p p p p p p
2023/2024
2. Thepnursepispprovidingpanpeducationpsessionptopanpadultpcommunitypgrouppaboutpthepeffectspofpsmoking
onpinfection.pWhichpinformationpispmostpimportantpforpthepnurseptopincludepinpthepeducationalpsession?
a. Smokepfromptobaccopproductspclingsptopyourpclothingpandphair.
b. Smokingpaffectspthepciliapliningpthepupperpairwayspinptheplungs.
c. Smokingpcanpaffectpthepcolorpofptheppatient’spfingernails.
d. Smokingptobaccopproductspcanpbepverypexpensive.
ANS:pB
Apnormalpdefensepmechanismpagainstpinfectionpinptheprespiratoryptractpispthepciliapliningpthepupperpairwa
yspofptheplungspandpnormalpmucus.pWhenpappatientpinhalespapmicrobe,pthepciliapandpmucusptrappthepmicrob
epandpsweeppthempuppandpoutptopbepexpectoratedporpswallowed.pSmokingpmaypalterpthispdefensepmechan
ismpandpincreaseptheppatient’sppotentialpforpinfection.pSmokingpcanpbepexpensive,pthepsmellpdoespclingpt
ophairpandpclothing,pandptheptarpwithinpthepsmokepcanpalterpthepcolorpofpappatient’spnails.pThispinformationp
canpbepincludedpinpthepeducationpbutpdoespnotpconstitutepthepmostpimportantppoint.
3. Apfemalepadultppatientppresentsptopthepclinicpwithpreportspofpapwhitepdischargepandpitchingpinpthe
vaginalarea.pApnursepisptakingpaphealthphistory.pWhichpquestionpisptheppriority?
“Whenpwasptheplastptimepyoupvisitedpyourpprimaryphealthpcare
a. provider?”
b. “Haspthispconditionpaffectedpyourpeatingphabitspinpanypway?”
c. “Whatpmedicationsparepyoupcurrentlyptaking?”
d. “Arepyoupableptopsleeppatpnight?”
ANS:pC
,Antibioticspandporalpcontraceptivespcanpdisruptpnormalpflorapinpthepvagina,pcausingpanpovergrowthpofpCandid
apalbicanspinpthatparea.pItpispimportantptopaskptheppatientpaboutpcurrentpmedicationsptopobtainpinformationpth
atpmayassistpwithpdiagnosis.pThepbodypcontainspnormalpflorap(microorganisms)pthatpliveponpthepsurfacepofpski
n,psaliva,poralpmucosa,pgastrointestinalptract,pandpgenitourinaryptract.pThepnormalpflorapofpthepvaginapcausespv
aginalpsecretionsptopachievepaplowppH,pinhibitingpthepgrowthpofpmanypmicroorganisms.pVisitingpthepprimaryphe
althpcarepproviderpispimportantpforptheppatient’sphealthpmaintenancepbutpispnotptheppriority.pLearningpaboutpth
eppatient’speatingpandpsleepingphabitspwillpassistpinpthepplanpofpcarepbutpispnotptheppriority.
4. Thepnursepispcaringpforpapschool-
agedpchildpwhophaspinjuredptheprightplegpafterpapbicyclepaccident.pWhichsignspandpsymptomspwillpth
epnursepassesspforptopdeterminepifpthepchildpispexperiencingpaplocalized
inflammatorypresponse?
Malaise,panorexia,penlargedplymphpnodes,pandpincreasedpwhitepblood
a. cells
b. Chestppain,pshortnesspofpbreath,pandpnauseapandpvomiting
c. Dizzinesspandpdisorientationptoptime,pdate,pandpplace
43
,d.p p Edema,predness,ptenderness,pandplosspofpfunctio
n
ANS:pD
Thepbody’spcellularpresponseptopanpinjurypispseenpaspinflammation.pSignspofplocalizedpinflammationpinclu
depswelling,predness,pheat,ppainporptenderness,pandplosspofpfunctionpinpthepaffectedpbodyppart.pSystemicp
signspofpinflammationpincludepfever,pmalaise,pandpanorexia,paspwellpaspenlargedplymphpnodespandpincreas
edpwhitepbloodpcells.pChestppain,pshortnesspofpbreath,pandpnauseapandpvomitingparepsignspandpsymptoms
ofpapcardiacpalteration.Dizzinesspandpdisorientationptoptime,pdate,pandpplacepmaypindicatepapneurologi
p
cpalteration.
5. Whichpinterventionsputilizedpbypthepnursepwillpindicatepthepabilityptoprecognizepaplocalized
inflammatorypresponse?
a. Vigorousprange-of-motionpexercises
b. Turn,pcough,pandpdeeppbreathe
c. Orientptopdate,ptime,pandpplace
d. Rest,pice,pandpelevation
ANS:pD
Signspofplocalizedpinflammationpincludepswelling,predness,pheat,ppainporptenderness,pandplosspofpfunctio
npinpthepaffectedpbodyppart.pOnepsignpofpthepinflammatorypresponse,pparticularlypafterpanpinjury,pispswelling
orpedema.pRestingpthepaffectedpinjuredparea,pusingpicepaspordered,pwrappingpthepareaptopprovidepsupport—
p
particularlypifpitpispanpextremity—
andpelevatingpthepinjuredpareapwillphelpptopdecreasepswellingporpedema.pTurning,pcoughing,pandpdeeppbre
athingpareputilizedpforppostoperativeppatientspandpforpimmobilizedppatientsptophelpppreventpanpinfectiou
spprocesspsuchpasppneumonia.pOrientationptopdate,ptime,pandpplacepispanpinterventionputilizedpwithpmanyp
differentptypespofppatientspwhopmaypbepconfused.pVigorousprangepofpmotionpwouldpirritatepthepinflamma
torypprocess.pRangepofpmotionpisputilizedpforpindividualspwhopneedptopimprovepmovementpofptheirpextrem
ities,pincludingpimmobilizedppatients.
6. Thepnursepispcaringpforpapgrouppofpmedical-surgicalppatients.pWhichppatientpispmostpatpriskpfor
developingpaninfection?
a. Appatientpwhopispinpobservationpforpchestppain
, d.p p Edema,predness,ptenderness,pandplosspofpfunctio
nb. Appatientpwhophaspbeenpadmittedpwithpdehydration