Chapter 03: Overview of Health Concepts for
Medical-Surgical Nursing
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse in the emergency department (ED) is caring for four clients. Which client
does the nurse assess for gas exchange abnormalities first?
a. Involved in motor vehicle crash, has broken femur.
b. Brought in unconscious by roommate after opioid overdose.
c. Asthmatic client being discharged after bronchodilator therapy.
d. History of COPD, presents to ED after being bitten by a dog.
ANS: B
Opioid medications can cause respiratory depression, so this client is most at risk for
gas exchange problems. Diminished respirations will allow a buildup of carbon
dioxide in the blood. The clients with asthma and COPD have the potential for gas
exchange problems but this is not indicated in answer option as he or she is being
discharged. The client with a broken femur does not have information suggesting gas
exchange problems.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment
KEY: Gas exchange, Risk factors MSC: Client Needs
Category: Safe and Effective Care Environment: Management of Care
2. The nurse caring for a client with malnutrition assesses which laboratory value as the
priority?
a. Albumin
, b. Prealbumin
c. Prothrombin time
d. Serum sodium
ANS: B
Both albumin and prealbumin are indicators for nutrition. However, prealbumin
changes more rapidly with decreased nutrition, so it is the better test. Prothrombin
time and serum sodium are not directly related to nutritional status.
DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment
KEY: Nutrition, Laboratory values
3. A nurse is planning primary prevention measures for community-dwelling adults to
prevent visual impairment. What action by the nurse will best meet this objective?
a. Provide glaucoma screening.
b. Assess visual acuity.
c. Teach clients about instilling eyedrops.
d. Offer a healthy lifestyle class.
ANS: D
Primary prevention activities are those designed to actually prevent the onset of a
disease or health problem. Secondary prevention focuses on screening and early
diagnosis/detection. Tertiary measures are those that offer treatment and
rehabilitation. Encouraging a healthy lifestyle through classes may help prevent
diabetes, a common cause of visual impairment, and is a primary prevention measure.
Assessing for glaucoma and visual acuity is a secondary prevention measure.
Teaching clients how to instill eyedrops is tertiary.
DIF: Applying TOP: Integrated Process: Nursing Process: Planning
KEY: Sensory perception, Health teaching MSC: Client Needs
Category: Health Promotion and Maintenance
Medical-Surgical Nursing
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse in the emergency department (ED) is caring for four clients. Which client
does the nurse assess for gas exchange abnormalities first?
a. Involved in motor vehicle crash, has broken femur.
b. Brought in unconscious by roommate after opioid overdose.
c. Asthmatic client being discharged after bronchodilator therapy.
d. History of COPD, presents to ED after being bitten by a dog.
ANS: B
Opioid medications can cause respiratory depression, so this client is most at risk for
gas exchange problems. Diminished respirations will allow a buildup of carbon
dioxide in the blood. The clients with asthma and COPD have the potential for gas
exchange problems but this is not indicated in answer option as he or she is being
discharged. The client with a broken femur does not have information suggesting gas
exchange problems.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment
KEY: Gas exchange, Risk factors MSC: Client Needs
Category: Safe and Effective Care Environment: Management of Care
2. The nurse caring for a client with malnutrition assesses which laboratory value as the
priority?
a. Albumin
, b. Prealbumin
c. Prothrombin time
d. Serum sodium
ANS: B
Both albumin and prealbumin are indicators for nutrition. However, prealbumin
changes more rapidly with decreased nutrition, so it is the better test. Prothrombin
time and serum sodium are not directly related to nutritional status.
DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment
KEY: Nutrition, Laboratory values
3. A nurse is planning primary prevention measures for community-dwelling adults to
prevent visual impairment. What action by the nurse will best meet this objective?
a. Provide glaucoma screening.
b. Assess visual acuity.
c. Teach clients about instilling eyedrops.
d. Offer a healthy lifestyle class.
ANS: D
Primary prevention activities are those designed to actually prevent the onset of a
disease or health problem. Secondary prevention focuses on screening and early
diagnosis/detection. Tertiary measures are those that offer treatment and
rehabilitation. Encouraging a healthy lifestyle through classes may help prevent
diabetes, a common cause of visual impairment, and is a primary prevention measure.
Assessing for glaucoma and visual acuity is a secondary prevention measure.
Teaching clients how to instill eyedrops is tertiary.
DIF: Applying TOP: Integrated Process: Nursing Process: Planning
KEY: Sensory perception, Health teaching MSC: Client Needs
Category: Health Promotion and Maintenance
