TEST BANK FOR BRUNNER & SUDDARTH'S TEXTBOOK OF
MEDICAL-SURGICAL NURSING 16TH EDITION HINKLE
In an acute asthma attack, air flow may be so significantly restricted that wheezing is diminished.
If the client is successfully responding to bronchodilators and respiratory treatments, wheezing
becomes louder as air flow increases in the airways. As the airways open and mucous is
mobilized in response to treatment, the cough becomes more productive. vesicular sounds are
soft, low-pitched, gentle, rustling sounds heard over lung fields.
A client with sickle cell anemia is admitted with severe abdominal pain and the diagnosis is
sickle cell crisis. What is the most important nursing action to implement?
A. limit the client's intake of oral fluids
B. teach the client about prevention of crises
C. evaluate the effectiveness of narcotic analgesics
D. encourage the client to ambulate as tolerated C. evaluate the effectiveness of narcotic
analgesics
Pain management is the priority for a client during sickle cell crisis. Continuous narcotic
analgesics are the mainstay of pain control, which should be evaluated frequently to determine if
the client's pain is adequately controlled.
The nurse is caring for a client with non-Hodgkin's lymphoma who is receiving chemotherapy.
Laboratory results reveal a platelet count of 10,000/mL. What action should the nurse
implement?
A. provide oral hygiene every 2 hours
B. check for fever every 4 hours
C. encourage fluids to 3000 mL/day
D. check stools for occult blood D. check stools for occult blod
,Platelet counts less than 100,000/mm3 are indicative of thrombocytopenia, a common side effect
of chemotherapy. A client with thrombocytopenia should be assessed frequently for occult
bleeding in the emesis, sputum, feces, urine, nasogastric secretions, or wounds.
A client is admitted for complaints of chest pain and aching for the past 4 days. the results for
serum creatine kinase-MB (CK-MB) and troponin are obtained. What rationale should the nurse
use to evaluate the laboratory findings?
A. serum myoglobin levels are needed to confirm myocardial damage
B. myocardial damage that occurred several days earlier is best validated by serum troponin
levels
C. the most reliable indicator of myocardial necrosis is serum CK-MB
D. serum cardiac markers are inconclusive in determining myocardial injury after waiting several
days B. myocardial damage that occurred several days earlier is best validated by serum
troponin levels
Serum CK-MB and troponin are the two most important serum cardiac markers for confirming
myocardial infarction. CK-MB begins to rise in the first 3 to 12 hours after the myocardial
infarction, peaks in 24 hours, and returns to normal in 2 to 3 days. the troponin level rises as
quickly but remains elevated for 2 weeks.
Three weeks after discharge fro an acute myocardial infarction (MI), a client returns to the
cardiac center for follow-up. When the nurse asks about sleep patterns, the client tells the nurse
that he sleeps fine but that his wife moved into the spare bedroom to sleep when he returned
home. He states "I guess we will never have sex again after this." Which response is best for the
nurse to provide?
A. sexual activity can be resumed whenever you and you wife feel like it because the sexual
response is more emotional rather than physical
B. you should discuss your questions about your sexual activity with your healthcare provider
because sexual activity may be limited by your heart damage
C. sexual activity is similar in cardiac workload and energy expenditure as climbing two flights
of stairs and may be resumed like other activities
D. sexual intercourse can be strenuous on your heart, but closeness and intimacy, such C.
sexual activity is similar in cardiac workload and energy expenditure as climbing two flights of
stairs and may be resumed like other activities
The nurse is providing post-operative instructions for a female client after a mastectomy. Which
information should the nurse include in the teaching plan?
A. avoid lifting more than 4.5 kg (10 lb) or reaching above her head
B. empty surgical drains once a week using procedural gloves
C. report inflammation of the incision site or the affected arm
D. wearing clothing with snug sleeves over the arm on the operative side A and D
Part of the client's teaching plan should include reporting evidence of inflammation at the
incision or of the affected arm and to avoid lifting or reaching, which places the client at risk for
injury to the extremity that may have compromised lymphatic drainage. the client should be
instructed to empty surgical drains daily, no weekly. Activity that decreases circulation in the
, affected arm, such as carrying a handbag over the shoulder, wearing tight clothing, or tight
jewelry, should be avoided.
the nurse directs an unlicensed assisstive personnel (UAP) to obtain vital signs for a client who
returns to the unit after having a mastectomy for cancer. What information should the nurse
provide the UAP?
A. elevate the arm with an IV infusing on the operative side with a pillow
B. apply the blood pressure cuff to the arm on the non-operative side
C. position the arm on the operative side close to the body
D. collect a fingerstick blood specimen from the arm on the operative side B.
Blood pressure reading should be obtained from the arm on the unoperative side to reduce the
risk of injury of the extremity that may have compromised lymphatic drainage postoperatively.
The arm on the operative side of the mastectomy should be elevated on a pillow above the level
of the right atrium to facilitate lymphatic drainage, not close to the body. An IV infusion or
blood specimen collection should not involve the use of the arm on the operative side.
Which client is at the highest risk for compromised psychological adjustment after a
hysterectomy?
A. a 62-year-old widow who has three friends who had uncomplicated hysterectomies
B. A 29-year-old woman whose uterus ruptured after giving birth to her first child
C. A 46-year-old woman with three children and a recent promotion at work
D. A 55-year-old woman with abnormal bleeding and pain for 3 years B
The client who is a primipara and is still in her childbearing years is at highest risk for
unresolved conflicts about the end of her childbearing opportunities. The client with a family and
positive life events, the menopausal client with physical distress, the post-menopausal client with
support of peers with similar positive outcomes are less likely to be psychologically distressed.
A 48-year-old client with endometrial cancer is being discharged after a total hysterectomy and
bilateral salpingo-oophorectomy. Which client statement indicates that further teaching is
needed?
A. "I have asked my daughter to stay with me next week after I am discharged"
B. "Well, I don't have to worry about getting pregnant anymore"
C. "I know I will miss having sexual intercourse with my husband"
D. "I can't wait to go on the cruise that I have planned for this summer" C
further teaching is needed in response to the client's misunderstanding of sexuality after a
hysterectomy that is reflected in the statement. the client's knowledge about reproduction, a
positive outlook with plans for the future, and her anticipated need for assistance and support
during recovery indicate she understands the present status of her recovery.
A client in the pre-operative holding area receives a prescription for midazolam (Versed) IV. The
nurse determines that the surgical consent form needs to be signed by the client. Which action
should the nurse implement?
A. give the drug and allow the client to read and sign the consent form
MEDICAL-SURGICAL NURSING 16TH EDITION HINKLE
In an acute asthma attack, air flow may be so significantly restricted that wheezing is diminished.
If the client is successfully responding to bronchodilators and respiratory treatments, wheezing
becomes louder as air flow increases in the airways. As the airways open and mucous is
mobilized in response to treatment, the cough becomes more productive. vesicular sounds are
soft, low-pitched, gentle, rustling sounds heard over lung fields.
A client with sickle cell anemia is admitted with severe abdominal pain and the diagnosis is
sickle cell crisis. What is the most important nursing action to implement?
A. limit the client's intake of oral fluids
B. teach the client about prevention of crises
C. evaluate the effectiveness of narcotic analgesics
D. encourage the client to ambulate as tolerated C. evaluate the effectiveness of narcotic
analgesics
Pain management is the priority for a client during sickle cell crisis. Continuous narcotic
analgesics are the mainstay of pain control, which should be evaluated frequently to determine if
the client's pain is adequately controlled.
The nurse is caring for a client with non-Hodgkin's lymphoma who is receiving chemotherapy.
Laboratory results reveal a platelet count of 10,000/mL. What action should the nurse
implement?
A. provide oral hygiene every 2 hours
B. check for fever every 4 hours
C. encourage fluids to 3000 mL/day
D. check stools for occult blood D. check stools for occult blod
,Platelet counts less than 100,000/mm3 are indicative of thrombocytopenia, a common side effect
of chemotherapy. A client with thrombocytopenia should be assessed frequently for occult
bleeding in the emesis, sputum, feces, urine, nasogastric secretions, or wounds.
A client is admitted for complaints of chest pain and aching for the past 4 days. the results for
serum creatine kinase-MB (CK-MB) and troponin are obtained. What rationale should the nurse
use to evaluate the laboratory findings?
A. serum myoglobin levels are needed to confirm myocardial damage
B. myocardial damage that occurred several days earlier is best validated by serum troponin
levels
C. the most reliable indicator of myocardial necrosis is serum CK-MB
D. serum cardiac markers are inconclusive in determining myocardial injury after waiting several
days B. myocardial damage that occurred several days earlier is best validated by serum
troponin levels
Serum CK-MB and troponin are the two most important serum cardiac markers for confirming
myocardial infarction. CK-MB begins to rise in the first 3 to 12 hours after the myocardial
infarction, peaks in 24 hours, and returns to normal in 2 to 3 days. the troponin level rises as
quickly but remains elevated for 2 weeks.
Three weeks after discharge fro an acute myocardial infarction (MI), a client returns to the
cardiac center for follow-up. When the nurse asks about sleep patterns, the client tells the nurse
that he sleeps fine but that his wife moved into the spare bedroom to sleep when he returned
home. He states "I guess we will never have sex again after this." Which response is best for the
nurse to provide?
A. sexual activity can be resumed whenever you and you wife feel like it because the sexual
response is more emotional rather than physical
B. you should discuss your questions about your sexual activity with your healthcare provider
because sexual activity may be limited by your heart damage
C. sexual activity is similar in cardiac workload and energy expenditure as climbing two flights
of stairs and may be resumed like other activities
D. sexual intercourse can be strenuous on your heart, but closeness and intimacy, such C.
sexual activity is similar in cardiac workload and energy expenditure as climbing two flights of
stairs and may be resumed like other activities
The nurse is providing post-operative instructions for a female client after a mastectomy. Which
information should the nurse include in the teaching plan?
A. avoid lifting more than 4.5 kg (10 lb) or reaching above her head
B. empty surgical drains once a week using procedural gloves
C. report inflammation of the incision site or the affected arm
D. wearing clothing with snug sleeves over the arm on the operative side A and D
Part of the client's teaching plan should include reporting evidence of inflammation at the
incision or of the affected arm and to avoid lifting or reaching, which places the client at risk for
injury to the extremity that may have compromised lymphatic drainage. the client should be
instructed to empty surgical drains daily, no weekly. Activity that decreases circulation in the
, affected arm, such as carrying a handbag over the shoulder, wearing tight clothing, or tight
jewelry, should be avoided.
the nurse directs an unlicensed assisstive personnel (UAP) to obtain vital signs for a client who
returns to the unit after having a mastectomy for cancer. What information should the nurse
provide the UAP?
A. elevate the arm with an IV infusing on the operative side with a pillow
B. apply the blood pressure cuff to the arm on the non-operative side
C. position the arm on the operative side close to the body
D. collect a fingerstick blood specimen from the arm on the operative side B.
Blood pressure reading should be obtained from the arm on the unoperative side to reduce the
risk of injury of the extremity that may have compromised lymphatic drainage postoperatively.
The arm on the operative side of the mastectomy should be elevated on a pillow above the level
of the right atrium to facilitate lymphatic drainage, not close to the body. An IV infusion or
blood specimen collection should not involve the use of the arm on the operative side.
Which client is at the highest risk for compromised psychological adjustment after a
hysterectomy?
A. a 62-year-old widow who has three friends who had uncomplicated hysterectomies
B. A 29-year-old woman whose uterus ruptured after giving birth to her first child
C. A 46-year-old woman with three children and a recent promotion at work
D. A 55-year-old woman with abnormal bleeding and pain for 3 years B
The client who is a primipara and is still in her childbearing years is at highest risk for
unresolved conflicts about the end of her childbearing opportunities. The client with a family and
positive life events, the menopausal client with physical distress, the post-menopausal client with
support of peers with similar positive outcomes are less likely to be psychologically distressed.
A 48-year-old client with endometrial cancer is being discharged after a total hysterectomy and
bilateral salpingo-oophorectomy. Which client statement indicates that further teaching is
needed?
A. "I have asked my daughter to stay with me next week after I am discharged"
B. "Well, I don't have to worry about getting pregnant anymore"
C. "I know I will miss having sexual intercourse with my husband"
D. "I can't wait to go on the cruise that I have planned for this summer" C
further teaching is needed in response to the client's misunderstanding of sexuality after a
hysterectomy that is reflected in the statement. the client's knowledge about reproduction, a
positive outlook with plans for the future, and her anticipated need for assistance and support
during recovery indicate she understands the present status of her recovery.
A client in the pre-operative holding area receives a prescription for midazolam (Versed) IV. The
nurse determines that the surgical consent form needs to be signed by the client. Which action
should the nurse implement?
A. give the drug and allow the client to read and sign the consent form
