Test Bank for Medical-Surgical Nursing Critical Thinking in Client Care, 4th Edition Priscilla LeMon | Complete Guide 2023/2024

Test Bank for Medical-Surgical Nursing Critical Thinking in Client Care, 4th Edition Priscilla LeMon | Complete Guide 2023/2024. The physician has ordered for the nurse to obtain a sputum specimen. The nurse understands that the sputum specimen should be collected: 1. Immediately after the first dose of antibiotic is administered. 2. 30 minutes after the first dose of antibiotics is administered. 3. During the first dose of antibiotics. 4. Before the first dose of antibiotics is administered. Answer: 4 Rationale: When the physician orders a specimen to be collected, the nurse should collect the specimen before the first dose of antibiotics is administered, to ensure adequate organisms for culture. Cognitive Level: Comprehension Client Needs: Safe, Effective Care Environment Nursing Process: Planning 10. Which of the following manifestations indicates a systemic reaction associated with an inflammatory response? 1. Erythema 2. Pain 3. Tachypnea (RR 26) 4. Edema Answer: 3 download full file at Rationale: If the nurse observes a systemic reaction, the client will exhibit manifestations including temperature, increased pulse, tachypnea, and leukocytosis. Erythema, warmth, pain, edema, and functional impairment indicate a local reaction. Cognitive Level: Application Client Needs: Physiological Integrity Nursing Process: Assessment 11. A client develops hyperthermia related to a diagnosis of Pneumonia. Which of the following nursing interventions would be effective in the treatment of hyperthermia? Select all that apply. 1. Increase the temperature of the room environment to prevent shivering. 2. Use ice packs and a tepid bath as needed. 3. Administer antipyretic medications per physician’s orders. 4. Promote frequent rest periods to increase energy reserve. 5. Restrict fluids during periods of hyperthermia because of the risk of electrolyte imbalance. Answer: 2; 3; 4 Rationale: Hyperthemia is an expected consequence of the infectious disease process. Fever can produce mild, short-term effects or, when prolonged, can cause lifethreatening effects. The nurse should administer antipyretic medications as indicated for elevated temperatures. The nurse should use ice packs, cool/tepid baths, or hypothermia blanket with caution. The nurse should enforce frequent rest periods because rest increases energy reserve, which is depleted by an increased metabolic, heart, and respiratory rate. The nurse should encourage fluids rather than restrict fluids because of the risk of electrolyte imbalance. Cognitive Level: Assessment Client Needs: Physiological Integrity Nursing Process: Implementation 12. The nurse is assessing a client’s wound for signs and symptoms of inflammation. Which of the following would alert the nurse that the client is exhibiting signs of inflammation? Select all that apply. 1. Leg edema 2. Leg cool to touch 3. Severe pain from swelling download full file at 4. Decreased peripheral pulses 5. Severe erythema of leg Answer: 1; 3; 5 Rationale: Regardless of the cause, location, or extent of the injury, the acute inflammatory response follows the sequence of vascular response, cellular and phagocytic response, and healing. Many manifestations of inflammation are produced by inflammatory mediators such as histamines and prostaglandins released when tissue is damaged. The cardinal signs of inflammation include erythema, local heat caused by the increased blood flow to the injured area (hyperemia), swelling due to accumulated fluid at site, pain from tissue swelling and chemical irritation of nerve endings, and loss of function caused by the swelling and pain. Cognitive Level: Application Client Needs: Physiological Integrity Nursing Process: Assessment Alternate item format – Select all that apply Which of the following manifestations would the nurse expect to see with a client who has had previous knee surgery who suffered a surgical infection with signs of systemic manifestations? Select all that apply. 1. Erythema 2. WBC 14,200 mm3 3. Pain at the surgical site 4. 10% Bands 5. Respiratory rate of 16 6. Pulse 114 Answer: 2; 3; 6 Rationale: The client is post–surgical repair of the knee. The nurse should be able to distinguish between local reactions and system reactions. An elevated WBC and 10% bands are indicative of an infection. Vital sign changes typically associated with an infection include an elevation in temperature and tachycardia. Local manifestations include erythema, warmth, pain, edema, and functional impairment, whereas systemic manifestations include elevated temperature above 100.4°F, pulse greater than 90/min., respiratory rate greater than 20, and WBC greater than 12,000 mm3 or > 10% bands. Cognitive Level: Application download full file at Client Needs: Physiological Integrity Nursing Process: Assessment Chapter 2 1. When collecting data at the immunization clinic, which of the following disclosures by the client would cause the nurse to hold administration of the varicella vaccine? a. History of an allergic reaction to yeast bread b. Itching and swelling on the face and hands after ingesting eggs c. A low grade temperature within the past two days d. A blood transfusion after undergoing surgery three months ago Answer: d Rationale: Contradictions for the varicella vaccine include pregnancy, suppressed immunity, and a recent history of a blood transfusion. Recent hyperthermia and allergies to yeast or eggs do not indicate a potential difficulty with the administration of the varicella vaccine. Nursing Process Step: Assessment Client Needs Category: Health Promotion and Maintenance Client Needs Subcategory: Prevention and/or Early Detection of Health Problems Cognitive Level: Analysis 2. The nurse is planning an in-service to discuss primary levels of disease prevention. Which of the following topics should be included in this presentation? a. A discussion concerning the use of available community rehabilitation facilities b. Available locations for diabetes screening c. The need for annual colonoscopy examinations d. The elimination of smoking and alcohol use Answer: d Rationale: Primary prevention involves activities geared toward the prevention of illness and disease. Screening activities such as glucose testing and colonoscopy examinations are a form of secondary prevention. Rehabilitation activities are considered a tertiary level of prevention. Nursing Process Step: Planning Client Needs Category: Health Promotion and Maintenance Client Needs Category: Prevention and/or Early Detection of Health Problems download full file at Cognitive Level: Application 3. A 45-year-old client voices concerns about gaining 12 pounds over the past two years. The client reports no change in dietary habits. Which response by the nurse is most appropriate? a. “Age-related changes in metabolism can result in weight gain despite consistent dietary intake.” b. “Are you exercising?” c. “You might be eating more than you think.” d. “You are getting older.” Answer: a Rationale: A reduction in metabolic rate often accompanies aging. This will cause weight gain despite not eating more calories. Asking the client about exercise fails to provide the needed information to the client. It also assumes the client is sedentary. Implying the client is overeating is judgmental, and will do little to establish a therapeutic rapport. The client is aware of aging. Pointing this out does little to meet the client’s obvious interest in more information. Nursing Process Step: Diagnosis Client Needs Category: Physiological Integrity Client Needs Category: Physiological Adaptation Cognitive Level: Application 4. The nurse is assisting an 18-year-old female client to plan a healthy diet to support recent weight loss. Which of the following should be included in the dietary plan? Select all that apply. a. 200 mg folic acid are recommend in the daily diet. b. Eat at least six servings of grains. c. To avoid constipation, keep daily iron intake below 21 mg. d. Fat intake should be limited to less than 30% of the daily caloric intake. Answer: b; d Rationale: Grain intake should include at least six servings daily. To maintain a healthy weight and reduce incidence of cardiovascular disease, fat intake should not exceed 30% of the daily intake. Folic acid intake should be at 400 mg daily. Iron is a vital ingredient in the daily diet. 18 mg daily is reflective of the desired amount. Constipation should be managed by an adequate fluid and fiber intake. Nursing Process Step: Planning Client Needs Category: Health Promotion and Maintenance Client Needs Subcategory: Prevention and/or Detection of Early Health Problems download full file at Cognitive Level: Application 5. During a routine physical examination for a 52-year-old Caucasian male, the client declines to have his prostate gland examined. He states he does not have a family history and does not feel he is at risk. What initial response by the nurse is most appropriate? a. “You may refuse any screening test you wish.” b. “I will need to tell the physician about your refusal.” c. “Your risk factors increase with aging.” d. “You are right, Caucasian men have less incidence of prostate cancer.” Answer: c Rationale: The need for prostate screening begins at age 50. Individuals with risk factors should begin screening at age 45. The client’s age places him at an increased risk, so he should begin the screening process. While the client may refuse any testing, this does not allow the client to engage in secondary levels of prevention. The client’s refusal should be recorded in the medical record but not used as a means to coerce the client. Nursing Process Step: Implementation Client Needs Category: Health Promotion and Maintenance Client Needs Subcategory: Growth and Development through the Lifespan Cognitive Level: Analysis 6. The nurse is preparing to teach a class for a group of new parents. The nurse is attempting to determine what topic would be of the greatest interest to the audience. What selection would be most appropriate? a. Safety b. Chronic illness prevention c. Problem-solving skills d. Interventions to manage depression Answer: a Rationale: The parents of small children are interested in information geared toward keeping them safe. Household safety is a priority for children of all ages. The families attending the session likely will have limited interest in preventing illness, as they typically represent a healthy segment of the population. Depression is a greater concern for older adults. Nursing Process Step: Assessment Client Needs Category: Health Promotion and Maintenance Client Needs Subcategory: Growth and Development through the Lifespan Cognitive Level: Analysis