Dewitt’s Medical Surgical Nursing Concepts and Practice 4th Edition Stromberg Test Bank
Which method elicits the most accurate information during a physical assessment of an older adult?
A. use reliable assessment tools for older adults
B. Review the past medical record for medications
C. Ask the client to recount one's health history
D. Obtain the client's information from a caregiver - (Answer)A. use reliable assessment tools for older
adults
Specific assessment tools (D) for an older adult, such as Older Adult Resource Services Center
Instrument, mini-mental assessment, fall risk, depression, or skin breakdown risk, consider age-
related physiologic and psychosocial changes related to aging and provide the most accurate and
complete information. A and B are subjective and may vary in reliability based on the client's memory
and caregiver's current involvement. Although C is a good resource to identify polypharmacy, a
written record may not be available or currently accurate.
A client who has just tested positive for HIV does not appear to hear what the nurse is saying during
post-test counseling. Which information should the nurse offer to facilitate the client's adjustment to
HIV infection?
A. teach the client about the medications that are available for treatment
B. discuss retesting to verify the results, which will ensure continuing contact
C. identify the need to test others who have had risky contact with the client
D. inform the client how to protect sexual and needle-sharing partners - (Answer)B. discuss retesting
to verify results, which will ensure continuing contact
encouraging retesting supports hope and gives the client time to cope with the diagnosis. Although
post-test counseling should include education about A, B, and C, retesting encourages the client to
maintain medical follow-up and management.
The nurse is caring for a client with HIV infection who develops Mycobacterium avium complex (MAC).
what is the most significant desired outcome for this client?
A. free from injury of drug side effects
,Dewitt’s Medical Surgical Nursing Concepts and Practice 4th Edition Stromberg Test Bank
B. maintenance of intact perineal skin
c. adequate oxygenation
D. return to pre-illness weight - (Answer)D. return to pre-illness weight
MAC is an opportunistic infection that presents as a TB like pulmonary process. MAC is a major
contributing factor to the development of wasting syndrome, so the most significant desired outcome
is the client's return to a pre-illness weight. drug schedules and side effects remain a life-long
management problem. Client outcomes for adequate oxygenation are often dependent on
management of anemia, maintenance of activities without fatigue, and supplemental oxygen to
prevent hypoxia. Skin integrity is dependent upon resolution of diarrhea, which is not as significant as
optimal nutrition.
A client who had abdominal surgery two days ago has prescriptions for intravenous morphine sulfate
4 mg every 2 hours and a clear liquid diet. the client complains of feeling distended and has sharp,
cramping gas pains. What nursing intervention should be implemented?
A. assist the client to ambulate in the hall
B. obtain a prescription for a laxative
C. administer the prescribed morphine sulfate
D. withhold all oral fluid and food - (Answer)a. assist the client to ambulate in the hall
Post-operative abdominal distention is caused by decreased peristalsis as a result of handling the
intestine during surgery, limited dietary intake before and after surgery, and anesthetic and analgesic
agents. Peristalsis is stimulated and distention minimized by implementing early and frequent
ambulation. Based on the client's status, laxatives or withholding dietary progression are not
indicated at this time. although pain management should be implemented, another analgesic
prescription may be needed because morphine reduces intestinal motility and contributes to the
client's gas pains.
A client with Meniere's disease is incapacitated by vertigo and is lying in bed grasping the side rails
and staring at the television. Which nursing intervention should the nurse implement?
A. keep the head of the bed elevated 30 degrees
, Dewitt’s Medical Surgical Nursing Concepts and Practice 4th Edition Stromberg Test Bank
B. turn off the television and darken the room
c. encourage fluids to 3000 mL per day
D. change the client's position every two hours - (Answer)B. turn off the television and darken the
room
to decrease the client's vertigo during an acute attack of Meniere's disease, any visual stimuli or
rotational movement, such as sudden head movements or position changes, should be minimized.
Turning off the television and darkening the room minimize fluorescent lights, flickering television
lights, and distracting sound. The other are ineffective in managing the client's symptoms.
a client who has a chronic cough with blood-tinged sputum returns to the unit after a bronchoscopy.
What nursing interventions should be implemented in the immediate post-procedural period?
A. check vital signs every 15 minutes for 2 hours
B. allow the client nothing by mouth until the gag reflex returns
C. encourage fluid intake to promote elimination of the contrast media
D. keep the client on bed rest for 8 hours - (Answer)B. allow the client nothing by mouth until the gag
reflex returns
the nasal pharynx and oral pharynx are anesthetized with local anesthetic spray prior to
bronchoscopy, and the bronchoscope is coated with lidocaine gel to inhibit the gag reflex and prevent
laryngeal spasm during insertion. The client should be NPO until the client's gag reflex returns to
prevent aspiration from any oral intake or secretions. The others are not indicated after bronchoscopy
The nurse is assessing a client with a cuffed tracheostomy tube in place who is breathing
spontaneously. to evaluate if the client can tolerate cuff deflation to promote speaking and
swallowing, what action should the nurse implement?
A. observe the client for coughing colored sputum after drinking a small amount of colored water
B. ask the client to try to speak
C. auscultate for pulmonary crackles after the client drinks a small amount of clear water
Which method elicits the most accurate information during a physical assessment of an older adult?
A. use reliable assessment tools for older adults
B. Review the past medical record for medications
C. Ask the client to recount one's health history
D. Obtain the client's information from a caregiver - (Answer)A. use reliable assessment tools for older
adults
Specific assessment tools (D) for an older adult, such as Older Adult Resource Services Center
Instrument, mini-mental assessment, fall risk, depression, or skin breakdown risk, consider age-
related physiologic and psychosocial changes related to aging and provide the most accurate and
complete information. A and B are subjective and may vary in reliability based on the client's memory
and caregiver's current involvement. Although C is a good resource to identify polypharmacy, a
written record may not be available or currently accurate.
A client who has just tested positive for HIV does not appear to hear what the nurse is saying during
post-test counseling. Which information should the nurse offer to facilitate the client's adjustment to
HIV infection?
A. teach the client about the medications that are available for treatment
B. discuss retesting to verify the results, which will ensure continuing contact
C. identify the need to test others who have had risky contact with the client
D. inform the client how to protect sexual and needle-sharing partners - (Answer)B. discuss retesting
to verify results, which will ensure continuing contact
encouraging retesting supports hope and gives the client time to cope with the diagnosis. Although
post-test counseling should include education about A, B, and C, retesting encourages the client to
maintain medical follow-up and management.
The nurse is caring for a client with HIV infection who develops Mycobacterium avium complex (MAC).
what is the most significant desired outcome for this client?
A. free from injury of drug side effects
,Dewitt’s Medical Surgical Nursing Concepts and Practice 4th Edition Stromberg Test Bank
B. maintenance of intact perineal skin
c. adequate oxygenation
D. return to pre-illness weight - (Answer)D. return to pre-illness weight
MAC is an opportunistic infection that presents as a TB like pulmonary process. MAC is a major
contributing factor to the development of wasting syndrome, so the most significant desired outcome
is the client's return to a pre-illness weight. drug schedules and side effects remain a life-long
management problem. Client outcomes for adequate oxygenation are often dependent on
management of anemia, maintenance of activities without fatigue, and supplemental oxygen to
prevent hypoxia. Skin integrity is dependent upon resolution of diarrhea, which is not as significant as
optimal nutrition.
A client who had abdominal surgery two days ago has prescriptions for intravenous morphine sulfate
4 mg every 2 hours and a clear liquid diet. the client complains of feeling distended and has sharp,
cramping gas pains. What nursing intervention should be implemented?
A. assist the client to ambulate in the hall
B. obtain a prescription for a laxative
C. administer the prescribed morphine sulfate
D. withhold all oral fluid and food - (Answer)a. assist the client to ambulate in the hall
Post-operative abdominal distention is caused by decreased peristalsis as a result of handling the
intestine during surgery, limited dietary intake before and after surgery, and anesthetic and analgesic
agents. Peristalsis is stimulated and distention minimized by implementing early and frequent
ambulation. Based on the client's status, laxatives or withholding dietary progression are not
indicated at this time. although pain management should be implemented, another analgesic
prescription may be needed because morphine reduces intestinal motility and contributes to the
client's gas pains.
A client with Meniere's disease is incapacitated by vertigo and is lying in bed grasping the side rails
and staring at the television. Which nursing intervention should the nurse implement?
A. keep the head of the bed elevated 30 degrees
, Dewitt’s Medical Surgical Nursing Concepts and Practice 4th Edition Stromberg Test Bank
B. turn off the television and darken the room
c. encourage fluids to 3000 mL per day
D. change the client's position every two hours - (Answer)B. turn off the television and darken the
room
to decrease the client's vertigo during an acute attack of Meniere's disease, any visual stimuli or
rotational movement, such as sudden head movements or position changes, should be minimized.
Turning off the television and darkening the room minimize fluorescent lights, flickering television
lights, and distracting sound. The other are ineffective in managing the client's symptoms.
a client who has a chronic cough with blood-tinged sputum returns to the unit after a bronchoscopy.
What nursing interventions should be implemented in the immediate post-procedural period?
A. check vital signs every 15 minutes for 2 hours
B. allow the client nothing by mouth until the gag reflex returns
C. encourage fluid intake to promote elimination of the contrast media
D. keep the client on bed rest for 8 hours - (Answer)B. allow the client nothing by mouth until the gag
reflex returns
the nasal pharynx and oral pharynx are anesthetized with local anesthetic spray prior to
bronchoscopy, and the bronchoscope is coated with lidocaine gel to inhibit the gag reflex and prevent
laryngeal spasm during insertion. The client should be NPO until the client's gag reflex returns to
prevent aspiration from any oral intake or secretions. The others are not indicated after bronchoscopy
The nurse is assessing a client with a cuffed tracheostomy tube in place who is breathing
spontaneously. to evaluate if the client can tolerate cuff deflation to promote speaking and
swallowing, what action should the nurse implement?
A. observe the client for coughing colored sputum after drinking a small amount of colored water
B. ask the client to try to speak
C. auscultate for pulmonary crackles after the client drinks a small amount of clear water
