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Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e

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1. A nursing student working in an Adult Care for Elders unit learns that frailty in the older population includes which components? (Select all that apply.) a. Dementia b. Exhaustion c. Slowed physical activity d. Weakness e. Weight gain ANS: B, C, D Frailty is a syndrome consisting of unintentional weight loss, slowed physical activity and exhaustion, and weakness. Weight gain and dementia are not part of this cluster of manifestations. DIF: Remembering/Knowledge REF: 29 KEY: Frailty| frail elderly| older adult MSC: Integrated Process: Nursing Process: Assessment Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 17 Downloaded by No One () lOMoARcPSD| NOT: Client Needs Category: Health Promotion and Maintenance 2. A home health care nurse assesses an older client for the intake of nutrients needed in larger amounts than in younger adults. Which foods found in an older adults kitchen might indicate an adequate intake of these nutrients? (Select all that apply.) a. 1% milk b. Carrots c. Lean ground beef d. Oranges e. Vitamin D supplements ANS: A, B, D, E Older adults need increased amounts of calcium; vitamins A, C, and D; and fiber. Milk has calcium; carrots have vitamin A; the vitamin D supplement has vitamin D; and oranges have vitamin C. Lean ground beef is healthier than more fatty cuts, but does not contain these needed nutrients. DIF: Applying/Application REF: 30 KEY: Nutrition| nutritional requirements| older adults MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort 3. A nurse working with older adults assesses them for common potential adverse medication effects. For what does the nurse assess? (Select all that apply.) a. Constipation b. Dehydration c. Mania d. Urinary incontinence e. Weakness ANS: A, B, E Common adverse medication effects include constipation/impaction, dehydration, and weakness. Mania and incontinence are not among the common adverse effects, although urinary retention is. DIF: Remembering/Knowledge REF: 34 KEY: Medications| adverse effects MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. A nurse manager institutes the Fulmer Spices Framework as part of the routine assessment of older adults in the hospital. The nursing staff assesses for which factors? (Select all that apply.) a. Confusion b. Evidence of abuse c. Incontinence d. Problems with behavior e. Sleep disorders ANS: A, C, E SPICES stands for sleep disorders, problems with eating or feeding, incontinence, confusion, and evidence of falls. DIF: Remembering/Knowledge REF: 40 KEY: SPICES| older adult MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 5. A visiting nurse is in the home of an older adult and notes a 7-pound weight loss since last months visit. What actions should the nurse perform first? (Select all that apply.) a. Assess the clients ability to drive or transportation alternatives. b. Determine if the client has dentures that fit appropriately. Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 18 Downloaded by No One () lOMoARcPSD| c. Encourage the client to continue the current exercise plan. d. Have the client complete a 3-day diet recall diary. e. Teach the client about proper nutrition in the older population. ANS: A, B, D Assessment is the first step of the nursing process and should be completed prior to intervening. Asking about transportation, dentures, and normal food patterns would be part of an appropriate assessment for the client. There is no information in the question about the older adult needing to lose weight, so encouraging him or her to continue the current exercise regimen is premature and may not be appropriate. Teaching about proper nutrition is a good idea, but teaching needs to be tailored to the clients needs, which the nurse does not yet know. DIF: Applying/Application REF: 30 KEY: Nutrition| older adult MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. A hospitalized older adult has been assessed at high risk for skin breakdown. Which actions does the registered nurse (RN) delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assess skin redness when turning. b. Document Braden Scale results. c. Keep the clients skin dry. d. Obtain a pressure-relieving mattress. e. Turn the client every 2 hours. ANS: C, D, E The nurses aide or UAP can assist in keeping the clients skin dry, order a special mattress on direction of the RN, and turn the client on a schedule. Assessing the skin is a nursing responsibility, although the aide should be directed to report any redness noticed. Documenting the Braden Scale results is the RNs responsibility as the RN is the one who performs that assessment. DIF: Applying/Application REF: 42 KEY: Skin breakdown| older adult| delegation| unlicensed assistive personnel MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 7. A nurse admits an older client to the hospital who lives at home with family. The nurse assesses that the client is malnourished. What actions by the nurse are best? (Select all that apply.) a. Contact Adult Protective Services or hospital social work. b. Notify the provider that the client needs a tube feeding. c. Perform and document results of a Braden Scale assessment. d. Request a dietary consultation from the health care provider. e. Suggest a high-protein oral supplement between meals. ANS: C, D, E Malnutrition in the older population is multifactorial and has several potential adverse outcomes. Appropriate actions by the nurse include assessing the clients risk for skin breakdown with the Braden Scale, requesting a consultation with a dietitian, and suggesting a high-protein meal supplement. There is no evidence that the client is being abused or needs a feeding tube at this time. DIF: Applying/Application REF: 40 KEY: Nutrition| malnutrition| older adult| Braden Scale MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 19 Downloaded by No One () lOMoARcPSD| Chapter 04: Assessment and Care of Patients with Pain MULTIPLE CHOICE 1. A student asks the nurse what is the best way to assess a clients pain. Which response by the nurse is best? a. Numeric pain scale b. Behavioral assessment c. Objective observation d. Clients self-report ANS: D Many ways to measure pain are in use, including numeric pain scales, behavioral assessments, and other objective observations. However, the most accurate way to assess pain is to get a self-report from the client. DIF: Remembering/Knowledge REF: 46 KEY: Pain| pain assessment MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Health Promotion and Maintenance

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lOMoARcPSD|4653974




9th EDITION




Test Bank Ignatavicius Medical Surgical 9th 2017


Medical-Surgical Nursing (Miami Dade College)




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Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 1



Table of Contents
Table of Contents 1
Chapter 01: Overview of Professional Nursing Concepts for Medical-Surgical Nursing 3
Chapter 02: Overview of Health Concepts for Medical-Surgical Nursing 8
Chapter 03: Common Health Problems of Older Adults 13
Chapter 04: Assessment and Care of Patients with Pain 20
Chapter 05: Genetic Concepts for Medical-Surgical Nursing 32
Chapter 06: Rehabilitation Concepts for Chronic and Disabling Health Problems 38
Chapter 07: End-of-Life Care 44
Chapter 08: Concepts of Emergency and Trauma Nursing 50
Chapter 09: Care of Patients with Common Environmental Emergencies 56
Chapter 10: Concepts of Emergency and Disaster Preparedness 62
Chapter 11: Assessment and Care of Patients with Fluid and Electrolyte Imbalances 68
Chapter 12: Assessment and Care of Patients with Acid-Base Imbalances 76
Chapter 13: Infusion Therapy 83
Chapter 14: Care of Preoperative Patients 94
Chapter 15: Care of Intraoperative Patients 103
Chapter 16: Care of Postoperative Patients 109
Chapter 17: Inflammation and Immunity 116
Chapter 18: Care of Patients with Arthritis and Other Connective Tissue Diseases 122
Chapter 19: Care of Patients with HIV Disease 138
Chapter 20: Care of Patients with Hypersensitivity (Allergy) and Autoimmunity 147
Chapter 21: Cancer Development 152
Chapter 22: Care of Patients with Cancer 157
Chapter 23: Care of Patients with Infection 167
Chapter 24: Assessment of the Skin, Hair, and Nails 174
Chapter 25: Care of Patients with Skin Problems 179
Chapter 26: Care of Patients with Burns 196
Chapter 27: Assessment of the Respiratory System 213
Chapter 28: Care of Patients Requiring Oxygen Therapy or Tracheostomy 220
Chapter 29: Care of Patients with Noninfectious Upper Respiratory Problems 226
Chapter 30: Care of Patients with Noninfectious Lower Respiratory Problems 233
Chapter 31: Care of Patients with Infectious Respiratory Problems 245
Chapter 32: Care of Critically Ill Patients with Respiratory Problems 256
Chapter 33: Assessment of the Cardiovascular System 269
Chapter 34: Care of Patients with Dysrhythmias 278
Chapter 35: Care of Patients with Cardiac Problems 287
Chapter 36: Care of Patients with Vascular Problems 298
Chapter 37: Care of Patients with Shock 310
Chapter 38: Care of Patients with Acute Coronary Syndromes 317
Chapter 39: Assessment of the Hematologic System 327
Chapter 40: Care of Patients with Hematologic Problems 331
Chapter 41: Assessment of the Nervous System 343
Chapter 42: Care of Patients with Problems of the CNS: The Brain 353
Chapter 43: Care of Patients with Problems of the CNS: The Spinal Cord 364
Chapter 44: Care of Patients with Problems of the Peripheral Nervous System 374
Chapter 45: Care of Critically Ill Patients with Neurologic Problems 380
Chapter 46: Assessment of the Eye and Vision 394
Chapter 47: Care of Patients with Eye and Vision Problems 397
Chapter 48: Assessment and Care of Patients with Ear and Hearing Problems 403
Chapter 49: Assessment of the Musculoskeletal System 410
Chapter 50: Care of Patients with Musculoskeletal Problems 415



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Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 2



Chapter 51: Care of Patients with Musculoskeletal Trauma 424
Chapter 52: Assessment of the Gastrointestinal System 435
Chapter 53: Care of Patients with Oral Cavity Problems 441
Chapter 54: Care of Patients with Esophageal Problems 445
Chapter 55: Care of Patients with Stomach Disorders 454
Chapter 56: Care of Patients with Noninflammatory Intestinal Disorders 461
Chapter 57: Care of Patients with Inflammatory Intestinal Disorders 471
Chapter 58: Care of Patients with Liver Problems 481
Chapter 59: Care of Patients with Problems of the Biliary System and Pancreas 489
Chapter 60: Care of Patients with Malnutrition: Undernutrition and Obesity 497
Chapter 61: Assessment of the Endocrine System 506
Chapter 62: Care of Patients with Pituitary and Adrenal Gland Problems 512
Chapter 63: Care of Patients with Problems of the Thyroid and Parathyroid Glands 520
Chapter 64: Care of Patients with Diabetes Mellitus 527
Chapter 65: Assessment of the Renal/Urinary System 549
Chapter 66: Care of Patients with Urinary Problems 557
Chapter 67: Care of Patients with Kidney Disorders 568
Chapter 68: Care of Patients with Acute Kidney Injury and Chronic Kidney Disease 575
Chapter 69: Assessment of the Reproductive System 587
Chapter 70: Care of Patients with Breast Disorders 591
Chapter 71: Care of Patients with Gynecologic Problems 598
Chapter 72: Care of Patients with Male Reproductive Problems 605
Chapter 73: Care of Transgender Patients 614
Chapter 74: Care of Patients with Sexually Transmitted Diseases 618




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Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 3



Chapter 01: Overview of Professional Nursing Concepts for Medical-
Surgical Nursing
MULTIPLE CHOICE

1. A nurse wishes to provide client-centered care in all interactions. Which action by the nurse best
demonstrates this concept?
a. Assesses for cultural influences affecting health care
b. Ensures that all the clients basic needs are met
c. Tells the client and family about all upcoming tests
d. Thoroughly orients the client and family to the room

ANS: A
Competency in client-focused care is demonstrated when the nurse focuses on communication, culture, respect,
compassion, client education, and empowerment. By assessing the effect of the clients culture on health care,
this nurse is practicing client-focused care. Providing for basic needs does not demonstrate this competence.
Simply telling the client about all upcoming tests is not providing empowering education. Orienting the client
and family to the room is an important safety measure, but not directly related to demonstrating client-centered
care.

DIF: Understanding/Comprehension REF: 3
KEY: Patient-centered care| culture MSC: Integrated Process: Caring
NOT: Client Needs Category: Psychosocial Integrity

2. A nurse is caring for a postoperative client on the surgical unit. The clients blood pressure was 142/76 mm
Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse is best?
a. Call the Rapid Response Team.
b. Document and continue to monitor.
c. Notify the primary care provider.
d. Repeat blood pressure measurement in 15 minutes.

ANS: A
The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating before they
suffer either respiratory or cardiac arrest. Since the client has manifested a significant change, the nurse should
call the RRT. Changes in blood pressure, mental status, heart rate, and pain are particularly significant.
Documentation is vital, but the nurse must do more than document. The primary care provider should be
notified, but this is not the priority over calling the RRT. The clients blood pressure should be reassessed
frequently, but the priority is getting the rapid care to the client.

DIF: Applying/Application REF: 3
KEY: Rapid Response Team (RRT)| medical emergencies
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

3. A nurse is orienting a new client and family to the inpatient unit. What information does the nurse provide to
help the client promote his or her own safety?
a. Encourage the client and family to be active partners.
b. Have the client monitor hand hygiene in caregivers.
c. Offer the family the opportunity to stay with the client.
d. Tell the client to always wear his or her armband.

ANS: A
Each action could be important for the client or family to perform. However, encouraging the client to be
active in his or her health care as a partner is the most critical. The other actions are very limited in scope and
do not provide the broad protection that being active and involved does.

DIF: Understanding/Comprehension REF: 3
KEY: Patient safety




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