Prioritization Delegation and Assignment 4th Edition Test Bank

Prioritization Delegation and Assignment 4th Edition LaCharity Test Bank Prioritization Delegation and Assignment 4th Edition Test Bank Chapter 1. Pain MULTIPLE CHOICE 1.A client tells the nurse that she rarely experiences pain, but when she does, she seeks medical attention. The nurse realizes this client understands that pain is important because it: 1. is a protective system. 2. includes the automatic withdrawal reflex. 3. creates sensitivity to pain. 4. helps with healing. ANS: 1 Pain is a protective system that includes protection from unsafe behaviors by use of reflexes, memory, and avoidance. Even though the automatic withdrawal reflex is a part of the pain response, it does not explain why pain is important. Pain does not create sensitivity to pain. Pain does not help with healing. PTS: 1 DIF: Analyze REF: Definitions and Implications of Pain 2.A client complains that the bed sheets touching his skin are extremely painful. The nurse realizes this client is experiencing: 1. allodynia. 2. modulation. 3. kinesthesia. 4. proprioception. ANS: 1 Allodynia or hyperalgesia is a state where a slight or nonpainful stimulus is interpreted as very painful. Kinesthesia is the awareness of movement. Proprioception is the awareness of body position. Modulation is an influencing factor in the perception of pain. PTS: 1 DIF: Analyze REF: Peripheral Nervous System 3.A client is complaining of severe abdomen pain. The nurse realizes this client is experiencing which type of pain? 1. Neuralgia 2. Pathological 3. Somatic 4. Visceral ANS: 4 Visceral pain is pain arising from the body organs or gastrointestinal tract. Somatic pain is pain that originates from the bone, joints, muscles, skin, or connective pain. Neuralgia and pathological pain are both types of pain that result from injury to a nerve or malfunction of the neuronal transmission process or due to impaired regulation. PTS:1DIF:AnalyzeREF:Types of Pain 4.A client, diagnosed with acute appendicitis, is experiencing abdominal pain. The best way for the nurse to describe this clients pain would be: 1. chronic. 2. neuropathic. 3. referred. 4. acute. ANS: 4 Acute pain onset is sudden and of short duration. Chronic pain is a sudden or slow onset of mild to severe pain that lasts longer than 6 months. Referred pain is the result of the transfer of visceral pain sensations to a body surface at a distance from the actual origin. Neuropathic pain is paroxysmal pain that occurs along the branches of a nerve. PTS:1DIF:ApplyREF:Types of Pain 5.A client is observed holding a pillow over the abdominal region with both knees flexed in a side-lying position. Vital signs assessment reveals an elevated blood pressure and heart rate. Which of the following should the nurse say to this client? 1. Can I get you anything? 2. Would you like something for pain? 3. You look comfortable. 4. Your blood pressure is up. ANS: 2 Sympathetic responses to pain include elevated blood pressure and heart rate. And since the client is hugging a pillow over the abdominal region with both knees flexed in a side-lying position, the best thing for the nurse to say to this client is Would you like something for pain? The other responses are incorrect because they do not acknowledge that the client is experiencing pain. PTS: 1 DIF: Apply REF: Assessing the Clinical Manifestations of Pain 6.A client experiencing chronic pain asks the nurse why she is not prescribed Demerol like she received when she had a total knee replacement. Which of the following should the nurse respond to this client? 1. You dont need something that strong. 2. That medication does not exist anymore. 3. That medication does not last very long. 4. It can cause you have high blood pressure. ANS: 3 Meperidine is no longer a major drug for acute or chronic pain due to its short analgesic duration of 2 to 3 hours and the potential for accumulative toxic effects of its metabolite, normeperidine. The best response for the nurse to make to the client would be that medication does not last very long. The other responses are inaccurate. PTS:1DIF:ApplyREF:Opioid Analgesics 7.A client is informed that a tricyclic antidepressant medication is going to help control his chronic pain. The nurse would expect the physician to prescribe: 1. Amitriptyline. 2. Baclofen. 3. Gabapentin. 4. Diazepam. ANS: 1 Amitriptyline is an antidepressant. Gabapentin is an anticonvulsant. Baclofen is a muscle relaxant. Diazepam is a benzodiazepine. PTS: 1 DIF: Analyze REF: Adjuvant Medications 8.A client receiving around-the-clock medication for terminal cancer experiences additional pain when performing activities of daily living. The nurse realizes this client is experiencing: 1. breakthrough pain. 2. intractable pain. 3. psychosomatic pain. 4. acute pain. ANS: 1 Breakthrough pain is commonly seen in the advanced stages of cancer. It is spontaneous, unpredictable, and can be initiated by certain activities such as during activities of daily living. Intractable pain is resistant to some or all forms of therapy. Psychosomatic pain is that which has a psychological origin. The client is diagnosed with terminal cancer. Acute pain has a sudden onset and resolves within 6 months. PTS:1DIF:AnalyzeREF:Breakthrough Pain 9.A client recovering from surgery tells the nurse that she is nauseated and is experiencing an increase in pain. Which of the following does this clients symptoms suggest to the nurse? 1 . The client is becoming dependent upon the pain medication. 2 . The clients pain threshold is lower when experiencing nausea. 3 . The client is experiencing withdrawal symptoms from pain medication. 4 The client is experiencing referred pain. . ANS: 2 Pain threshold is influenced by nausea, fatigue, and lack of sleep. The client experiencing an increase in pain during nausea is demonstrating an alteration in the pain threshold. The client is not becoming dependent upon the pain medication. The client is not experiencing withdrawal symptoms. The client is also not experiencing referred pain. PTS: 1 DIF: Analyze REF: Pain Threshold and Pain Tolerance 10.A client with a history of malingering pain tells the nurse that he needs a prescription for pain medication. Which of the following should the nurse do first to assist this client? 1 . Ask the physician for a pain medication prescription for the client. 2 . Remind the client that he does not have pain but just wants the medication. 3 . Thoroughly assess the client for pain. 4 . Suggest the client seek counseling for his pain medication-seeking behavior. ANS: 3 Pain of a psychological origin is when an individual seeks treatment for pain when no actual pain exists. This is also referred to as malingering or pretending pain. The nurse should not assume that the pain does not exist but rather should conduct a thorough pain assessment to rule out an actual physiological problem. The nurse should not immediately ask the physician for pain medication. The nurse should not remind the client that he does not have pain but just wants the medication. The nurse should also not suggest the client seek counseling for pain medication- seeking behavior. PTS: 1 DIF: Apply REF: Box 16-1 Pain Descriptions 11.The nurse is implementing the five Cs of pain management for a client. Which of the following is included in this intervention? 1 . Caring for the client in a holistic manner 2 . Creating a calm environment 3 . Comparing the degree of pain reported with previous episodes 4 . Continuously assessing the clients pain ANS: 4 The five Cs of pain management include comprehensive assessment, consistent use of assessment tools, continuous reassessment, customize the plan of care, and collaborate with other health care providers to plan pain management. The other choices are not included in the five Cs of pain management. PTS: 1 DIF: Apply REF: Planning and Implementation 12.A client, diagnosed with arthritis, should be instructed to avoid the use of NSAIDs because of which of the following prescribed medications? 1. Penicillin 2. Coumadin 3. Digoxin 4. Diazide ANS: 2 Persons at greatest risk for adverse reactions to NSAIDs include those who are prescribed warfarin (Coumadin) since the NSAID can increase the effects of the Coumadin and promote bleeding. PTS: 1 DIF: Apply REF: Box 16-2 Groups of NSAID Drugs MULTIPLE RESPONSE 1. Prior to hospitalization, a client had been ingesting high doses of oxycodone. The nurse suspects the client is experiencing symptoms of withdrawal when which of the following are assessed? (Select all that apply.) 1. Muscle twitching and spasms 2. Restlessness 3. Increased heart rate 4. Drop in blood pressure 5. Increase in blood pressure 6. Irritability ANS: 1, 2, 3, 5, 6 Withdrawal symptoms include myoclonus or muscle twitching and spasms, restlessness, irritability, increased heart rate, and increased blood pressure. A decrease in blood pressure is not a symptom of narcotic medication withdrawal. PTS:1DIF:Analyze REF: Potential and Actual Side Effects of Opioid Analgesics 2. The nurse would be concerned that a client is at risk for developing chronic pain when which of the following health problems are diagnosed? (Select all that apply.) 1. Osteoarthritis 2. Osteoporosis 3. Heart disease 4. Diabetes mellitus 5. Chronic pulmonary disease 6. Anemia ANS: 1, 2, 5 Common health problems associated with chronic pain include osteoarthritis, osteoporosis, and chronic pulmonary disease. Heart disease, diabetes mellitus, and anemia are not associated with chronic pain. PTS:1DIF:AnalyzeREF:Chronic Pain 3. An 84-year-old client is experiencing severe arthritis pain. The nurse realizes that which of the following pain management approaches would be the most beneficial for this client? (Select all that apply.) 1. Avoid NSAIDs. 2. Utilize morphine or morphine-like medication. 3. Provide medication through the oral route. 4. Utilize diazepam. 5. Suggest Darvocet. 6. Provide medication through the intramuscular route. ANS: 1, 2, 3 When providing pain medication to a geriatric client, pain management approaches include the utilization of morphine or morphine-like medication to control pain and provide medication using the oral route. NSAIDs should also be avoided because of the risk of gastrointestinal bleeding. Diazepam should be avoided because of a long half-life. Darvocet should be avoided because of toxic effects with renal insufficiency. Medication should not be provided using the intramuscular route because of muscle wasting and loss of fatty tissue in the elderly client. PTS: 1 DIF: Apply REF: Geriatric Considerations 4.A client with severe pain from spinal stenosis is prescribed Methadone. The nurse realizes that the advantages of this medication are what? (Select all that apply.) 1. Decrease in the need for antidepressant adjuvant medication 2. Less frequent dosing schedule 3. Long half-life 4. Inexpensive 5. Can be used for intermittent pain 6. Does not cause respiratory depression ANS: 1, 2, 4 The advantages of methadone include that it decreases the need for antidepressant adjuvant medication because it increases the release of serotonin and norepinephrine, dosing is every 12 hours, and it is inexpensive. Disadvantages of this medication include: it has a long half-life; it cannot be used for intermittent pain management; and it does cause respiratory depression. PTS:1DIF:AnalyzeREF:Intractable Pain 5.The nurse is using the PAINAID Scale to assess a clients level of pain. Which of the following are assessed with this pain scale? (Select all that apply.) 1. Breathing rate 2. Assign a number to the degree of pain 3. Negative vocalizations 4. Assign a facial expression to the degree of pain 5. Facial expression 6. Body language ANS: 1, 3, 5, 6 The PAINAID scale assesses breathing, negative vocalizations, facial expression, body language, and comfort. The Numerical Rating Scale assigns a number to the degree of pain. The Wong- Baker FACES Scale assigns a facial expression to the degree of pain. PTS: 1 DIF: Apply REF: Skills 360: Pain Assessment Tools 6.A client diagnosed with severe arthritis tells the nurse that she always has some degree of pain. Which of the following could explain this clients poor pain management? (Select all that apply.) 1. Client does not appear to be in pain. 2. Client does not report pain. 3. Client cannot afford pain medication. 4. Client is fearful of becoming addicted to pain medication. 5. Client believes pain medication means the condition is worse. 6. Client has a high pain tolerance. ANS: 1, 2, 4, 5 Barriers to pain assessment and management include that the client is not demonstrating overt signs of pain, and therefore she does not need pain medication; the client does not report pain, so therefore she does not need pain medication; the client is fearful of becoming addicted to pain medication; and the client believes pain medication means the condition is worse. The fact that the client is unable to afford pain medication and is having a high pain tolerance are not identified barriers to pain assessment and management. PTS: 1 DIF: Analyze REF: Barrier to Pain Assessment and Pain Management 7.The nurse determines that a client is experiencing chronic pain when which of the following is assessed? (Select all that apply.) 1. Suffering 2. Fatigue 3. Sleeplessness 4. Apathy 5. Sadness 6. Anger ANS: 1, 3, 5 The descriptor triad for chronic pain is suffering, sleeplessness, and sadness. Fatigue, apathy, and anger do not describe chronic pain. Chapter 2. Cancer MULTIPLE CHOICE 1.The nurse realizes that for a cell to become cancer, it needs to progress through four stages. Which of the following is not a stage of this process? 1. Initiation 2. Metastasis 3. Progression 4. Stimulation ANS: 4 The four stages of oncogenesis or carcinogenesis are: 1) initiation, 2) promotion, 3) progression, and 4) metastasis. Stimulation is not a stage of carcinogenesis. PTS:1DIF:AnalyzeREF:Carcinogenesis 2.A clients most recent prostate-specific antigen level has decreased since starting treatment for prostate cancer. The nurse realizes this level would indicate that the client: 1. no longer has the disease. 2. has an increase in the severity of the disease process. 3. is responding to treatment. 4. should be retested. ANS: 3 A decrease in a tumor marker is important in the assessment of cancer, monitoring tumor response during treatment strategies, and diagnosis of recurrence of disease. A decrease in the prostate-specific antigen level once treatment has begun for prostate cancer would indicate that the client is responding to treatment. A drop in the level does not mean that the client no longer has the disease, that the disease is progressing, or that the client needs to be retested. PTS:1DIF:AnalyzeREF:Laboratory Tests 3.A clients tumor was staged using the TNM system. The tumor was staged as T4,N1,Mx. The nurse realizes that this staging means: 1 tumor in situ, minimal node involvement, no presence of metastasis. . 2 large tumor, no node involvement, presence of metastasis. . 3 medium tumor, multiple nodes involvement, no presence of metastasis. . 4 . large tumor, single node involvement, unable to assess metastasis. ANS: 4 The larger the number in the TNM staging system, the increasing involvement or larger size of the tumor, node, and metastasis. T4 reflects the size of the tumor. N1 describes the regional node involvement. Mx signals the inability to assess the presence or absence of distant metastasis. PTS:1DIF:AnalyzeREF:Staging and Grading 4.Which of the following statements made by a client after receiving instruction regarding internal radiation would indicate that teaching has been successful? 1 . My children can come visit me after school. 2 . Individuals will need to keep at least 3 feet away when possible. 3 . I will be sharing a room near the nursing station. 4 . The hospital staff will limit the amount of time in my room. ANS: 4 General guidelines include assigning the patient to a private room; postradiation precaution signage; limiting the amount of time in the room; observing a distance of at least 6 feet from the source when possible; and prohibiting pregnant staff, family, visitors, and children from interacting or visiting with the patient. The other choices would indicate the need for additional instruction and are incorrect. PTS:1DIF:AnalyzeREF:Internal Radiation 5.A client, prescribed to begin chemotherapy, asks the nurse How does chemotherapy work? Which of the following should the nurse respond to this client? 1. It prevents the process of cell growth and replication. 2. It kills only cancer cells. 3. It treats the exposed area only with high-energy rays. 4. Agents are implanted in an area to inhibit cancer growth. ANS: 1 Chemotherapy is the use of drugs that prevent, kill, or block the growth and spread of cancer cells. Some noncancerous cells can be damaged during chemotherapy. External radiation treats an exposed area with high-energy rays. Internal radiation uses implanted agents. PTS:1DIF:ApplyREF:Chemotherapy 6.A client is prescribed interferon as part of treatment for cancer. Which of the following should the nurse instruct the client regarding this medication? 1. Flu-like symptoms should be reported to the physician. 2. General fatigue while receiving this medication is common. 3. Seek emergency care with a high fever. 4. Side effects are short term and will resolve in a few days. ANS: 2 Side effects vary by the type of biological agent, including a flu-like illness, high fever, headache, and general fatigue. These are expected effects and do not need to be reported to the physician. Side effects of these medications are long term and can vary in intensity during the course of treatment. PTS:1DIF:ApplyREF:Biological Therapy 7.A client recovering from bone marrow transplantation is experiencing vomiting, fatigue, and skin reactions. Which of the following should the nurse do to help this client? 1 . Prepare to administer platelets as prescribed. 2 . Prepare to administer red blood cells as prescribed. 3 . Limit fluids. 4 . Explain that the client is experiencing expected short-term side effects. ANS: 4 Clients who undergo bone marrow transplantation may experience short-term side effects, including nausea, vomiting, fatigue, loss of appetite, mouth sores, hair loss, and skin reactions. These side effects are not treated with platelets or red blood cells. Limiting fluids can make the side effects worse. PTS: 1 DIF: Apply REF: Blood and Bone Marrow Transplantation 8.A client receiving chemotherapy for cancer has a hemoglobin level of 9.7 g/dL. Which of the following should the nurse anticipate as treatment for this client? 1. Place client in reverse isolation. 2. Administer antibiotics as prescribed. 3. Administer epoetin alfa as prescribed. 4. Administer filgrastim as prescribed. ANS: 3 Treatment for moderate anemia in the client receiving chemotherapy for cancer would include the administration of epoetin alfa as prescribed. This medication elevates hemoglobin levels and improves the quality of life for clients. The other choices would be appropriate for the client diagnosed with neutropenia and not anemia. PTS: 1 DIF: Apply REF: Anemia 9.A client receiving chemotherapy has a platelet count of 85,000. Which of the following should the nurse do to assist this client? 1. Assess for bruising and frank bleeding. 2. Provide a razor for shaving. 3. Remind the client to floss before brushing the teeth each day. 4. Provide NSAIDs as prescribed. ANS: 1 A platelet count of less than 100,000 indicates thrombocytopenia, and the client should be assessed for bruising and frank bleeding. The client should avoid the use of a razor, avoid flossing, and NSAIDs should not be provided since they promote bleeding. PTS:1DIF:ApplyREF:Thrombocytopenia 10.A client receiving chemotherapy tells the nurse that he is concerned that he may be developing Alzheimers disease since he is having a new onset of memory loss. Which of the following should the nurse do to help this client? 1 . Discuss the clients memory issues with the physician. 2 . Suggest the client use a journal to aid with short-term chemo fog problems. 3 . Assess for signs of pending stroke. 4 Notify the physician and plan for transferring the client to an intensive care . area. ANS: 2 Twenty to 50% of cancer clients receiving chemotherapy describe cognitive changes such as being in a fog. To aid this client, the nurse should suggest the client keep a log or journal to document activities in order to identify when the fog is more acute. Chemo fog can last up to 2 years after treatment, but it is not permanent. The clients memory issues do not need to be discussed with a physician. The client is not experiencing a stroke. The client does not need to be transferred to an intensive care area. PTS:1DIF:ApplyREF:Cognitive Disorders 11.A client is experiencing nausea and vomiting 1 day after chemotherapy has begun for cancer treatment. The nurse realizes this clients nausea and vomiting would be considered: 1. anticipatory. 2. acute. 3. delayed. 4. chronic. ANS: 3 Delayed nausea and vomiting occurs more than 24 hours after chemotherapy. Anticipatory nausea and vomiting occur before, during, or after chemotherapy, and they appear earlier than expected. Acute nausea and vomiting occur within 24 hours after starting chemotherapy. Chronic nausea and vomiting affect people with advanced cancer and is not well understood. PTS: 1 DIF: Analyze REF: GI System 12. The nurse is planning interventions to address the potential problem of mucositis for a client receiving chemotherapy. Which of the following assessment findings caused the nurse to identify the client as being at risk for this side effect? 1. Client prescribed chemotherapy 2. Client age 50 3. Client lives alone 4. Client is fatigued ANS: 1 High risks for developing mucositis include age younger than 20, hematologic or head and neck cancer, preexisting oral disease, and chemotherapy and radiation. Age greater than 50, living arrangements, and level of fatigue do not increase a clients risk of developing mucositis. PTS: 1 DIF: Analyze REF: Mucositis 13. Even though a client has completed a course of chemotherapy and has been found to be cancer free at this time, she continues to experience fatigue. Which of the following should the nurse instruct this client? 1 . Fatigue is the first warning sign of cancer and should be reported to the physician. 2 . Fatigue indicates a poor diet. 3 . Fatigue is caused by poor fluid intake. 4 . Fatigue can persist after treatment ends, but it will eventually improve. ANS: 4 Fatigue is the most common symptom associated with cancer and cancer treatment. Fatigue is more often a result of the treatment than the cancer itself. The client should be informed that fatigue may persist after cancer therapy is completed, but it will eventually improve. PTS: 1 DIF: Apply REF: Fatigue MULTIPLE RESPONSE 1.A client is diagnosed with cancer. The nurse realizes that which of the following are characteristics of this type of cell? (Select all that apply.) 1. Aneuploid 2. Cohesive 3. Migratory 4. Poorly differentiated 5. Specific morphology 6. Abnormal chromosomes ANS: 1, 3, 4, 6 Characteristics of malignant cells include uncontrolled cell division; large, variably shaped nuclei; anaplasia; poor differentiation; noncohesion; migration; lack of contact inhibition; aneuploidy; and abnormal chromosomes. Specific morphology and cohesiveness are characteristics of either benign or normal cells. PTS:1DIF:AnalyzeREF:Malignant Cells 2.A nurse is teaching at a health fair about the early warning signs of cancer. Which of the following would the nurse include as early warning signs? (Select all that apply.) 1. A sore that does not heal 2. Change in bladder or bowel habits 3. Family history 4. Unusual discharge 5. Obvious change in nevus 6. Nagging cough ANS: 1, 2, 4, 5, 6 Early warning signs can be easily remember using the acronym CAUTION: C, change in bladder or bowel habits; A, a sore that does not heal; U, unusual bleeding or discharge; T, presence of a lump or thickening; I, indigestion; O, obvious change in a wart or mole; and N, a nagging cough or hoarseness. PTS: 1 DIF: Apply REF: Box 15-1 Warning Signs of Cancer 3.A client is experiencing nausea and vomiting related to chemotherapy. Which of the following strategies can the nurse use to improve nutrition in this client? (Select all that apply.) 1. Adding peppermint to foods 2. Administering ondansetron 3. Drinking adequate fluids 4. Drinking hot beverages 5. Eating food at room temperature 6. Sipping ice water ANS: 1, 2, 3, 5 Strategies to improve nutrition in the client experiencing nausea and vomiting from chemotherapy include using herbs such as peppermint, administering prescribed anti-emetics, ensuring an adequate intake of fluids, and ingesting foods at room temperature. Foods and fluids of extreme temperatures such as hot beverages and ice water should be avoided by the patient with nausea and vomiting. PTS: 1 DIF: Apply REF: Chemotherapy: Side Effects 4.A client asks the nurse what he can do to prevent the onset of cancer. The nurse realizes that which of the following contribute to the development of cancer? (Select all that apply.) 1. Heredity 2. Environment 3. Lifestyle 4. Stress 5. Age 6. Blood pressure ANS: 1, 2, 3, 5 The factors known to contribute to the development of cancer include heredity, environment, and lifestyle. Aging has a direct effect on ones risk of developing cancer. The longer one lives, the greater the risk for developing cancer. Stress and blood pressure are not factors known to contribute to the development of cancer. PTS: 1 DIF: Analyze REF: Etiology 5.The nurse is planning to instruct a client on strategies to lessen the impact of lifestyle on the development of cancer. Which of the following should the nurse include in these instructions? (Select all that apply.) 1. Follow a low-fat diet. 2. Avoid prescribed medications. 3. Exercise regularly. 4. Limit sun exposure. 5. Sleep less than 7 hours each night. 6. Do not smoke or use any tobacco products. ANS: 1, 3, 4, 6 Strategies to lessen the impact of lifestyle on the development of cancer include following a lowfat diet, exercising regularly, limiting sun exposure, and avoiding all use of tobacco products. Prescribed medications will not lessen the impact of lifestyle on the development of cancer. Sleeping less than 7 hours each night will not lessen the impact of lifestyle on the development of cancer. PTS: 1 DIF: Apply REF: Lifestyle 6.A client is prescribed a selective estrogen receptor modulator as treatment for ovarian cancer. Which of the following should the nurse instruct the client regarding side effects of this medication? (Select all that apply.) 1. Hot flashes 2. Blood clots 3. Drop in blood pressure 4. Reduce libido 5. Increased risk of developing other cancer 6. Weight gain ANS: 1, 2, 4, 5 Side effects of selective estrogen modulator medications include hot flashes, blood clots, loss of interest in sex, and a higher risk of other cancers. Drop in blood pressure and weight gain are not side effects associated with this classification of medication. Chapter 3. Immunologic Problems MULTIPLE CHOICE 1.A pregnant client diagnosed with human immunodeficiency virus (HIV) is asking about her babys risk of infection. Which of the following does put the newborn at risk? 1. Bottle-feeding 2. Changing diapers 3. Kissing the baby 4. Vaginal birth ANS: 4 Breastfeeding and vaginal birth put the newborn at risk for HIV. HIV cannot be transmitted by changing diapers (feces) or kissing the baby (saliva). PTS:1DIF:Apply REF: Human Immunodeficiency Virus Infection: Etiology 2.A health care provider has accidentally been stuck with a used needle. The health care provider is going to be tested for human immunodeficiency virus (HIV). Which of the following would be the testing schedule for the health care provider? 1. Tested at 2 months, 4 months, and then at 6 months 2. Tested immediately and then again at 2 months 3. Tested immediately and then again at 6 months 4. Tested in 6 months and then again in 1 year ANS: 3 The health care provider should be tested immediately to show if any preexisting infection exists. Seroconversion usually occurs in 1 to 3 months but can take up to 6 months. Testing at 2 months is too late to discover a preexisting infection and can be too early to detect a new infection. Testing at 6 months or 1 year would not detect a preexisting infection. PTS:1DIF:Apply REF: Human Immunodeficiency Virus Infection: Etiology 3. Which of the following CD4+ count would be used to confirm the diagnosis of acquired immunodeficiency syndrome (AIDS)? 1. 155 cells/mcL 2. 255 cells/mcL 3. 455 cells/mcL 4. 755 cells/mcL ANS: 1 A CD4+ count of less than 200 cells/mcL is used as a criterion to establish the diagnosis of AIDS. In cell counts less than 500 to 600 cells/mcL, antiviral therapy should be initiated. Cell counts greater than 600 cells/mcL are in the normal range. PTS:1DIF:Analyze REF:Human Immunodeficiency Virus Infection: Pathophysiology 4. The nurse, planning care for a client diagnosed with human immunodeficiency virus, realizes that the most common infection that occurs in clients with this health problem is: 1. cytomegalovirus infection. 2. Mycobacterium tuberculosis. 3. Pneumocystis carinii pneumonia. 4. Streptococcus pneumoniae. ANS: 3 As the immune system becomes overpowered, opportunistic infections can occur. The most common infection is Pneumocystis carinii pneumonia. The other infections can also occur, but they occur less frequently. PTS:1DIF:Analyze REF: Human Immunodeficiency Virus Infection: Assessment with Clinical Manifestations 5.A client diagnosed with acquired immunodeficiency syndrome (AIDS) 6 years ago has a purple lesion located on the inner thigh. This lesion is most likely to be: 1. AIDS-related syndrome. 2. Burkitts lymphoma. 3. cachexia. 4. Kaposis sarcoma. ANS: 4 Kaposis sarcoma presents as abnormal lesions that appear purple or blue-red in color. They can be found anywhere but are common on the feet, arms, thighs, perineal area, and face. Cachexia is tissue wasting. Burkitts lymphoma is characterized by enlarged lymph nodes. AIDS-related syndrome is a collection of symptoms and infections resulting from the specific damage to the immune system caused by the HIV virus. PTS:1DIF:Analyze REF: Human Immunodeficiency Virus Infection: Assessment with Clinical Manifestations 6.The nurse realizes that which of the following tests can be used to initially identify the presence of human immunodeficiency virus (HIV) antibodies in a client? 1. Enzyme-linked immunosorbent assay (ELISA) 2. Platelet count 3. Red blood cell count 4. Western blot ANS: 1 The ELISA test detects HIV antibodies. The Western blot is used as a confirmatory test to a positive ELISA test. Red blood cell counts and platelet counts are part of standard blood studies. PTS:1DIF:Analyze REF:Human Immunodeficiency Virus Infection: Diagnostic Tests 7.A client diagnosed with acquired immunodeficiency syndrome (AIDS) is sitting alone crying. Which of the following is an appropriate response for the nurse to give? 1. Everything will be okay. 2. Let me call your doctor about your depression. 3. Whats wrong now? 4. Would you like to talk? ANS: 4 Asking the client if he would like to talk allows the client an opportunity to express his feelings. The other responses give the client false reassurance or put off the client. PTS:1DIF:Apply REF: Human Immunodeficiency Virus Infection: Planning and Implementation 8. The nurse is instructing a client on ways to reduce the risk of exposure to the human immunodeficiency virus. Which of the following activities would present the least risk of exposure to this virus? 1. Exposure to used needles 2. Multiple sex partners 3. Perinatal exposure 4. Teeth cleaning ANS: 4 Teeth cleaning is a procedure in a dental office that routinely sterilizes its equipment and is not considered to present an increased risk of exposure to HIV. Exposure to used needles, multiple sex partners, and perinatal exposure during pregnancy and childbirth all would increase the clients risk of exposure to the virus. PTS:1DIF:Apply REF:Human Immunodeficiency Virus Infection: Epidemiology 9. The nurse is teaching a small group of clients about human immunodeficiency virus (HIV) at a health clinic. Which of the following statements by a group member will need further clarification? 1. Condoms should be used during sexual contact. 2. Exposure can occur to a baby during pregnancy. 3. HIV-infected mothers can breastfeed their babies. 4. Needles should never be reused or shared. ANS: 3 Exposure to HIV can occur while breastfeeding an infant. This is the statement that would necessitate further clarification. The other statements are correct. PTS:1DIF:Analyze REF:Human Immunodeficiency Virus Infection: Epidemiology 10. The nurse is caring for a client diagnosed with human immunodeficiency virus (HIV). Which of the following precautions is best in the care of the client? 1 . Gloves and an N-95 mask 2 . Gown, gloves, and mask if splashing with body fluids is likely 3 . Gown, gloves, mask, and placement into a negative-pressure room 4 . Only handwashing is needed ANS: 2 Standard precautions should be followed when handling any body fluids and blood. An N-95 mask and a negative-pressure room are not necessary. Handwashing is always recommended, but it should be accompanied by other precautions if contact with body fluids or blood is likely. PTS:1DIF:Apply REF: Human Immunodeficiency Virus Infection: Planning and Implementation 11.A client receiving treatment for human immunodeficiency virus infection is demonstrating signs of resistance to the medication. Which of the following does this suggest to the nurse? 1 . The medication dosages need to be increased. 2 . The client needs to be taken off all medication. 3 . The client needs additional medication to treat side effects. 4 . The client is not adhering to the prescribed medication schedule. ANS: 4 Resistance to medication prescribed to treat human immunodeficiency virus infection can develop if the client does not adhere to the dose schedule for each drug. Resistance to the medication does not mean the dosages need to be increased. The client should not be taken off all medication. Signs of resistance to the medication are not the same as side effects. PTS:1DIF:Analyze REF:Human Immunodeficiency Virus Infection: Pharmacology 12.A client diagnosed with rheumatoid arthritis receives a prescription for indomethacin. Which of the following statements by the client would indicate the need for further instruction about this medication? 1 . I have to let my doctor know if I need to start blood pressure medications. 2 . I have to make sure I get my kidneys tested as scheduled. 3 . I need to get my eyes checked regularly. 4 . This medication shouldnt upset my stomach. ANS: 4 Indomethacin can cause nausea, dyspepsia, gastrointestinal pain, diarrhea, vomiting, constipation, and flatulence. This is the statement that would indicate the need for further instruction about this medication. The client should regularly have her eyes, kidneys, and liver checked for impairment. PTS:1DIF:Analyze REF: Table 42-2 Examples of Drugs Used for RA Therapy 13.The nurse is providing discharge instructions to a client diagnosed with systemic lupus erythematosus (SLE). Which of the following would not be including in these instructions? 1. Activity will need to be decreased during an exacerbation. 2. Body temperature should be monitored. 3. Corticosteroid treatment must be slowly tapered off. 4. Sunbathing decreases symptoms. ANS: 4 Exposure to sunlight exacerbates the disease process. Body temperature should be monitored for increases and possible infection. Corticosteroid treatment cannot be abruptly stopped. Activity with rest periods should be encouraged. PTS:1DIF:Apply REF:Systemic Lupus Erythematosus: Planning and Implementation 14.A client is scheduled for a bone marrow transplant from cells that were donated by his identical twin. The nurse realizes that the type of transplant this client is planning would be: 1. syngeneic. 2. autologous. 3. allograft. 4. apheresis ANS: 1 A syngeneic transplant uses bone marrow donated by an identical twin. An autologous transplant is the removal of bone marrow cells from the individual; the cells are treated and stored and then returned after the individual receives intensive chemotherapy or radiation. Allograft refers to cells and tissue obtained from the same species who has a similar type or cell compatibility. Apheresis is a procedure used to treat autoimmune disorders. PTS: 1 DIF: Analyze REF: Graft-versus-Host Disease MULTIPLE RESPONSE 1.The nurse is instructing a client on the modes of transmitting the human immunodeficiency virus infection. Which of the following can transmit this infection? (Select all that apply.) 1. Blood 2. Breast milk 3. Emesis 4. Saliva 5. Semen 6. Sweat ANS: 1, 2, 5 HIV can be transmitted only under specific conditions that permit contact with infected body fluids. Common high-risk sources are infected blood via contaminated needlestick or sharp object, contact with infected breast milk, mucous secretions (vaginal, semen), and exposure to blood in the laboratory. HIV is not transmitted through tears, saliva, urine, emesis, sputum, feces, or sweat. PTS:1DIF:Apply REF:Human Immunodeficiency Virus Infection: Epidemiology 2.A client diagnosed with human immunodeficiency virus infection is prescribed antiretroviral Group 1 medications. Which medications are included in Group 1? (Select all that apply.) 1. Enfuvirtide (Fuzeon) 2. Ziduvudine (AZT) 3. Didanosine (Videx) 4. Abacavir (Ziagen) 5. Ritonavir (Norvir) 6. Saquinavir (Fortovase) ANS: 2, 3, 4 Ziduvudine (AZT), didanosine (Videx), and abacavir (Ziagen) are all Group 1 medications. Ritonavir (Norvir) and Saquinavir (Fortovase) are protease inhibitors or medications within Group 2. Enfuvirtide (Fuzeon) is a fusion inhibitor or a Group 3 medication. PTS: 1 DIF: Analyze REF: Box 42-3 Antiretroviral Drug Classifications 3.The nurse suspects a client is experiencing rheumatoid arthritis when which of the following are assessed? (Select all that apply.) 1. Morning stiffness lasting more than 1 hour 2. Arthritis of three or more joint areas 3. Arthritis of the hand joints 4. Symmetrical arthritis 5. Nodules over bony prominences 6. Bruising ANS: 1, 2, 3, 4, 5 Findings consistent with rheumatoid arthritis include morning stiffness lasting more than 1 hour, arthritis of three or more joint areas, arthritis of the hand joints, symmetrical arthritis, nodules over bony prominences, presence of serum rheumatoid factions, and radiographic changes. Bruising is not a finding consistent with rheumatoid arthritis. PTS:1DIF:Analyze REF: Box 42-4 The American College of Rheumatology Criteria for Diagnosis of RA 4.The nurse is planning care for a client diagnosed with rheumatoid arthritis. Which of the following should be included in this plan of care? (Select all that apply.) 1. Muscle strengthening exercises 2. Range-of-motion exercises 3. Application of heat 4. Application of cold 5. Joint massage 6. Yoga ANS: 1, 2, 3, 4, 6 Interventions proven to help clients diagnosed with rheumatoid arthritis include muscle strengthening exercises, range-of-motion exercises, application of heat, application of cold, and yoga. Actual massage of the joints can aggravate the inflammation. PTS:1DIF:Apply REF: Rheumatoid Arthritis: Planning and Implementation 5.A client is diagnosed with progressive systemic sclerosis. Which of the following will the nurse most likely assess in this client? (Select all that apply.) 1. Telangiectasia 2. Sclerodactyly 3. Difficulty swallowing 4. Painful cold hands and fingers 5. Small white calcium deposits under the skin 6. Hematuria ANS: 1, 2, 3, 4, 5 In progressive systemic sclerosis, the skin, muscle, joints, lungs, esophagus, heart, digestive system, and kidneys are often affected in the diffuse subcutaneous form, often termed as CREST. Clinical manifestations include calcinosis, or small white calcium deposits under the skin; Raynauds syndrome, or painful cold hands and fingers; alteration in esophageal movement, or difficulty swallowing; sclerodactyly of the fingers and toes; and telangiectasia or permanent dilation of the capillaries, arterioles, and venules. Hematuria is not seen in this disorder. Chapter 4. Fluid, Electrolyte, and Acid-Base Balance Problems MULTIPLE CHOICE 1.The nurse is concerned that a client can become dehydrated when which of the following is assessed? 1. History of arthritis 2. Appendicitis diagnosis 3 years ago 3. Age 30 4. Obese female ANS: 4 An adult female has 50% of body weight that is fluid. Adipose cells contain less fluid than other cells. Females have more fat cells than males. Overweight people have less body fluid than thin people. A history of arthritis and appendicitis does not predispose the client to dehydration. PTS:1DIF:AnalyzeREF:Fluid Balance 2.A client has lost a significant amount of blood. The nurse realizes that the fluid compartment most effected with the blood loss will be: 1. intracellular. 2. interstitial. 3. intravascular. 4. transcellular. ANS: 3 Intravascular fluid is the fluid in the bloodstream. Intracellular fluid is the fluid inside each cell. Interstitial fluid is the fluid between cells. Transcellular fluid is the fluid outside all of the other fluid compartments, and it includes cerebrospinal fluid, joint fluid, and fluid within the gastrointestinal tract. PTS:1DIF:AnalyzeREF:Fluid Balance 3.A client is diagnosed with chronic renal failure. Which of the following electrolytes should the nurse monitor for this client? 1. Hydrogen 2. Phosphorus 3. Calcium 4. Vitamin D ANS: 1 The kidneys contribute to the regulation of electrolyte levels. Two electrolytes regulated by the kidneys are hydrogen and bicarbonate. The kidneys do not directly influence a clients phosphorus level. The kidneys affect calcium by activation of vitamin D; however, the kidneys do not regulate calcium levels. Vitamin D is not an electrolyte. PTS: 1 DIF: Analyze REF: Control of Fluid and Electrolyte Balance 4.A client had a 2 kg weight loss in one day. The nurse realizes this change in weight is due to: 1. fluid loss. 2. poor appetite. 3. medications. 4. bed rest. ANS: 1 A weight loss of more than 0.5 kg over 24 hours generally is the result of fluid loss and not of body mass. The client would not lose 2 kgs of body weight because of poor appetite, medications, or bed rest. PTS:1DIF:Analyze REF:Fluid Imbalances: Assessment with Clinical Manifestations 5.A client has a serum sodium level of 129 mEq/L. The nurse should prepare to administer which of the following intravenous solutions? 1. Dextrose 5% and Lactated Ringer 2. Dextrose 5% and 0.45% Normal Saline 3. 0.9% Normal Saline 4. Dextrose 5% and 0.9% Normal Saline ANS: 3 Normal saline (0.9%) is commonly provided to restore extracellular fluid volume and increase sodium levels. Dextrose 5% and Lactated Ringers, Dextrose 5% and 0.45% Normal Saline, and Dextrose 5% and 0.9% Normal Saline are hypertonic solutions, and they will move water from the cells into the bloodstream. PTS:1DIF:Apply REF: Table 12-3 Isotonic IV Solutions; Table 12-4 Hypertonic IV Solutions 6.A client is diagnosed with fluid volume excess. Which of the following will the nurse most likely assess in this client? 1. Poor skin turgor 2. Jugular vein distention 3. Dry mouth 4. Increased heart rate ANS: 2 Excess fluid in the intravascular space causes an elevation in blood pressure, and increased jugular venous pressure may be visible in distended neck veins. Poor skin turgor, dry mouth, and increased heart rate are findings consistent with fluid volume deficit. PTS:1DIF:Apply REF:Fluid Volume Excess: Assessment with Clinical Manifestations 7.A client is demonstrating dizziness and lightheadedness upon standing. The nurse is concerned the client is experiencing postural hypotension when which of the following is assessed? 1 . Lying BP 120/70 mmHg, P 70; standing BP 116/78 mmHg, P 78 2 . Lying BP 116/64 mmHg, P 62; standing BP 94/58 mmHg, P 78 3 . Lying BP 130/80 mmHg, P 84; standing BP 118/72 mmHg, P 90 4 Lying BP 126/74 mmHg, P 74; standing BP 108/62 mmHg, P 84 . ANS: 2 A decrease in systolic blood pressure of more than 20 mmHg when going from lying to standing, along with an increase in heart rate of 10 beats per minute or a decrease in diastolic blood pressure of more than 10 mmHg, along with a 10 beats per minute increase in heart rate, is considered postural hypotension. The other vital sign measurements do not support the criteria for postural hypotension. PTS:1DIF:Analyze REF:Fluid Imbalances: Assessment with Clinical Manifestations 8. The nurse assesses a client to have mild pitting edema of the lower extremities. The nurse would document this finding as being: 1. 0+. 2. 1+. 3. 2+. 4. 3+. ANS: 2 Mild pitting edema is documented as being +1. No pitting edema would be documented as 0+. Moderate pitting edema would be documented as 2+. Moderately severe pitting edema would be documented as 3+. PTS: 1 DIF: Apply REF: Figure 12-4 Pitting Edema Grading Scale 9. An elderly client is demonstrating new signs of confusion. Which of the following should the nurse consider when caring for this client? 1. Assess for signs of elevated sodium level. 2. Restrict fluids. 3. Administer prescribed diuretic medication. 4. Monitor daily weights. ANS: 1 Elderly clients who develop a new onset of confusion should have their serum sodium levels checked for an elevated serum sodium level. Restricting fluids, administering diuretics, and monitoring daily weights are all interventions appropriate for a client with a low-serum sodium level. PTS:1DIF:Apply REF:Excess Sodium Ion: Assessment with Clinical Manifestations 10.A client diagnosed with hypokalemia should have which of the following electrolytes also assessed? 1. Sodium 2. Calcium 3. Bicarbonate 4. Magnesium ANS: 4 Clients with hypokalemia often have concurrent hypomagnesemia. Hypokalemia is resistant to treatment unless the hypomagnesemia is corrected. Sodium, calcium, and bicarbonate changes are not associated with hypokalemia. PTS:1DIF:Apply REF: Deficient Potassium Ion: Planning and Implementation 11.A client is diagnosed with hypophosphatemia. The nurse realizes that this electrolyte imbalance is most likely associated with: 1. diabetes mellitus. 2. congestive heart failure. 3. arthritis. 4. chronic alcoholism. ANS: 4 A diet deficient in phosphorous may cause hypophosphatemia and reduced absorption of phosphorous occurs with chronic alcoholism. Hypophosphatemia is not associated with diabetes mellitus, congestive heart failure, or arthritis. PTS: 1 DIF: Analyze REF: Deficient Phosphorus Ion: Etiology 12.A client diagnosed with chronic renal failure is experiencing muscle weakness, paresthesias, and depression. Which of the following do these assessment findings suggest to the nurse? 1. Hyperkalemia 2. Hyponatremia 3. Hypocalcemia 4. Hypermagnesemia ANS: 4 Signs and symptoms of hypermagnesemia are similar to those seen with hypercalcemia and include paresthesias, muscle weakness, anorexia, nausea, diminished bowel sounds, and constipation. Confusion, depression, lethargy, and coma can also occur. Muscle weakness, paresthesias, and depression are not seen in hyperkalemia, hyponatremia, or hypocalcemia. PTS:1DIF:Analyze REF:Excess Magnesium Ion: Assessment with Clinical Manifestations 13.A client begins rapid breathing and demonstrates anxiety after learning of a diagnosis of breast cancer. After a short while, the client complains of tingling lips and fingers. Which of the following should the nurse do to assist this client? 1 . Provide oxygen. 2 . Coach the client in the use of an incentive spirometer. 3 . Help the client slow the respiratory rate or breathe into a paper bag. 4 . Administer intravenous fluids. ANS: 3 With the clients rapid respirations, too much carbon dioxide is being excreted. This leads to alkalosis. Symptoms of respiratory alkalosis include tingling of the lips and fingers. If the client is unable to control the respiratory rate, the nurse may have the client breathe into a paper bag, which forces the rebreathing of carbon dioxide. Providing oxygen, using an incentive spirometer, and intravenous fluids is not going to help correct the clients rapid respiratory rate and respiratory alkalosis. PTS:1DIF:ApplyREF:Respiratory Alkalosis MULTIPLE RESPONSE 1.A client is diagnosed with hyponatremia. Which of the following assessment findings would cause the nurse to become concerned? (Select all that apply.) 1. Confusion 2. Poor appetite 3. Restlessness 4. Lethargy 5. Seizures 6. Coma ANS: 1, 3, 4, 5, 6 The change in osmolality that occurs with hyponatremia causes fluid to shift into the intracellular space. Signs and symptoms associated with an expanded intracellular compartment include confusion, restlessness, lethargy, seizures, and coma. Poor appetite is not an assessment finding of hyponatremia. PTS:1DIF:Analyze REFeficient Sodium Ion: Assessment with Clinical Manifestations 2.After reviewing a clients most recent electrocardiogram, the nurse suspects the client is experiencing hyperkalemia. Which of the following did the nurse assess on the clients rhythm strip? (Select all that apply.) 1. Tall peaked T-waves 2. Short QRS complex 3. Dysrhythmias 4. Wide QRS complex 5. Bradycardia 6. Tachycardia ANS: 1, 3 Tall peaked T-waves and dysrhythmias are seen on the electrocardiogram of a client experiencing hyperkalemia. The other choices are not seen with hyperkalemia. PTS: 1 DIF: Analyze REF: Excess Potassium Ion: Diagnostic Tests 3.A client has a serum potassium level of 2.9 mEq/L. Which of the following should be done to assist this client? (Select all that apply.) 1. Implement continuous cardiac monitoring. 2. Check for an elevated ST segment. 3. Assess muscle strength, tone, and reflexes. 4. Monitor digoxin levels. 5. Monitor for seizure activity. ANS: 1, 3, 4 Interventions for a patient with hypokalemia are continuous cardiac monitoring; assessing for flattening T-waves; monitoring for digoxin toxicity, which may cause dysrhythmias; and assessing muscle strength, tone, and reflexes. Seizure activity is a sign of a sodium imbalance. PTS:1DIF:Apply REF: Deficient Potassium Ion: Assessment with Clinical Manifestations 4.Which of the following assessment techniques can the nurse use to determine if a client is experiencing hypocalcemia? (Select all that apply.) 1. Allen test 2. Chvosteks sign 3. Percussion of the abdomen 4. Auscultation of the lungs 5. Trousseaus sign 6. Palpation of the neck ANS: 2, 5 Trousseaus sign is assessed by inflating a blood pressure cuff for up to 4 minutes and assessing for hand spasms as a sign of hypocalcemia. Chvosteks sign is done by tapping on the facial nerve and assessing for a spasm of the facial muscle on the same side as evidence of hypocalcemia. The Allens test, percussion of the abdomen, auscultation of the lungs, and palpation of the neck are not performed specifically for hypocalcemia. PTS:1DIF:Apply REFeficient Calcium Ion: Assessment with Clinical Manifestations 5.A client is diagnosed with a serum calcium level of 11.2 mEq/L. Which of the following interventions would be appropriate for this client? (Select all that apply.) 1. Administer diuretics as prescribed. 2. Restrict fluids. 3. Administer intravenous fluids as prescribed. 4. Continuous cardiac monitoring. 5. Administer intravenous sodium as prescribed. 6. Change to a low fat diet. ANS: 1, 3, 4, 5 Management of hypercalcemia is focused on removing calcium, which is accomplished by administering diuretics, administering intravenous fluids, and administering intravenous sodium. Continuous cardiac monitoring is needed for clients at risk for developing dysrhythmias. Restricting fluids and changing to a low-fat diet are not used to treat hypercalcemia. PTS: 1 DIF: Apply REF: Excess Calcium Ion: Planning and Implementation 6.Which of the following components of the arterial blood gas will the nurse focus when on determining a clients acid-base status? (Select all that apply.) 1. pH 2. PO2 3. PCO2 4. HCO3 5. O2 Sat 6. Hgb ANS: 1, 3, 4 Interpretation of the clients acid-base status involves the evaluation of three components of the arterial blood gas: pH, PCO2 and HCO3-.. PO2 and O2 Sat are not used to evaluate the clients acid-base status. Hgb level is not a component of the arterial blood gas. Chapter 5. Safety and Infection Control MULTIPLE CHOICE 1.The nurse, assessing a clients leukocyte level, determines the amount to be within normal limits. Which of the following would indicate a normal level of leukocytes in the clients blood? 1. 14 to 18 g/dL 2. 4.6 to 6.2 million/mm3 3. 4500 to 11,000 mm3 4. 50 to 60 percent ANS: 3 The normal amount of leukocytes or white blood cells in the blood is 4500 to 11,000 mm3. The value of 14 to 18 g/dL is the normal hemoglobin level. The value of 4.6 to 6.2 million/mm3 represents the normal amount of red blood cells. The value of 50 to 60 percent represents a normal neutrophil level. PTS: 1 DIF: Analyze REF: Leukocytes 2.A clients complete blood count reveals a large amount of phagocytic cells present. The nurse realizes that this type of cell is most likely: 1. basophils. 2. eosinophils. 3. monocytes. 4. neutrophils. ANS: 4 Monocytes are phagocytic but in a smaller amount than neutrophils. Basophils are stimulated by allergens and eosinophils by parasites. Neutrophils are the chief phagocytic cells and are present in larger numbers as a response to early inflammation. PTS: 1 DIF: Analyze REF: Leukocytes 3.According to assessment findings, the nurse determines that a client is experiencing an inflammatory process. Which of the following did the nurse assess in this client? 1. Redness, swelling, heat, and pain 2. Reduced urine output 3. Thirst 4. Elevated blood pressure and slow heart rate ANS: 1 The symptoms of the inflammatory process are redness, swelling, heat, and pain. Reduced urine output, thirst, elevated blood pressure, and slow heart rate are not symptoms of the inflammatory process. PTS: 1 DIF: Analyze REF: Signs of Inflammation 4.A client is diagnosed with a bacterial infection. Which of the following is an example of this type of infection? 1. Malaria 2. Gastroenteritis 3. Urinary tract infection 4. Typhus ANS: 3 Urinary tract infections are caused by bacteria. Malaria and gastroenteritis are caused by protozoa. Typhus is caused by rickettsia. PTS: 1 DIF: Understand REF: Table 11-3 Types of Agents Causing Disease 5.A client is diagnosed with gastroenteritis. The nurse realizes that this illness occurs from which type of disease-causing organism? 1. Bacteria 2. Fungi 3. Protozoa 4. Viruses ANS: 3 Protozoa are single-cell parasitic organisms that form cysts or spores. Diseases caused by protozoa include malaria and gastroenteritis. Hepatitis A, B, and C are examples of a disease caused by a virus. Pneumonia and urinary tract infections are examples of diseases caused by bacteria. Ringworm is an example of a disease caused by fungi. PTS: 1 DIF: Analyze REF: Table 11-3 Types of Agents Causing Disease 6.A client has been diagnosed with Rocky Mountain spotted fever. The causative organism for this disease process is: 1. bacteria. 2. helminth. 3. mycoplasma. 4. rickettsia. ANS: 4 Rocky Mountain spotted fever is caused by the infectious organism rickettsia. Disease processes from bacteria, helminths, and mycoplasma include urinary tract infections, tapeworm infection, and pneumonia, respectively. PTS: 1 DIF: Understand REF: Table 11-3 Types of Agents Causing Disease 7. Which of the following will the nurse most likely assess in a client diagnosed with asthma? 1. Wheezing and anxiety 2. Barking cough and increased blood pressure 3. Bradycardia and restlessness 4. Anemia and hypoxia ANS: 1 Common symptoms in asthma include wheezing, anxiety, cough, shortness of breath, tachycardia, restlessness, increased blood pressure, and hypoxia. Barking cough, bradycardia, and anemia are not common symptoms of asthma. PTS: 1 DIF: Analyze REF: Asthma: An Allergic Disease 8. The nurse would expect that a client diagnosed with arthritis will be prescribed which of the following medications? 1. Albuterol 2. Furosemide 3. Ibuprofen 4. Nortriptyline ANS: 3 Nonsteroidal anti-inflammatory drugs (NSAIDs) and cortisol drugs are common treatments for arthritis. Albuterol relaxes bronchial smooth muscle. Furosemide is a loop diuretic, and nortriptyline is an antidepressant. PTS: 1 DIF: Analyze REF: Arthritis 9.A client is being admitted to a health care facility. Which type of precautions will the nurse implement at this time? 1. Airborne 2. Contact 3. Droplet 4. Standard ANS: 4 Standard precautions are actions used with all clients. Transmission-based precautions such as airborne, contact, and droplet are used when a client is known or suspected of having a communicable disease. PTS:1DIF:ApplyREF:Standard Precautions 10.A client diagnosed with tuberculosis is scheduled for a chest x-ray to be completed in the radiology department. Which of the following devices should be utilized when transporting this client? 1. Face shield with mask and gown 2. N-95 mask 3. Surgical mask 4. Patient does not need to wear a device ANS: 3 For a client diagnosed with tuberculosis, transport out of the room should only be done when absolutely necessary and the client should wear a surgical mask during transport. A face shield, gown, or N-95 mask are not needed to transport this client. PTS:1DIF:ApplyREF:Airborne Precautions 11.The nurse is preparing to administer medications to a client diagnosed with varicella. Which of the following personal protective equipment should the nurse use when entering the clients room? 1. Face shield with mask and gown 2. Gloves and gown 3. A high-efficiency particulate air filter mask 4. Surgical mask ANS: 3 A high-efficiency particulate air filter mask is required personal protective equipment for the care of a client with varicella. A mask may be worn for clients on droplet precautions, and the gown and gloves are for a client on contact precautions. PTS:1DIF:ApplyREF:Airborne Precautions 12.A client is diagnosed with venous leg ulcers. The nurse would expect that these wounds will heal by which of the following types of intention? 1. Primary 2. Secondary 3. Tertiary 4. Quaternary ANS: 2 Primary intention type of healing occurs in wounds that are clean, and have little loss of tissue. Secondary intention occurs when a wound heals by spread of granulation tissue from the base of a wound. Venous leg ulcers heal by secondary intention. In tertiary intention, the wound must be sutured through several layers of granulation tissue in order to bring closure. Quaternary is not a type of wound healing. PTS: 1 DIF: Analyze REF: Types of Wound Healing 13.The nurse is using the Braden Scale to determine a clients risk for developing a pressure ulcer. Which of the following areas are assessed with this scale? 1. Home environment 2. Finances 3. Medications 4. Friction and shear ANS: 4 The Braden Scale is used to assess a clients risk for developing a pressure ulcer. This scale assesses the areas of sensory perception, moisture, activity, mobility, nutrition, and friction and shear. Home environment, finances, and medications are not assessed with the use of this scale. PTS: 1 DIF: Apply REF: Table 11-7 Elements in Braden Pressure Scale MULTIPLE RESPONSE 1. The nurse is identifying nursing diagnoses for a client experiencing inflammation. Which of the following diagnoses would be appropriate for this client? (Select all that apply.) 1. Risk for infection 2. Thermoregulation: Ineffective 3. Ineffective coping 4. Pain: Acute 5. Nutrition: Imbalanced, less than body requirements 6. Anxiety ANS: 1, 2, 4, 5 Nursing diagnoses appropriate for a client experiencing inflammation include risk for infection; thermoregulation: ineffective; pain: acute; and nutrition: imbalanced, less than body requirements. Ineffective coping and anxiety are not diagnoses appropriate for a client with an inflammation. PTS: 1 DIF: Apply REF: Nursing Response: Inflammation 2. The nurse is determining the route of transmission for an infectious organism. Which of the following are types of transmission routes? (Select all that apply.) 1. Ingestion 2. Vector-borne 3. Common vehicle 4. Airborne 5. Droplet 6. Contact ANS: 2, 3, 4, 5, 6 There are five types of transmission routes: 1) contact, 2) droplet, 3) airborne, 4) common vehicle, and 5) vector-borne. Ingestion is not a type of transmission route. PTS: 1 DIF: Analyze REF: Infectious Disease Control 3. The nurse is determining when gloves should be worn when providing client care. Which of the following situations would necessitate the wearing of gloves? (Select all that apply.) 1. In contact with blood 2. In contact with mucous membranes 3. Delivering a meal tray 4. Providing medications 5. Measuring urine output 6. Suctioning oral secretions ANS: 1, 2, 5, 6 Gloves should be worn when in contact with blood, body fluids, secretions, excretions, contaminated items, mucous membranes, and nonintact skin. Gloves are not needed when delivering a meal try or providing medications. PTS:1DIF:Analyze REF: Table 11-4 Summary of the Updated Centers for Disease Control and Prevention Isolation Guidelines 4. The nurse is concerned that a client will experience delayed wound healing when which of the following is assessed? (Select all that apply.) 1. Prescribed a beta-blocker medication 2. Poor appetite 3. Ambulating in the room several times a day 4. Age 85 5. Prescribed steroids 6. Skin warm and dry ANS: 1, 2, 4, 5 Risk factors for delayed wound healing include ischemia, medications such as beta-blockers, smoking, exposure to cold, repetitive injury, altered nutrition infection, anti-inflammatory steroids, and older age. Ambulating in the room several times a day may encourage wound healing. Skin warm and dry will not delay wound healing. PTS:1DIF:Analyze REF: Table 11-6 Risk Factors for Delayed Wound Healing 5. The nurse is planning care for a client with a chronic wound. Which of the following principles should be reflected in this clients care? 1. Debridement 2. Restrict fluids 3. Provide moist environment 4. Prevent further injury 5. Maintain on bed rest 6. Nutrition ANS: 1, 3, 4, 6 The four principles of chronic wound management include debridement, provide moist environment, prevent further injury, and nutrition. Restricting fluids and maintaining on bed rest are not principles of chronic wound management. Chapter 6. Respiratory Problems MULTIPLE CHOICE 1.A child is diagnosed with severe allergic rhinitis. Which of the following manifestations would the nurse most likely assess in this client? 1. Edematous neck glands 2. Reduced hearing 3. Pruritis 4. Frequent wiping of the nose with the palm of the hand ANS: 4 Frequent wiping of the nose with the palm of the hand is one symptom seen in the client diagnosed with severe allergic rhinitis. Edematous neck glands, reduced hearing, and pruritis are not manifestations of severe allergic rhinitis. PTS:1DIF:Analyze REF:Allergic Rhinitis: Assessment with Clinical Manifestations 2.A client tells the nurse that she experiences a stuffy nose, nasal pain, and postnasal drip every time she works in her companys office. Which of the following types of allergic rhinitis is this client most likely experiencing? 1. Infectious 2. Perennial 3. Occupational 4. Seasonal ANS: 3 Occupational allergic rhinitis occurs from airborne substances in the workplace. Seasonal allergic rhinitis occurs during a specific time of the year. Perennial allergic rhinitis occurs in response to exposure to environ