodilation and profuse sweating, leading to dehydration, decreased plasma volumes, hypotension, decreased cardiac output, and tachycardia. Symptoms include weakness, dizziness, confusion, nausea, and fainting. Heat cramping is severe, spasmodic cramps in the abdomen and extremities that follow prolonged sweating and associated sodium loss. Heat cramping usually occurs in those not accustomed to heat or those performing strenuous work in very warm climates. Heat stroke is a potentially lethal result of an overstressed thermoregulatory center. With very high core temperatures (>40° C; 104° F), the regulatory center ceases to function, and the body's heat loss mechanisms fail. Malignant hyperthermia is a potentially lethal complication of a rare inherited muscle disorder that may be triggered by inhaled anesthetics and depolarizing muscle relaxants. REF: p. 344

A 40-year-old male complains of uncontrolled excessive movement and progressive dysfunction of intellectual and thought processes. He is experiencing movement problems that begin in the face and arms and eventually affect the entire body. The most likely diagnosis is: a. tardive dyskinesia. b. Huntington disease. c. hypokinesia. d. Alzheimer disease.

ANS: B Huntington disease is manifested by chorea, abnormal movement that begins in the face and arms and eventually affects the entire body. There is progressive dysfunction of intellectual and thought processes. Tardive dyskinesia is manifested by rapid, repetitive, and stereotypic movements. Most characteristic is continual chewing with intermittent protrusions of the tongue, lip smacking, and facial grimacing. Hypokinesia is a loss of voluntary movement despite preserved consciousness and normal peripheral nerve and muscle function. Alzheimer disease is manifested by cognitive deficits and not movement problems; motor impairments will occur in the later stages. REF: p. 378 | p. 380

What is the physiological response when the body's core temperature is altered due to prolonged exposure to a cold environment? a. Increased respirations b. Ischemic tissue damage c. CNS excitation d. Increased cellular metabolism

ANS: B Hypothermia (marked cooling of core temperature) produces depression of the central nervous and respiratory systems, vasoconstriction, alterations in microcirculation, coagulation, and ischemic tissue damage. Hypothermia does not lead to increased respirations, CNS excitation, or increased cellular metabolism. REF: p. 344

A patient is diagnosed with a sprain to her right ankle after a fall. The patient asks the nurse about using ice on her injured ankle. The nurse should tell the patient that a. she should use ice only when the ankle hurts. b. ice should be applied for 15 to 20 minutes every 2 to 3 hours over the next 1 to 2 days. c. she should wrap an ice pack around the injured ankle for the next 24 to 48 hours. d. ice is not recommended for use on the sprain because it would inhibit the inflammatory response.

ANS: B Ice is used on areas of injury during the first 24 to 48 hours after the injury occurs to prevent damage to surrounding tissues from excessive inflammation. Ice should be used for a maximum of 20 minutes at a time every 2 to 3 hours. Ice must be used according to a schedule for it to be effective and not be overused. Using ice more often or for longer periods of time can cause additional tissue damage. Ice is recommended to inhibit the inflammatory process from damaging surrounding tissue.

The predominant antibody of a typical primary immune response is: a. IgG. b. IgM. c. IgA. d. IgE.

ANS: B IgM is the largest immunoglobulin and is the first antibody produced during the initial, or primary, response to antigen.

A 30-year-old male was involved in a motor vehicle accident. The glass from the shattered window cut his face and neck. The scar, however, was raised and extended beyond the original boundaries of the wound. This pattern of scarring is caused by impaired: a. Nutritional status b. Collagen synthesis c. Epithelialization d. Contraction

ANS: B Impaired production of collagen can cause surface overhealing, leading to a keloid or a hypertrophic scar. Nutritional deficiencies would lead to healing problems, but not extended scarring. Necrosis or steroid use leads to impaired epithelialization. Impaired contraction would lead to drawing of tissues, not raised.

A patient reports tiring easily, having difficulty rising from a sitting position, and the inability to stand on toes. The nurse would expect a diagnosis of: a. Parkinson disease. b. hypotonia. c. Huntington disease. d. paresis.

ANS: B Individuals with hypotonia tire easily (asthenia) or are weak. They may have difficulty rising from a sitting position, sitting down without using arm support, and walking up and down stairs, as well as an inability to stand on their toes. Individuals with Parkinson disease have rigidity and stiffness. Symptoms of Huntington disease include irregular, uncontrolled, and excessive movement. Paresis, or weakness, is partial paralysis with incomplete loss of muscle power. REF: pp. 376-377

A patient has been admitted for a skin graft following third degree burns to the bilateral calves. The plan of care involves 3 days inpatient and 6 months outpatient treatment, to include home care and dressing changes. When should the nurse initiate the educational plan? a. After the operation and the patient is awake b. On admission, along with the initial assessment c. The day before the patient is to be discharged d. When narcotics are no longer needed routinely

ANS: B Initial discharge planning begins upon admission. After the operation has been completed is too late to begin the discharge planning process. The day before discharge is too late for the nurse to gather all pertinent information and begin teaching and coordinating resources. After a complicated operation, the patient may well be discharged on narcotic analgesics. Waiting for the patient to not need them anymore might mean the patient gets discharged without teaching being done.

A public health nurse is teaching the community about health promotion. Which information should the nurse include for innate immunity? Innate immunity is gained: a. Following an illness b. At birth c. Via injection of specific antibodies d. In adulthood

ANS: B Innate immunity is present at birth. Innate immunity is present at birth and does not require an illness. Innate immunity is present at birth and does not require injection. Innate immunity is present at birth.

When thought content and arousal level are intact but a patient cannot communicate and is immobile, the patient is experiencing: a. cerebral death. b. locked-in syndrome. c. dysphagia. d. cerebellar motor syndrome.

ANS: B Locked-in syndrome occurs when the individual cannot communicate through speech or body movement but is fully conscious, with intact cognitive function. In cerebral death, the person is in a coma with eyes closed. Dysphagia is difficulty speaking. Cerebellar motor syndrome is characterized by problems with coordinated movement. REF: p. 365

The post-surgical patient is experiencing delayed wound healing. The dietician believes the delay is related to nutritional intake. A deficiency in which of the following substances could directly affect healing? a. Vitamin D b. Ascorbic acid c. Melanin d. Cholesterol

ANS: B Most of the factors that interfere with the production of collagen in healing tissues are nutritional. Scurvy, for example, is caused by lack of ascorbic acid—one of the cofactors required for collagen formation by fibroblasts. The results of scurvy are poorly formed connective tissue and greatly impaired healing. Vitamin D deficiency will not directly affect healing; ascorbic acid does. Melanin deficiency will not directly affect healing; ascorbic acid does. Cholesterol deficiency will not directly affect healing; ascorbic acid does.

The predominant phagocyte of early inflammation is the: a. Eosinophil b. Neutrophil c. Lymphocyte d. Macrophage

ANS: B Neutrophils are the predominant phagocytes in the early inflammatory site, arriving within 6 to 12 hours after the initial injury. Eosinophils help limit and control inflammation, but they are not the prominent phagocyte. Lymphocytes are part of the innate immune response. Macrophages kill microorganisms.

A 20-year-old male shoots his hand with a nail gun while replacing roofing shingles. Which of the following cell types would be the first to aid in killing bacteria to prevent infection in his hand? a. Eosinophils b. Neutrophils c. Leukotrienes d. Monocytes

ANS: B Neutrophils are the predominant phagocytes in the early inflammatory site, arriving within 6 to 12 hours after the initial injury. Eosinophils help limit and control inflammation. Leukotrienes are activators of the inflammatory response. Monocytes enter much later and replace leukocytes.

A 16-year-old male fell off the bed of a pickup truck and hit his forehead on the road. He now has resistance to passive movement that varies proportionally with the force applied. He is most likely suffering from: a. spasticity. b. paratonia. c. rigidity. d. dystonia.

ANS: B Paratonia is manifested by resistance to passive movement that varies in direct proportion to force applied. Spasticity is manifested by a gradual increase in tone causing increased resistance until tone suddenly reduces. Rigidity is manifested by muscle resistance to passive movement of a rigid limb that is uniform in both flexion and extension throughout the motion. Dystonia is manifested by sustained involuntary twisting movement. REF: p. 377, Table 15-16

The nurse is developing a care plan for a patient who is taking an anticholinergic drug. Which nursing diagnosis would be appropriate for this patient? a. Diarrhea b. Urinary retention c. Risk for infection d. Disturbed sleep pattern

ANS: B Patients receiving anticholinergic drugs are at risk for urinary retention and constipation, not diarrhea. The other nursing diagnoses are not applicable to anticholinergic drugs.

A 16-year-old's level of arousal was altered after taking a recreational drug. Physical exam revealed a negative Babinski sign, equal and reactive pupils, and roving eye movements. Which of the following diagnoses will the nurse most likely see on the chart? a. Psychogenic arousal alteration b. Metabolically induced coma c. Structurally induced coma d. Structural arousal alteration

ANS: B Persons with metabolically induced coma generally retain ocular reflexes even when other signs of brainstem damage are present. Psychogenic arousal activation demonstrates a general psychiatric disorder. Structurally induced coma is manifested by asymmetric responses. Structural arousal alteration does not have drug use as its etiology. REF: p. 360, Table 15-2

The nurse teaches a patient diagnosed with systemic lupus erythematosus (SLE) about plasmapheresis. What instructions about plasmapheresis should the nurse include in the teaching plan? a. Plasmapheresis will eliminate eosinophils and basophils from blood. b. Plasmapheresis will remove antibody-antigen complexes from circulation. c. Plasmapheresis will prevent foreign antibodies from damaging various body tissues. d. Plasmapheresis will decrease the damage to organs caused by attacking T lymphocytes.

ANS: B Plasmapheresis is used in SLE to remove antibodies, antibody-antigen complexes, and complement from blood. T lymphocytes, foreign antibodies, eosinophils, and basophils do not directly contribute to the tissue damage in SLE.

A 25-year-old male is in a car accident and sustains a fracture to his left femur with extensive soft tissue injury. The pain associated with the injury is related to: a. Histamine and serotonin b. Kinins and prostaglandins c. Vasoconstriction d. Immune complex formation

ANS: B Prostaglandins cause increased vascular permeability, neutrophil chemotaxis, and pain by direct effects on nerves. Kinins also promote pain. Prostaglandins produce pain; histamine promotes vasodilation. Prostaglandins produce pain, not vasoconstriction. Prostaglandins produce pain, not the immune complex.

A patient has a disease state that results from the secretion of toxins by bacteria. Which medical diagnosis will the nurse see documented on the chart? a. Malaria b. Tetanus c. Smallpox d. Hepatitis

ANS: B Some bacteria secrete toxins that harm individuals. For instance, specific bacterial toxins cause the symptoms of tetanus or diphtheria. This is not true of malaria, smallpox, or hepatitis.

Spinal shock is characterized by: a. loss of voluntary motor function with preservation of reflexes. b. cessation of spinal cord function below the lesion. c. loss of spinal cord function at the level of the lesion only. d. temporary loss of spinal cord function above the lesion.

ANS: B Spinal shock is the complete cessation of spinal cord function below the lesion. The reflexes are not preserved in spinal shock. Spinal shock is the complete cessation of spinal cord function below the lesion, not at the lesion only. REF: p. 382

Which finding indicates the patient is having complications from heat stroke? a. Mild elevation of core body temperatures b. Cerebral edema and degeneration of the CNS c. Spasmodic cramping in the abdomen and extremities d. Alterations in calcium uptake

ANS: B Symptoms of heat stroke include high core temperature, absence of sweating, rapid pulse, confusion, agitation, and coma, and complications include cerebral edema and degeneration of the CNS. Neither cramping nor alterations in calcium uptake are considered complications of a heat stroke. REF: p. 344

A neurologist is teaching about the region responsible for motor aspects of speech. Which area is the neurologist discussing? a. Wernicke area b. Broca area c. Brodmann area 4 d. Brodmann area 6

ANS: B The Broca area is responsible for the motor aspects of speech. Motor aspects of speech are not the function of the Wernicke area or Brodmann areas 4 and 6.

Which statement indicates teaching was successful regarding the classic pathway of the complement system? The classic pathway of the complement system is activated by: a. Histamine b. Antigen-antibody complexes c. Leukotrienes d. Prostaglandins

ANS: B The classic pathway of the complement system is activated by antibodies of the immune system. The classic pathway of the complement system is activated by antibodies, not by histamine. The classic pathway of the complement system is activated by antibodies, not by leukotrienes. The classic pathway of the complement system is activated by antibodies, not by prostaglandins.

What common symptom should be assessed in individuals with immunodeficiency? a. Anemia b. Recurrent infections c. Hypersensitivity d. Autoantibody production

ANS: B The clinical hallmark of immunodeficiency is a propensity to unusual or recurrent severe infections. The type of infection usually reflects the immune system defect. Neither anemia, autoantibody production, nor hypersensitivity is a manifestation of immunodeficiency.

When a nurse is teaching about the transverse fiber tract that connects the two cerebral hemispheres, what term should the nurse use? a. Peduncle b. Corpus callosum c. Basal ganglia d. Pons

ANS: B The corpus callosum connects the two cerebral hemispheres and is essential in coordinating activities between hemispheres. The peduncle is made up of efferent fibers of the corticospinal, corticobulbar, and corticopontocerebellar tracts. The basal ganglia is a portion of the pyramidal system. The pons (bridge) is easily recognized by its bulging appearance below the midbrain and above the medulla.

A patient is admitted to the neurological critical care unit with a severe closed head injury. All four extremities are in rigid extension, the forearms are hyperpronated, and the legs are in plantar extension. How should the nurse chart this condition? a. Decorticate posturing b. Decerebrate posturing c. Dystonic posturing d. Basal ganglion posturing

ANS: B The description is of a patient in decerebrate posturing. The description provided is not associated with decorticate, dystonic, or basal ganglion posturing. REF: p. 385

After teaching the staff about the clotting system, which statement indicates teaching was successful? The end product of the clotting system is: a. Plasmin b. Fibrin c. Collagen d. Factor X

ANS: B The end product of the clotting system is fibrin. Plasmin activates the complement cascade. Collagen plays a factor in wound healing. Factor X is a first step in the clotting system.

The nurse assesses a patient's surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate? a. Obtain wound cultures. b. Document the assessment. c. Notify the health care provider. d. Assess the wound every 2 hours.

ANS: B The incisional redness and warmth are indicators of the normal initial (inflammatory) stage of wound healing by primary intention. The nurse should document the wound appearance and continue to monitor the wound. Notification of the health care provider, assessment every 2 hours, and obtaining wound cultures are not indicated because the healing is progressing normally.

A patient who is anxious and has difficulty breathing seeks treatment after being stung by a wasp. What is the nurse's priority action? a. Have the patient lie down. b. Assess the patient's airway. c. Administer high-flow oxygen. d. Remove the stinger from the site.

ANS: B The initial action with any patient with difficulty breathing is to assess and maintain the airway. The other actions also are part of the emergency management protocol for anaphylaxis, but the priority is airway maintenance.

An adolescent patient seeks care in the emergency department after sharing needles for heroin injection with a friend who has hepatitis B. To provide immediate protection from infection, what medication will the nurse administer? a. Corticosteroids b. Gamma globulin c. Hepatitis B vaccine d. Fresh frozen plasma

ANS: B The patient should first receive antibodies for hepatitis B from injection of gamma globulin. The hepatitis B vaccination series should be started to provide active immunity. Fresh frozen plasma and corticosteroids will not be effective in preventing hepatitis B in the patient

A 19-year-old college student reports to his primary care provider that he cannot stay awake in class regardless of how much sleep he gets. Under-stimulation of which area of the brain is likely the site of the problem? a. Corpora quadrigemina b. Reticular activating system c. Cerebellum d. Hypothalamus

ANS: B The reticular activating system is responsible for wakefulness, not the corpora quadrigemina, the cerebellum, or the hypothalamus.

During inflammation, the liver is stimulated to release plasma proteins, collectively known as: a. Opsonins b. Acute phase reactants c. Antibodies d. Phagolysosome

ANS: B The synthesis of many plasma proteins by the liver is increased during inflammation. These proteins, which can be either proinflammatory or antiinflammatory in nature, are referred to as acute phase reactants. Opsonins coat the surface of bacteria and increase their susceptibility to being phagocytized. Antibodies are proteins of the immune system. Phagolysosome destroys bacterium.

A nurse recalls that characteristics of upper motor neurons include: a. directly innervating muscles. b. influencing and modifying spinal reflex arcs. c. cell bodies located in the gray matter of the spinal cord. d. dendritic processes extending out of the CNS.

ANS: B Upper motor neurons are completely contained within the CNS. Their primary roles are controlling fine motor movement and influencing/modifying spinal reflex arcs and circuits. They do not innervate muscles. Lower motor neurons interact with gray matter. Dendrites are part of neurons.

The primary care provider states that the patient is experiencing vasogenic edema. The nurse realizes vasogenic edema is clinically important because: a. it usually has an infectious cause. b. the blood-brain barrier is disrupted. c. ICP is excessively high. d. it always causes herniation.

ANS: B Vasogenic edema is clinically important because the blood-brain barrier (selective permeability of brain capillaries) is disrupted, and plasma proteins leak into the extracellular spaces. Vasogenic edema does not have an infectious cause. ICP is increased, but not more so than other forms of edema. Vasogenic edema does not always cause herniation. REF: p. 375

Which information indicates a correct understanding of viral vaccines? Most viral vaccines contain: a. active viruses. b. attenuated viruses. c. killed viruses. d. viral toxins.

ANS: B Viral vaccines contain live viruses that are weakened (attenuated). Viral vaccines do not contain active viruses, killed viruses, or toxins.

A 20-year-old experiences a severe closed head injury as a result of a motor vehicle accident. Which of the following structures is most likely keeping the patient in a vegetative state (VS) 1 month after the accident? a. Cerebral cortex b. Brainstem c. Spinal cord d. Cerebellum

ANS: B When a person loses cerebral function, the reticular activating system and brainstem can maintain a crude waking state known as a VS. Cognitive cerebral functions, however, cannot occur without a functioning reticular activating system. A VS is not associated with the cerebral cortex, spinal cord, or cerebellum. REF: p. 364

When a presynaptic neuron is stimulated in a patient's body by an electrical current, neurotransmitters are released from the: a. synapse. b. synaptic bouton. c. synaptic cleft. d. receptor.

ANS: B When an impulse originates in a presynaptic neuron, the impulse reaches the vesicles, where chemicals (neurotransmitters) are stored in the synaptic bouton. Neurons are not physically continuous with one another. The region between adjacent neurons is called a synapse. The synaptic cleft is the space between the neurons. Neurotransmitters attach to the receptor.

A patient has been given a prescription for levodopa-carbidopa (Sinemet) for her newly diagnosed Parkinson's disease. She asks the nurse, "Why are there two drugs in this pill?" The nurse's best response reflects which fact? a. Carbidopa allows for larger doses of levodopa to be given. b. Carbidopa prevents the breakdown of levodopa in the periphery. c. There are concerns about drug-food interactions with levodopa therapy that do not exist with the combination therapy. d. Carbidopa is the biologic precursor of dopamine and can penetrate into the central nervous system.

ANS: B When given in combination with levodopa, carbidopa inhibits the breakdown of levodopa in the periphery and thus allows smaller doses of levodopa to be used. Lesser amounts of levodopa result in fewer unwanted adverse effects. Levodopa, not carbidopa, is the biologic precursor of dopamine and can penetrate into the CNS.

Which intervention will the nurse include in the plan of care for a patient with primary restless legs syndrome (RLS) who is having difficulty sleeping? a. Teach about the use of antihistamines to improve sleep. b. Suggest that the patient exercise regularly during the day. c. Make a referral to a massage therapist for deep massage of the legs. d. Assure the patient that the problem is transient and likely to resolve.

ANS: B Nondrug interventions such as getting regular exercise are initially suggested to improve sleep quality in patients with RLS. Antihistamines may aggravate RLS. Massage does not alleviate RLS symptoms, and RLS is likely to progress in most patients.

The health care provider is considering the use of sumatriptan (Imitrex) for a 54-yr-old male patient with migraine headaches. Which information obtained by the nurse is most important to report to the health care provider? a. The patient drinks 1 to 2 cups of coffee daily. b. The patient had a recent acute myocardial infarction. c. The patient has had migraine headaches for 30 years. d. The patient has taken topiramate (Topamax) for 2 months.

ANS: B The triptans cause coronary artery vasoconstriction and should be avoided in patients with coronary artery disease.

A patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care? a. Observe for agitation and paranoia. b. Assist with active range of motion (ROM). c. Give muscle relaxants as needed to reduce spasms. d. Use simple words and phrases to explain procedures.

ANS: B ALS causes progressive muscle weakness, but assisting the patient to perform active ROM will help maintain strength as long as possible.

Which information about a 60-yr-old patient with multiple sclerosis indicates that the nurse should consult with the health care provider before giving the prescribed dose of dalfampridine (Ampyra)? a. The patient complains of pain with neck flexion. b. The patient has an increased serum creatinine level. c. The patient walks a mile each day for exercise. d. The patient has the relapsing-remitting form of MS.

ANS: B Dalfampridine should not be given to patients with impaired renal function.

A patient with Parkinson's disease has bradykinesia. Which action will the nurse include in the plan of care? a. Instruct the patient in activities that can be done while lying or sitting. b. Suggest that the patient rock from side to side to initiate leg movement. c. Have the patient take small steps in a straight line directly in front of the feet. d. Teach the patient to keep the feet in contact with the floor and slide them forward.

ANS: B Rocking the body from side to side stimulates balance and improves mobility. The patient will be encouraged to continue exercising because this will maintain functional abilities. Maintaining a wide base of support will help with balance. The patient should lift the feet and avoid a shuffling gait.

Which action will the nurse plan to take for a patient with multiple sclerosis who has urinary retention caused by a flaccid bladder? a. Encourage a decreased evening intake of fluid. b. Teach the patient how to use the Credé method. c. Suggest the use of adult incontinence briefs for nighttime only. d. Assist the patient to the commode every 2 hours during the day.

ANS: B The Credé method can be used to improve bladder emptying. Decreasing fluid intake will not improve bladder emptying and may increase risk for urinary tract infection and dehydration.

When a 74-yr-old patient is seen in the health clinic with new development of a stooped posture, shuffling gait, and pill rolling-type tremor, the nurse will anticipate teaching the patient about a. oral corticosteroids. b. antiparkinsonian drugs. c. magnetic resonance imaging (MRI). d. electroencephalogram (EEG) testing.

ANS: B The clinical diagnosis of Parkinson's is made when tremor, rigidity, and akinesia, and postural instability are present. The confirmation of the diagnosis is made on the basis of improvement when antiparkinsonian drugs are administered. MRI and EEG are not useful in diagnosing Parkinson's disease, and corticosteroid therapy is not used to treat it.

A hospitalized patient complains of a bilateral headache (4/10 on the pain scale) that radiates from the base of the skull. Which prescribed PRN medications should the nurse administer initially? a. Lorazepam (Ativan) b. Acetaminophen (Tylenol) c. Morphine sulfate (MS Contin) d. Butalbital and aspirin (Fiorinal)

ANS: B The patient's symptoms are consistent with a tension headache, and initial therapy usually involves a nonopioid analgesic such as acetaminophen, which is sometimes combined with a sedative or muscle relaxant. Lorazepam may be used in conjunction with acetaminophen but would not be appropriate as the initial monotherapy. Morphine sulfate and butalbital and aspirin would be more appropriate for a headache that did not respond to a nonopioid analgesic.

The nurse expects the assessment of a patient who is experiencing a cluster headache to include a. nuchal rigidity. b. unilateral ptosis. c. projectile vomiting. d. throbbing, bilateral facial pain.

ANS: B Unilateral eye edema, tearing, and ptosis are characteristic of cluster headaches. Nuchal rigidity suggests meningeal irritation, such as occurs with meningitis

Which of the following is a characteristic of the human immunodeficiency virus (HIV), which causes AIDS? a. HIV only infects B cells. b. HIV is a retrovirus. c. Infection does not require a host cell receptor. d. After infection, cell death is immediate.

ANS: B AIDS is an acquired dysfunction of the immune system caused by a retrovirus (HIV) that infects and destroys CD4+ lymphocytes (T-helper cells). HIV infection begins when a virion binds to CD4, not a B cell. Infection requires a host cell receptor. The cell remains dormant but does not die.

In addition to matching ABO antigens, a blood transfusion must also be matched for: a. HLA type. b. Rh antigen. c. immunoglobulins. d. platelet compatibility.

ANS: B Blood transfusions must also be matched for the Rh antigen. Blood transfusions do not need to be matched to HLA, immunoglobulins, or platelet compatibility.

A 5-year-old male presents with low-set ears, a fish-shaped mouth, and involuntary rapid muscular contraction. Laboratory testing reveals decreased calcium levels. Which of the following diagnosis is most likely? a. B-lymphocyte deficiency b. T-lymphocyte deficiency c. Combined immunologic deficiency d. Complement deficiency

ANS: B DiGeorge syndrome results in greatly decreased T cell numbers and function and is evidenced by abnormal development of facial features that are controlled by the same embryonic pouches; these include low-set ears, fish-shaped mouth, and other altered features. B-lymphocyte deficiency is not manifested by these symptoms. Neither combined immunologic deficiency nor complement deficiency is manifested by these symptoms.

A 30-year-old female complains of fatigue, arthritis, rash, and changes in urine color. Laboratory testing reveals anemia, lymphopenia, and kidney inflammation. Assuming a diagnosis of SLE, which of the following is also likely to be present? a. Anti-LE antibodies b. Autoantibodies c. Antiherpes antibodies d. Anti-CMV antibodies

ANS: B The presence of autoantibodies is a diagnostic criterion for SLE. Diagnostic criterion for SLE would include positive LE. Neither antiherpes nor anti-CMV antibodies are associated with a diagnosis SLE.

A nurse is teaching a patient with contact dermatitis of the arms and legs about ways to decrease pruritus. Which information should the nurse include in the teaching plan? (select all that apply) a. add oil to you bath water to moisturize the affected skin b. cool, wet clothes or compresses can be used to reduce itching c. use an OTC antihistamine to reduce itching d. take cool or tepid baths several times daily to decrease itching e. rub yourself dry with a towel after bathing to prevent skin maceration

ANS: B, C, D Cool or tepid baths, cool dressings, and OTC antihistamines all help reduce pruritus and scratching

Which statements about antiepileptic drug (AED) therapy are accurate? (Select all that apply.) a.AED therapy can be stopped when seizures are stopped. b.AED therapy is usually lifelong. c.Consistent dosing is the key to controlling seizures. d.A dose may be skipped if the patient is experiencing adverse effects. e.Do not abruptly discontinue AEDs because doing so may cause rebound seizure activity.

ANS: B, C, E Patients need to know that AED therapy is usually lifelong, and compliance (with consistent dosing) is important for effective seizure control. Abruptly stopping AED therapy may cause withdrawal (or rebound) seizure activity.

While planning care for an elderly patient, the nurse remembers that increased age is associated with: (select all that apply) a. increased T-cell function. b. decreased immune function. c. increased production of antibodies. d. decreased numbers of circulating immune complexes. e. decreased ability to fight infection.

ANS: B, D, E Increased age is associated with diminished T-cell function, decreased immune function, diminished production of antibody responses, decreased circulating immune complexes, and decreased ability to fight infection.

Which information should the nurse include in the teaching plan for a patient diagnosed with basal cell carcinoma? a. treatment plans include watchful waiting b. screening for metastasis will be important c. minimizing sun exposure reduces the risk for future BCC d. low-dose systemic chemotherapy is used to treat BCC

ANS: C BCC is frequently associated with sun-exposure, and preventive measures should be taken for future sun exposure

What is the most effective method to prevent the spread of infection to others when the nurse is changing the dressing over a wound infected with Staphylococcus aureus? a. change the dressing with sterile gloves b. apply antibiotic ointment over the wound c. wash hands and properly dispose of the soiled dressings d. soak the dressing in sterile normal saline before removal

ANS: C Careful hand washing and safe disposal of soiled dressings are the best means of preventing the spread of skin problems

The nurse teaches a patient about the application of corticosteroid cream to an area of contact dermatitis on the right leg. Which patient action indicates that further teaching is needed? a. the patient takes a tepid bath before applying the cream b. the patient spreads the cream using a downward motion c. the patient applies a thick layer of the cream to the affected skin d. the patient covers the area with a dressing after applying the cream

ANS: C Creams and ointments should be applied in a thin layer to avoid wasting the medication

A patient has a 9-year history of a seizure disorder that has been managed well with oral phenytoin (Dilantin) therapy. He is to be NPO (consume nothing by mouth) for surgery in the morning. What will the nurse do about his morning dose of phenytoin? a.Give the same dose intravenously. b.Give the morning dose with a small sip of water. c.Contact the prescriber for another dosage form of the medication. d.Notify the operating room that the medication has been withheld.

ANS: C If there are any questions about the medication order or the medication prescribed, contact the prescriber immediately for clarification and for an order of the appropriate dose form of the medication. Do not change the route without the prescriber's order. Withholding the medication may lead to seizure activity during the surgical procedure.

The nurse assesses a patient who has just arrived in the postanesthesia recovery area after a blepharoplasty. Which assessment data should be reported to the surgeon immediately? a. the patient reports incisional pain b. the patients HR is 100 beats/min c. the skin around the incision is pale and cold d. the patient is unable to sense touch on the eyelids

ANS: C Pale, cool skin indicates a possible decrease in circulation, so the surgeon should be notified immediately

A teenaged male patient who is on the wrestling team is examined by the nurse in the clinic. Which assessment finding would prompt the nurse to teach the patient about the importance of not sharing headgear to prevent the spread of pediculosis? a. ringlike rashes with red, scaly borders over the entire scalp b. red, hivelike papules and plaques with circumscribed borders c. papular, wheal-like lesions with white deposits in the hair shaft d. patchy areas of alopecia with small vesicles and excoriated areas

ANS: C Pediculosis is characterized by wheal-like lesions with parasites that attach eggs to the base of the hair shaft

There is one opening in the schedule at the dermatology clinic, and four patients are seeking appointments today. Which patient will the nurse schedule for the available opening? a. 42 yr old with itching after using topical fluorouracil on the nose b. 50 yr old with skin redness after having a chemical peel 3 days ago c. 38 yr old with a 7mm nevus on the face that has recently become darker d. 62 yr old with multiple small, soft, pedunculated papules in both axillary areas

ANS: C The description if the lesion is consistent with possible malignant melanoma

During an admission assessment, the nurse discovers that the patient does not speak English. Which is considered the ideal resource for translation? a. A family member of the patient b. A close family friend of the patient c. A translator who does not know the patient d. Prewritten note cards with both English and the patient's language

ANS: C The nurse should communicate with the patient in the patient's native language if at all possible. If the nurse is not able to speak the patient's native language, a translator should be made available so as to prevent communication problems, minimize errors, and help boost the patient's level of trust and understanding of the nurse. In practice, this translator may be another nurse or health care professional, a nonprofessional member of the health care team, or a layperson, family member, adult friend, or religious leader or associate. However, it is best to avoid family members as translators, if possible, because of issues with bias, misinterpretation, and potential confidentiality issues.

Which information should the nurse include when teaching patients about decreasing the risk for sun damage to the skin? a. use a sunscreen with an SPF of at least 10 for adequate protection b. water-resistant sunscreens provide good protection when swimming c. try to stay out of the direct sun between the hours of 1000 and 1400 d. increase sun exposure by no more than 10 min a day to avoid skin damage

ANS: C The risk for skin damage from the sun is highest with exposure between 1000 and 1400

The nurse is developing a care plan for a patient who will be self-administering insulin injections. Which statement reflects a measurable outcome? a. The patient will know about self-administration of insulin injections. b. The patient will understand the principles of self-administration of insulin injections. c. The patient will demonstrate the proper technique of self-administering insulin injections. d. The patient will comprehend the proper technique of self-administering insulin injections.

ANS: C The word demonstrate is a measurable verb, and measurable terms should be used when developing goals and outcome criteria statements. The other options are incorrect because the terms know, understand, and comprehendare not measurable terms.

A patient who is receiving immunotherapy has just received an allergen injection. Which assessment finding is most important to communicate to the health care provider? a. The patient's IgG level is increased. b. The injection site is red and swollen. c. There is a 2-cm wheal at the site of the allergen injection. d. The patient's allergy symptoms have not improved in 2 months.

ANS: C A local reaction larger than quarter size may indicate that a decrease in the allergen dose is needed. An increase in IgG indicates that the therapy is effective. Redness and swelling at the site are not unusual. Because immunotherapy usually takes 1 to 2 years to achieve an effect, an improvement in the patient's symptoms is not expected after a few months

Barriers to patient education the nurse considers in implementing a teaching plan include a. family resources. b. high school education. c. hunger and pain. d. need perceived by patient.

ANS: C A patient who is hungry or in pain has limited ability to concentrate or learn. Family resources would be considered in developing a plan of care and could be an asset or a barrier to patient education. The patient's educational level would be considered in planning teaching strategies but would not be a barrier to education. A need perceived by a patient would provide motivation for learning and would not be a barrier.

A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer. The base of the wound is yellow and involves subcutaneous tissue. How should the nurse classify this pressure ulcer? a. Stage I b. Stage II c. Stage III d. Stage IV

ANS: C A stage III pressure ulcer has full-thickness skin damage and extends into the subcutaneous tissue. A stage I pressure ulcer has intact skin with some observable damage such as redness or a boggy feel. Stage II pressure ulcers have partial-thickness skin loss. Stage IV pressure ulcers have full-thickness damage with tissue necrosis, extensive damage, or damage to bone, muscle, or supporting tissues

The most appropriate resources to include when planning to provide patient education related to a goal in the psychomotor domain would be a. diagnosis-related support groups. b. Internet resources. c. manikin practice sessions. d. self-directed learning modules.

ANS: C A teaching goal in the psychomotor domain should be matched with teaching strategies in the psychomotor domain, such as demonstration, practice sessions with a manikin, and return demonstrations. Diagnosis-related support groups would be most effective with goals in the affective domain. Internet resources would be most effective for goals in the cognitive domain. Self-directed learning modules would be most effective for goals in the cognitive domain

Which teaching should the nurse provide about intradermal skin testing to a patient with possible allergies? a. "Do not eat anything for about 6 hours before the testing." b. "Take an oral antihistamine about an hour before the testing." c. "Plan to wait in the clinic for 20 to 30 minutes after the testing." d. "Reaction to the testing will take about 48 to 72 hours to occur."

ANS: C Allergic reactions usually occur within minutes after injection of an allergen, and the patient will be monitored for at least 20 minutes for anaphylactic reactions after the testing. Medications that might modify the response, such as antihistamines, should be avoided before allergy testing. There is no reason to be NPO for skin testing. Results with intradermal testing occur within minutes.

The health care provider asks the nurse whether a patient's angioedema has responded to prescribed therapies. Which assessment should the nurse perform? a. Ask the patient about any clear nasal discharge. b. Obtain the patient's blood pressure and heart rate. c. Check for swelling of the patient's lips and tongue. d. Assess the patient's extremities for wheal and flare lesions.

ANS: C Angioedema is characterized by swelling of the eyelids, lips, and tongue. Wheal and flare lesions, clear nasal drainage, and hypotension and tachycardia are characteristic of other allergic reactions.

Immediately after the nurse administers an intracutaneous injection of an allergen on the forearm, a patient complains of itching at the site and of weakness and dizziness. What action should the nurse take first? a. Remind the patient to remain calm. b. Administer subcutaneous epinephrine. c. Apply a tourniquet above the injection site. d. Rub a local antiinflammatory cream on the site.

ANS: C Application of a tourniquet will decrease systemic circulation of the allergen and should be the first reaction. A local antiinflammatory cream may be applied to the site of a cutaneous test if the itching persists. Epinephrine will be needed if the allergic reaction progresses to anaphylaxis. The nurse should assist the patient to remain calm, but this is not an adequate initial nursing action.

A neurologist explains that arousal is mediated by the: a. cerebral cortex. b. medulla oblongata. c. reticular activating system. d. cingulate gyrus.

ANS: C Arousal is mediated by the reticular activating system, which regulates aspects of attention and information processing and maintains consciousness. The cerebral cortex affects movement. The medulla oblongata controls things such as hiccups and vomiting. The cingulate gyrus plays other roles in response. REF: p. 359

A 25-year-old female experiences a headache and takes aspirin for relief. A nurse recalls aspirin relieves the headache by: a. Decreasing leukotriene production b. Increasing histamine release c. Decreasing prostaglandin production d. Increasing platelet-activating factor

ANS: C Aspirin is a prostaglandin inhibitor. Aspirin inhibits prostaglandins; it does not affect leukotriene production. Aspirin inhibits prostaglandins; it does not affect histamine release. Aspirin does not play a role in the platelet activating factor; this is a leukotriene response.

A compensatory alteration in the diameter of cerebral blood vessels in response to increased intracranial pressure is called: a. herniation. b. vasodilation. c. autoregulation. d. amyotrophy.

ANS: C Autoregulation is the compensatory alteration in the diameter of the intracranial blood vessels designed to maintain a constant blood flow during changes in cerebral perfusion pressure. Herniation is the downward protrusion of the brainstem. Vasodilation is an enlargement in vessel diameter and a part of autoregulation, but the vessels should not dilate in the presence of increased intracranial pressure. Amyotrophy is involved with the anterior horn cells of the spinal cord and not related to autoregulation. REF: p. 374

When the nurse is taking a patient's temperature, which principle should the nurse remember? Regulation of body temperature primarily occurs in the: a. cerebrum. b. brainstem. c. hypothalamus. d. pituitary gland.

ANS: C Temperature regulation (thermoregulation) is mediated primarily by the hypothalamus, not the cerebrum, the brainstem, or the pituitary gland. REF: p. 342

A patient who collects honey to earn supplemental income has developed a hypersensitivity to bee stings. Which statement, if made by the patient, would indicate a need for additional teaching? a. "I need to find another way to earn extra money." b. "I will get a prescription for epinephrine and learn to self-inject it." c. "I will plan to take oral antihistamines daily before going to work." d. "I should wear a Medic-Alert bracelet indicating my allergy to bee stings."

ANS: C Because the patient is at risk for bee stings and the severity of allergic reactions tends to increase with added exposure to allergen, taking oral antihistamines will not adequately control the patient's hypersensitivity reaction. The other patient statements indicate a good understanding of management of the problem

The nurse, who is reviewing a clinic patient's medical record, notes that the patient missed the previous appointment for weekly immunotherapy. Which action by the nurse is most appropriate? a. Schedule an additional dose that week. b. Administer the usual dosage of the allergen. c. Consult with the health care provider about giving a lower allergen dose. d. Re-evaluate the patient's sensitivity to the allergen with a repeat skin test.

ANS: C Because there is an increased risk for adverse reactions after a patient misses a scheduled dose of allergen, the nurse should check with the health care provider before administration of the injection. A skin test is used to identify the allergen and would not be used at this time. An additional dose for the week may increase the risk for a reaction.

After receiving a change-of-shift report, which patient should the nurse assess first? a. The patient who has multiple black wounds on the feet and ankles b. The newly admitted patient with a stage IV pressure ulcer on the coccyx c. The patient who has been receiving chemotherapy and has a temperature of 102° F d. The patient who needs to be medicated with multiple analgesics before a scheduled dressing change

ANS: C Chemotherapy is an immunosuppressant. Even a low fever in an immunosuppressed patient is a sign of serious infection and should be treated immediately with cultures and rapid initiation of antibiotic therapy. The nurse should assess the other patients as soon as possible after assessing and implementing appropriate care for the immunosuppressed patient

Which statement indicates teaching was successful regarding collectins? Collectins are produced by the: a. Kidneys b. Bowel c. Lungs d. Integument

ANS: C Collectins are produced by the lungs. Collectins are produced by the lungs, not the kidneys. Collectins are produced by the lungs, not the bowel. Collectins are produced by the lungs, not the integument.

A new mother expresses concern about her baby developing allergies and asks what the health care provider meant by "passive immunity." Which example should the nurse use to explain this type of immunity? a. Early immunization b. Bone marrow donation c. Breastfeeding her infant d. Exposure to communicable diseases

ANS: C Colostrum provides passive immunity through antibodies from the mother. These antibodies protect the infant for a few months. However, memory cells are not retained, so the protection is not permanent. Active immunity is acquired by being immunized with vaccinations or having an infection. It requires that the infant has an immune response after exposure to an antigen. Cell-mediated immunity is acquired through T lymphocytes and is a form of active immunity.

The nurse is reviewing the lab data of a newly admitted patient. The nurse notes the patient had an erythrocyte sedimentation done, and the results are quite elevated. The nurse would focus the care plan on which of the following conditions? a. Anemia b. Infection c. Inflammation d. Electrolyte imbalance

ANS: C Common laboratory tests for inflammation measure levels of acute phase reactants. An increase in fibrinogen is associated with an increased erythrocyte sedimentation rate, which is considered a good indicator of an acute inflammatory response. Anemia would not result in an increased erythrocyte sedimentation rate. An infection would result in an increase in white blood cell count, but not the erythrocyte sedimentation rate. An electrolyte imbalance would not cause a rise in the sedimentation rate.

A nurse recalls the mast cell, a major activator of inflammation, initiates the inflammatory response through the process of: a. Chemotaxis b. Endocytosis c. Degranulation d. Opsonization

ANS: C Degranulation of mast cells is a major cellular component of inflammation. Chemotaxis is the process of white cell migration. Endocytosis is a part of phagocytosis and is not a factor in mast cell response. Opsonization is part of phagocytosis and is not a factor in mast cell response.

The nurse reviews the patient's complete blood count (CBC) results and notes that the neutrophil levels are elevated, but monocytes are still within normal limits. This indicates _____ inflammatory response. a. chronic b. resolved c. early stage acute d. late stage acute

ANS: C Elevated neutrophils and monocytes within normal limits are findings indicative of early inflammatory response. Neutrophils increase in just a few hours, while it takes the body days to increase the monocyte levels. Chronic inflammation results in varying elevations in WBCs dependent on multiple issues. Elevated neutrophils are not indicative of resolved inflammation. Elevations in monocytes occur later in the inflammatory response.

A nurse is instructing her patient with ulcerative colitis regarding the need to avoid enteric coated medications. The nurse knows that the patient understands the reason for this teaching when he states which of the following? a. "The coating on these medications is irritating to my intestines." b. "I need a more immediate response from my medications than can be obtained from enteric coated medications." c. "Enteric coated medications are absorbed lower in the digestive tract and can be irritating to my intestines or inadequately absorbed by my inflamed tissue." d. "I don't need to use these medications because they cause diarrhea, and I have had enough trouble with diarrhea and rectal bleeding over the past weeks."

ANS: C Enteric coatings on medications are designed to prevent breakdown and absorption of the medication until lower in the digestive tract, usually to prevent stomach irritation or to reach a certain point in the digestive tract for optimal absorption. For the patient with ulcerative colitis, the intestinal lining is inflamed or susceptible to inflammation and can have impaired absorption; therefore, enteric coated medications should be avoided. The coating is not irritating, but the medication can be. The response time of the medication is not a concern in this instance. Enteric coated medicines do not cause diarrhea simply because they are enteric coated.

Which portion of the antibody is responsible for the biologic functions of antibodies? a. Heavy chain b. Variable region c. Fc portion d. Epitope

ANS: C The Fc portion is responsible for most of the functions of antibodies. None of the remaining options are responsible for most of the functions of antibodies.

A patient received a prescription for a weight loss pill. One effect of the pills is to increase the release of epinephrine. Which of the following would be expected to also occur? a. Decreased vascular tone b. Increased skeletal muscle tone c. Increased heat production d. Decreased basal metabolic rate

ANS: C Epinephrine causes vasoconstriction, stimulates glycolysis, and increases metabolic rate, thus increasing secondary heat production. Epinephrine does not lead to decreased vascular tone or increased skeletal muscle tone but does increase metabolic rate. REF: p. 342

Biochemical secretions that trap and kill microorganisms include: a. Hormones b. Neurotransmitters c. Earwax d. Gastric acid

ANS: C Epithelial cells secrete several substances that protect against infection, including earwax. Hormones do not contain biochemical secretions that trap and kill microorganisms. Neurotransmitters carry important messages, but they do not contain biochemical secretions. Gastric acid helps break down food into its component parts, but does not contain biochemical secretions.

A 10-year-old male is stung by a bee while playing in the yard. He experiences a severe allergic reaction and has to go to the ER. The nurse providing care realizes this reaction is the result of: a. toxoids. b. IgA. c. IgE. d. IgM.

ANS: C IgE is normally at low concentrations in the circulation. It has very specialized functions as a mediator of many common allergic responses. Neither toxoids, IgA, nor IgM is the mediator of common allergic response.

A 23-year-old pregnant female visits her primary care provider for her final prenatal checkup. The primary care provider determines that the fetus has developed an infection in utero. Which of the following would be increased in the fetus at birth? a. IgG b. IgA c. IgM d. IgD

ANS: C IgM is synthesized early in neonatal life, and its synthesis may be increased as a response to infection in utero.

The nurse is assessing the patient with a pen light. The integrity of which cranial nerve is being evaluated? a. Olfactory b. Vagus c. Oculomotor d. Trigeminal

ANS: C In evaluating the oculomotor nerve, the pupils are examined for size, shape, and equality; pupillary reflex tested with a pen light (pupils should constrict when illuminated); and ability to follow moving objects. The olfactory nerve is assessed using smells. The vagus nerve is assessed using the ophthalmoscope. The trigeminal nerve is assessed with a safety pin and hot and cold objects for sensations of pain, touch, and temperature.

When the immunologist says that pathogens possess infectivity, what is the immunologist explaining? Infectivity allows pathogens to: a. spread from one individual to others and cause disease. b. induce an immune response. c. invade and multiply in the host. d. damage tissue.

ANS: C Infectivity is the ability of the pathogen to invade and multiply in the host. Communication is the ability to spread from one individual to others and cause disease. Immunogenicity is the ability of pathogens to induce an immune response. Damaging tissues is the pathogen's mechanism of action.

A macrophage was isolated and analyzed for major histocompatibility complex. Which of the following would be expected? a. MHC I only b. MHC II only c. MHC I and II d. Neither MHC I nor MHC II

ANS: C MHC I and II would be expected.

A cell was isolated from the CNS. A researcher revealed that its main function was to clear cellular debris. What type of cell is the researcher studying? a. Astrocyte b. Ependymal cell c. Microglia d. Schwann cell

ANS: C Microglia remove debris (phagocytosis) in the CNS. Astrocytes and ependymal cells are neuroglial cells and do not have phagocytic properties. Schwann cells help form the myelin sheath in the peripheral nervous system (PNS).

A patient has done research on monoclonal antibodies on the Internet. Which statement indicates a correct understanding? Pure monoclonal antibodies are produced by: a. T lymphocytes. b. bone marrow. c. laboratories. d. fetuses.

ANS: C Monoclonal antibodies are produced in the laboratory from one B cell that has been cloned; thus, the entire antibody is of the same class, specificity, and function. Pure monoclonal antibodies are not produced by T lymphocytes, bone marrow, or fetuses.

A 5-month-old child is admitted to the hospital with recurring respiratory infections. A possible cause of this condition is: a. hypergammaglobulinemia. b. increased maternal IgG. c. immune insufficiency. d. decreased maternal antibody breakdown, resulting in hyposensitivity.

ANS: C Normal human infants are immunologically immature when born, with deficiencies in antibody production, phagocytic activity, and complement activity, especially components of alternative pathways. They do not possess hypergammaglobulinemia. Possessing increased maternal IgG would not lead to recurring infections. The recurrent infections are due to decreased immunity, not maternal antibody breakdown.

When an aide asks the nurse what is a purpose of the inflammatory process, how should the nurse respond? a. To provide specific responses toward antigens b. To lyse cell membranes of microorganisms c. To prevent infection of the injured tissue d. To create immunity against subsequent tissue injury

ANS: C One purpose of the inflammatory process is to prevent infection and further damage by contaminating microorganisms. Specific response toward antigens is a part of the complement system that assists in the inflammatory response, but not its purpose. Lysis of cell membranes is part of the process of phagocytosis, which removes foreign material, but this is not the purpose of the inflammatory response. Immunity cannot be achieved against future tissue injury.

Which of the following individuals would be at greatest risk for an opportunistic infection? a. 18-year-old with diabetes b. 70-year-old with congestive heart failure c. 24-year-old who is immunocompromised d. 30-year-old with pneumonia

ANS: C Opportunistic microorganisms can cause disease if the individual's defenses are compromised. An 18-year-old with diabetes would not be immunocompromised and would not be at risk. A 70-year-old with congestive heart failure would not be immunocompromised and would not be at risk. A 30-year-old with pneumonia would not be immunocompromised and would not be at risk.

Which neurotransmitter is released when a patient's parasympathetic motor neurons are stimulated? a. Epinephrine b. Serotonin c. Acetylcholine d. Substance P

ANS: C Parasympathetic motor neurons release acetylcholine. Adrenergic motor neurons release epinephrine. Serotonin is associated with the brain. Substance P is a neurotransmitter in pain transmission pathways. Blocking the release of substance P by morphine reduces pain.

A nurse has obtained donor tissue typing information about a patient who is waiting for a kidney transplant. Which results should be reported to the transplant surgeon? a. Patient is Rh positive and donor is Rh negative b. Six antigen matches are present in HLA typing c. Results of patient-donor cross matching are positive d. Panel of reactive antibodies (PRA) percentage is low

ANS: C Positive crossmatching is an absolute contraindication to kidney transplantation, since a hyperacute rejection will occur after the transplant. The other information indicates that the tissue match between the patient and potential donor is acceptable

An experiment looking at an isolated neuron revealed a sensory nerve with one process containing a dendritic portion extending away from the CNS and an axon extending toward the CNS. Which of the following classifications would this neuron fall into? a. Bipolar b. Multipolar c. Pseudounipolar d. Interpolar

ANS: C Pseudounipolar neurons have one process; the dendritic portion of each of these neurons extends away from the CNS, and the axon portion projects into the CNS. Bipolar neurons have two distinct processes arising from the cell body. Multipolar neurons are the most common and have multiple processes capable of extensive branching. A motor neuron is typically multipolar. Interpolar is not a type of neuron.

Which neurons have the capacity for regeneration? a. Unmyelinated neurons in the brain b. Myelinated neurons in the spinal cord c. Myelinated peripheral neurons d. Postganglionic motor neurons

ANS: C Regeneration is limited to myelinated fibers and generally occurs only in the PNS. Regeneration does not occur in unmyelinated neurons, myelinated neurons in the spinal cord, or postganglionic motor neurons.

A 12-year-old male is fighting with another child when he receives a puncture wound from a pencil. The school nurse cleans and bandages the wound. After about 1 week, the wound would be in which phase of healing? a. Debridement b. Primary intention c. Resolution d. Maturation

ANS: C Resolution occurs when repaired tissue is approaching close to normal. Debridement is the scraping away of dead tissue and is not a phase of wound healing. Primary intention is the stage of healing of wounds that are closely proximated. Maturation is the result of severe wounds which would begin several weeks after injury and may take 2 years.

A patient has memory loss of events that occurred before a head injury. What cognitive disorder does the nurse suspect the patient is experiencing? a. Selective memory deficit b. Anterograde amnesia c. Retrograde amnesia d. Executive memory deficit

ANS: C Retrograde amnesia is manifested by loss of past personal history memories or past factual memories. In selective memory deficit, the person reports inability to focus attention and has failure to perceive objects and other stimuli. Anterograde amnesia is a loss of the ability to form new memories. Executive memory deficit involves the failure to stay alert and oriented to stimuli. REF: p. 365

Which patient should the nurse assess first? a. Patient with urticaria after receiving an IV antibiotic b. Patient who has graft-versus-host disease and severe diarrhea c. Patient who is sneezing after having subcutaneous immunotherapy d. Patient with multiple chemical sensitivities who has muscle stiffness

ANS: C Sneezing after subcutaneous immunotherapy may indicate impending anaphylaxis and assessment and emergency measures should be initiated. The other patients also have findings that need assessment and intervention by the nurse, but do not have evidence of life-threatening complications.

Which statement by a patient would alert the nurse to a possible immunodeficiency disorder? a. "I take one baby aspirin every day to prevent stroke." b. "I usually eat eggs or meat for at least 2 meals a day." c. "I had my spleen removed many years ago after a car accident." d. "I had a chest x-ray 6 months ago when I had walking pneumonia."

ANS: C Splenectomy increases the risk for septicemia from bacterial infections. The patient's protein intake is good and should improve immune function. Daily aspirin use does not affect immune function. A chest x-ray does not have enough radiation to suppress immune function.

A 70-year-old patient is being closely monitored in the neurological critical care unit for a severe closed head injury. After 48 hours, signs of deterioration occur: pupils are small and sluggish, pulse pressure is widening, and heart rate is bradycardic. These clinical findings are evidence of what stage of intracranial hypertension? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4

ANS: C Stage 3 is characterized by decreasing levels of arousal or central neurogenic hyperventilation, widened pulse pressure, bradycardia, and pupils that become small and sluggish. Stage 1 is characterized by an ICP that may not change because of the effective compensatory mechanisms, and there may be few symptoms. Stage 2 is characterized by subtle and transient symptoms, including episodes of confusion, restlessness, drowsiness, and slight pupillary and breathing changes. Stage 4 is characterized by cessation of cerebral blood flow. REF: p. 374

Which action will occur when a patient's α1-receptors are stimulated? a. Dilation of the coronary arteries b. Vasoconstriction of arteries c. Increase in the strength of myocardial contraction d. Decrease in the rate of myocardial contraction

ANS: C Stimulation of α1-receptors results in increased strength and rate of myocardial contraction. α1-receptor stimulation does not affect the coronary arteries. α1-receptor simulation leads to dilation.

A woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. How should the nurse respond? a. "MS symptoms may be worse after the pregnancy." b. "Women with MS frequently have premature labor." c. "Symptoms of MS are likely to improve during pregnancy." d. "MS is associated with an increased risk for congenital defects."

ANS: C Symptoms of MS may improve during pregnancy.

A 50-year-old female experiences decreased blood pressure, decreased oxygen delivery, cardiovascular shock, and subsequent death. A complication of endotoxic shock is suspected. Which of the following is the most likely cause? a. Gram-positive bacteria b. Fungi c. Gram-negative bacteria d. Virus

ANS: C Symptoms of gram-negative septic shock are produced by endotoxins. Once in the blood, endotoxins cause the release of vasoactive peptides and cytokines that affect blood vessels, producing vasodilation, which reduces blood pressure, causes decreased oxygen delivery, and produces subsequent cardiovascular shock. Gram-positive bacteria nor fungi do not produce endotoxins and thus do not manifest in shock. Viruses do not produce symptoms of shock.

Which condition would be treated with therapeutic hypothermia? a. Malnutrition b. Hypothyroidism c. Reimplantation surgery d. Parkinson disease

ANS: C Therapeutic hypothermia is seen with reimplantation surgery, not malnutrition, hypothyroidism, or Parkinson disease. REF: p. 345, Box 14-3

A 5-year-old male is diagnosed with a bacterial infection. Cultures of the bacteria revealed lipopolysaccharides on the bacterial cell surface. Which of the complement pathways would be activated in this case? a. Classical pathway b. Lectin pathway c. Alternative pathway d. Kinin pathway

ANS: C The alternative pathway is activated by several substances found on the surface of infectious organisms, such as those containing lipopolysaccharides. The classical pathway is primarily activated by antibodies that are proteins of the acquired immune system. The lectin pathway is similar to the classic pathway but is independent of antibody. It is activated by several plasma proteins. The kinin pathway is involved in coagulation.

A nurse remembers the brain receives approximately ____% of the cardiac output. a. 80 b. 40 c. 20 d. 10

ANS: C The brain receives approximately 20% of the cardiac output.

Which structure ensures collateral blood flow from blood vessels supplying the brain? a. Carotid arteries b. Basal artery c. Circle of Willis d. Vertebral arteries

ANS: C The circle of Willis ensures collateral blood circulation. Collateral circulation is not associated with the basal artery or the vertebral arteries. The carotid arteries supply the brain.

A nurse is teaching about the area of the spinal cord that contains cell bodies involved in the autonomic nervous system. Which of the following areas is the nurse discussing? a. Anterior horn b. Ventral horn c. Lateral horn d. Dorsal horn

ANS: C The lateral horn contains cell bodies within the autonomic nervous system. Both the anterior and ventral horns contain the nerve cell bodies for efferent pathways that leave the spinal cord by way of spinal nerves. The dorsal horn contains sensory neurons.

Which of the following is responsible for initiating clonal selection? a. T cells b. B cells c. Antigens d. Lymphocytes

ANS: C The lymphocytes remain dormant until an antigen initiates clonal selection. T cells do not initiate clonal selection. B cells are antibodies. Lymphocytes are released into the circulation as immature cells that react with antigens.

While obtaining a health history from a patient, the nurse learns that the patient has a history of allergic rhinitis and multiple food allergies. Which action by the nurse is most appropriate? a. Encourage the patient to carry an epinephrine kit in case a type IV allergic reaction to latex develops. b. Advise the patient to use oil-based hand creams to decrease contact with natural proteins in latex gloves. c. Document the patient's allergy history and be alert for any clinical manifestations of a type I latex allergy. d. Recommend that the patient use vinyl gloves instead of latex gloves in preventing blood-borne pathogen contact.

ANS: C The patient's allergy history and occupation indicate a risk of developing a latex allergy. The nurse should be prepared to manage any symptoms that may occur. Epinephrine is not an appropriate treatment for contact dermatitis that is caused by a type IV allergic reaction to latex. Oil-based creams will increase the exposure to latex from latex gloves. Vinyl gloves are appropriate to use when exposure to body fluids is unlikely.

A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding will the nurse expect next? a. Skin flushing b. Muscle cramps c. Rising body temperature d. Decreasing blood pressure

ANS: C The patient's complaints of feeling cold and shivering indicate that the hypothalamic set point for temperature has been increased and the temperature is increasing. Because associated peripheral vasoconstriction and sympathetic nervous system stimulation will occur, skin flushing and hypotension are not expected. Muscle cramps are not expected with chills and shivering or with a rising temperature

After rehabilitation for severe brain damage following a motor vehicle accident, a patient reports that her thought processes and ability to concentrate are impaired. Which area does the nurse suspect is damaged? a. Thalamus b. Limbic c. Prefrontal d. Occipital

ANS: C The prefrontal area is responsible for goal-oriented behavior (e.g., ability to concentrate), short-term or recall memory, the elaboration of thought, and inhibition of the limbic areas of the CNS. Goal-oriented behavior is not the function of the thalamus, limbic system, or occipital area.

When a patient asks what the somatic nervous system controls, how should the nurse respond? It controls: a. the heart. b. the spinal cord. c. skeletal muscle. d. smooth muscle organs.

ANS: C The somatic nervous system consists of pathways that regulate voluntary motor control, the skeletal muscle system. The somatic nervous system does not control the heart; the autonomic nervous system controls the heart, the spinal cord, and the smooth muscle organs.

A neurologist is teaching about sensory pathways. Which information should the neurologist include? Sensory pathways in the spinal cord to the thalamus are included in the: a. corticospinal tract. b. pyramids. c. spinothalamic tract. d. anterior column.

ANS: C The spinothalamic tract carries nerve impulses from the spinal cord to the thalamus in the diencephalon; the corticospinal tract carries motor impulses. The pyramids assist with motor movements. The anterior column carries nerve impulses.

Where is the primary visual cortex of the brain located? a. Frontal lobe b. Temporal lobe c. Occipital lobe d. Parietal lobe

ANS: C The visual cortex is located in the occipital lobe.

When treating patients with medications for Parkinson's disease, the nurse knows that the wearing-off phenomenon occurs for which reason? a. There are rapid swings in the patient's response to levodopa. b. The patient cannot tolerate the medications at times. c. The medications begin to lose effectiveness against Parkinson's disease. d. The patient's liver is no longer able to metabolize the drug.

ANS: C The wearing-off phenomenon occurs when antiparkinson medications begin to lose their effectiveness, despite maximal dosing, as the disease progresses. The other options are incorrect.

A patient's 4 ´ 3-cm leg wound has a 0.4 cm black area in the center of the wound surrounded by yellow-green semiliquid material. Which dressing should the nurse apply to the wound? a. Dry gauze dressing (Kerlix) b. Nonadherent dressing (Xeroform) c. Hydrocolloid dressing (DuoDerm) d. Transparent film dressing (Tegaderm)

ANS: C The wound requires debridement of the necrotic areas and absorption of the yellow-green slough. A hydrocolloid dressing such as DuoDerm would accomplish these goals. Transparent film dressings are used for red wounds or approximated surgical incisions. Dry dressings will not debride the necrotic areas. Nonadherent dressings will not absorb wound drainage or debride the wound

A nurse wants to teach about one of the primary organs responsible for heat production. Which organ should the nurse include? a. Pancreas b. Liver c. Adrenal medulla d. Heart

ANS: C Thyroxine acts on the adrenal medulla, causing the release of epinephrine into the bloodstream. Epinephrine causes vasoconstriction that increases metabolic rates, thus increasing heat production. Heat production does not involve the pancreas, the liver, or the heart.

The nurse is assessing the medication history of a patient with a new diagnosis of Parkinson's disease. Which condition is a contraindication for the patient, who will be taking tolcapone (Tasmar)? a. Glaucoma b. Seizure disorder c. Liver failure d. Benign prostatic hyperplasia

ANS: C Tolcapone is contraindicated in patients who have shown a hypersensitivity reaction to it, and it should be used with caution in patients with pre-existing liver disease. The other conditions listed are not contraindications.

The charge nurse is assigning rooms for new admissions. Which patient would be the most appropriate roommate for a patient who has acute rejection of an organ transplant? a. A patient who has viral pneumonia b. A patient with second-degree burns c. A patient who is recovering from an anaphylactic reaction to a bee sting d. A patient with graft-versus-host disease after a recent bone marrow transplant

ANS: C Treatment for a patient with acute rejection includes administration of additional immunosuppressants, and the patient should not be exposed to increased risk for infection as would occur from patients with viral pneumonia, graft-versus-host disease, and burns. There is no increased exposure to infection from a patient who had an anaphylactic reaction.

A 65-year-old female is diagnosed with metastatic breast cancer. She has developed muscle wasting. Which of the following substances would be produced in large quantities to eliminate the tumor cells and cause muscle wasting? a. Interleukin-6 b. Eosinophils c. Tumor necrosis factor d. Platelets

ANS: C Tumor necrosis factor causes muscle wasting. Interleukin-6 stimulates growth and differentiation of blood cells. Eosinophils are stimulated for parasites. Platelets stimulate clotting.

Which information indicates a good understanding of bacterial vaccines? Most bacterial vaccines contain: a. fully active bacteria. b. synthetic bacteria. c. dead bacteria. d. bacterial toxins.

ANS: C Vaccines are biologic preparations of weakened or dead pathogens that when administered stimulate production of antibodies or cellular immunity against the pathogen without causing disease. Vaccines are not fully active bacteria, nor are they synthetic or toxins.

When the immunologist says that pathogens possess virulence, what does virulence mean? a. Spreads from one individual to others and causes disease. b. Induces an immune response. c. Causes disease. d. Damages tissue.

ANS: C Virulence is the capacity of a pathogen to cause severe disease—for example, measles virus is of low virulence; rabies virus is highly virulent. Communication is the ability to spread from one individual to others and cause disease. Immunogenicity is the ability of pathogens to induce an immune response. Damaging tissues is the pathogen's mechanism of action.

After studying about viruses, which information indicates the student has a good understanding of viruses? Viruses: a. contain no DNA or RNA. b. are capable of independent reproduction. c. replicate their genetic material inside host cells. d. are easily killed by antimicrobials.

ANS: C Virus replication depends totally on the ability of the virus to infect a permissive host cell, a cell that cannot resist viral invasion and replication. Viruses contain both DNA and RNA, are incapable of independent reproduction, and cannot be killed by antimicrobials.

A patient presents to the emergency room (ER) reporting excessive vomiting. A CT scan of the brain reveals a mass in the: a. skull fractures. b. thalamus. c. medulla oblongata. d. frontal lobe.

ANS: C Vomiting is due to disruptions in the medulla oblongata. Skull fractures can result in vomiting but would not be related to the mass. The thalamus controls other things such as temperature. The frontal lobe deals with emotions. REF: p. 363

A 33-yr-old patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information will the nurse include in patient teaching? a. Recommendation to drink at least 4 L of fluid daily b. Need to avoid driving or operating heavy machinery c. How to draw up and administer injections of the medication d. Use of contraceptive methods other than oral contraceptives

ANS: C Copaxone is administered by self-injection. Oral contraceptives are an appropriate choice for birth control.

Which prescribed intervention will the nurse implement first for a patient in the emergency department who is experiencing continuous tonic-clonic seizures? a. Give phenytoin (Dilantin) 100 mg IV. b. Monitor level of consciousness (LOC). c. Administer lorazepam (Ativan) 4 mg IV. d. Obtain computed tomography (CT) scan.

ANS: C To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure medications such as the benzodiazepines.

When the maternal immune system becomes sensitized against antigens expressed by the fetus, what type of immune reaction occurs? a. Autoimmune b. Anaphylaxis c. Alloimmune d. Allergic

ANS: C Alloimmunity can be observed during immunologic reactions against transfusions, transplanted tissue, or the fetus during pregnancy. Autoimmunity is a disturbance in the immunologic tolerance of self-antigens. The most rapid and severe immediate hypersensitivity reaction is anaphylaxis. An allergic response occurs related to exposure to an allergen

A 10-year-old male is stung by a bee while playing in the yard. He begins itching and develops pain, swelling, redness, and respiratory difficulties. He is suffering from: a. immunodeficiency. b. autoimmunity. c. anaphylaxis. d. tissue-specific hypersensitivity.

ANS: C Anaphylaxis occurs within minutes of reexposure to the antigen and can be either systemic (generalized) or cutaneous (localized). Immunodeficiency is a decrease in the immune response. Autoimmunity is a disturbance in the immunologic tolerance of self-antigens. Tissue-specific reaction is an autoimmune reaction.

An infant is experiencing hemolytic disease of the newborn. Which of the following would the nurse expect to find in the infant's history and physical? a. The mother was exposed to measles. b. The father was exposed to Agent Orange. c. The baby is Rh positive. d. The baby was born 6 weeks prematurely

ANS: C Hemolytic disease of the newborn was most commonly caused by IgG anti-D alloantibody produced by Rh-negative mothers against erythrocytes of their Rh-positive fetuses. This disorder is not due to the mother's exposure to measles, the father's exposure to Agent Orange, or the baby's prematurity.

When a patient asks the nurse what hypersensitivity is, how should the nurse respond? Hypersensitivity is best defined as: a. a reduced immune response found in most pathologic states. b. a normal immune response to an infectious agent. c. an excessive or inappropriate response of the immune system to a sensitizing antigen. d. antigenic desensitization.

ANS: C Hypersensitivity is an altered immunologic response to an antigen that results in disease or damage to the individual. It is not a reduced immune response or a response to an infectious agent. Antigenic desensitization is performed to decrease hypersensitivity

A nurse recalls that an example of an immune-complex-mediated disease is: a. bronchial asthma. b. contact dermatitis. c. serum sickness. d. rheumatoid arthritis.

ANS: C Immune-complex disease can be a systemic reaction, such as serum sickness, and related to type III reactions. Bronchial asthma is not an immune-complex-mediated disease and is related to type I reactions. Neither contact dermatitis nor rheumatoid arthritis is related to type III reactions.

When a patient presents at the emergency department for an allergic reaction, the nurse recognizes the most severe consequence of a type I hypersensitivity reaction is: a. urticaria. b. hives. c. anaphylaxis. d. antibody-dependent cell-mediated cytotoxicity (ADCC).

ANS: C The most rapid and severe immediate hypersensitivity type I reaction is anaphylaxis. Urticaria, or hives, is a dermal (skin) manifestation of allergic reactions. Hives and urticaria are similar responses. ADCC is a mechanism that involves natural killer (NK) cells. Antibodies on the target cell are recognized by Fc receptors on the NK cells, which release toxic substances that destroy the target cel

A patient presents with poison ivy on the extremities, face, and buttocks after an initial exposure 48 hours ago. This condition is an example of: a. anaphylaxis. b. serum sickness. c. delayed hypersensitivity. d. viral disease.

ANS: C The response to poison ivy is a delayed hypersensitivity because it takes up to 72 hours to develop. Anaphylaxis is immediate. Serum sickness-type reactions are caused by the formation of immune complexes in the blood and their subsequent generalized deposition in target tissues. Poison ivy is not a viral disease.

When a nurse notices that a patient has type O blood, the nurse realizes that anti-_____ antibodies are present in the patient's body. a. A only b. B only c. A and B d. O

ANS: C Type O individuals have both anti-A and anti-B antibodies but not O.

When the immunologist says that pathogens possess virulence, what does virulence mean? a. Spreads from one individual to others and causes disease. b. Induces an immune response. c. Causes disease. d. Damages tissue.

ANS: C Virulence is the capacity of a pathogen to cause severe disease—for example, measles virus is of low virulence; rabies virus is highly virulent. Communication is the ability to spread from one individual to others and cause disease. Immunogenicity is the ability of pathogens to induce an immune response. Damaging tissues is the pathogen's mechanism of action

Which nursing diagnosis is appropriate for the patient who has just received a prescription for a new medication? a. Noncompliance related to new drug therapy b. Impaired memory related to new drug therapy c. Lack of knowledge regarding newly prescribed drug therapy d. Deficient knowledge related to newly prescribed drug therapy

ANS: D A patient who has a limited understanding of newly prescribed drug therapy may have the nursing diagnosis of deficient knowledge. Noncompliance is incorrect because that term implies that the patient does not follow a recommended regimen, which is not the case with a newly prescribed drug. Impaired memory is not appropriate in this situation. "Lack of knowledge" is not a nursing diagnosis.

The nurse is teaching a 16-year-old patient who has a new diagnosis of type 1 diabetes about blood glucose monitoring and the importance of regulating glucose intake. When developing a teaching plan for this teenager, which of Erikson's stages of development should the nurse consider? a. Trust versus mistrust b. Intimacy versus isolation c. Industry versus inferiority d. Identity versus role confusion

ANS: D According to Erikson, the adolescent (12 to 18 years of age) is in the identity versus role confusion stage of development. Trust versus mistrust reflects the infancy stage; intimacy versus isolation reflects the young adulthood stage; and industry versus inferiority reflects the schoolage stage of development.

An older adult patient with squamous cell carcinoma on the lower arm has a Mohs procedure in the dermatology clinic. Which nursing action will be included in the postoperative plan of care? a. schedule daily appointments for dressing changes b. describe the use of topical fluorouracil on the incision c. instruct how to use sterile technique to clean the suture line d. teach the use of cold packs to reduce bruising and swelling

ANS: D Application of cold packs to the incision after the surgery will help decrease bruising and swelling at the site

A 60-year-old patient is on several new medications and expresses worry that she will forget to take her pills. Which action by the nurse would be most helpful in this situation? a. Teaching effective coping strategies b. Asking the patient's prescriber to reduce the number of drugs prescribed c. Assuring the patient that she will not forget once she is accustomed to the routine d. Assisting the patient with obtaining and learning to use a calendar or pill container

ANS: D Calendars, pill containers, or diaries may be helpful to patients who may forget to take prescribed drugs as scheduled. The nurse must ensure that the patient knows how to use these reminder tools. Teaching coping strategies is a helpful suggestion but will not help with remembering to take medications. Asking the prescriber to reduce the number of drugs that are prescribed is not an appropriate action by the nurse. Assuring the patient that she will not forget is false reassurance by the nurse and inappropriate when education is needed.

The nurse is caring for a patient diagnosed with furunculosis. Which action could the nurse delegate to unlicensed assistive personnel? a. applying antibiotic cream to the groin b. obtaining cultures from the ruptured lesions c. evaluating the patient's personal hygiene d. cleaning the skin with antimicrobial soap

ANS: D Clean the skin is within the education and scope of practice for UAP

When teaching a patient about taking a newly prescribed antiepileptic drug (AED) at home, the nurse will include which instruction? a."Driving is allowed after 2 weeks of therapy." b."If seizures recur, take a double dose of the medication." c."Antacids can be taken with the AED to reduce gastrointestinal adverse effects." d."Regular, consistent dosing is important for successful treatment."

ANS: D Consistent dosing, taken regularly at the same time of day, at the recommended dose, and with meals to reduce the common gastrointestinal adverse effects, is the key to successful management of seizures when taking AEDs. Noncompliance is the factor most likely to lead to treatment failure.

The nurse is setting up a teaching session with an 85-year-old patient who will be going home on anticoagulant therapy. Which educational strategy would reflect consideration of the age-related changes that may exist with this patient? a. Show a video about anticoagulation therapy. b. Present all the information in one session just before discharge. c. Give the patient pamphlets about the medications to read at home. d. Develop large-print handouts that reflect the verbal information presented.

ANS: D Developing large-print handouts addresses altered perception in two ways. First, by using visual aids to reinforce verbal instructions, one addresses the possibility of decreased ability to hear high-frequency sounds. By developing the handouts in large print, one addresses the possibility of decreased visual acuity. Showing a video does not allow discussion of the information; furthermore, the text and print may be small and difficult to read and understand. Presenting all the information in one session before discharge also does not allow for discussion, and the patient may not be able to hear or see the information sufficiently. Because of the possibility of decreased short-term memory and slowed cognitive function, giving pamphlets to read may not be appropriate.

The nurse in interviewing a patient with contact dermatitis. Which finding indicates a need for patient teaching? a. the patient applies corticosteroid cream to pruritic areas b. the patient adds oilated oatmeal to the bath water every day c. the patient takes diphenhydramine at night for persistent itching d. the patient uses bacitracin-neomycin-polymyxin on minor abrasions

ANS: D Neosporin can cause contact dermatitis, the patient is using the other medications appropriately

When the nurse teaches a skill such as self-injection of insulin to the patient, what is the best way to set up the teaching/learning session? a. Provide written pamphlets for instruction. b. Show a video, and allow the patient to practice as needed on his own. c. Verbally explain the procedure, and provide written handouts for reinforcement. d. After demonstrating the procedure, allow the patient to do several return demonstrations.

ANS: D Return demonstration allows the nurse to evaluate the patient's newly learned skills. The techniques in the other options are incorrect because those suggestions do not allow for evaluation of the patient's technique.

A patient with an enlarging, irregular mole that is 7mm in diameter is scheduled for outpatient treatment. The nurse should plan to prepare the patient for which procedure? a. curettage b. cryosurgery c. punch biopsy d. surgical excision

ANS: D The description of the mole is consistent with cancer, so excision and biopsy are indicated

A patient is undergoing psoralen plus ultraviolet A light therapy for treatment of psoriasis. What action should the nurse take to prevent adverse effects from this procedure? a. shield any unaffected areas with lead-lined drapes b. apply petroleum jelly to the areas around the lesions c. cleanse the skin carefully with antiseptic soap prior to PUVA d. have the patient use protective eyewear while receiving PUVA

ANS: D The eyes should be shielded from UV light during and after PUVA therapy to prevent the development of cataracts

A patient who has severe refractory psoriasis on the face, neck, and extremities is socially withdrawn because of the appearance of the lesions. Which action should the nurse take first? a. discuss the possibility of taking part in an online support group b. encourage the patient to volunteer to work on community projects c. suggest that the patient use cosmetics to cover the psoriatic lesions d. ask the patient to describe the impact of psoriasis on the quality of life

ANS: D The nurse's initial actions should be to assess the impact of the disease on the patient's life and allow to verbalize feelings about the psoriasis

During a routine appointment, a patient with a history of seizures is found to have a phenytoin (Dilantin) level of 23 mcg/mL. What concern will the nurse have, if any? a.The patient is at risk for seizures because the drug level is not at a therapeutic level. b.The patient's seizures should be under control because this is a therapeutic drug level. c.The patient's seizures should be under control if she is also taking a second antiepileptic drug. d.The drug level is at a toxic level, and the dosage needs to be reduced.

ANS: D Therapeutic drug levels for phenytoin are usually 10 to 20 mcg/mL (see Table 14-6). The other options are incorrect.

A neurologist is teaching the staff about motor neurons. Which structural classification identifies motor neurons? a. Unipolar b. Pseudounipolar c. Bipolar d. Multipolar

ANS: D A motor neuron is typically multipolar. Unipolar neurons are found in the retina. Pseudounipolar neurons have one process; the dendritic portion of each of these neurons extends away from the CNS, and the axon portion projects into the CNS. Bipolar neurons are found in the eye.

A nurse recalls bacteria become resistant to antimicrobials by: a. proliferation. b. attenuation. c. specialization. d. plasmid exchange.

ANS: D Antibiotic resistance is usually a result of genetic mutations that can be transmitted directly to neighboring microorganisms by plasmid exchange. Antibiotic resistance is not a result of proliferation, attenuation, or specialization.

A patient has a new order for a catechol ortho-methyltransferase (COMT) inhibitor as part of treatment for Parkinson's disease. The nurse recognizes that which of these is an advantage of this drug class? a. It has a shorter duration of action. b. It causes less gastrointestinal distress. c. It has a slower onset than traditional Parkinson's disease drugs. d. It is associated with fewer wearing-off effects.

ANS: D COMT inhibitors are associated with fewer wearing-off effects and have prolonged therapeutic benefits. They have a quicker onset, and they prolong the duration of action of levodopa.

A patient experiences a severe head injury hitting a tree while riding a motorcycle. Breathing becomes deep and rapid but with normal pattern. What term should the nurse use for this condition? a. Gasping b. Ataxic breathing c. Apneusis d. Central neurogenic hyperventilation

ANS: D Central neurogenic hyperventilation is a sustained, deep, rapid, but regular, pattern (hyperpnea) of breathing. Gasping is a pattern of deep "all-or-none" breaths accompanied by a slow respiratory rate. Ataxic breathing is completely irregular breathing that occurs with random shallow and deep breaths and irregular pauses. Apneusis is manifested by a prolonged inspiratory pause alternating with an end-expiratory pause. REF: p. 362, Table 15-4

Carbidopa-levodopa (Sinemet) is prescribed for a patient with Parkinson's disease. The nurse informs the patient that which common adverse effects can occur with this medication? a. Drowsiness, headache, weight loss b. Dizziness, insomnia, nausea c. Peripheral edema, fatigue, syncope d. Heart palpitations, hypotension, urinary retention

ANS: D Common adverse reactions associated with carbidopa-levodopa include palpitations, hypotension, urinary retention, dyskinesia, and depression. The other effects may occur with other antiparkinson drugs.

A patient with rheumatoid arthritis has been taking corticosteroids for 11 months. Which nursing action is most likely to detect early signs of infection in this patient? a. Monitor white blood cell count. b. Check the skin for areas of redness. c. Check the temperature every 2 hours. d. Ask about fatigue or feelings of malaise.

ANS: D Common clinical manifestations of inflammation and infection are frequently not present when patients receive immunosuppressive medications. The earliest manifestation of an infection may be "just not feeling well."

An adult is diagnosed with communicating hydrocephalus. The form of hydrocephalus in adults is most often caused by: a. overproduction of CSF. b. intercellular edema. c. elevated arterial blood pressure. d. defective CSF reabsorption.

ANS: D Communicating hydrocephalus occurs because of defective reabsorption of the fluid. Hydrocephalus can occur because of overproduction of CSF, but in adults it occurs most often because of defective reabsorption of the fluid. Hydrocephalus is not due to either intercellular edema or elevated arterial blood pressure.

After studying about fungi, which information indicates a correct understanding of fungi? Fungi causing deep or systemic infections: a. are easily treated with penicillin. b. are extremely rare. c. never occur with other infections. d. are commonly opportunistic.

ANS: D Diseases caused by fungi are called mycoses. Mycoses are common and can be opportunistic and occur with other infections but are not treatable with penicillin.

When a patient is taking an anticholinergic such as benztropine (Cogentin) as part of the treatment for Parkinson's disease, the nurse should include which information in the teaching plan? a. Minimize the amount of fluid taken while on this drug. b. Discontinue the medication if adverse effects occur. c. Take the medication on an empty stomach to enhance absorption. d. Use artificial saliva, sugarless gum, or hard candy to counteract dry mouth.

ANS: D Dry mouth can be managed with artificial saliva through drops or gum, frequent mouth care, forced fluids, and sucking on sugar-free hard candy. Anticholinergics should be taken with or after meals to minimize GI upset and must not be discontinued suddenly. The patient must drink at least 3000 mL/day unless contraindicated. Drinking water is important, even if the patient is not thirsty or in need of hydration, to prevent and manage the adverse effect of constipation.

What type of cell supports the forming of the blood-brain barrier (BBB)? a. Endothelial b. Schwann c. Oligodendrocyte d. Astrocyte

ANS: D Endothelial cells in brain capillaries, with their intracellular tight junctions, are the sites of the BBB. Supporting cells include astrocytes, pericytes, and microglia. Schwann cells provide structural support and nutrition for the neurons. Oligodendrocytes form the myelin sheaths.

When a patient has a fever, which of the following thermoregulatory mechanisms is activated? a. The body's thermostat is adjusted to a lower temperature. b. Temperature is raised above the set point. c. Bacteria directly stimulate peripheral thermogenesis. d. The body's thermostat is reset to a higher level.

ANS: D Fever (febrile response) is a temporary "resetting of the hypothalamic thermostat" to a higher level in response to endogenous or exogenous pyrogens. Fever is the result of the body's attempt to raise temperature, not adjust it to a lower level. When fever occurs, the temperature is raised, but the rise is due to a reset of the thermostat. Bacteria do not stimulate peripheral thermogenesis, but their endotoxins do. REF: pp. 342-343

A 35-year-old male is diagnosed with lobar pneumonia (lung infection). Which of the following exudates would be present in highest concentration at the site of this advanced inflammatory response? a. Serous b. Purulent c. Hemorrhagic d. Fibrinous

ANS: D Fibrinous exudates occur in the lungs of individuals with pneumonia. Serous fluid is watery fluid, as in a blister. Purulent is characterized by an abscess, such as pus. Hemorrhagic occurs when the exudates are filled with erythrocytes.

An older adult patient has a prescription for cyclosporine following a kidney transplant. Which information in the patient's health history has the most implications for planning patient teaching about the medication at this time? a. The patient restricts salt to treat prehypertension. b. The patient drinks 3 to 4 quarts of fluids every day. c. The patient has many concerns about the effects of cyclosporine. d. The patient has a glass of grapefruit juice every day for breakfast.

ANS: D Grapefruit juice can increase the toxicity of cyclosporine. The patient should be taught to avoid grapefruit juice. High fluid intake will not affect cyclosporine levels or renal function. Cyclosporine may cause hypertension, and the patient's many concerns should be addressed, but these are not potentially life-threatening problems.

A 54-year-old male intravenous (IV) drug user is diagnosed with chronic hepatitis C. Testing revealed that he is a candidate for treatment. Which of the following could be used to treat his condition? a. Interleukin-1 b. Interleukin-6 c. Interleukin-10 d. INFs

ANS: D INFs are members of a family of cytokines that protect against viral infections. Interleukin-1 is responsible for fever production. Interleukin-6 stimulates growth and differentiation of blood cells. Interleukin-10 helps decrease the immune response.

The progress notes read: the cerebellar tonsil has shifted through the foramen magnum due to increased pressure within the posterior fossa. The nurse would identify this note as a description of _____ herniation. a. supratentorial b. central c. cingulated gyrus d. infratentorial

ANS: D In infratentorial herniation, the cerebellar tonsil shifts through the foramen magnum because of increased pressure within the posterior fossa. Supratentorial herniation involves temporal lobe and hippocampal gyrus shifting from the middle fossa to posterior fossa. Central herniation is a type of supratentorial herniation and is the straight downward shift of the diencephalon through the tentorial notch. Gyrus herniation occurs when the cingulate gyrus shifts under the falx cerebri. Little is known about its clinical manifestations. REF: p. 375, Box 15-5

A child fell off the swing and scraped the right knee. The injured area becomes painful. What else will the nurse observe upon assessment? a. Vasoconstriction at injured site b. Decreased RBC concentration at injured site c. Pale skin at injured site d. Edema at injured site

ANS: D Increased vascular permeability and leakage of fluid out of the vessel cause edema at the site of injury. Vasodilation occurs, not vasoconstriction. Increased RBCs come to the site, not fewer. Redness occurs, not paleness, during inflammation.

When describing patient education approaches, the nurse educator would explain that informal teaching is an approach that a. addresses group needs. b. follows formalized plans. c. has standardized content. d. often occurs one-to-one.

ANS: D Informal teaching is individualized one-on-one teaching which represents the majority of patient education done by nurses that occurs when an intervention is explained or a question is answered. Group needs are often the focus of formal patient education courses or classes. Informal teaching does not necessarily follow a specific formalized plan. It may be planned with specific content, but it is individualized responses to patient needs. Formal teaching involves the use of a curriculum/course plan with standardized content.

The nurse could delegate care of which patient to a licensed practical/vocational nurse (LPN/LVN)? a. The patient who has increased tenderness and swelling around a leg wound b. The patient who was just admitted after suturing of a full-thickness arm wound c. The patient who needs teaching about home care for a draining abdominal wound d. The patient who requires a hydrocolloid dressing change for a stage III sacral ulcer

ANS: D LPN/LVN education and scope of practice include sterile dressing changes for stable patients. Initial wound assessments, patient teaching, and evaluation for possible poor wound healing or infection should be done by the registered nurse (RN).

A clinic patient is experiencing an allergic reaction to an unknown allergen. Which action is most appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Perform a focused physical assessment. b. Obtain the health history from the patient. c. Teach the patient about the various diagnostic studies. d. Administer skin testing by the cutaneous scratch method.

ANS: D LPN/LVNs are educated and licensed to administer medications under the supervision of an RN. RN-level education and the scope of practice include assessment of health history, focused physical assessment, and patient teaching.

Which factor will help the nurse differentiate leukotrienes from histamine? a. Site of production b. Vascular effect c. Chemotactic ability d. Time of release

ANS: D Leukotrienes are released slower and longer than histamine. Leukotrienes and histamine are produced from mast cells. Leukotrienes and histamine have similar vascular effects. Leukotrienes and histamine have similar chemotactic ability.

The macrophage secretion that stimulates procollagen synthesis and secretion is: a. Angiogenesis factor b. Matrix metalloproteinase c. Vascular endothelial growth factor d. Transforming growth factor-beta

ANS: D Macrophages secrete transforming growth factor-beta to stimulate fibroblasts to secrete the collagen precursor procollagen. Angiogenesis factor supports the growth of new vessels. Matrix metalloproteinase remodels proteins at the site of injury. Vascular endothelial growth factors are also involved in vessel growth.

The nurse will perform which action when doing a wet-to-dry dressing change on a patient's stage III sacral pressure ulcer? a. Soak the old dressings with sterile saline 30 minutes before removing them. b. Pour sterile saline onto the new dry dressings after the wound has been packed. c. Apply antimicrobial ointment before repacking the wound with moist dressings. d. Administer the ordered PRN hydrocodone (Lortab) 30 minutes before the dressing change.

ANS: D Mechanical debridement with wet-to-dry dressings is painful, and patients should receive pain medications before the dressing change begins. The new dressings are moistened with saline before being applied to the wound. Soaking the old dressings before removing them will eliminate the wound debridement that is the purpose of this type of dressing. Application of antimicrobial ointments is not indicated for a wet-to-dry dressing

A young adult patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8° F (38.7° C). Which action by the nurse is most appropriate? a. Apply a cooling blanket. b. Notify the health care provider. c. Give the prescribed PRN aspirin (Ascriptin) 650 mg. d. Check the patient's oral temperature again in 4 hours.

ANS: D Mild to moderate temperature elevations (less than 103° F) do not harm the young adult patient and may benefit host defense mechanisms. The nurse should continue to monitor the temperature. Antipyretics are not indicated unless the patient is complaining of fever-related symptoms. There is no need to notify the patient's health care provider or to use a cooling blanket for a moderate temperature elevation

The nurse is caring for a patient undergoing plasmapheresis. The nurse should assess the patient for which clinical manifestation? a. Shortness of breath b. High blood pressure c. Transfusion reaction d. Numbness and tingling

ANS: D Numbness and tingling may occur as the result of the hypocalcemia caused by the citrate used to prevent coagulation. The other clinical manifestations are not associated with plasmapheresis.

A patient experiences a stroke and now has difficulty writing and producing language. This condition is most likely caused by occlusion of the: a. anterior communicating artery. b. posterior communicating artery. c. circle of Willis. d. middle cerebral artery.

ANS: D Occlusion of the left middle cerebral artery leads to the inability to find words and difficulty with writing. The inability to find words and difficulty with writing are not associated with occlusions of the anterior or posterior communicating arteries or the circle of Willis. REF: p. 367

A nurse is preparing to teach on the subject of opsonins. Which information should the nurse include? Opsonins are molecules that: a. Are composed of fatty acids b. Regulate inflammation c. Degranulate mast cells d. Enhance phagocytosis

ANS: D Opsonins coat the surface of bacteria and increase their susceptibility to being phagocytized. Opsonins are not composed of fatty acids; they are antibodies. Opsonins coat the surface of bacteria and increase their susceptibility to being phagocytized. They do not regulate inflammation; mast cells do. Opsonins coat the surface of bacteria and increase their susceptibility to being phagocytized; they do not react with mast cells.

After the home health nurse teaches a patient's family member about how to care for a sacral pressure ulcer, which finding indicates that additional teaching is needed? a. The family member uses a lift sheet to reposition the patient. b. The family member uses clean tap water to clean the wound. c. The family member places contaminated dressings in a plastic grocery bag. d. The family member dries the wound using a hair dryer set on a low setting.

ANS: D Pressure ulcers need to be kept moist to facilitate wound healing. The other actions indicate a good understanding of pressure ulcer care

A new nurse performs a dressing change on a stage II left heel pressure ulcer. Which action by the new nurse indicates a need for further teaching about pressure ulcer care? a. The new nurse uses a hydrocolloid dressing (DuoDerm) to cover the ulcer. b. The new nurse inserts a sterile cotton-tipped applicator into the pressure ulcer. c. The new nurse irrigates the pressure ulcer with sterile saline using a 30-mL syringe. d. The new nurse cleans the ulcer with a sterile dressing soaked in half-strength peroxide.

ANS: D Pressure ulcers should not be cleaned with solutions that are cytotoxic, such as hydrogen peroxide. The other actions by the new nurse are appropriate

The nurse is implementing a plan of care for a patient newly diagnosed with type 2 diabetes mellitus. The plan includes educating the patient about diet choices. The patient states that they enjoy exercising and understand the need to diet; however, they can't see living without chocolate on a daily basis. Using the principles of responding in the Model of Clinical Judgment, how would the nurse proceed with the teaching? a. The nurse explains to the patient that chocolate has a high glycemic index. The nurse then focuses on foods that have low glycemic indexes and provides a list for the patient to choose from. b. The nurse explains that the patient may eat whatever they would like as long as the patient's glucose reading and A1c remain stable. c. The nurse derives a new nursing diagnosis of Knowledge Deficit and readjusts the plan of care to include additional sessions with the registered dietician. d. The nurse examines the patient's daily glucose log and incorporates the snack into the time of day that has the lowest readings. The nurse then follows up and evaluates the response in 1 week.

ANS: D Responding entails adjusting the plan of care to the particular patient issue through one or more nursing interventions. In this case, the nurse is working with the patient's wishes, knowing that the patient will most likely cheat. The patient will be allowed to "cheat." The plan will be evaluated to be sure the snack does not elevate the glucose excessively and be readjusted if warranted. While it is true that most chocolate has a high glycemic index, providing a list of foods that do not include the one thing the patient enjoys will most likely lead to nonadherence to the diet. Advising the patient that they can have whatever they want to eat may lead to further dietary indiscretions and cause side effects such as obesity or high glucose readings. Knowledge Deficit is an inaccurate diagnosis for this patient as evidenced by the patient stating they understand the need to exercise and the need to diet.

The nurse educator would identify a need for further teaching when the student lists the types of learning as a. affective. b. cognitive. c. psychomotor. d. self-directed.

ANS: D Self-directed is one approach to learning but is not considered a type or domain of learning. Self-directed would be a cognitive way of learning. Affective (feelings/attitude), cognitive (knowledge), and psychomotor (skills/performance) are the main domains of learning.

A teenager sustains a severe closed head injury following an all-terrain vehicle (ATV) accident and is in a state of deep sleep that requires vigorous stimulation to elicit eye opening. How should the nurse document this in the chart? a. Confusion b. Coma c. Obtundation d. Stupor

ANS: D Stupor is a condition of deep sleep or unresponsiveness from which a person may be aroused or caused to open his or her eyes only by vigorous and repeated stimulation. Confusion is the loss of the ability to think rapidly and clearly and is characterized by impaired judgment and decision making. Coma is a condition in which there is no verbal response to the external environment or to any stimuli; noxious stimuli such as deep pain or suctioning do not yield motor movement. Obtundation is a mild-to-moderate reduction in arousal (awakeness) with limited response to the environment. REF: p. 361, Table 15-3

A patient brought to the emergency room (ER) with severe burns is requesting something for the excruciating pain and is medicated with morphine, which blocks which of the following neurotransmitters, thus reducing the pain? a. Enkephalin b. Dopamine c. Acetylcholine d. Substance P

ANS: D Substance P is a neurotransmitter in pain transmission pathways. Blocking the release of substance P by morphine reduces pain. The opiates morphine and heroin bind to endorphin and enkephalin receptors on presynaptic neurons. Dopamine is a neurotransmitter involved in activity. Acetylcholine plays a role in nerve conduction presynaptically.

When the nurse is discussing the patient's cyclical temperature fluctuation occurring on a daily basis, what term should the nurse use? a. Thermogenesis cycle b. Thermoconductive phases c. Adaptive pattern d. Circadian rhythm

ANS: D Temperature fluctuation is related to circadian rhythm, not the thermogenesis cycle, thermoconductive phases, or adaptive patterns. REF: p. 342

A 20-year-old female is applying for nursing school and is required to be tested for immunity against several illnesses. Testing that looks at which of the following would be the best to determine immunity? a. Culture and sensitivity b. Agglutination c. Precipitation d. Titer

ANS: D The amount of antibody in a serum sample is referred to as the titer; a higher titer indicates more antibodies. Culture determines the type of organism that causes an infection, and sensitivity identifies the antibody it is sensitive to. The terms agglutination and precipitation are not used to identify a test to determine immunity.

A nurse is preparing to teach about functions to maintain homeostasis and instinctive behavioral patterns. Which area of the brain is the nurse discussing? a. Thalamus b. Medulla c. Cerebellum d. Hypothalamus

ANS: D The hypothalamus functions to maintain a constant internal environment and instinctive behavioral patterns. The thalamus serves as a relay center for information from the basal ganglia and cerebellum to the appropriate motor area. The medulla controls reflex activities, such as heart rate, respiration, blood pressure, coughing, sneezing, swallowing, and vomiting. The cerebellum is responsible for reflexive, involuntary fine-tuning of motor control, for maintaining balance and posture through extensive neural connections.

Interrelated concepts to the professional nursing role a nurse manager would consider when addressing concerns about the quality of patient education include a. adherence. b. developmental level. c. motivation. d. technology.

ANS: D The interrelated concepts to the professional role of a nurse include health promotion, leadership, technology/informatics, quality, collaboration, and communication. Adherence, culture, developmental level, family dynamics, and motivation are considered interrelated concepts to patient attributes and preference.

Which of the following statements indicates more teaching is needed regarding secondary lymph organs? ________ is/are a secondary lymphoid organ. a. The spleen b. Peyer patches c. Adenoids d. The liver

ANS: D The liver is not a secondary lymph organ. The spleen, Peyer patches, and adenoids are secondary lymphoid organs.

A young male patient who is a paraplegic has a stage II sacral pressure ulcer and is being cared for at home by his mother. To prevent further tissue damage, what instructions are most important for the nurse to teach the mother? a. Change the patient's bedding frequently. b. Use a hydrocolloid dressing over the ulcer. c. Record the size and appearance of the ulcer weekly. d. Change the patient's position at least every 2 hours.

ANS: D The most important intervention is to avoid prolonged pressure on bony prominences by frequent repositioning. The other interventions may also be included in family teaching, but the most important instruction is to change the patient's position at least every 2 hours

A patient presents with altered respiratory patterns following head trauma. Based on the symptoms, which of the following areas does the nurse suspect is injured? a. Cerebrum b. Cerebellum c. Midbrain d. Reticular formation

ANS: D The reticular formation is a large network of diffuse nuclei that control vital reflexes, such as those controlling cardiovascular function and respiration. Respiratory function is not controlled by the cerebrum, cerebellum, or midbrain.

A patient is looking at a picture of the brain and points to the convolutions on the surface of the cerebrum. The nurse should tell the patient these are called: a. sulci. b. fissures. c. reticular formations. d. gyri.

ANS: D The surface of the cerebrum (cerebral cortex) is covered with convolutions called gyri, which greatly increase the cortical surface area and the number of neurons. Neither sulci, fissures, nor reticular formations cover the cerebrum in a fashion that increases its surface.

A patient has been treated with antiparkinson medications for 3 months. What therapeutic responses should the nurse look for when assessing this patient? a. Decreased appetite b. Gradual development of cogwheel rigidity c. Newly developed dyskinesias d. Improved ability to perform activities of daily living

ANS: D Therapeutic responses to antiparkinson agents include an improved sense of well-being, improved mental status, increased appetite, increased ability to perform activities of daily living and to concentrate and think clearly, and less intense parkinsonian manifestations.

The nurse should plan to use a wet-to-dry dressing for which patient? a. A patient who has a pressure ulcer with pink granulation tissue b. A patient who has a surgical incision with pink, approximated edges c. A patient who has a full-thickness burn filled with dry, black material d. A patient who has a wound with purulent drainage and dry brown areas

ANS: D Wet-to-dry dressings are used when there is minimal eschar to be removed. A full-thickness wound filled with eschar will require interventions such as surgical debridement to remove the necrotic tissue. Wet-to-dry dressings are not needed on approximated surgical incisions. Wet-to-dry dressings are not used on uninfected granulating wounds because of the damage to the granulation tissue

The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider? a. Blood glucose 136 mg/dL b. Oral temperature 101° F (38.3° C) c. Patient complaint of increased incisional pain d. Separation of the proximal wound edges by 1 cm

ANS: D Wound separation 3 days postoperatively indicates possible wound dehiscence and should be immediately reported to the health care provider. The other findings will also be reported but do not require intervention as rapidly

Which medication taken by a patient with restless legs syndrome should the nurse discuss with the patient? a. Ibuprofen b. Multivitamin c. Acetaminophen d. Diphenhydramine

ANS: D Antihistamines can aggravate restless legs syndrome.

A patient is being treated with carbidopa/levodopa (Sinemet) for Parkinson's disease. Which information indicates a need for change in the medication or dosage? a. Shuffling gait b. Tremor at rest c. Cogwheel rigidity of limbs d. Uncontrolled head movement

ANS: D Dyskinesia is an adverse effect of the Sinemet, indicating a need for a change in medication or decrease in dose. The other findings are typical with Parkinson's disease.

A 62-yr-old patient who has Parkinson's disease is taking bromocriptine (Parlodel). Which information obtained by the nurse may indicate a need for a decrease in the dosage? a. The patient has a chronic dry cough. b. The patient has four loose stools in a day. c. The patient develops a deep vein thrombosis. d. The patient's blood pressure is 92/52 mm Hg.

ANS: D Hypotension is an adverse effect of bromocriptine, and the nurse should check with the health care provider before giving the medication

A 15-year-old male suffers from severe hemorrhage following a motor vehicle accident. He is given a blood transfusion, but shortly afterward the red blood cells are destroyed by agglutination and lysis. Which of the following blood type transfusion type matches would cause this? a. A-A b. B-O c. AB-O d. A-AB

ANS: D A person with type A blood also has circulating antibodies to the B carbohydrate antigen. If this person receives blood from a type AB or B individual, a severe transfusion reaction occurs, and the transfused erythrocytes are destroyed by agglutination or complement-mediated lysis. Type A can receive type A blood. Type B and type AB can receive type O.

The nurse would correctly respond that the etiology of a congenital immune deficiency is due to a(n): a. negative response to an immunization. b. adverse response to a medication. c. renal failure. d. genetic defect

ANS: D A primary (congenital) immune deficiency is caused by a genetic defect. A primary (congenital) immune deficiency is not a response to an immunization, an adverse response to a medication, or due to renal failure.

What is the chance that two siblings share both HLA haplotypes, making them a good match for an organ transplant from one to the other? a. 100% b. 75% c. 50% d. 25%

ANS: D Odds dictate that children will share one haplotype with half their siblings and either no haplotypes or both haplotypes with a quarter of their siblings. Thus, the chance of finding a match among siblings is much higher (25%) than the general population

A 40-year-old female is diagnosed with SLE. Which of the following findings would be considered a symptom of this disease? a. Gastrointestinal ulcers b. Decreased glomerular filtration rate c. Rash on trunk and extremities d. Photosensitivity

ANS: D Photosensitivity is one of the 11 common clinical findings in SLE. Gastrointestinal ulcers are not a finding in SLE. Proteinuria is a symptom of SLE. A rash on the face is a symptom, but not a rash on the body

A 30-year-old male is having difficulty breathing and has been spitting blood. He reports that he began experiencing this reaction after cleaning his pigeons' cages. Testing reveals he is suffering from allergic alveolitis. Which of the following is he experiencing? a. Serum sickness b. Raynaud phenomenon c. Antibody-dependent cytotoxicity d. Arthus reaction

ANS: D The Arthus reaction is a model of localized or cutaneous reactions. Serum sickness-type reactions are caused by the formation of immune complexes in the blood and their subsequent generalized deposition in target tissues. Typically affected tissues are the blood vessels, joints, and kidneys. Raynaud phenomenon is a condition caused by the temperature-dependent deposition of immune complexes in the capillary beds of the peripheral circulation. Antibody-dependent cytotoxicity is a type II form.

A 30-year-old male was diagnosed with HIV. Which of the following treatments would be most effective? a. Reverse transcriptase inhibitors b. Protease inhibitors c. Entrance inhibitors d. Antiretroviral therapy (ART)

ANS: D The current regimen for treatment of HIV infection is a combination of drugs, termed antiretroviral therapy (ART). The remaining options are individual components of the ART treatment format.

Which information would indicate more teaching is needed regarding hypersensitivity reactions? Type _______ hypersensitivity reactions involve an antibody response. a. I b. II c. III d. IV

ANS: D Type IV reactions are mediated by T lymphocytes and do not involve antibodies. All the remaining options are associated with antibody responses.

An unconscious patient with a traumatic head injury has a blood pressure of 130/76 mm Hg and an intracranial pressure (ICP) of 20 mm Hg. The nurse will calculate the cerebral perfusion pressure (CPP) as ____ mm Hg.

Ans: 74

A homeless person is brought to the emergency department after prolonged exposure to cold weather. The nurse would assess the patient for manifestations of hypothermia, including A. Stupor B. Erythema C. Increased anxiety D. Rapid respirations

Answer. A Stupor may occur with hypothermia because of slowed cerebral metabolic processes. Pallor, not erythema, would be present as a result of peripheral vasoconstriction. Drowsiness occurs; the patient would be unable to focus on anxiety-producing aspects of the situation. Respirations would be decreased.

The nurse identifies which priority nursing invention for a patient with hyperthermia? A. Initiating seizure precautions. B. Limiting oral intake. C. Providing a blanket. D. Removing excess clothing

Answer. D The priority nursing intervention would be removal of excess clothing. Seizures may occur because of a high body temperature, but seizure precautions should not be the first intervention. Oral intake, especially of fluids, should not be limited for a patient with hyperthermia, because of the dangers of dehydration. Blanketing, like clothing, should be removed.

A patient with hypothermia is brought to the emergency department. The nurse should explain to the family members that treatment will include A. Core rewarming with warm fluids. B. Ambulation to increase metabolism. C. Frequent oral temperature assessment. D. Gastric tube feedings to increase fluids.

Answer: A Core rewarming with heated oxygen and administration of warmed oral or intravenous fluids is the preferred method of treatment. The patient would be too weak to ambulate. Oral temperatures are not the most accurate assessment of core temperature because of environmental influences. Warmed oral feedings are advised; gastric gavage is unnecessary.

A child is about to be admitted to the pediatric intensive care unit (PICU) after surgery for removal of a tumor in the hypothalamic region of the brain. The nurse manager should intervene immediately when the child's nurse A. Places a hypothermia blanket at the bedside. B. Adjusts the bed to the Trendelenburg position. C. Obtains electronic equipment for monitoring the vital signs. D. Secures a pump to administer the ordered intravenous fluids.

Answer: B It is not safe to put the bed in the Trendelenburg position, because raising the foot increases blood flow to the brain, thereby increasing intracranial pressure. Temperature elevations may occur after a craniotomy because of stimulation of the hypothalamus. A hypothermic blanket should be ready if the temperature becomes precipitously elevated. Monitoring vital signs is a critical component of postoperative care. Intravenous infusions must be regulated precisely to minimize the possibility of cerebral edema.

What clinical indicator will the nurse most likely identify when assessing a patient with pyrexia? A. Dyspnea B. Precordial pain C. Increased pulse rate D. Elevated blood pressure

Answer: C The pulse rate increases to meet increased tissue demands for oxygen in the febrile state. Fever may increase but does not cause difficulty in breathing. Pain is not related to fever. Blood pressure is not necessarily elevated in fever.

A 63-yr-old patient who began experiencing right arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol? (Put a comma and a space between each answer choice [A, B, C, D].) a. Obtain CT scan without contrast. b. Infuse tissue plasminogen activator (tPA). c. Administer oxygen to keep O2 saturation >95%. d. Use National Institute of Health Stroke Scale to assess patient.

Answer: C, D, A, B Rationale: The initial actions should be those that help with airway, breathing, and circulation. Baseline neurologic assessments should be done next. A CT scan will be needed to rule out hemorrhagic stroke before tPA can be administered.

19. The nurse plans to provide instructions about diabetes to a patient who has a low literacy level. Which teaching strategies should the nurse use? (Select all that apply.) a. Discourage use of the Internet as a source of health information. b. Avoid asking the patient about reading abilities and level of education. c. Provide illustrations and photographs showing various types of insulin. d. Schedule one-to-one teaching sessions to practice insulin administration. e. Obtain CDs and DVDs that illustrate how to perform blood glucose testing.

Answer: C, D, E Rationale: For patients with low literacy, visual and hands-on learning techniques are most appropriate. The nurse will need to obtain as much information as possible about the patient's reading level in order to provide appropriate learning materials. The nurse should guide the patient to Internet sites established by reputable heath care organizations such as the American Diabetes Association.

After receiving change-of-shift report on the following four patients, which patient should the nurse see first? a. A 60-yr-old patient with right-sided weakness who has an infusion of tPA prescribed. b. A 50-yr-old patient who has atrial fibrillation and a new order for warfarin (Coumadin). c. A 30-yr-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine scheduled. d. A 40-yr-old patient who had a transient ischemic attack yesterday and has a dose of aspirin due.

Answer: a. A 60-yr-old patient with right-sided weakness who has an infusion of tPA prescribed. Rationale: tPA needs to be infused within the first few hours after stroke symptoms start to be effective in minimizing brain injury. The other medications should also be given as quickly as possible, but timing of the medications is not as critical.

A patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will the nurse include in the plan of care? a. Apply intermittent pneumatic compression stockings. b. Assist to dangle on edge of bed and assess for dizziness. c. Encourage patient to cough and deep breathe every 4 hours. d. Insert an oropharyngeal airway to prevent airway obstruction.

Answer: a. Apply intermittent pneumatic compression stockings. Rationale: The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboembolism. Activities, such as coughing and sitting up, that might increase intracranial pressure or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.

A female patient who had a stroke 24 hours ago has expressive aphasia. What is an appropriate nursing intervention to help the patient communicate? a. Ask questions that the patient can answer with "yes" or "no." b. Develop a list of words that the patient can read and practice reciting. c. Have the patient practice her facial and tongue exercises with a mirror. d. Prevent embarrassing the patient by answering for her if she does not respond.

Answer: a. Ask questions that the patient can answer with "yes" or "no." Rationale: Communication will be facilitated and less frustrating to the patient when questions that require a "yes" or "no" response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond.

16. A middle-aged patient who has diabetes tells the nurse, "I want to know how to give my own insulin so I don't have to bother my wife all the time." What action should the nurse complete first? a. Demonstrate how to draw up and administer insulin. b. Discuss the use of exercise to decrease insulin needs. c. Teach about differences between the various types of insulin. d. Provide handouts about therapeutic and adverse effects of insulin.

Answer: a. Demonstrate how to draw up and administer insulin. Rationale: Adult education is most effective when focused on information that the patient thinks is needed right now. All the indicated information will need to be included when planning teaching for this patient, but the teaching will be most effective if the nurse starts with the patient's stated priority topic.

13. The hospital nurse implements a teaching plan to assist an older patient who lives alone to independently accomplish daily activities. How would the nurse best evaluate the patient's long-term response to the teaching? a. Make a referral to the home health nursing agency for home visits. b. Have the patient demonstrate the learned skills at the end of the teaching session. c. Arrange a physical therapy visit before the patient is discharged from the hospital. d. Check the patient's ability to bathe and get dressed without assistance the next day

Answer: a. Make a referral to the home health nursing agency for home visits. Rationale: A home health referral would allow for the assessment of the patient's long-term response after discharge. The other actions allow evaluation of the patient's short-term response to teaching.

14. A patient who smokes a pack of cigarettes per day tells the nurse, "I enjoy smoking and have no plans to quit." When using the Transtheoretical Model of Health Behavior Change, the nurse identifies that this patient is in which stage of change? a. Precontemplation b. Contemplation c. Maintenance d. Termination

Answer: a. Precontemplation Rationale: The patient's statement shows that he or she is not considering smoking cessation. In the precontemplation stage, patients are not concerned about their cigarette smoking and are not considering changing their behavior.

5. A patient states, "I told my husband I will go the grocery store to buy fresh fruit, vegetables, and whole grains instead of prepared food snacks." When using the Transtheoretical Model of Health Behavior Change, the nurse identifies that this patient is in which stage of change? a. Preparation b. Termination c. Maintenance d. Contemplation

Answer: a. Preparation Rationale: The patient's statement indicating that the plan for change is being shared with someone else indicates that the preparation stage has been achieved. Contemplation of a change would be indicated by a statement like "I know I should exercise." Maintenance of a change occurs when the patient practices the behavior regularly. Termination would be indicated when the change is a permanent part of the lifestyle.

Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness. Which patient problem do they determine has the highest priority for the patient? a. Risk for aspiration. b. Impaired skin integrity. c. Impaired physical mobility. d. Disturbed sensory perception.

Answer: a. Risk for aspiration. Rationale: Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other diagnoses are also appropriate, but interventions to prevent aspiration are the priority at this time.

A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate? a. "The diseased portion of the artery is replaced with a synthetic graft." b. "The obstructing plaque is surgically removed from inside an artery in the neck." c. "A wire is threaded through an artery in the leg to the clots in the carotid artery, and clots are removed." d. "A catheter with a deflated balloon is positioned at the narrow area, and the balloon flattens the plaque."

Answer: b. "The obstructing plaque is surgically removed from inside an artery in the neck." Rationale: In a carotid endarterectomy, the carotid artery is incised, and the plaque is removed. The response beginning, "The diseased portion of the artery is replaced" describes an arterial graft procedure. The answer beginning, "A catheter with a deflated balloon is positioned at the narrow area" describes an angioplasty. The final response beginning, "A wire is threaded through the artery" describes the mechanical embolus removal in cerebral ischemia (MERCI) procedure.

8. The nurse is planning a teaching session with a patient newly diagnosed with migraine headaches. To assess the patient's readiness to learn, which question should the nurse ask first? a. "What kind of work and leisure activities do you do?" b. "What information do you think you need right now?" c. "Can you describe the types of activities that help you learn new information?" d. "Do you have any religious beliefs that are inconsistent with the planned treatment?"

Answer: b. "What information do you think you need right now?" Rationale: Motivation and readiness to learn depend on what the patient values and perceives as important. The other questions are also important in developing the teaching plan, but do not address what information most interests the patient at present.

7. A patient who is morbidly obese states, "I've recently decreased my fat intake, and I've stopped smoking." Which statement, if made by the nurse, is the best initial response? a. "Although those are important, it is essential that you make other changes." b. "You have accomplished changes that are important for the health of your heart." c. "Are you having any difficulty in maintaining the changes you have already made?" d. "Which additional changes in your lifestyle would you like to implement at this time?"

Answer: b. "You have accomplished changes that are important for the health of your heart." Rationale: Positive reinforcement of the learner's achievements is critical in making lifestyle changes. This patient is in the action stage of the Transtheoretical Model when reinforcement of the changes being made is an important nursing intervention. The other responses are also appropriate but are not the best initial response.

A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. What topic should the nurse anticipate teaching the patient? a. tPA b. Aspirin c. Warfarin d. Nimodipine

Answer: b. Aspirin Rationale: After a transient ischemic attack, patients typically are started on medications such as aspirin to inhibit platelet function and decrease stroke risk. tPA is used for acute ischemic stroke. Warfarin is usually used for patients with atrial fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage.

Several weeks after a stroke, a 50-yr-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention should be planned to begin an effective bladder training program? a. Limit fluid intake to 1200 mL daily to reduce urine volume. b. Assist the patient onto the bedside commode every 2 hours. c. Perform intermittent catheterization after each voiding to check for residual urine. d. Use an external "condom" catheter to protect the skin and prevent embarrassment.

Answer: b. Assist the patient onto the bedside commode every 2 hours. Rationale: Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder. A 1200-mL fluid restriction may lead to dehydration. Intermittent catheterization and use of a condom catheter are appropriate in the acute phase of stroke but should not be considered solutions for long-term management because of the risks for urinary tract infection and skin breakdown.

What will the nurse tell the patient who has cerebral atherosclerosis about taking clopidogrel (Plavix)? a. Monitor and record the blood pressure daily. b. Call the health care provider if stools are tarry. c. Clopidogrel will dissolve clots in the cerebral arteries. d. Clopidogrel will reduce cerebral artery plaque formation.

Answer: b. Call the health care provider if stools are tarry. Rationale: Clopidogrel inhibits platelet function and increases the risk for gastrointestinal bleeding, so patients should be advised to notify the health care provider about any signs of bleeding. The medication does not lower blood pressure, decrease plaque formation, or dissolve clots.

A 70-yr-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? a. Take the patient's blood pressure. b. Check the respiratory rate and effort. c. Assess the Glasgow Coma Scale score. d. Send the patient for a computed tomography (CT) scan.

Answer: b. Check the respiratory rate and effort. Rationale: The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, and circulation) are completed.

11. The nurse and the patient who is diagnosed with hypertension develop this goal: "The patient will select a 2-g sodium diet from the hospital menu for 3 days." Which evaluation method will the nurse use to determine whether teaching was effective? a. Have the patient list substitutes for favorite foods that are high in sodium. b. Check the sodium content of the patient's menu choices over the next 3 days. c. Compare the patient's sodium intake before and after the teaching was implemented. d. Ask the patient to identify which foods on the hospital menus are high in sodium for 3 days in a row.

Answer: b. Check the sodium content of the patient's menu choices over the next 3 days. Rationale: The desired patient behaviors in the learning objective are most clearly addressed by evaluating the sodium content of the patient's menu choices. Other answers address the patient's sodium intake but not the specific goal.

2. After the nurse provides diet instructions for a patient with diabetes, the patient can restate the information but does not make the recommended diet changes. How would the nurse evaluate this outcome? a. Learning did not occur because the patient's behavior did not change. b. Choosing not to follow the diet is the behavior that resulted from learning. c. The nurse's responsibility for helping the patient make diet changes has been fulfilled. d. The teaching methods were ineffective in helping the patient learn about the necessary diet changes.

Answer: b. Choosing not to follow the diet is the behavior that resulted from learning. Rationale: Although the patient behavior has not changed, the patient's ability to restate the information indicates that learning has occurred, and the patient is choosing at this time not to change the diet. The patient may be in the contemplation or preparation stage in the transtheoretical model. The nurse should reinforce the need for change and continue to provide information and assistance with planning for change.

18. . A postoperative patient and caregiver need discharge teaching. Which actions included in the teaching plan can the nurse delegate to unlicensed assistive personnel (UAP)? a. Evaluate whether the patient and caregiver understand the teaching. b. Give the patient a pamphlet to reinforce teaching done by the nurse. c. Plan for the discharge teaching session with the patient and caregiver. d. Show the caregiver how to accurately check the patient's temperature.

Answer: b. Give the patient a pamphlet to reinforce teaching done by the nurse. Rationale: Providing a pamphlet to a patient to reinforce previously taught material does not require nursing judgment and can safely be delegated to UAP. Demonstration of how to take a temperature accurately, determining the best time for teaching, and evaluation of the success of patient teaching all require judgment and critical thinking and should be done by the registered nurse.

4. A patient who was admitted to the hospital with hyperglycemia and newly diagnosed diabetes is scheduled for discharge the second day after admission. When implementing patient teaching, what is the priority action for the nurse? a. Provide detailed information about dietary control of glucose. b. Teach glucose self-monitoring and medication administration. c. Give information about the effects of exercise on glucose control. d. Instruct about the risk for cardiovascular disease with hyperglycemia.

Answer: b. Teach glucose self-monitoring and medication administration. Rationale: When time is limited, the nurse should focus on the priorities of teaching. In this situation, the patient should know how to test blood glucose and administer medications to control glucose levels. The patient will need further teaching about the role of diet, exercise, various medications, and the many potential complications of diabetes, but these topics can be addressed through planning for appropriate referrals.

The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? a. The pulse rate is 102 beats/min. b. The patient has difficulty speaking. c. The blood pressure is 144/86 mm Hg. d. There are fine crackles at the lung bases.

Answer: b. The patient has difficulty speaking. Rationale: Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke during the procedure. Slightly elevated pulse rate and blood pressure are not unusual because of anxiety associated with the procedure. Fine crackles at the lung bases may indicate atelectasis caused by immobility during the procedure.

1. The nurse has assessed that a patient with newly diagnosed colon cancer does not have basic knowledge about colon cancer. The nurse should initially focus on which learning goal for this patient? a. The patient will state ways of preventing the recurrence of the cancer. b. The patient will explore and select an appropriate colon cancer therapy. c. The patient will demonstrate coping skills needed to manage the disease. d. The patient will choose methods to minimize adverse effects of treatment.

Answer: b. The patient will explore and select an appropriate colon cancer therapy. Rationale: Adults learn best when given information that can be used immediately. The first action the patient will need to take after a cancer diagnosis is to explore and choose a treatment option. The other goals may be appropriate as treatment progresses.

9. A patient with diabetic neuropathy requires teaching about foot care. Which learning goal should the nurse include in the teaching plan? a. The nurse will demonstrate the proper technique for trimming toenails. b. The patient will list three ways to protect the feet from injury by discharge. c. The nurse will instruct the patient on appropriate foot care before discharge. d. The patient will understand the rationale for proper foot care after instruction.

Answer: b. The patient will list three ways to protect the feet from injury by discharge. Rationale: Learning goals should state clear, measurable outcomes of the learning process. Demonstrating technique for trimming toenails and providing instructions on foot care are actions that the nurse will take rather than behaviors that indicate that patient learning has occurred. A learning goal that states that the patient will understand the rationale for proper foot care is too vague and nonspecific to measure whether learning has occurred.

Which information about the patient who had a subarachnoid hemorrhage is most important to communicate to the health care provider? a. The patient reports having a stiff neck. b. The patient's blood pressure (BP) is 90/50 mm Hg. c. The patient reports a severe and unrelenting headache. d. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).

Answer: b. The patient's blood pressure (BP) is 90/50 mm Hg. Rationale: To prevent cerebral vasospasm and maintain cerebral perfusion, BP needs to be maintained at a level higher than 90 mm Hg systolic after a subarachnoid hemorrhage. A low BP or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP. An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider.

12. The nurse prepares written handouts to be used as part of the standardized teaching plan for patients who have been recently diagnosed with diabetes. What statement is written at a level appropriate to include in the handouts? a. Polyphagia, polydipsia, and polyuria are common symptoms of diabetes. b. Eating the right foods can help in keeping blood glucose at a near-normal level. c. Some patients with diabetes control blood glucose with oral medications, injections, or dietary interventions. d. Diabetes is characterized by chronic hyperglycemia and the associated symptoms than can lead to long-term complications.

Answer: b. b. Eating the right foods can help in keeping blood glucose at a near-normal level. Rationale: The reading level for patient teaching materials should be at the fifth-grade level. The other responses have words with three or more syllables, use many medical terms, or are too long.

The nurse is caring for a patient who has been experiencing stroke symptoms for 60 minutes. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/VN)? a. Assess the patient's gag and cough reflexes. b. Determine when the stroke symptoms began. c. Administer the prescribed short-acting insulin. d. Infuse the prescribed IV metoprolol (Lopressor).

Answer: c. Administer the prescribed short-acting insulin. Rationale: Administration of subcutaneous medications is included in LPN/VN education and scope of practice. The other actions require more education and scope of practice and should be done by the registered nurse (RN).

15. An older Asian patient seen at the health clinic is diagnosed with protein malnutrition. What action should the nurse plan to implement first? a. Suggest the use of liquid supplements as a way to increase protein intake. b. Encourage the patient to increase the dietary intake of meat, cheese, and milk. c. Ask the patient to record the intake of all foods and beverages for a 3-day period. d. Focus on the use of combinations of beans and rice to improve daily protein intake.

Answer: c. Ask the patient to record the intake of all foods and beverages for a 3-day period. Rationale: Assessment is the first step in assisting a patient with health changes. The other answers may be appropriate for the patient, but the nurse will not be able to determine this until the assessment of the patient is complete.

17. The nurse plans to teach a patient and the caregiver how to manage high blood pressure. Which action should the nurse take first? a. Teach the caregiver how to use a manual blood pressure cuff. b. Give written information about hypertension to the patient and caregiver. c. Ask the patient to select information from a list of hypertension teaching topics. d. Have the dietitian meet with the patient and caregiver to discuss a low-sodium diet

Answer: c. Ask the patient to select information from a list of hypertension teaching topics. Rationale: Because adults learn best when given information that they view as being needed immediately, asking the caregiver and patient to prioritize learning needs is likely to be the most successful approach to home management of health problems. The other actions may also be appropriate, depending on what learning needs the caregiver and patient have, but the initial action should be to assess what the learners feel is important.

A patient will attempt oral feedings for the first time after having a stroke. After assessing the gag reflex, what action should the nurse take? a. Order a varied pureed diet. b. Assess the patient's appetite. c. Assist the patient into a chair. d. Offer the patient a sip of juice.

Answer: c. Assist the patient into a chair. Rationale: The patient should be as upright as possible before attempting to feed to make swallowing easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the patient. Pureed diets are not recommended because the texture is too smooth. The patient may have a poor appetite, but the oral feeding should be attempted.

A left-handed patient with left-sided hemiplegia has difficulty feeding himself. Which intervention should the nurse include in the plan of care? a. Provide a wide variety of food choices. b. Provide oral care before and after meals. c. Assist the patient to eat with the right hand. d. Teach the patient the "chin-tuck" technique.

Answer: c. Assist the patient to eat with the right hand. Rationale: Because the patient has difficulty feeding himself, the appropriate interventions will focus on teaching the patient to use the right hand for self-feeding. The other interventions are appropriate for patients with other etiologies for the imbalanced nutrition.

A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first? a. Complete blood count (CBC). b. Chest radiograph (chest x-ray). c. Computed tomography (CT) scan. d. 12-Lead electrocardiogram (ECG).

Answer: c. Computed tomography (CT) scan. Rationale: Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the less brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.

What concern should the nurse anticipate for a patient who had a right hemisphere stroke? a. Right-sided hemiplegia. b. Speech-language deficits. c. Denial of deficits and impulsiveness. d. Depression and distress about disability.

Answer: c. Denial of deficits and impulsiveness. Rationale: The patient with right-sided brain damage typically denies any deficits and has poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability.

A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, "I don't need the aspirin today. I don't have a fever." Which action should the nurse take? a. Document that the patient refused the aspirin. b. Tell the patient that the aspirin is used to prevent a fever. c. Explain that the aspirin is ordered to decrease stroke risk. d. Call the health care provider to clarify the medication order.

Answer: c. Explain that the aspirin is ordered to decrease stroke risk. Rationale: Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation of the patient's refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the health care provider. The aspirin is not ordered to prevent aches and pains.

What topic should the nurse anticipate teaching a patient who had a brief episode of tinnitus, diplopia, and dysarthria with no residual effects? a. Cerebral aneurysm clipping. b. Heparin intravenous infusion. c. Oral low-dose aspirin therapy. d. Tissue plasminogen activator (tPA).

Answer: c. Oral low-dose aspirin therapy. Rationale: The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent a stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA.

11. Which intervention should the nurse include in the plan of care for a patient with new right-sided homonymous hemianopsia after a stroke?? a. Apply an eye patch to the right eye. b. Approach the patient from the right side. c. Place needed objects on the patient's left side. d. Teach the patient that the left visual deficit will resolve.

Answer: c. Place needed objects on the patient's left side. Rationale: During the acute period, the nurse should place objects on the patient's unaffected side. Because there is a visual defect in the right half of each eye, an eye patch is not appropriate. The patient should be approached from the left side. The visual deficit may not resolve, although the patient can learn to compensate for the defect.

The home health nurse is caring for an 81-yr-old who had a stroke 2 months ago. Based on patient information shown in the accompanying figure, which action should the nurse take? History: * Well controlled type 2 diabetes for 10 years * Married 45 years; spouse has a heart failure and chronic obstructive pulmonary disease Physical Assessment: * Oriented to time, place, person * Speech clear * Minimal left leg weakness Physical/Occupational Therapy * Uses cane with walking * Spouse does household cleaning and cooking and assists patient with bathing and dressing a. Teach about preventing hypoglycemia. b. Begin processes to obtain a wheelchair. c. Provide support to the spouse caregiver. d. Remind the patient to take prescribed medications.

Answer: c. Provide support to the spouse caregiver. Rationale: The spouse's household and patient care responsibilities, in combination with chronic illnesses, indicate a high risk for caregiver role strain. The nurse should take appropriate actions to provide support to the souse caregiver. The data about the control of the patient's diabetes indicates that hypoglycemia and medication adherence are not a current concern.

A patient admitted with possible stroke has been aphasic for 3 hours and has a current blood pressure (BP) of 174/94 mm Hg. Which order by the health care provider should the nurse question? a. Keep head of bed elevated at least 30 degrees. b. Infuse normal saline intravenously at 75 mL/hr. c. Start a labetalol drip to keep BP less than 140/90 mm Hg. d. Begin tissue plasminogen activator (tPA) intravenously per protocol.

Answer: c. Start a labetalol drip to keep BP less than 140/90 mm Hg. Rationale: Because elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if mean arterial pressure (MAP) is greater than130 mm Hg or systolic pressure is greater than 220 mm Hg. Fluid intake should be 1500 to 2000 mL/day to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees unless the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient meets the other criteria for tPA use.

A patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving a prescribed dose of aspirin? a. The patient has dysphasia. b. The patient has atrial fibrillation. c. The patient reports that symptoms began with a severe headache. d. The patient has a history of brief episodes of right-sided hemiplegia.

Answer: c. The patient reports that symptoms began with a severe headache. Rationale: A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack are not contraindications to aspirin use.

Which stroke risk factor for a 48-yr-old male patient in the clinic is most important for the nurse to address? a. The patient is 25 pounds above the ideal weight. b. The patient drinks a glass of red wine with dinner daily. c. The patient's usual blood pressure (BP) is 170/94 mm Hg. d. The patient works at a desk and relaxes by watching television.

Answer: c. The patient's usual blood pressure (BP) is 170/94 mm Hg. Rationale: Hypertension is the single most important modifiable risk factor. People who drink more than 1 (for women) or 2 (for men) alcoholic beverages a day may increase their risk for hypertension. Physical inactivity and obesity contribute to stroke risk but not as much as hypertension.

During change of shift report, a nurse is told that a patient has an occluded left posterior cerebral artery. What finding should the nurse anticipate? a. Dysphasia. b. Confusion. c. Visual deficits. d. Poor judgment.

Answer: c. Visual deficits. Rationale: Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle cerebral artery involvement. Cognitive deficits and changes in judgment are more typical of anterior cerebral artery occlusion.

The nurse admitting a patient to the emergency room on a cold winter night would suspect hypothermia when the patient demonstrates A. Increased respirations. B. Rapid pulse rate. C. Red, sweaty skin D. Slow capillary refill

Answer: d With hypothermia, there is slow capillary refill. There is an increased respiration rate with hyperthermia. The heart rate increases with hyperthermia. The skin is usually pale or cyanotic with hypothermia.

A patient being admitted with a stroke has right-sided facial drooping and right-sided arm and leg paralysis. Which finding should the nurse expect? a. Impulsive behavior. b. Right-sided neglect. c. Hyperactive left-sided tendon reflexes. d. Difficulty comprehending instructions.

Answer: d. Difficulty comprehending instructions. Rationale: Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and use of language. The left-side reflexes are likely to be intact. Impulsive behavior and neglect are more likely with a right-side stroke.

3. A patient is diagnosed with heart failure after being admitted to the hospital for shortness of breath and fatigue. Which teaching strategy, if implemented by the nurse, is most likely to be effective? a. Assure the patient that the nurse is an expert on management of heart failure. b. Delay teaching until the patient is seen by a home health nurse after discharge. c. Discuss the importance of medication control to avoid long-term complications. d. Explain to the patient at each meal about the amounts of sodium in various foods.

Answer: d. Explain to the patient at each meal about the amounts of sodium in various foods. Rationale: Principles of adult education indicate that readiness and motivation to learn are high when facing new tasks (e.g., learning about the sodium amounts in various food items) and when demonstration and practice of skills are available. Although a home health referral may be needed for this patient, teaching should not be postponed until discharge. Adult learners are independent. The nurse should act as a facilitator for learning, rather than as the expert. Adults learn best when the topic is of immediate usefulness. Long-term goals may not be very motivating.

10. A patient needs to learn how to instill eyedrops. Which teaching strategy, if implemented by the nurse, would be most effective? a. Peer teaching b. Lecture-discussion c. Printed instructions d. Return demonstration

Answer: d. Return demonstration. Rationale: Demonstration with return demonstration (show back) is best used to teach a patient how to learn to perform a skill. Lecture-discussion, peer teaching, and printed materials are more useful for other learning needs.

A patient with a left-brain stroke suddenly bursts into tears when family members visit. How should the nurse respond? a. Use a calm voice to ask the patient to stop the crying behavior. b. Explain to the family that depression is normal following a stroke. c. Have the family members leave the patient alone for a few minutes. d. Teach the family that emotional outbursts are common after strokes.

Answer: d. Teach the family that emotional outbursts are common after strokes. Rationale: Patients who have left-sided brain stroke are prone to emotional outbursts that are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient's outburst suggests that depression is not the major cause of the behavior. The family should stay with the patient. The crying is not within the patient's control. Asking the patient to stop will lead to embarrassment.

A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a. The patient's speech is difficult to understand. b. The patient's blood pressure (BP) is 144/90 mm Hg. c. The patient takes a diuretic because of a history of hypertension. d. The patient has atrial fibrillation and takes warfarin (Coumadin).

Answer: d. The patient has atrial fibrillation and takes warfarin (Coumadin). Rationale: The use of warfarin probably contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient's care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated.

A patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. Health records show a history of several transient ischemic attacks (TIAs). What should the nurse anticipate for this patient? a. Surgical endarterectomy. b. Transluminal angioplasty. c. Intravenous heparin drip administration. d. Tissue plasminogen activator (tPa) infusion.

Answer: d. Tissue plasminogen activator (tPa) infusion. Rationale: The patient's history and clinical manifestations suggest an acute ischemic stroke, and a patient who is seen within 4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is having an acute ischemic stroke.

6. While admitting a patient to the medical unit, the nurse determines that the patient has a hearing impairment. How should the nurse use this information to plan teaching and learning strategies? a. Motivation and readiness to learn will be affected. b. The family must be included in the teaching process. c. The patient will have problems understanding information. d. Written materials should be provided with verbal instructions.

Answer: d. Written materials should be provided with verbal instructions. Rationale: The information that the patient has a hearing impairment indicates that the nurse should use written and verbal materials in teaching along with other strategies. The patient does not indicate a lack of motivation or an inability to understand new information. The patient's decreased hearing does not necessarily imply that the family must be included in the teaching process.

A nurse is educating a 21-year-old lifeguard about the risk of skin cancer and the need to wear sunscreen. Which statement by the patient indicates that the need for further teaching?a."I wear a hat and sit under the umbrella when not in the water."b."I don't bother with sunscreen on overcast days."c."I use a sunscreen with the highest SPF number."d."I wear a UV shirt and limit exposure to the sun by covering up."

B

A patient in the outpatient setting was diagnosed with atopic dermatitis. What interventions will the plan of care focus primarily on?a.Decreasing painb.Decreasing pruritusc.Preventing infectiond.Promoting drying of lesions

B

A 50-year-old man who has been taking phenobarbital for 1 week is found very lethargic and unable to walk after eating out for dinner. His wife states that he has no other prescriptions and that he did not take an overdose—the correct number of pills is in the bottle. The nurse suspects that which of these may have happened? a. He took a multivitamin. b. He drank a glass of wine. c. He took a dose of aspirin. d. He developed an allergy to the drug.

B Alcohol has an additive effect when combined with barbiturates and causes central nervous system (CNS) depression. Multivitamins and aspirin do not interact with barbiturates, and this situation does not illustrate an allergic reaction.

Which nursing diagnosis is appropriate for a patient who has started aminoglycoside therapy? a. Constipation b. Risk for injury (renal damage) c. Disturbed body image related to gynecomastia d. Imbalanced nutrition, less than body requirements, related to nausea

B Patients on aminoglycoside therapy have an increased risk for injury caused by nephrotoxicity. The other options are incorrect.

The nurse is preparing to administer a barbiturate. Which conditions or disorders would be a contraindication to the use of these drugs? (Select all that apply.) a. Gout b. Pregnancy c. Epilepsy d. Severe chronic obstructive pulmonary disease e. Severe liver disease f. Diabetes mellitus

B, D, E Contraindications to barbiturates include pregnancy, significant respiratory difficulties, and severe liver disease. The other disorders are not contraindications.

A patient has cellulitis on the right forearm. The nurse would anticipate orders to administer medications to eradicate which organism?a.Candida albicansb.Group A beta-hemolytic streptococcic.Staphylococcus aureusd.E. Coli

C

A patient is to receive phototherapy for the treatment of psoriasis. What is the nursing priority for this patient?a.Obtaining a complete blood count (CBC)b.Protection from excessive heatc.Protection from excessive ultraviolet (UV) exposured.Instructing the patient to take their multivitamin prior to treatment

C

A patient was given a patch test to determine what allergen was responsible for their atopic dermatitis. The provider prescribes a steroid cream. What important instructions should the nurse give to the patient?a.Apply the cream generously to affected areas.b.Apply a thin coat to affected areas, especially the face.c.Apply a thin coat to affected areas; avoid the face and groin.d.Apply an antihistamine along with applying a thin coat of steroid to affected areas.

C

An older patient has developed age spots and is concerned about skin cancer. How would the nurse instruct the patient to perform skin checks to assess for signs of skin cancer?a."Limit the time you spend in the sun."b."Monitor for signs of infection."c."Monitor spots for color change."d."Use skin creams to prevent drying."

C

A patient has been taking temazepam (Restoril) for intermittent insomnia. She calls the nurse to say that when she takes it, she sleeps well, but the next day she feels "so tired." Which explanation by the nurse is correct? a. "Long-term use of this drug results in a sedative effect." b. "If you take the drug every night, this hangover effect will be reduced." c. "These drugs affect the sleep cycle, resulting in daytime sleepiness." d. "These drugs increase the activity of the central nervous system, making you tired the next day."

C Benzodiazepines suppress REM sleep to a degree (although not as much as barbiturates) and, thus, result in daytime sleepiness (a hangover effect). The other statements are incorrect.

When a patient is on aminoglycoside therapy, the nurse will monitor the patient for which indicators of potential toxicity? a. Fever b. White blood cell count of 8000 cells/mm3 c. Tinnitus and dizziness d. Decreased blood urea nitrogen (BUN) levels

C Dizziness, tinnitus, hearing loss, or a sense of fullness in the ears could indicate ototoxicity, a potentially serious toxicity in a patient. Nephrotoxicity is indicated by rising blood urea nitrogen and creatinine levels. Fever may be indicative of the patient's infection; a white blood cell count of 7000 cells/mm3 is within the normal range of 5000 to 10,000 cells/mm3 .

The nurse checks the patient's laboratory work prior to administering a dose of vancomycin (Vancocin) and finds that the trough vancomycin level is 24 mcg/mL. What will the nurse do next? a. Administer the vancomycin as ordered. b. Hold the drug, and administer 4 hours later. c. Hold the drug, and notify the prescriber. d. Repeat the test to verify results.

C Optimal blood levels of vancomycin are a trough level of 10 to 20 mcg/mL. Measurement of peak levels is no longer routinely recommended, and only trough levels are commonly monitored. Blood samples for measurement of trough levels are drawn immediately before administration of the next dose. Because of the increase in resistant organisms, many clinicians use a trough level of 15 to 20 mcg/mL as their goal. These trough levels mean that even just before the next dose is due, when drug levels should be low, the drug levels are actually too high.

Ramelteon (Rozerem) is prescribed for a patient with insomnia. The nurse checks the patient's medical history, knowing that this medication is contraindicated in which disorder? a. Coronary artery disease b. Renal insufficiency c. Liver disease d. Anemia

C Ramelteon is contraindicated in cases of severe liver dysfunction. The other conditions are not contraindications.

A patient is brought to the emergency department for treatment of a suspected overdose. The patient was found with an empty prescription bottle of a barbiturate by his bedside. He is lethargic and barely breathing. The nurse would expect which immediate intervention? a. Starting an intravenous infusion of diluted bicarbonate solution b. Administering medications to increase blood pressure c. Implementing measures to maintain the airway and support respirations d. Administrating naloxone (Narcan) as an antagonist

C There are no antagonists/antidotes for barbiturates. Treatment supports respirations and maintains the airway. The other interventions are not appropriate.

A patient who has been hospitalized for 2 weeks has developed a pressure ulcer that contains multidrug-resistant Staphylococcus aureus (MRSA). Which drug would the nurse expect to be chosen for therapy? a. Metronidazole (Flagyl) b. Ciprofloxacin (Cipro) c. Vancomycin (Vancocin) d. Tobramycin (Nebcin)

C Vancomycin is the drug of choice for the treatment of MRSA. The other drugs are not used for MRSA.

A patient who takes multiple medications develops acute gouty arthritis. The nurse will consult with the health care provider before giving the prescribed dose of a. sertraline (Zoloft). b. famotidine (Pepcid). c. hydrochlorothiazide. d. oxycodone (Roxicodone).

C. Hydrochlorothiazide Diuretic use increases uric acid levels and can precipitate gout attacks. The other medications are safe to administer.

A nurse is instructing a nursing assistant in how to prevent pressure ulcers in a frail elderly client. The nursing assistant indicates that she understands the instruction when she agrees to perform which actions?Select all that apply.a) Bathe and dry the skin vigorously to stimulate circulation.b) Keep the head of the bed elevated 30 degrees.c) Offer nutritional supplements and frequent snacks.d) Turn the patient at least every 2 hours.e) Maintain a cooler environment when bathing.

CD

A patient asks the nurse what the purpose of the Wood's light is. Which response by the nurse is accurate?a."We will put an anesthetic on your skin to prevent pain."b."The lamp can help detect skin cancers."c."Some patients feel a pressure-like sensation."d."It is used to identify the presence of infectious organisms and proteins associated with specific skin conditions."

D

The nurse is instructing the nursing assistant to prevent pressure ulcers in a frail older patient. Which action indicates the nursing assistant has understood the nurse's teaching?a.Bathing and drying the skin vigorously to stimulate circulationb.Keeping the head of the bed elevated 30 degreesc.Limiting intake of fluid and offer frequent snacksd.Turning the patient at least every 2 hours

D

To help decrease the threat of a melanoma in a blonde-haired, fair-skinned patient at risk, the nurse would advise the patient to do which of the following?a.Apply sunscreen 1 hour prior to exposure.b.Drink plenty of water to prevent hot skin.c.Use vitamins to help prevent sunburn by replacing lost nutrients.d.Apply sunscreen 30 minutes prior to exposure.

D

A 79-year-old patient is receiving a quinolone as treatment for a complicated incision infection. The nurse will monitor for which adverse effect that is associated with these drugs? a. Neuralgia b. Double vision c. Hypotension d. Tendonitis and tendon rupture

D A black-box warning is required by the U.S. Food and Drug Administration for all quinolones because of the increased risk for tendonitis and tendon rupture with use of the drugs. This effect is more common in elderly patients, patients with renal failure, and those receiving concurrent glucocorticoid therapy (e.g., prednisone). The other options are not common adverse effects.

A patient has been taking phenobarbital for 2 weeks as part of his therapy for epilepsy. He tells the nurse that he feels tense and that "the least little thing" bothers him now. Which is the correct explanation for this problem? a. These are adverse effects that usually subside after a few weeks. b. The drug must be stopped immediately because of possible adverse effects. c. This drug causes the rapid eye movement (REM) sleep period to increase, resulting in nightmares and restlessness. d. This drug causes deprivation of REM sleep and may cause the inability to deal with normal stress.

D Barbiturates such as phenobarbital deprive people of REM sleep, which can result in agitation and the inability to deal with normal stress. A rebound phenomenon occurs when the drug is stopped (not during therapy), and the proportion of REM sleep increases, sometimes resulting in nightmares. The other options are incorrect.

A patient has been diagnosed with carbapenemase-resistant Enterobacteriaceae (CRE). The nurse expects to see orders for which drug? a. Dapsone (Cubicin), a miscellaneous antibiotic b. Ciprofloxacin (Cipro), a quinolone c. Linezolid (Zyvox), an oxazolidinone d. Colistimethate sodium (Coly-Mycin), a polypeptide antibiotic

D Colistimethate (Coly-Mycin), commonly referred to as colistin, is now being used again, often as one of the only drugs available to treat CRE. The other options are incorrect.

The nurse is reviewing the medication orders for a patient who will be receiving gentamicin therapy. Which other medication or medication class, if ordered, would be a potential interaction concern? a. Calcium channel blockers b. Phenytoin c. Proton pump inhibitors d. Loop diuretics

D Concurrent use of aminoglycosides, such as gentamicin, with loop diuretics increases the risk for ototoxicity. The other drugs and drug classes do not cause interactions.

A patient has experienced insomnia for months, and the physician has prescribed a medication to help with this problem. The nurse expects which drug to be used for long-term treatment of insomnia? a. Secobarbital (Seconal), a barbiturate b. Diazepam (Valium), a benzodiazepine c. Midazolam (Versed), a benzodiazepine d. Eszopiclone (Lunesta), a nonbenzodiazepine sleep aid

D Eszopiclone (Lunesta) is one of the newest prescription hypnotics to be approved for long-term use in treatment of insomnia. Barbiturates and benzodiazepines are not appropriate for long-term treatment of insomnia; midazolam is used for procedural (moderate) sedation.

The nurse is administering a vancomycin (Vancocin) infusion. Which measure is appropriate for the nurse to implement in order to reduce complications that may occur with this drug's administration? a. Monitoring blood pressure for hypertension during the infusion b. Discontinuing the drug immediately if red man syndrome occurs c. Restricting fluids during vancomycin therapy d. Infusing the drug over at least 1 hour

D Infuse the medication over at least 1 hour to reduce the occurrence of red man syndrome. Adequate hydration (at least 2 L of fluid in 24 hours) during vancomycin therapy is important for the prevention of nephrotoxicity. Hypotension may occur during the infusion, especially if it is given too rapidly.

A patient tells the nurse that he likes to drink kava herbal tea to help him relax. Which statement by the patient indicates that additional teaching about this herbal product is needed? a. "I will not drink wine with the kava tea." b. "If I notice my skin turning yellow, I will stop taking the tea." c. "I will not take sleeping pills if I have this tea in the evening." d. "I will be able to drive my car after drinking this tea."

D Patients should not drive after drinking this tea because it may cause sedation. Kava tea may cause skin discoloration (with long-term use). In addition, it must not be taken with alcohol, barbiturates, and psychoactive drugs.

A 40-yr-old patient is diagnosed with early Huntington's disease (HD). What information should the nurse provide when teaching the patient, spouse, and adult children about this disorder? a. improved nutrition and exercise can delay disease progression b. Levodopa-carbidopa (Sinemet) will help reduce HD symptoms c. prophylactic antibiotics decrease the risk for aspiration pneumonia d. genetic testing is an option for the patient's children to determine their own HD risks.

D. option of genetic testing for the patient's children to determine their own HD risks.

A patient has excessive movement. What disorder will the nurse see documented on the chart? a. Hypokinesia b. Akinesia c. Hyperkinesia d. Dyskinesia

REF: p. 378 ANS: C Excessive movement is the definition of hyperkinesia. Hypokinesia is decreased movement. Akinesia is loss of movement. Dyskinesia is abnormal movement.

After the nurse has taught a 28-yr-old with fibromyalgia, which statement by the patient indicates a good understanding of effective self-management? a. "I will need to stop drinking so much coffee and soda." b. "I am going to join a soccer team to get more exercise." c. "I will call the doctor every time my symptoms get worse." d. "I should avoid using over-the-counter medications for pain."

a. "I will need to stop drinking so much coffee and soda." Dietitians frequently suggest patients with fibromyalgia limit their intake of caffeine and sugar because these substances are muscle irritants. Mild exercise such as walking is recommended for patients with fibromyalgia, but vigorous exercise is likely to make symptoms worse. Because symptoms may fluctuate from day to day, the patient should be able to adapt the regimen independently rather than calling the provider whenever symptoms get worse. Over-the-counter medications such as ibuprofen and acetaminophen are frequently used for symptom management.

During the change of shift report, the nurse learns that a patient with a head injury has decorticate posturing to noxious stimulation. Which positioning shown in the accompanying figure will the nurse expect to observe? a. 1 b. 2 c. 3 d. 4

a. 1

Which action will the nurse include in the plan of care for a patient with newly diagnosed ankylosing spondylitis? a. Advise the patient to sleep on the back with a flat pillow. b. Emphasize that application of heat may worsen symptoms. c. Schedule annual laboratory assessment for the HLA-B27 antigen. d. Assist patient to choose physical activities that involve spinal flexion.

a. Advise the patient to sleep on the back with a flat pillow. Because ankylosing spondylitis results in flexion deformity of the spine, postures that extend the spine (e.g., sleeping on the back and with a flat pillow) are recommended. HLA-B27 antigen is assessed for initial diagnosis but is not needed annually. To counteract the development of flexion deformities, the patient should choose activities that extend the spine, such as swimming. Heat application is used to decrease localized pain.

The nurse preparing to care for a patient after a suspected stroke would question which order? a. Antihypertensive b. Antipyretic c. Osmotic diuretic d. Sedative

a. Antihypertensive

Which finding for a patient who is taking hydroxychloroquine (Plaquenil) to treat rheumatoid arthritis is likely to be an adverse effect of the medication? a. Blurred vision b. Joint tenderness c. Abdominal cramping d. Elevated blood pressure

a. Blurred vision Plaquenil can cause retinopathy. The medication should be stopped. Other findings are not related to the medication although they will also be reported.

Which assessment finding would the earliest and most sensitive indicator that there is an alteration in intracranial regulation? a. Change in level of consciousness b. Inability to focus visually c.Loss of primitive reflexes d. Unequal pupil size

a. Change in level of consciousness

The nurse is evaluating the need to refer a patient with osteoarthritis for a home care visit to be sure the patient can function in accomplishing daily activities independently. What is the nurse's first priority? a. Determine if the patient has had home visits before and if the experience was positive. b. Check the patient's ability to bathe without any assistance the next day. c. Have the patient demonstrate the learned skills at the end of the teaching session. d. Arrange a physical therapy visit before the patient is discharged from the hospital.

a. Determine if the patient has had home visits before and if the experience was positive.

The nurse is assessing a patient with a diagnosis of inflammation. The nurse would expect to find which of the following signs and symptoms consistent with acute inflammation? (select all that apply) a. Heat b. Erythema c. Pain d. Swelling e. Paleness f. Loss of function

a. Heat b. Erythema c. Pain d. Swelling f. Loss of function

The nurse is caring for a postoperative patient who had an open appendectomy. The nurse understands that this patient should have some erythema and edema at the incision site 12 to 24 hours post operation dependent on which condition? a. His immune system is functioning properly. b. He is properly vaccinated. c. He has an infection. d. The suppressor T-cells in his body are activated.

a. His immune system is functioning properly.

When caring for a patient after a head injury, the nurse would be most concerned with assessment findings which included respiratory changes along with what other findings? a. Hypertension and bradycardia b. Hypertension and tachycardia c. Hypotension and bradycardia d. Hypotension and tachycardia

a. Hypertension and bradycardia

An 18-month-old female patient is diagnosed with her fifth ear infection in the past 10 months. The physician notes that the child's growth rate has decreased from the 60th percentile for height and weight to the 15th percentile over that same time period. The child has been treated for thrush consistently since the third ear infection. The nurse understands that the patient is at risk for which condition? a. Primary immunodeficiency b. Secondary immunodeficiency c. Cancer d. Autoimmunity

a. Primary immunodeficiency Primary immunodeficiency is a risk for patients with two or more of the listed problems. Secondary immunodeficiency is induced by illness or treatment. Cancer is caused by abnormal cells that will trigger an immune response. Autoimmune diseases are caused by hyperimmunity.

A patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient's assigned room (select all that apply)? a. Side-rail pads b. Tongue blade c. Oxygen mask d. Suction tubing e. Urinary catheter f. Nasogastric tube

a. Side-rail pads c. Oxygen mask d. Suction tubing

During assessment of the patient with fibromyalgia, the nurse would expect the patient to report which of the following (select all that apply)? a. Sleep disturbances b. Multiple tender points c. Cardiac palpitations and dizziness d. Multijoint inflammation and swelling e. Widespread bilateral, burning musculoskeletal pain

a. Sleep disturbances b. Multiple tender points e. Widespread bilateral, burning musculoskeletal pain These symptoms are commonly described by patients with fibromyalgia. Cardiac involvement and joint inflammation are not typical of fibromyalgia.

A patient who had arthroscopic surgery of the right knee 7 days ago is admitted with a red, swollen, hot knee. Which assessment finding by the nurse should be reported to the health care provider immediately? a. The blood pressure is 86/50 mm Hg. b. The patient says the knee pain is severe. c. The white blood cell count is 11,500/µL. d. The patient is taking ibuprofen (Motrin).

a. The blood pressure is 86/50 mm Hg. The low blood pressure suggests the patient may be developing septicemia as a complication of septic arthritis. Immediate blood cultures and initiation of antibiotic therapy are indicated. The other information is typical of septic arthritis and should also be reported to the health care provider, but it does not indicate any immediately life-threatening problems.

A patient with dermatomyositis is receiving long-term prednisone therapy. Which assessment finding by the nurse is important to report to the health care provider? a. The patient has painful hematuria. b. Acne is noted on the patient's face. c. Fasting blood glucose is 112 mg/dL. d. The patient has an increased appetite.

a. The patient has painful hematuria. Corticosteroid use is associated with an increased risk for infection, so the nurse should report the urinary tract symptoms immediately to the health care provider. The increase in blood glucose, increased appetite, and acne are also adverse effects of corticosteroid use but do not need diagnosis and treatment as rapidly as the probable urinary tract infection.

A patient has been newly diagnosed with hypertension. The nurse assesses the need to develop a collaborative plan of care that includes a goal of adhering to the prescribed regimen. When the nurse is planning teaching for the patient, which is the most important initial learning goal? a. The patient will select the type of learning materials they prefer. b. The patient will verbalize an understanding of the importance of following the regimen. c. The patient will demonstrate coping skills needed to manage hypertension. d. The patient will verbalize the side effects of treatment.

a. The patient will select the type of learning materials they prefer.

Which patient is most appropriate for the intensive care unit (ICU) charge nurse to assign to a registered nurse (RN) who has floated from the medical unit? a. A 45-year-old receiving IV antibiotics for meningococcal meningitis b. A 25-year-old admitted with a skull fracture and craniotomy the previous day c. A 55-year-old who has increased intracranial pressure (ICP) and is receiving hyperventilation therapy d. A 35-year-old with ICP monitoring after a head injury last week

a. a 45 y.o. receiving IV antibiotics for meningococcal meningitis

A male patient who has possible cerebral edema has a serum sodium level of 116 mEq/L (116 mmol/L) and a decreasing level of consciousness (LOC). He is now complaining of a headache. Which prescribed interventions should the nurse implement first? a. Administer IV 5% hypertonic saline. b. Draw blood for arterial blood gases (ABGs). c. Send patient for computed tomography (CT). d. Administer acetaminophen (Tylenol) 650 mg orally.

a. administer IV 5% hypertonic saline

The nurse observes a patient ambulating in the hospital hall when the patient's arms and legs suddenly jerk and the patient falls to the floor. The nurse will first a. assess the patient for a possible injury. b. give the scheduled divalproex (Depakote). c. document the timing and description of the seizure. d. notify the patient's health care provider about the seizure.

a. assess the patient for a possible injury.

The nurse teaching a support group of women with rheumatoid arthritis (RA) about how to manage activities of daily living suggests they should a. avoid activities requiring repetitive use of the same muscles and joints. b. protect the knee joints by sleeping with a small pillow under the knees. c. stand rather than sit when performing daily household and yard chores. d. strengthen small hand muscles by wringing out sponges or washcloths.

a. avoid activities requiring repetitive use of the same muscles and joints. Patients are advised to avoid repetitious movements. Sitting during household chores is recommended to decrease stress on joints. Wringing water out of sponges would increase joint stress. Patients are encouraged to position joints in the extended (neutral) position. Sleeping with a pillow behind the knees would decrease the ability of the knee to extend and also decrease knee range of motion.

Admission vital signs for a brain-injured patient are blood pressure 128/68, pulse 110, and respirations 26. Which set of vital signs, if taken 1 hour after admission, will be of most concern to the nurse? a. Blood pressure 154/68, pulse 56, respirations 12 b. Blood pressure 134/72, pulse 90, respirations 32 c. Blood pressure 148/78, pulse 112, respirations 28 d. Blood pressure 110/70, pulse 120, respirations 30

a. blood pressure 154/68, pulse 56, respirations 12

A 68-year-old male patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by his spouse. Which action will the nurse take first? a. Check oxygen saturation. b. Assess pupil reaction to light. c. Verify Glasgow Coma Scale (GCS) score. d. Palpate the head for hematoma or bony irregularities.

a. check oxygen saturation

A 42-year-old patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care? a. Encourage family members to remain at the bedside. b. Apply soft restraints to protect the patient from injury. c. Keep the room well-lighted to improve patient orientation. d. Minimize contact with the patient to decrease sensory input.

a. encourage family members to remain at the beside

Which action will the public health nurse take to reduce the incidence of epidemic encephalitis in a community? a. Encourage the use of effective insect repellents during mosquito season. b. Remind patients that most cases of viral encephalitis can be cared for at home. c. Teach about the importance of prophylactic antibiotics after exposure to encephalitis. d. Arrange for screening of school-age children for West Nile virus during the school year.

a. encourage the use of effective insect repellents during mosquito season

Physical barriers that offer the body protection from damage and infection are located in the: (select all that apply) a. gastrointestinal tract. b. genitourinary tract. c. respiratory tract. d. lymph system. e. hematopoietic system.

a. gastrointestinal tract. b. genitourinary tract. c. respiratory tract.

A nurse remembers that the primary actions of the complement cascade include: (select all that apply) a. increased vascular permeability. b. vasoconstriction. c. chemotaxis. d. opsonization. e. cell killing. f. increased clotting

a. increased vascular permeability. c. chemotaxis. d. opsonization. e. cell killing.

The nurse determines that colchicine has been effective for a patient with an acute attack of gout upon finding a. reduced joint pain. b. increased urine output. c. elevated serum uric acid. d. increased white blood cells (WBC).

a. reduced joint pain. Colchicine reduces joint pain in 24 to 48 hours by decreasing inflammation. The recommended increase in fluid intake of 2 to 3 L/day during acute gout would increase urine output but would not indicate the effectiveness of colchicine. Elevated serum uric acid would result in increased symptoms. The WBC count might decrease with decreased inflammation but would not increase.

A college athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will the nurse collect to determine whether a patient is developing postconcussion syndrome? a. Short-term memory b. Muscle coordination c. Glasgow Coma Scale d. Pupil reaction to light

a. short term memory

A 25-yr-old female patient with systemic lupus erythematosus (SLE) who has a facial rash and alopecia tells the nurse, "I never leave my house because I hate the way I look." The nurse will plan interventions with the patient to address the nursing diagnosis of a. social isolation. b. activity intolerance. c. impaired skin integrity. d. impaired social interaction.

a. social isolation. The patient's statement about not going anywhere because of hating the way he or she looks expresses social isolation because of embarrassment about the effects of the SLE. Activity intolerance is a possible problem for patients with SLE, but the information about this patient does not support this. The rash with SLE is nonpruritic. There is no evidence of lack of social skills for this patient.

When admitting a 42-year-old patient with a possible brain injury after a car accident to the emergency department (ED), the nurse obtains the following information. Which finding is most important to report to the health care provider? a. The patient takes warfarin (Coumadin) daily. b. The patient's blood pressure is 162/94 mm Hg. c. The patient is unable to remember the accident. d. The patient complains of a severe dull headache.

a. the patient takes wafarin daily

A high school teacher who has been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse, "I cannot teach any more. It will be too upsetting if I have a seizure at work." Which response by the nurse specifically addresses the patient's concern? a. "You might benefit from some psychologic counseling." b. "Epilepsy usually can be well controlled with medications." c. "You will want to contact the Epilepsy Foundation for assistance." d. "The Department of Vocational Rehabilitation can help with work retraining.

b. "Epilepsy usually can be well controlled with medications."

The nurse determines additional instruction is needed when a patient diagnosed with scleroderma makes which statement? a. "Paraffin baths can be used to help my hands." b. "I should lie down for an hour after each meal." c. "Lotions will help if I rub them in for a long time." d. "I should perform range-of-motion exercises daily."

b. "I should lie down for an hour after each meal." Because of the esophageal scarring, patients should sit up for 2 hours after eating. The other patient statements are correct and indicate teaching has been effective.

After the nurse has finished teaching a patient with osteoarthritis (OA) of the right hip about how to manage the OA, which patient statement indicates a need for more teaching? a. "I can exercise every day to help maintain joint motion." b. "I will take 1 g of acetaminophen (Tylenol) every 4 hours." c. "I will take a shower in the morning to help relieve stiffness." d. "I can use a cane to decrease the pressure and pain in my hip."

b. "I will take 1 g of acetaminophen (Tylenol) every 4 hours." No more than 4 g of acetaminophen (1 g every 6 hours) should be taken daily to decrease the risk for liver damage. Regular exercise, moist heat, and supportive equipment are recommended for OA management.

Which statement by a patient with systemic lupus erythematosus (SLE) indicates the patient has understood the nurse's teaching about the condition? a. "I will exercise even if I am tired." b. "I will use sunscreen when I am outside." c. "I should avoid nonsteroidal antiinflammatory drugs." d. "I should take birth control pills to avoid getting pregnant."

b. "I will use sunscreen when I am outside." Severe skin reactions can occur in patients with SLE who are exposed to the sun. Patients should avoid fatigue by balancing exercise with rest periods as needed. Oral contraceptives can exacerbate lupus. Aspirin and nonsteroidal antiinflammatory drugs are used to treat the musculoskeletal manifestations of SLE.

A patient with two school-age children has recently been diagnosed with rheumatoid arthritis (RA) and tells the nurse that home life is very stressful. Which initial response by the nurse is most appropriate? a. "You need to see a family therapist for some help with stress." b. "Tell me more about the situations that are causing you stress." c. "Your family should understand the impact of your rheumatoid arthritis." d. "Perhaps it would be helpful for your family to be involved in a support group."

b. "Tell me more about the situations that are causing you stress." The initial action by the nurse should be further assessment. The other three responses might be appropriate based on the information the nurse obtains with further assessment.

Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring. Which response by the nurse is best? a. "This type of monitoring system is complex and it is managed by skilled staff." b. "The monitoring system helps show whether blood flow to the brain is adequate." c. "The ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure." d. "This monitoring system has multiple benefits including facilitation of cerebrospinal fluid drainage."

b. "the monitoring system helps show whether blood flow to the brain is adequate"

A 46-year-old patient with a head injury opens the eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. The nurse records the patient's Glasgow Coma Scale score as a. 9. b. 11. c. 13. d. 15.

b. 11

Which information will the nurse include when teaching a patient with newly diagnosed systemic exertion intolerance disease (SEID) about self-management? a. Symptoms usually progress as patients become older. b. A gradual increase in daily exercise may help decrease fatigue. c. Avoid use of over-the-counter antihistamines or decongestants. d. A low-residue, low-fiber diet will reduce any abdominal distention.

b. A gradual increase in daily exercise may help decrease fatigue. A graduated exercise program is recommended to avoid fatigue while encouraging ongoing activity. Because many patients with SEID syndrome have allergies, antihistamines and decongestants are used to treat allergy symptoms. A high-fiber diet is recommended. SEID usually does not progress.

The health care provider has prescribed the following interventions for a patient who is taking azathioprine (Imuran) for systemic lupus erythematosus. Which order will the nurse question? a. Draw anti-DNA blood titer. b. Administer varicella vaccine. c. Naproxen (Aleve) 200 mg BID. d. Famotidine (Pepcid) 20 mg daily.

b. Administer varicella vaccine. Live virus vaccines, such as varicella, are contraindicated in a patient taking immunosuppressive drugs. The other orders are appropriate for the patient.

1. The nurse is caring for a patient with increased intracranial pressure (ICP). Which action would be considered as a collaborative intervention? a. Decreasing perfusion b. Administering an osmotic diuretic c. Reviewing orientation d. Reviewing for edema

b. Administering an osmotic diuretic

Which information will the nurse include when preparing teaching materials for a patient with an exacerbation of rheumatoid arthritis? a. Affected joints should not be exercised when pain is present. b. Applying cold packs before exercise may decrease joint pain. c. Exercises should be performed passively by someone other than the patient. d. Walking may substitute for range-of-motion (ROM) exercises on some days.

b. Applying cold packs before exercise may decrease joint pain. Cold application is helpful in reducing pain during periods of exacerbation of RA. Because the joint pain is chronic, patients are instructed to exercise even when joints are painful. ROM exercises are intended to strengthen joints and improve flexibility, so passive ROM alone is not sufficient. Recreational exercise is encouraged but is not a replacement for ROM exercises.

The parents of a newborn question the nurse about the need for vaccinations: "Why does our baby need all those shots? He's so small, and they have to cause him pain." The nurse can explain to the parents that which of the following are true about vaccinations? (Select all that apply.) a. Are only required for infants b. Are part of primary prevention for system disorders c. Prevent the child from getting childhood diseases d. Help protect individuals and communities e. Are risk free f. Are recommended by the Centers for Disease Control and Prevention (CDC)

b. Are part of primary prevention for system disorders d. Help protect individuals and communities f. Are recommended by the Centers for Disease Control and Prevention (CDC)

After the nurse implements a teaching plan for a newly diagnosed patient with hypertension, the patient can explain the information but fails to take the medications as prescribed. What is the nurse's next action? a. Reeducate the patient, because learning did not occur because the patient's behavior did not change. b. Assess the patient's perception and attitude toward the risks associated with not taking their anti-hypertensives. c. Take full responsibility for helping the patient make dietary changes. d. Ask the provider to prescribe a different medication, because the patient does not want to take this medication.

b. Assess the patient's perception and attitude toward the risks associated with not taking their anti-hypertensives.

The nurse is caring for a patient who is being discharged home after a splenectomy. What information on immune function needs to be included in this patient's discharge planning? a. The mechanisms of the inflammatory response b. Basic infection control techniques c. The importance of wearing a face mask in public d. Limiting contact with the general population

b. Basic infection control techniques

Which laboratory result will the nurse monitor to determine if prednisone has been effective for a patient with an acute exacerbation of rheumatoid arthritis? a. Blood glucose b. C-reactive protein c. Serum electrolytes d. Liver function tests

b. C-reactive protein C-reactive protein is a serum marker for inflammation, and a decrease would indicate the corticosteroid therapy was effective. Blood glucose and serum electrolytes will also be monitored to assess for side effects of prednisone. Liver function is not routinely monitored in patients receiving corticosteroids.

The nurse is caring for a patient with increased intracranial pressure. Which action is considered unsafe? a. Aligning the neck with the body b. Clustering many nursing activities c. Elevating the head of the bed 30 degrees d. Providing stool softeners or laxatives as ordered

b. Clustering many nursing activities

A patient with psoriatic arthritis and back pain is receiving etanercept (Enbrel). Which finding is most important for the nurse to report to the health care provider? a. Red, scaly patches are noted on the arms. b. Crackles are auscultated in the lung bases. c. Hemoglobin is 11.1g/dL, and hematocrit is 35%. d. Patient has continued pain after first week of etanercept therapy.

b. Crackles are auscultated in the lung bases. Because heart failure is a possible adverse effect of etanercept, the medication may need to be discontinued. The other information will also be reported to the health care provider but does not indicate a need for a change in treatment. Red, scaly patches of skin and mild anemia are commonly seen with psoriatic arthritis. Treatment with biologic therapies requires time to improve symptoms.

Which finding will the nurse expect when assessing a patient who has osteoarthritis (OA) of the knee? a. Presence of Heberden's nodules b. Discomfort with joint movement c. Redness and swelling of the knee joint d. Stiffness that increases with movement

b. Discomfort with joint movement Initial symptoms of OA include pain with joint movement. Heberden's nodules occur on the fingers. Redness of the joint is associated with inflammatory arthritis such as rheumatoid arthritis. Stiffness in OA is worse right after the patient rests and decreases with joint movement.

Which information will the nurse include when teaching a patient with newly diagnosed ankylosing spondylitis (AS) about management of the condition? a. Exercise by taking long walks. b. Do daily deep-breathing exercises. c. Sleep on the side with hips flexed. d. Take frequent naps during the day.

b. Do daily deep-breathing exercises. Deep-breathing exercises are used to decrease the risk for pulmonary complications that may result from reduced chest expansion that can occur with AS. Patients should sleep on the back and avoid flexed positions. Prolonged standing and walking should be avoided. There is no need for frequent naps.

Which nursing action can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP) who are assisting with the care of a patient with scleroderma? a.Monitor for difficulty in breathing. b. Document the patient's oral intake. c. Check finger strength and movement. d. Apply capsaicin (Zostrix) cream to hands.

b. Document the patient's oral intake. Monitoring and documenting patient's oral intake is included in UAP education and scope of practice. Assessments for changes in physical status and administration of medications require more education and scope of practice, and should be done by RNs.

Which result for a patient with systemic lupus erythematosus (SLE) is most important for the nurse to communicate to the health care provider? a. Decreased C-reactive protein (CRP) b. Elevated blood urea nitrogen (BUN) c. Positive antinuclear antibodies (ANA) d. Positive lupus erythematosus cell prep

b. Elevated blood urea nitrogen (BUN) Elevated BUN and serum creatinine indicate possible lupus nephritis and a need for a change in therapy to avoid further renal damage. The positive lupus erythematosus cell prep and ANA would be expected in a patient with SLE. A drop in CRP shows decreased inflammation.

Which action will the nurse include in the plan of care for a patient with a new diagnosis of rheumatoid arthritis (RA)? a. Instruct the patient to purchase a soft mattress. b. Encourage the patient to take a nap in the afternoon. c. Teach the patient to use lukewarm water when bathing. d. Suggest exercise with light weights several times daily.

b. Encourage the patient to take a nap in the afternoon. Adequate rest helps decrease the fatigue and pain associated with RA. Patients are taught to avoid stressing joints, use warm baths to relieve stiffness, and use a firm mattress. When the disease is stabilized, a therapeutic exercise program is usually developed by a physical therapist to include exercises that improve flexibility and strength of affected joints, as well as the patient's general endurance.

A diabetic patient presents to the diabetes clinic with A1c levels of 7.5%. The nurse has met this patient for the first time. When applying principles of Theory of Planned Behavior (TPB), which teaching strategy by the nurse is most likely to be effective? a. Provide information on the importance of blood glucose control in maintenance of long-term health and evaluate how the patient has been following the prescribed regime. b. Establish a rapport with the patient by complimenting them on what they did correctly, and ask what strategies they have tried thus far. c. Refer the patient to a certified diabetic educator, because the educator is an expert on management of diabetes complications. d. Have the patient explain what medications they are on and what diet they should be following.

b. Establish a rapport with the patient by complimenting them on what they did correctly, and ask what strategies they have tried thus far.

After shunt procedure, the nurse would monitor the patient's neurologic status by using which test? a. Electroencephalogram b. Glasgow Coma Scale c. National Institutes of Health Stroke Scale d. Monro-Kellie doctrine

b. Glasgow Coma Scale

A patient has scleroderma manifested by CREST (calcinosis, Raynaud's phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia) syndrome. Which action will the nurse include in the plan of care? a. Avoid use of capsaicin cream on hands. b. Keep the environment warm and draft free. c. Obtain capillary blood glucose before meals. d. Assist to bathroom every 2 hours while awake.

b. Keep the environment warm and draft free. Keeping the room warm will decrease the incidence of Raynaud's phenomenon, one aspect of the CREST syndrome. Capsaicin cream may be used to improve circulation and decrease pain. There is no need to obtain blood glucose or to assist the patient to the bathroom every 2 hours.

After a thymectomy, a patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient complains of nausea and severe abdominal cramps. Which action should the nurse take first? a. Auscultate the patient's bowel sounds. b. Notify the patient's health care provider. c. Administer the prescribed PRN antiemetic drug. d. Give the scheduled dose of prednisone (Deltasone).

b. Notify the patient's health care provider

The home health registered nurse (RN) is planning care for a patient with a seizure disorder related to a recent head injury. Which nursing action can be delegated to a licensed practical/vocational nurse (LPN/LVN)? a. Make referrals to appropriate community agencies. b. Place medications in the home medication organizer. c. Teach the patient and family how to manage seizures. d. Assess for use of medications that may precipitate seizures.

b. Place medications in the home medication organizer.

The nurse identified each of the following clinical manifestations of inflammation. Which would the nurse classify as a local response? (select all that apply) a. Fever b. Redness c. Swelling d. Heat e. Pain

b. Redness c. Swelling d. Heat e. Pain

A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first? a. Document the BP and ICP in the patient's record. b. Report the BP and ICP to the health care provider. c. Elevate the head of the patient's bed to 60 degrees. d. Continue to monitor the patient's vital signs and ICP

b. Report the bp and icp to the health care provider

A 73-year-old male patient is seen in the home setting for a routine physical. The nurse notes which behavior as the most reassuring sign that the patient has been following the treatment plan for the diagnoses of hypertension, diabetes, and hyperlipidemia? a. The patient has a list of glucose readings for the past 10 days. b. The patient has a list of medications along with newly refilled meds. c. The patient has a list of all foods and beverages for a 3-day period. d. The patient verbalizes the side effects of all his medications.

b. The patient has a list of medications along with newly refilled meds.

Which assessment finding for a patient using naproxen (Naprosyn) to treat osteoarthritis is likely to require a change in medication? a. The patient has gained 3 lb. b. The patient has dark-colored stools. c. The patient's pain affects multiple joints. d. The patient uses capsaicin cream (Zostrix).

b. The patient has dark-colored stools. Dark-colored stools may indicate the patient is experiencing gastrointestinal bleeding caused by the naproxen. The patient's ongoing pain and weight gain will also be reported and may indicate a need for a different treatment and/or counseling about avoiding weight gain, but these are not as large a concern as the possibility of gastrointestinal bleeding. Use of capsaicin cream with oral medications is appropriate.

A 29-yr-old woman is taking methotrexate to treat rheumatoid arthritis. Which information from the patient's health history is important for the nurse to report to the health care provider related to the methotrexate? a. The patient had a history of infectious mononucleosis as a teenager. b. The patient is trying to get pregnant before her disease becomes more severe. c. The patient has a family history of age-related macular degeneration of the retina. d. The patient has been using large doses of vitamins and health foods to treat the RA.

b. The patient is trying to get pregnant before her disease becomes more severe. Methotrexate is teratogenic, and the patient should be taking contraceptives during methotrexate therapy. The other information will not impact the choice of methotrexate as therapy.

The nurse suggests that a patient recently diagnosed with rheumatoid arthritis (RA) plan to start each day with a. a brief routine of isometric exercises. b. a warm bath followed by a short rest. c. active range-of-motion (ROM) exercises. d. stretching exercises to relieve joint stiffness.

b. a warm bath followed by a short rest. Taking a warm shower or bath is recommended to relieve joint stiffness, which is worse in the morning. Isometric exercises would place stress on joints and would not be recommended. Stretching and ROM should be done later in the day, when joint stiffness is decreased.

Which assessment information obtained by the nurse indicates a patient with an exacerbation of rheumatoid arthritis (RA) is experiencing a side effect of prednisone? a. The patient has joint pain and stiffness. b. The patient's blood glucose is 165 mg/dL. c. The patient has experienced a recent 5-pound weight loss. d. The patient's erythrocyte sedimentation rate (ESR) has increased.

b. The patient's blood glucose is 165 mg/dL. Corticosteroids have the potential to cause diabetes mellitus. The finding of elevated blood glucose reflects this side effect of prednisone. Corticosteroids increase appetite and lead to weight gain. An elevated ESR with no improvement in symptoms would indicate the prednisone was not effective but would not be side effects of the medication.

An unconscious 39-year-old male patient is admitted to the emergency department (ED) with a head injury. The patient's spouse and teenage children stay at the patient's side and ask many questions about the treatment being given. What action is best for the nurse to take? a. Ask the family to stay in the waiting room until the initial assessment is completed. b. Allow the family to stay with the patient and briefly explain all procedures to them. c. Refer the family members to the hospital counseling service to deal with their anxiety. d. Call the family's pastor or spiritual advisor to take them to the chapel while care is given.

b. allow the family to stay with the patient and briefly explain the procedures to them

To assess for functional deficits, which question will the nurse ask a patient who has been admitted for treatment of a benign occipital lobe tumor? a. "Do you have difficulty in hearing?" b. "Are you experiencing visual problems?" c. "Are you having any trouble with your balance?" d. "Have you developed any weakness on one side?"

b. are you experiencing visual problems?

A patient with gout has a new prescription for losartan (Cozaar) to control the condition. The nurse will plan to monitor a. blood glucose. b. blood pressure. c. erythrocyte count. d. lymphocyte count.

b. blood pressure. Losartan, an angiotensin II receptor antagonist, will lower blood pressure. It does not affect blood glucose, red blood cells, or lymphocytes.

A 20-year-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take? a. Have the patient gently blow the nose. b. Check the drainage for glucose content. c. Teach the patient that rhinorrhea is expected after a head injury. d. Obtain a specimen of the fluid to send for culture and sensitivity.

b. check the drainage for glucose content

What should the nurse advises a patient with myasthenia gravis (MG) to do? a. anticipate the need for weekly plasmapheresis treatments. b. complete physically demanding activities early in the day c. protect the extremities from injury due to poor sensory perception. d. perform physically demanding activities early in the day.

b. complete physically demanding activities early in the day

After endotracheal suctioning, the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14 to 17 mm Hg. Which action should the nurse take first? a. Document the increase in intracranial pressure. b. Ensure that the patient's neck is in neutral position. c. Notify the health care provider about the change in pressure. d. Increase the rate of the prescribed propofol (Diprivan) infusion.

b. ensure that the patient's neck is in neutral position

Which statement by a 40-year-old patient who is being discharged from the emergency department (ED) after a concussion indicates a need for intervention by the nurse? a. "I will return if I feel dizzy or nauseated." b. "I am going to drive home and go to bed." c. "I do not even remember being in an accident." d. "I can take acetaminophen (Tylenol) for my headache."

b. i am going to drive home and go to bed

The nurse admitting a patient who has a right frontal lobe tumor would expect the patient may have a. expressive aphasia. b. impaired judgment. c. right-sided weakness. d. difficulty swallowing.

b. impaired judgement

Which patient problem should the nurse identify as of highest priority for a patient who has Parkinson's disease and is unable to move the facial muscles? a. activity intolerance b. inadequate nutrition c. disturbed body image d. impaired physical mobility

b. inadequate nutrition

When obtaining a health history and physical assessment for a 36-yr-old female patient with possible multiple sclerosis (MS), the nurse should a. assess for the presence of chest pain. b. inquire about urinary tract problems. c. inspect the skin for rashes or discoloration. d. ask the patient about any increase in libido.

b. inquire about urinary tract problems

The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patient's nose. Which admission order should the nurse question? a. Keep the head of bed elevated. b. Insert nasogastric tube to low suction. c. Turn patient side to side every 2 hours d. Apply cold packs intermittently to face.

b. insert nasogastric tube to low suction

Which finding for a patient who has a head injury should the nurse report immediately to the health care provider? a. Intracranial pressure is 16 mm Hg when patient is turned. b. Pale yellow urine output is 1200 mL over the last 2 hours. c. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg. d. Ventriculostomy drained 40 mL of cerebrospinal fluid in the last 2 hours.

b. pale yellow urine output is 1200 mL over the last 2 hours

A 23-year-old patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action will the nurse plan to take? a. Administer IV furosemide (Lasix). b. Prepare the patient for craniotomy. c. Initiate high-dose barbiturate therapy. d. Type and crossmatch for blood transfusion.

b. prepare the patient for craniotomy

Which action will the emergency department nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness? a. Coordinate the transfer of the patient to the operating room. b. Provide discharge instructions about monitoring neurologic status. c. Transport the patient to radiology for magnetic resonance imaging (MRI). d. Arrange to admit the patient to the neurologic unit for 24 hours of observation.

b. provide discharge instructions about monitoring neurologic status

patient with possible viral meningitis is admitted to the nursing unit after lumbar puncture was performed in the emergency department. Which action prescribed by the health care provider should the nurse question? a. Elevate the head of the bed 20 degrees. b. Restrict oral fluids to 1000 mL daily. c. Administer ceftriaxone (Rocephin) 1 g IV every 12 hours. d. Give ibuprofen (Motrin) 400 mg every 6 hours as needed for headache.

b. restrict oral fluids to 1000 mL daily

A patient hospitalized with polymyositis has joint pain; erythematous facial rash; eyelid edema; and a weak, hoarse voice. The safety priority for the patient is addressing the a. acute pain. b. risk for aspiration. c. disturbed visual perception. d. risk for impaired skin integrity.

b. risk for aspiration. The patient's vocal weakness and hoarseness indicate weakness of the pharyngeal muscles and a high risk for aspiration. The other concerns are also appropriate but are not as high a priority as the maintenance of the patient's airway.

After evacuation of an epidural hematoma, a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter. Which information obtained by the nurse is most important to communicate to the health care provider? a. Pulse 102 beats/min b. Temperature 101.6° F c. Intracranial pressure 15 mm Hg d. Mean arterial pressure 90 mm Hg

b. temperature 101.6

The nurse is developing a care plan for a patient who has low motivation and nonadherence with blood glucose monitoring. Which statement by the patient would indicate to the nurse that the patient is not motivated and will most likely not comply? a. "I do not like to test my sugar, but I do it because my wife nags me." b. "I forget to check my sugar once in a while." c. "I don't see or feel any different when I do keep my blood sugars under control." d. "I have no idea what the signs of low blood sugar are."

c. "I don't see or feel any different when I do keep my blood sugars under control."

The nurse determines that teaching about management of migraine headaches has been effective when the patient says which of the following? a. "I can take the (Topamax) as soon as a headache starts." b. "A glass of wine might help me relax and prevent a headache." c. "I will lie down someplace dark and quiet when the headaches begin." d. "I should avoid taking aspirin and sumatriptan (Imitrex) at the same time."

c. "I will lie down someplace dark and quiet when the headaches begin."

When the nurse brings medications to a patient with rheumatoid arthritis, the patient refuses the prescribed methotrexate. The patient tells the nurse, "My arthritis isn't that bad yet. The side effects of methotrexate are worse than the arthritis." The most appropriate response by the nurse is a. "You have the right to refuse to take the methotrexate." b. "Methotrexate is less expensive than some of the newer drugs." c. "It is important to start methotrexate early to decrease the extent of joint damage." d. "Methotrexate is effective and has fewer side effects than some of the other drugs."

c. "It is important to start methotrexate early to decrease the extent of joint damage." Disease-modifying antirheumatic drugs (DMARDs) are prescribed early to prevent the joint degeneration that occurs as soon as the first year with RA. The other statements are accurate, but the most important point for the patient to understand is that it is important to start DMARDs as quickly as possible.

While caring for a patient preparing for a kidney transplant, the nurse knows that the patient understands teaching on immunosuppression when she makes which statement? a. "My body will treat the new kidney like my original kidney." b. "I will have to make sure that I avoid being around people." c. "The medications that I take will help prevent my body from attacking my new kidney." d. "My body will only have a problem with my new kidney if the donor is not directly related to me."

c. "The medications that I take will help prevent my body from attacking my new kidney."

Which patient seen by the nurse in the outpatient clinic is most likely to require teaching about ways to reduce the risk for osteoarthritis (OA)? a. A 56-yr-old man who has a sedentary office job b. A 38-yr-old man who plays on a summer softball team c. A 56-yr-old woman who works on an automotive assembly line d. A 38-yr-old woman who is newly diagnosed with diabetes mellitus

c. A 56-yr-old woman who works on an automotive assembly line OA is more likely to occur in women as a result of estrogen reduction at menopause and in individuals whose work involves repetitive movements and lifting. Moderate exercise, such as softball, reduces the risk for OA. Diabetes is not a risk factor for OA. Sedentary work is not a risk factor for OA.

A new clinic patient with joint swelling and pain is being tested for systemic lupus erythematosus. Which test will provide the most specific findings for the nurse to review? a. Rheumatoid factor (RF) b. Antinuclear antibody (ANA) c. Anti-Smith antibody (Anti-Sm) d. Lupus erythematosus (LE) cell prep

c. Anti-Smith antibody (Anti-Sm) The anti-Sm is antibody found almost exclusively in SLE. The other blood tests are also used in screening but are not as specific to SLE.

The nurse notices a circular lesion with a red border and clear center on the arm of a summer camp counselor who is in the clinic complaining of chills and muscle aches. Which action should the nurse take to follow up on that finding? a. Palpate the abdomen. b. Auscultate the heart sounds. c. Ask the patient about recent outdoor activities. d. Question the patient about immunization history.

c. Ask the patient about recent outdoor activities. The patient's clinical manifestations suggest possible Lyme disease. A history of recent outdoor activities such as hikes will help confirm the diagnosis. The patient's symptoms do not suggest cardiac or abdominal problems or lack of immunization.

A 22-yr-old patient seen at the health clinic with a severe migraine headache tells the nurse about having similar headaches recently. Which initial action should the nurse take? a. Teach about the use of triptan drugs. b. Refer the patient for stress counseling. c. Ask the patient to keep a headache diary. d. Suggest the use of muscle-relaxation techniques.

c. Ask the patient to keep a headache diary.

A patient being seen in the clinic has rheumatoid nodules on the elbows. Which action will the nurse take? a. Draw blood for rheumatoid factor analysis. b. Teach the patient about injections for the nodules. c. Assess the nodules for skin breakdown or infection. d. Discuss the need for surgical removal of the nodules.

c. Assess the nodules for skin breakdown or infection. Rheumatoid nodules can break down or become infected. They are not associated with changes in rheumatoid factor, and injection is not needed. Rheumatoid nodules are usually not removed surgically because of a high probability of recurrence.

The nurse will anticipate the need to teach a patient who has osteoarthritis (OA) about which medication? a. Prednisone b. Adalimumab (Humira) c. Capsaicin cream (Zostrix) d. Sulfasalazine (Azulfidine)

c. Capsaicin cream (Zostrix) Capsaicin cream blocks the transmission of pain impulses and is helpful for some patients in treating OA. The other medications would be used for patients with rheumatoid arthritis

The nurse is preparing to administer medications to a patient with rheumatoid arthritis (RA). The nurse should explain which goal of treatment to the patient? a. Eradicate the disease b. Enhance immune response c. Control inflammation d. Manage pain

c. Control inflammation

A patient with hypertension is prescribed a low-sodium diet. The patient's teaching plan includes this goal: "The patient will select a 2-gram sodium diet from the hospital menu for the next 3 days." Which intervention would be most effective at increasing the patient's compliance with the diet? a. Check the sodium content of the patient's menu choices over the next 3 days. b. Ask the patient to identify which foods on the hospital menus are high in sodium. c. Have the patient list favorite foods that are high in sodium and foods that could be substituted for these favorites. d. Compare the patient's sodium intake over the next 3 days with the sodium intake before the teaching was implemented.

c. Have the patient list favorite foods that are high in sodium and foods that could be substituted for these favorites.

Which assessment is most important for the nurse to make regarding a patient with myasthenia gravis? a. Pupil size b. Grip strength c. Respiratory effort d. Level of consciousness

c. Respiratory effort

A patient with rheumatoid arthritis (RA) complains to the clinic nurse about having chronically dry eyes. Which action by the nurse is appropriate? a. Ask the HCP about discontinuing methotrexate b. Remind the patient that RA is a chronic health condition. c. Suggest the patient use over-the-counter (OTC) artificial tears. d. Teach the patient about adverse effects of the RA medications.

c. Suggest the patient use over-the-counter (OTC) artificial tears. The patient's dry eyes are consistent with Sjögren's syndrome, a common extraarticular manifestation of RA. Symptomatic therapy such as OTC eye drops is recommended. Dry eyes are not a side effect of methotrexate. A focus on the prognosis for RA is not helpful. The dry eyes are not caused by RA treatment but by the disease itself.

A patient with an acute attack of gout in the right great toe has a new prescription for probenecid. Which information about the patient's home routine indicates a need for teaching regarding gout management? a. The patient sleeps 8-10 hours each night. b. The patient usually eats beef once a week. c. The patient takes one aspirin a day to prevent angina. d. The patient usually drinks about 3 quarts water each day.

c. The patient takes one aspirin a day to prevent angina. Aspirin interferes with the effectiveness of probenecid and should not be taken when the patient is taking probenecid. The patient's sleep pattern will not affect gout management. Drinking 3 quarts of water and eating beef only once or twice a week are appropriate for the patient with gout.

Which laboratory result is important to communicate to the health care provider for a patient who is taking methotrexate to treat rheumatoid arthritis (RA)? a. Rheumatoid factor is positive. b. Fasting blood glucose is 90 mg/dL. c. The white blood cell (WBC) count is 1500/µL. d. The erythrocyte sedimentation rate is elevated.

c. The white blood cell (WBC) count is 1500/µL. Bone marrow suppression is a possible side effect of methotrexate, and the patient's low WBC count places the patient at high risk for infection. The elevated erythrocyte sedimentation rate and positive rheumatoid factor are expected in RA. The blood glucose is normal.

While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take? a. Insert an oral airway during the seizure to maintain a patent airway. b. Restrain the patient's arms and legs to prevent injury during the seizure. c. Time and observe and record the details of the seizure and postictal state. d. Avoid touching the patient to prevent further nervous system stimulation.

c. Time and observe and record the details of the seizure and postictal state.

The nurse is planning care for a patient with hypertension and gout who has a red, painful right great toe. Which nursing action will be included in the plan of care? a. Gently palpate the toe to assess swelling. b. Use pillows to keep the right foot elevated. c. Use a footboard to hold bedding away from the toe. d. Teach the patient to avoid use of acetaminophen (Tylenol).

c. Use a footboard to hold bedding away from the toe. Because any touch on the area of inflammation may increase pain, bedding should be held away from the toe, and touching the toe should be avoided. Elevation of the foot will not reduce the pain, which is caused by urate crystals. Acetaminophen can be used for pain management.

A patient has increased intracranial pressure and a ventriculostomy after a head injury. Which action can the nurse delegate to unlicensed assistive personnel (UAP) who regularly work in the intensive care unit? a. Document intracranial pressure every hour. b. Turn and reposition the patient every 2 hours. c. Check capillary blood glucose level every 6 hours. d. Monitor cerebrospinal fluid color and volume hourly.

c. check capillary blood glucose level every 6 hours

When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, the nurse reports the response as a. flexion withdrawal. b. localization of pain. c. decorticate posturing. d. decerebrate posturing.

c. decorticate posturing

The public health nurse is planning a program to decrease the incidence of meningitis in adolescents and young adults. Which action is most important? a. Encourage adolescents and young adults to avoid crowds in the winter. b. Vaccinate 11- and 12-year-old children against Haemophilus influenzae. c. Immunize adolescents and college freshman against Neisseria meningitides. d. Emphasize the importance of hand washing to prevent the spread of infection.

c. immunize adolescents and college freshmen against Neisseria meningtides

The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication's effectiveness? a. Blood pressure b. Oxygen saturation c. Intracranial pressure d. Hemoglobin and hematocrit

c. intracranial pressure

A patient hospitalized with a fever and red, hot, painful knees is suspected of having septic arthritis. Information obtained during the nursing history that indicates a risk factor for septic arthritis is that the patient a. had several knee injuries as a teenager. b. recently returned from South America. c. is sexually active with multiple partners. d. has a parent who has rheumatoid arthritis.

c. is sexually active with multiple partners. Neisseria gonorrhoeae is the most common cause for septic arthritis in sexually active young adults. The other information does not point to any risk for septic arthritis.

A 41-year-old patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care? a. Encourage coughing and deep breathing. b. Position the patient with knees and hips flexed. c. Keep the head of the bed elevated to 30 degrees. d. Cluster nursing interventions to provide rest periods.

c. keep the head of the bed elevated to 30 degrees

Which information about a 30-year-old patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse? a. Intracranial pressure of 15 mm Hg b. Cerebrospinal fluid (CSF) drainage of 25 mL/hour c. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg d. Cardiac monitor shows sinus tachycardia at 128 beats/minute

c. pressure of oxygen in brain tissue is 14 mm Hg

Anakinra (Kineret) is prescribed for a patient with rheumatoid arthritis (RA). When teaching the patient about this drug, the nurse will include information about a. avoiding concurrent aspirin use. b. symptoms of gastrointestinal (GI) bleeding. c. self-administration of subcutaneous injections. d. taking the medication with at least 8 oz of fluid.

c. self-administration of subcutaneous injections. Anakinra is administered by subcutaneous injection. GI bleeding is not a side effect of this medication. Because the medication is injected, instructions to take it with 8 oz of fluid would not be appropriate. The patient is likely to be concurrently taking aspirin or nonsteroidal antiinflammatory drugs (NSAIDs), and these should not be discontinued.

The nurse is caring for a patient who has a head injury and fractured right arm after being assaulted. Which assessment information requires the most rapid action by the nurse? a. The apical pulse is slightly irregular. b. The patient complains of a headache. c. The patient is more difficult to arouse. d. The blood pressure (BP) increases to 140/62 mm Hg.

c. the patient is more difficult arouse

The charge nurse observes an inexperienced staff nurse caring for a patient who has had a craniotomy for resection of a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene? a. The staff nurse assesses neurologic status every hour. b. The staff nurse elevates the head of the bed to 30 degrees. c. The staff nurse suctions the patient routinely every 2 hours. d. The staff nurse administers an analgesic before turning the patient.

c. the staff nurse suctions the patient routinely every 2 hours

The nurse is caring for a patient who was started on intravenous antibiotic therapy earlier in the shift. As the second dose is being infused, the patient reports feeling dizzy and having difficulty breathing and talking. The nurse notes that the patient's respirations are 26 breaths/min with a weak pulse of 112 beats/min. The nurse suspects that the patient is experiencing which condition? a. Suppressed immune response b. Hyperimmune response c. Allergic reaction d. Anaphylactic reaction

d. Anaphylactic reaction

The nurse is assessing a newly diagnosed diabetic, and the patient's readiness to learn about glucose monitoring. Before planning teaching activities, which approach would be most effective? a. Assist the patient with long-term goals and plan teaching according to these goals. b. Provide the patient with all the latest research from the Internet on glucose monitoring. c. Refer the patient to the diabetic specialist who can assist the patient with the glucometer. d. Assist the patient in developing realistic short-term goals.

d. Assist the patient in developing realistic short-term goals.

Which is the correct point on the accompanying figure where the nurse will assess for ecchymosis when admitting a patient with a basilar skull fracture? a. A b. B c. C d. D

d. D

hen reviewing the health record for a new patient with rheumatoid arthritis, the nurse reads that the patient has swan neck deformities. Which deformity will the nurse expect to observe when assessing the patient? a. A b. B c. C d. D

d. D Swan neck deformity involves distal interphalangeal joint hyperflexion and proximal interphalangeal joint hyperextension of the hands. The other deformities are also associated with rheumatoid arthritis: ulnar drift, boutonniere deformity, and hallux vagus.

The nurse assesses a 78-yr-old who uses naproxen (Aleve) daily for hand and knee osteoarthritis management. Which information requires a discussion with the health care provider about an urgent change in the treatment plan? a. Knee crepitation is noted with normal knee range of motion. b. Patient reports embarrassment about having Heberden's nodes. c. Patient's knee pain while golfing has increased over the last year. d. Laboratory results indicate blood urea nitrogen (BUN) is elevated.

d. Laboratory results indicate blood urea nitrogen (BUN) is elevated. Older patients are at increased risk for renal toxicity caused by nonsteroidal antiinflammatory drugs (NSAIDs) such as naproxen. The other information will also be reported to the health care provider but is consistent with the patient's diagnosis of osteoarthritis and will not require an immediate change in the patient's treatment plan.

Which information about a patient who has a new prescription for phenytoin (Dilantin) indicates that the nurse should consult with the health care provider before administration of the medication? a. Patient has tonic-clonic seizures. b. Patient experiences an aura before seizures. c. Patient's most recent blood pressure is 156/92 mm Hg. d. Patient has slight elevations in liver function test results

d. Patient has slight elevations in liver function test results

The home health nurse is making a follow-up visit to a patient with recently diagnosed rheumatoid arthritis (RA). Which assessment made by the nurse indicates more patient teaching is needed? a. The patient takes a 2-hour nap each day. b. The patient has been taking 16 aspirins each day. c. The patient sits on a stool while preparing meals. d. The patient sleeps with two pillows under the head.

d. The patient sleeps with two pillows under the head. The joints should be maintained in an extended position to avoid contractures, so patients should use a small, flat pillow for sleeping. Rest, aspirin, and energy management are appropriate for a patient with RA and indicate teaching has been effective.

The nurse is preparing a discharge teaching plan for a patient who has peripheral vascular disease and has poor circulation to the feet. Which learning goal should the nurse include in the teaching plan? a. The nurse will demonstrate the proper technique for trimming toenails. b. The patient will understand the rationale for proper foot care after instruction. c. The nurse will instruct the patient on appropriate foot care before discharge. d. The patient will post reminder stickers on the calendar to check feet every day and record scheduled appointments with podiatrist.

d. The patient will post reminder stickers on the calendar to check feet every day and record scheduled appointments with podiatrist.

A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action? a. The bedrails at the head and foot of the bed are both elevated. b. The patient receives a regular diet from the dietary department. c. The lights in the patient's room are turned off and the blinds are shut. d. Unlicensed assistive personnel enter the patient's room without a mask.

d. UAP assistive personnel enter the patient's room without a mask

Components of the Glasgow Coma Scale (GCS) the nurse would use to assess a patient after a head injury include which assessment? a. Blood pressure b. Cranial nerve function c. Head circumference d. Verbal responsiveness

d. Verbal responsiveness

The nurse should teach a patient that which is a primary prevention strategy to reduce the occurrence of head injuries? a. Blood pressure control b. Smoking cessation c. Maintaining a healthy weight d. Violence prevention

d. Violence prevention

After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first? a. A 20-year-old patient whose cranial x-ray shows a linear skull fracture b. A 30-year-old patient who has an initial Glasgow Coma Scale score of 13 c. A 40-year-old patient who lost consciousness for a few seconds after a fall d. A 50-year-old patient whose right pupil is 10 mm and unresponsive to light

d. a 50 y.o. patient whose right pupil is 10 mm and unresponsive to light

A patient reporting painful urination and knee pain is diagnosed with reactive arthritis. The nurse will plan to teach the patient about the need for several months of therapy with a. methotrexate b. anakinra (Kineret). c. etanercept (Enbrel). d. doxycycline (Vibramycin).

d. doxycycline (Vibramycin). Reactive arthritis associated with urethritis is usually caused by infection with Chlamydia trachomatis and requires 3 months of treatment with doxycycline. The other medications are used for chronic inflammatory problems such as rheumatoid arthritis.

After having a craniectomy and left anterior fossae incision, a 64-year-old patient has a nursing diagnosis of impaired physical mobility related to decreased level of consciousness and weakness. An appropriate nursing intervention is to a. cluster nursing activities to allow longer rest periods. b. turn and reposition the patient side to side every 2 hours. c. position the bed flat and log roll to reposition the patient. d. perform range-of-motion (ROM) exercises every 4 hours.

d. perform ROM exercises every 4 hours

A patient being admitted with bacterial meningitis has a temperature of 102.5° F (39.2° C) and a severe headache. Which order for collaborative intervention should the nurse implement first? a. Administer ceftizoxime (Cefizox) 1 g IV. b. Give acetaminophen (Tylenol) 650 mg PO. c. Use a cooling blanket to lower temperature. d. Swab the nasopharyngeal mucosa for cultures.

d. swab the nasopharyngeal mucosa for cultures

The nurse is caring for a patient who was admitted the previous day with a basilar skull fracture after a motor vehicle crash. Which assessment finding is most important to report to the health care provider? a. Complaint of severe headache b. Large contusion behind left ear c. Bilateral periorbital ecchymosis d. Temperature of 101.4° F (38.6° C)

d. temperature of 101.4

When assessing a 53-year-old patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider? a. The patient exhibits nuchal rigidity. b. The patient has a positive Kernig's sign. c. The patient's temperature is 101° F (38.3° C). d. The patient's blood pressure is 88/42 mm Hg.

d. the patient's blood pressure is 88/42 mm Hg