Test Bank Introduction Medical Surgical Nursing 6th Edition, Linton
Chapter 01: The Health Care System
1. An 89-year-old man, who was recently discharged from a rehabilitation hospital because of an inability to concentrate and frequent memory lapses, cannot be left alone while his family works. What options should the discharge planning team suggest that will satisfy safety concerns and give the greatest quality of life to the patient?
a. Placement in a day care center from 8 AM to 5 PM daily
b. Placement in a long-term psychiatric facility
c. Placement in a high-security nursing home
d. Admission to a general hospital for evaluation
2. A 66-year-old hospitalized patient is anxious about how the physician will be paid now that he is on Medicare Parts A and B, instead of his previous privately funded insurance plan. Who should the nurse explain is the payor to the physician on this plan?
a. Previous privately funded insurance plan
b. Medicare Part A
c. Medicare Part B
d. Patient or patient’s family
3. What health care plan is the best referral for an unemployed 42-year-old patient with renal failure who has lost his job-related private insurance?
c. Public health facility
d. Community-based outpatient clinic
4. A patient with terminal lung cancer with extensive metastasis is requesting a hospice transfer. What criteria are included as requirements for this transfer?
a. The patient requests and agrees to the guidelines of hospice care without requiring a physician’s order.
b. The physician confirms that the patient has 6 months or less of life remaining and has provided a written order for hospice care.
c. Proof confirms that the family can no longer care for the patient at home.
d. The patient’s specific diagnosis is included on a list of accepted diseases that qualifies the patient for hospice care.
5. A patient admitted yesterday with a diagnosis-related group (DRG) diagnosis of abdominal pain of an unknown cause is being discharged this afternoon because all diagnostic test results have been negative. What does this scenario exemplify?
a. Effective laboratory response
b. Medicare guidelines limiting hospital stay
c. Cost containment related to a DRG diagnosis
d. Patient who should not have been admitted in the first place
6. A nurse is discussing discharge to a transitional subacute facility with a 72-year-old patient diagnosed with diabetes and bilateral leg amputation. What should the nurse inform the patient regarding the stay in the new facility?
a. It will be limited to 25 days.
b. It will be limited to 50 days.
c. It will be limited to 75 days.
d. It is totally unlimited.
7. A patient is applying for Medicaid. What does the receipt of benefits require?
a. Following a supervised health maintenance plan
b. Enrolling in the Medicare-Preferred Drug Plan
c. Qualifying for the food stamp program
d. Having an annual income of less than $10,000
8. Which is true concerning proprietary agencies?
a. They are organized to be nonprofit operations.
b. They are organized to make a profit on their operation.
c. Any profit they make is immediately used to purchase better equipment and services.
d. They must participate in Medicare.
9. Which patient should the nurse recognize as eligible for a referral to Medicaid?
a. Military automobile mechanic with severe asthma
b. Pregnant unmarried young woman employed at a discount retail store for 3 years
c. College student on scholarship who works part-time at the college library and who needs medication for arthritis
d. Unemployed young mother on welfare who needs diabetic medication for one of her children
10. Why was the Balanced Budget Act of 1997 the cause of closures of many proprietary home health care agencies?
a. It specified that all care be given by registered nurses (RNs).
b. It listed specific diagnoses that could qualify a patient for home health care.
c. It limited the amount of money that could be spent on a patient.
d. It increased the criteria for patient eligibility for home care.
Chapter 02: Nursing in Varied Patient Care Settings
1. While a home health nurse is making the entry to a service assessment on a home-bound patient, the spouse of the patient asks whether Medicare will cover the patient’s ventilator therapy and insulin injections. What is the best response by the nurse?
a. “Yes, Medicare will cover both the ventilator therapy and the insulin injections.”
b. “No, Medicare will not cover either of these ongoing therapies.”
c. “Medicare will cover the ventilator therapy, but it does not cover the insulin injections.”
d. “Medicare will cover the ongoing insulin therapy, but it does not cover a highly technical skill such as ventilator therapy.”
2. The wife of a patient asks the nurse whether her husband would be considered for placement in a skilled nursing care facility when he is discharged from the general hospital. The patient is incontinent, has mild dementia but is able to ambulate with a walker, and must have help to eat and dress himself. What is the nurse’s most appropriate response?
a. “Yes, your husband would qualify for a skilled care facility because of his inability to feed and dress himself.”
b. “No, your husband’s disabilities would not qualify him for a skilled facility.”
c. “Yes, your husband qualifies for placement in a skilled care facility because of his dementia.”
d. “Yes, anyone who is willing to pay can be placed in a skilled nursing facility.”
3. A nurse has noted that a newly admitted resident to an extended care facility stays in her room, does not take active part in activities, and leaves the meal table after having eaten very little. The nurse should analyze this relocation response as
b. social withdrawal.
d. passive aggressive.
4. A nurse clarifies to a new patient in a rehabilitation center what rehabilitation means. What statement made by the patient indicates a correct understanding?
a. “I will return to my previous level of functioning.”
b. “I will be counseled into a new career.”
c. “I will develop better coping skills to accept his disability.”
d. “I will attain the greatest degree of independence possible.”
5. A nurse assesses a patient who needs to be reminded to take premeasured oral medications, wash, go to meals, and undress and come to bed at night, but coming and going as he pleases is considered safe for him. What facility placement would be most appropriate for this patient?
a. Skilled care
b. Intermediate care
c. Sheltered housing
d. Domiciliary care
6. A nurse is making a list of the members of the rehabilitation team so the different types of services available to patients may be taught to a group of families. Which lists should be used?
a. Physical therapist, nurse, family members, and personal physician
b. Occupational therapist, dietitian, nurse, and patient
c. Rehabilitation physician, laboratory technician, patient, and family
d. Vocational rehabilitation specialist, patient, and psychiatrist
7. A nurse explains the level of disability to a patient who was injured in a construction accident that resulted in the loss of both his right arm and right leg. This loss has affected his quality of life and ability to return to previous employment. At what level should the client be classified as being disabled?
8. A nurse explains that in 1990, the Americans with Disabilities Act (ADA) was passed. For which extended services for the disabled persons did this act provide?
a. Covering the costs for the rehabilitation of disabled World War I servicemen by providing job training
b. Extending protection to the disabled in the military sector, such as wheelchair ramps on military bases
c. Extending protection to the disabled in private areas, such as accessibility to public restaurant bathrooms and telephones
d. Affording disabled persons full access to all health care services
9. A frail patient in a long-term care facility asks the nurse if a bath is to be given this morning. What is the best reply by the nurse to encourage independence and give the patient the most flexibility?
a. “Based on your room number, you get bathed on Monday, Wednesday, and Friday. Today is Tuesday.”
b. “If you want to eat breakfast in the dining room with the others, you may sponge yourself off in your bathroom.”
c. “When your daughter comes this evening, ask her if she can give you a bath.”
d. “I will bring a basin of water for a sponge off for right now. After breakfast, we will talk about a bath schedule.”
10. A computer programmer who lost both legs is being retained by his employer, who has made arrangements for a ramp and a special desk to accommodate the patient’s wheelchair. What is the disability level of the computer programmer?
Chapter 03: Legal and Ethical Considerations
1. A good friend of a licensed practical/vocational nurse (LPN/LVN) confides that she is in a serious romantic relationship with a man the LPN/LVN had as a patient when he was diagnosed with the human immunodeficiency virus (HIV). The policies of the Health Insurance Portability and Accountability Act (HIPAA) prevent the nurse from warning her friend. What is this situation considered?
a. Moral dilemma
b. Moral uncertainty
c. Moral distress
d. Moral outrage
2. A nurse reminds a resident in a long-term care facility that he has autonomy in many aspects of his institutionalization. What is an example of autonomy?
a. Selection of medication times
b. Availability of his own small electrical appliances
c. Smoking in the privacy of his own room
d. Application of advance directives
3. How might an LPN/LVN exhibit beneficence?
a. Remove defective equipment from the patient’s room.
b. Willingly work extra shifts during a staff shortage.
c. Adhere to agency policy.
d. Join the National Association for Practical Nurse Education and Service (NAPNES) and attend educational seminars.
4. An LPN/LVN is educating a group of nursing students regarding values demonstrated in their nursing practice. Where will the LPN/LVN indicate the base of these values is derived?
a. Nursing school education
b. Family influence
c. Peer relationships
d. Agency policies
5. One obstetric nurse remarks, “I don’t see how these young single women can keep on having babies without being married. Everyone knows a child needs a father.” What is this nurse exhibiting?
b. Moral uncertainty
c. Values clarification
d. Professional concern
6. A nursing student asks the instructor to define the philosophic stand of utilitarianism. What example should the instructor provide?
a. An army officer sacrifices six paratroopers to save 100 prisoners of war.
b. A priest burns down his church because it was defiled by Satanists.
c. A mother jumps off a cliff with her baby to avoid being captured by Indians.
d. A soldier murders captured enemies to prevent their divulging military secrets.
7. An LPN/LVN explains to a patient that the hospital has an institutional ethics committee. What is the main function of this committee?
a. Preside over policy implementation.
b. Revoke the license of someone who violates the law.
c. Solve personnel disputes.
d. Ensure that hiring adheres to ethnic equality.
8. An LPN/LVN charts that “the patient is drunk and acting in a crazy manner.” The team leader cautions the LPN/LVN that this documentation is not appropriate. What charges of commission of the intentional tort is this an example of?
b. Wrongful publication
c. Defamation of character
d. Invasion of privacy
9. When an LPN/LVN assists an older woman to stand after a fall in a shopping mall parking lot, the woman twists and sprains her ankle. What protects the LPN/LVN from litigation or an unintentional tort?
a. Hospital malpractice insurance
b. Good faith agreement
c. Good Samaritan law
d. Personal professional insurance
10. An LPN/LVN trimmed the toenails of a patient with diabetes too short, which results in a toe amputation from infections. What is the LPN/LVN guilty of?
a. Unintentional tort
b. Intentional tort
Chapter 04: The Leadership Role of the Licensed Practical Nurse
1. A licensed practical/vocational nurse (LPN/LVN), as a regular staff member, knows all the patients and anticipates many of their needs. Other staff members are comfortable asking for advice. The advice is given freely with a clear explanation or demonstration or both. In what role is this nurse acting?
a. Self-appointed teacher
b. Management-assigned instructor
c. Informal leader
d. Designated supervisor
2. A case conference is called to plan for a patient who has caused stress in the staff with constant calls and trivial requests. The nurse leader expresses personal views when leading the discussion about approaches to the problem and then makes the decision for care based on the discussion. What type of leadership style does this exemplify?
3. From what source does an LPN/LVN receive authority to delegate care to unlicensed personnel?
a. Physician or registered nurse (RN) who hired them
b. National Nurse Practice Act
c. 1994 Entry Level Competencies Report
d. Nurse practice act of the individual state
4. When staff members complain about being pulled to other areas to work without prior notice, the leader agrees with their request to develop a more effective system and does so with assistance and input from the entire staff. Which leadership theory does this exemplify?
5. An LPN/LVN in charge of two units on the evening shift notices that two of the nursing assistants (NAs) are constantly bickering. This appears to be interfering with patient care time. Both units are extremely busy with care needs. Which solution best reflects the process of accommodation?
a. Their issues are trivial and do not affect patient care actions. No time is presently available for extended discussions. Send one of the NAs to another area and allow time for both to defuse. Good patient care in an expedient manner is the priority at this time.
b. Call the supervisor to send the arguing dissenters home.
c. Call the dissenters into the office. Listen to their concerns and make a decision about the resolution of their trivial matters.
d. Allow the NAs to leave the building and settle their differences before they come back. Make no notation of their absence on their timesheets or in the report.
6. A team leader is preparing to type the evening shift report. Which comment should be included in the report?
a. Patient A complained of a headache until his wife arrived to visit. She was 20 minutes late because of unavoidable traffic.
b. Patient B ate everything on her dinner tray—roast beef, mashed potatoes, and green beans—and the dessert, too, which is her usual pattern.
c. Patient C was so restless that the dressing on her sacrum came off and had to be replaced. No change occurred in the assessment of the decubitus.
d. Patient D had her usual visitors. She is sleeping after her regular evening medications, which were given as ordered at 2000.
7. A director of nursing in a long-term care facility appoints an LPN/LVN to be project head to coordinate a review of end-of-shift reporting times and to develop a new, more timely format for the entire agency to use. What is the role of the LPN/LVN?
a. Goal-setting organizer
b. Organizing leader
c. Assigned manager
8. A head nurse puts a blank copy of the shift duty schedule on the table in the break room. The staff is permitted to fill in the shifts that they want to work during the next cycle. What leadership style does this reflect?
9. A team leader is making out the patient care assignment. A new patient needs several extensive dressing changes for open diabetic wounds, a nasogastric (NG) tube feeding, and irrigation of the Foley catheter as needed. Which member of the care team is best suited for this assignment?
a. Nurse aide A, who has had 10 years’ experience working at this facility, especially because this room is on the hall area where this NA is usually assigned
b. Nurse aide B, who has just been employed but has recently been through the state nurse aide certificate program and needs the experience of these treatment modalities
c. Nurse aide C, who is always asking for something new to try out and who is attending LPN/LVN school in off-duty hours
d. LPN/LVN C because these treatments are covered under the LPN/LVN state practice act
10. The role of the LPN/LVN as a team leader has been developed to broaden and improve patient care. Which statement best reflects this role implementation?
a. As LPN/LVN team leaders, these nurses are totally and only personally responsible, under the terms of licensure, for personal care actions and the nursing actions of the others assigned on their units and shifts.
b. As an LPN/LVN team leader, this nurse, under the supervision and guidance of an RN, is responsible for all aspects of patient care that is assigned to this team.
c. As an LPN/LVN team leader, this nurse uses skills and judgments learned in school to guide and direct the team members in what the nurse believes is correct patient care. The LPN/LVN is accountable only to patients for the care provided.
d. The team leader LPN/LVN decides on patient care assignments, takes care to promote accident prevention and safety, and is accountable only to self-professionalism for the nursing actions of the team.
Chapter 05: The Nurse-Patient Relationship
1. A nurse is preparing an anxious patient for major surgery and remarks, “Everyone feels some anxiety, but you will be asleep during the whole thing.” Which communication style does this exemplify?
c. False reassurance
d. Premature advice
2. A nurse is explaining a pamphlet called the “Patient Care Partnership” to a patient and family. Who should the nurse indicate created this pamphlet?
a. The Joint Commission
b. Medicare/Medicaid Act
c. Social Security Act
d. American Hospital Association
3. A nurse is discussing the discharge plan with a recovering patient. What is the most effective communication technique for this nurse to implement?
a. Assess nonverbal clues.
b. Allow communication to focus on whatever topic the patient desires.
c. Insist on postrecovery activities as stated in the care plan.
d. Reduce eye contact to convey nondirective attitudes.
4. A 6-year-old child is brought to the Public Health Clinic Building to receive immunizations for the beginning of school. What is the proper classification for the recipient of this service?
5. A patient says, “I am sick of being sick.” What is the most therapeutic response?
a. “I can’t believe you really feel that way.”
b. “I don’t think that attitude is very helpful.”
c. “I think you sound pretty frustrated.”
d. “I want you to feel more positive.”
6. On returning to the nurse’s station, a licensed practical/vocational nurse (LPN/LVN) discovers that the daughter of a frail but competent resident is reading her mother’s chart. The woman says, “I am entitled to see my mother’s medical record.” What is the nurse’s best response?
a. “What is it that you believe you need to know? Give me the chart.”
b. “You must understand that only your mother has the right to read the contents of her medical record. Please give me the chart.”
c. “Although the chart itself is not available to you to read, I would be glad to try to answer any questions you have. May I have the chart, please?”
d. “Reading that chart is a very serious violation of your mother’s privacy. I cannot allow you to see it. Please put down the chart.”
7. A PN/VN student is assigned to a patient who makes homosexual remarks and asks the student to meet after discharge. What is the student’s best response?
a. “I am required to report inappropriate sexual behavior to my instructor.”
b. “I am uncomfortable dealing with homosexuals. Let’s just forget this conversation and get on with your care as quickly as possible.”
c. “I am here as your nurse to meet your treatment needs. Such provocative conversation is not acceptable to me as part of your care.”
d. “Your chosen lifestyle makes me uncomfortable. I will be back with your medication.”
8. A patient with newly diagnosed cancer states, “I can’t stand to think about chemo.” What is the most therapeutic response?
a. “What about chemo concerns you?”
b. “Chemo is so much better than it used to be.”
c. “Wow! I can sure understand that!”
d. “Have you had chemo before?”
9. The families of patients expect their hospitalized member to receive holistic care. What characteristic is an example of provision of holistic care?
a. Providing safety with the side rails up
b. Providing only foods and drinks that are to the patient’s liking
c. Bathing at a time and manner that is specified by the patient
d. Including the family in the holistic approach
10. A nurse, as a unique person, brings to each practice-patient relationship qualities such as knowledge, experiences, strengths, and weaknesses. What is the inclusive term used to describe this phenomenon?
a. Personhood experiences
b. Physiologic influence
c. Sociologic influence
d. Use of self in nursing
Chapter 06: Cultural Aspects of Nursing Care
1. A home health nurse prepares to teach a Latino patient who neither speaks nor reads English how to measure and administer insulin. Which teaching tool should be the most helpful?
a. Booklet from the American Diabetes Association explaining the effects of too much or too little insulin
b. Nutrition pamphlet explanation discussing amounts of each food group needed each day
c. Alarm clock, magazine pictures showing sunrise and sunset, several clean insulin syringes, and insulin bottles filled with colored water
d. Large sheet explaining the need for washing hands, times, amounts of insulin to inject, and the nurse’s home phone number
2. A young Asian wife of a businessman recently transferred to the United States is brought to the hospital for an emergency appendectomy. The nurses make every effort to plan correct care. Which term best describes the integration of cultural concepts into the nursing care plan?
a. Assimilation of culture
b. Cultural diversity
c. Enculturation of the patient
d. Transcultural nursing
3. A nurse is clearing the bedside area to give a bed bath to a Muslim woman the day after a cesarean section. What action should the culturally sensitive nurse implement?
a. Pick up and move the copy of the Koran so it will not be soiled with bath water.
b. Ask the patient to remove the taviz to prevent it from being touched by a non-Muslim.
c. Offer a quiet time after the bath for prayer.
d. Be especially protective of her modesty.
4. A nurse is caring for a young woman who is a member of the Church of Jesus Christ of Latter Day Saints (Mormon).What should be offered as an appropriate snack by the nurse?
a. Juice and cookies
b. Tea and a piece of fruit
c. Coffee and a cinnamon roll
d. Cola drink and chips
5. Two licensed practical/vocational nurses (LPN/LVNs) are colleagues on the same medical-surgical floor. They went to the same LPN/LVN school. When on break time, they discuss the holistic entries of the nursing care plans they are helping create. What does this behavior exemplify?
6. At the request of the family, an instructor makes an assignment change for a black male student who had been assigned to take care of a postpartum Muslim woman. What is the most likely reason that the request was made by the family?
a. Muslim culture does not allow black practitioners to care for women.
b. Muslim culture prefers that women health care providers care for Muslim women.
c. The husband will be present, and he will object.
d. After childbirth, all care must be performed by women.
7. A severely injured man is brought into the emergency department after an automobile accident and is given two units of O-negative blood while waiting for a cross-match to be completed for the other 4 units of blood that the physician has ordered. The nurse discovers a card identifying the man as a Jehovah’s Witness. What is the most appropriate nursing action?
a. Inform the laboratory to hold the process on typing and crossmatching the 4 units of blood.
b. Call the hospital administration to obtain a court order to intervene.
c. Inform the physician that the patient is a Jehovah’s Witness.
d. Remove all tourniquets and cardiac monitoring devices.
8. A nurse is leading a discussion with a group of residents of a Jewish long-term care facility. When discussing dietary laws and other religious practices, what should the nurse anticipate as the most prominent need of these patients?
a. Fasting every Friday night from sunset until sunset on the following Saturday and not taking them to the dining room
b. Having a quiet time for prayer provided before and after all meals
c. Serving meat and milk products at the same time but on separate plates
d. Allowing Jewish men to shave before their Sabbath
9. A Filipino man is admitting his elderly mother to a long-term care facility for custodial care. During the intake interview, the man is alternately tearful and defensive. To what Filipino belief does the culturally competent nurse assess this labile behavior as being related?
a. Medical facilities are a place of death.
b. Families should care for the older family members at home.
c. His language barrier is causing him to be misunderstood.
d. Such facilities will limit visitations from the family.
10. A Japanese patient, hospitalized for arteriosclerotic heart disease and hypertension, is allowed to have a regular diet with cultural provisions of Asian food. A diuretic, antibiotic, bronchodilator, and vasodilator have been prescribed. Which medication would be hampered by an Asian diet?
Chapter 07: The Nurse and the Family
1. What is the primary reason that family is an important unit in society?
a. Offers unconditional love and acceptance
b. Provides emotional support and security
c. Is essential to life and society
d. Promotes cultural values and attitudes
2. What should a nurse assess when a patient comes from an extended family?
a. Multiple wage earners
b. Three generations living together
c. Children from previous marriages
d. Parents of different ethnic origins
3. What type of families is most prevalent in the United States according to the latest Census Bureau report?
4. In what type of family are children of racial minorities most likely to belong?
5. A nurse is designing a home care plan for a child with a congenital disease and is assessing the family values regarding home care. What is the best resource for the nurse to use?
a. Current literature on congenital deformities
b. General knowledge of the culture
c. Patient’s family
d. Written survey
6. A nurse counsels a family regarding the stage of families with adolescents. Which developmental task is appropriate for the nurse to include?
a. Maintaining relationships with the extended family
b. Developing parental roles to meet the needs of children
c. Maintaining a satisfying marital relationship
d. Maintaining open communication between parent and children
7. Which developmental task should families master in later life?
a. Becoming role models for their grandchildren
b. Making a significant contribution to society
c. Abandoning the parental role to grown children
d. Maintaining a satisfactory living arrangement
8. Culture and social class usually set a precedent for different roles and responsibilities of each family member. Which example best demonstrates the healthiest family?
a. The father assumes the role as breadwinner.
b. The mother assumes the role as homemaker.
c. The father or mother shares the roles of breadwinner and homemaker.
d. The roles of breadwinner or homemaker can be shifted as needed.
9. During a family counseling session, a patient, a mother of a 5-year-old son, states, “I don’t understand why my husband continually tries to get our son involved in T-ball. My son said the coach and his dad yelled at him and told him the game was lost because he couldn’t catch the ball.” What is the most important family interaction to maintain a healthy family unit?
a. Maintain open communication among all family members.
b. Encourage self-acceptance and self-esteem for all family members.
c. Encourage all family members to participate in community events.
d. Realize that not all family members may be able to fulfill assigned roles.
10. For the past three evenings, shortly after their arrival in the hospital unit, the parents of a 14-year-old daughter begin to argue about the cost of the hospitalization and the time required to come to the hospital. The patient begins to cry and complains about her abdominal pain. What role is the patient assuming?
Chapter 08: Health and Illness
1. What is the basis for the health–illness continuum?
a. Prevention of acute illness
b. Individual response to health or illness
c. Promotion of health and wellness
d. Variation in degree of health or illness
2. What is the current concern of the health care system?
a. Treating illness
b. Preventing illness
c. Promoting optimal function in the chronically ill
d. Caring for patients with acute and chronic illness
3. What is the traditional view of health?
a. Promotes optimal function
b. Views health and illness as separate concepts
c. Defines health as an absence of illness
d. Emphasizes the prevention of disease
4. What is the current view of health?
a. Promotes the highest quality of life possible, both mentally and socially
b. Includes mental, physical, social, and emotional adaptation to the environment
c. Includes the basic physiologic needs and self-actualization
d. Relies on alternative therapies for the treatment and cure of diseases
5. During the initial gathering of data, a patient reveals a weight loss of 17 lb since the death of his spouse 5 weeks earlier. He says that he is not sleeping and has no appetite. What category of unmet needs should be considered by the nurse according to Maslow’s hierarchy of needs?
b. Safety and security
c. Love and belonging
6. What is the major advantage of using Maslow’s hierarchy of needs when planning nursing care for patients?
a. Establishes a nursing diagnosis
b. Improves problem-solving techniques
c. Prioritizes patient care
d. Establishes priorities of care
7. A nurse points out that a physiologic response to stress involves the total body. Which syndrome is this considered?
a. General adaptation
b. Local adaptation
c. Negative feedback
d. Total adaptation
8. What are the ability to solve problems and to maintain self-confidence and the willingness to accept criticism incorporated in according to Maslow?
a. Safety and security
d. Love and belonging
9. A patient returning from surgery complains of incisional pain that is now rated 7 in intensity on the 1-to-10 pain scale. What should the nurse be aware that pain exemplifies?
a. General adaptation syndrome
b. Local adaptation syndrome
c. Counter-current response
d. Neuroendocrine response
10. A nurse clarifies that a neuroendocrine response involves both the autonomic nervous system and the endocrine system. Which syndrome is this considered?
a. Local adaptation
b. Total adaptation
c. Acute adaptation
d. General adaptation
Chapter 09: Nutrition
1. What two mechanisms does the regulation of the gastrointestinal system require?
a. Neural control and cardiovascular control
b. Secretion of hormones and kidney filtration
c. Neural control and secretions of hormones
d. Cardiovascular control and kidney filtration
2. The mouth and stomach are two areas of the gastrointestinal system in which the digestion of food occurs. What is the third area of the gastrointestinal system in which digestion of food occurs?
a. Large intestine
b. Small intestine
3. What is formed after food is masticated, swallowed, and mixed with gastric secretions in the stomach?
4. The stomach is normally emptied in 1 to 4 hours, depending on the amount and kind of food eaten. Which foods, when eaten separately, leave the stomach most rapidly?
5. What is the name of the sphincter that prevents the backflow of the food mass from the duodenum into the stomach?
6. Into what do the villi absorb the nutrients from the small intestine?
a. Large intestine
b. Blood and liver
c. Gallbladder and liver
d. Lymph and kidneys
7. Which carrier protein is responsible for absorption of vitamin B12?
b. Intrinsic factor
c. Hydrochloric acid
8. Where does the digestion of carbohydrates begin?
d. Small intestine
9. Where does most digestion of protein begin?
c. Small intestine
d. Large intestine
10. Where is the major portion of fat digested?
c. Small intestine
d. Large intestine
Chapter 10: Developmental Processes
1. What should a nurse take into consideration regarding developmental tasks when planning patient care?
a. All of the activities performed throughout life
b. Activities learned primarily in the middle years of life
c. Things to be learned and accomplished in each stage of life
d. All actions taken when confronted with specific problems
2. An unmarried 21-year-old patient is admitted to the hospital. During his hospitalization, he has visitors from work and church who come and go continuously. What part of the developmental process of young adults does this display?
a. Young adults require many superficial relationships.
b. Young adults do not require much rest for recovery.
c. Young adults are socially oriented.
d. Young adults need to combat loneliness.
3. What does intimacy accomplish when developed in a relationship?
a. Allows for sexual expression
b. Gives priority to the well-being of another over one’s own
c. Guarantees a suitable setting for the selection of a partner
d. Requires exclusion of all others
4. Which behavior is not characteristic of a young adult’s developmental task?
a. Living in his or her own apartment
b. Accepting a place on the board of a community agency
c. Interacting with a large group of friends
d. Dating many different young women
5. What should young adults be thinking about by the age of 35 years?
a. Leaving home and establishing their own lives
b. Establishing career goals
c. New career paths
d. Health promotion for the prevention of chronic disease
6. A 25-year-old man receives a tetanus booster. When should the nurse instruct the man to get his next booster?
a. Next year
b. In 2 years
c. In 5 years
d. In 10 years
7. What is the major cause of death in young adults?
a. Cervical and testicular cancer
b. Overwhelming infection
c. Accidents and violence
d. Human immunodeficiency virus (HIV)
8. An 18-year-old patient reports to the nurse that she has been sexually active since the age of 15 years and uses oral contraceptives regularly. What is the priority diagnostic test for this patient?
b. Digital rectal examination
c. Papanicolaou (Pap) stain/test
d. Pregnancy test
9. What age group is balancing work and other roles as a developmental task?
a. Middle adulthood
b. Young adulthood
c. Older adulthood
d. Late adulthood
10. What age range defines middle adulthood?
a. 45 to 65 years
b. 20 to 35 years
c. 65 to 75 years
d. 30 to 50 years
Chapter 11: The Older Patient
1. How is the term old age or aged best defined?
a. Person’s state of mind
b. Person older than 65 years of age
c. Process of growing older
d. Person of advanced age
2. How is aging recognized by gerontologists as a developmental process?
a. Measured in chronologic years
b. Directly related to heredity
c. Related to behavioral characteristics
d. Begins at the time of birth
3. What understanding is a prerequisite for a nurse working with the geriatric patient?
a. Specialized knowledge is needed.
b. Geriatric patients are physically impaired.
c. Most geriatric patients will develop dementia.
d. Geriatric patients need to be closely supervised.
4. A 78-year-old resident of a long-term care facility insists on wearing high heels and miniskirts to the dining room for meals and will not leave her room without first applying glamorous makeup. What should the gerontologic nurse assess as the reason for this behavior?
a. Insecurity about her appearance
b. Trying to cope with the changes of aging
c. Denial concerning her advancing age
d. Her fashion consciousness
5. What does Butler, a well-known gerontologist, relay regarding ageism?
a. It dehumanizes older individuals.
b. It is based on the biologic theory of aging.
c. It is based on natural and purposeful occurrences.
d. It continues to change as the population ages.
6. What are the effects of aging on the nervous system?
a. Accelerated loss of neurons in the brain
b. Gradually declining loss of intellectual capability
c. Decreased conduction speed of neurons
d. Loss of long-term memory
7. A nurse is caring for older adult patients with mild cognitive impairment (MCI). What are these patients more likely to develop?
a. Dementia, non-Alzheimer type
b. Alzheimer dementia
c. Parkinson disease
d. Psychotic disorders
8. What is the most appropriate nursing action when planning activities to improve short-term memory for an older adult patient experiencing memory deficits?
a. Maintain the same daily schedule.
b. Rehearse memory training.
c. Provide a varied and stimulating daily schedule.
d. Conduct deep-breathing exercises.
9. What is the best example of normal memory change or lapse of memory?
a. Relying on another person to remember names or important events
b. Occasional forgetfulness or inability to recall names or facts
c. Difficulty in recalling recent events
d. Difficulty in recalling past events
10. Which facts are generally accepted for most older adults?
a. Intellectual capabilities are impaired.
b. Functional brain activities decrease.
c. Functional intellectual capability is maintained.
d. Creativity and judgment are severely impaired.
Chapter 12: The Nursing Process and Critical Thinking
1. What is the primary purpose of incorporating the nursing process into the care of patients?
a. Establish a basis of communication with other nursing staff members.
b. Maintain compliance with existing national nursing standards.
c. Provide structure and organization to the delivery of medical care to the patient.
d. Address current health issues, as well as health maintenance and rehabilitation.
2. What is the correct order of the five steps of the nursing process?
a. Data collection, nursing diagnosis, planning, intervention, and evaluation
b. Assessment, planning, documentation, intervention, and evaluation
c. Data collection, diagnosis, assessment, planning, and evaluation
d. History, physical, diagnosis, intervention, and evaluation
a. Medical diagnosis of the patient
b. Identified physiologic and psychologic needs of the patient
c. Standards of nursing care provided by the American Nurses Association
d. Orders of the primary care provider
4. Who is responsible for initiating the nursing care plan?
a. Primary care provider
b. Registered nurse (RN)
c. Licensed practical/vocational nurse (LPN/LVN)
d. Nurse manager
5. What is the most accurate statement about the patient plan of care?
a. It is continually reviewed and evaluated.
b. It must be reviewed by the primary caregiver.
c. It remains in effect until the patient is discharged.
d. It can only be changed by the initiating nurse.
6. What is the purpose of palpation?
a. Determining areas of tenderness
b. Differentiating between fluid- and air-filled organs
c. Hearing sounds produced by the body
d. Systematically approaching a physical assessment
7. A patient complains of a headache. What type of data is this information considered?
c. Pain assessment
8. A nurse notes the previous 24-hour urine output was 950 mL, well below the normal of 1500 mL. What is an effective nursing order to remedy the impending dehydration?
a. Offer more fluids daily.
b. Offer 8 oz of juice or water at 0800 (8 AM), 1200 (12 noon), 1600 (4 PM), and 2000 (8 PM).
c. Request extra fluid on a diet tray from the kitchen.
d. Place a large water pitcher at the bedside during each shift.
9. What sound should a nurse anticipate when percussing a patient’s abdomen?
10. Which documentation entry reflects objective data?
a. An area of erythema is noted on the upper right extremity, measuring approximately 1 ´ 4 inches.
b. The patient complains of pain in the right left quadrant (RLQ) of the abdomen and rates it 5 on a pain scale of 1 to 10.
c. The family states that the patient does not sleep at night and wanders around the house.
d. The medical history reveals a history of drug abuse.
Chapter 13: Immunity, Inflammation, and Infection
1. A patient in early labor says to the nurse, “I will pass on protection from diseases, and the baby will not ever need any shots.” What is the best response by the nurse?
a. “Babies are born with innate (natural) immunity at birth.”
b. “Babies are born with immunoglobulin E (IgE), an antibody that crosses the placenta, but it only briefly protects the baby.”
c. “Yes, immediate antibody immunity from the mother is the first line of defense against disease for babies.”
d. “Yes, the mother passes on cell-mediated immunity.”
2. A school nurse starts a clean-up campaign at a local elementary school in an effort to combat allergens. What is the most common allergic response disorder?
c. Contact dermatitis
3. A nurse is discussing the body’s first and second lines of defense against infection with a community group. What does the body’s first line of defense include?
c. White blood cells
d. T lymphocytes
4. A nurse explains that a medication given to a patient with a severe inflammatory response mimics a hormone secreted by the adrenal cortex. To what hormone is the nurse referring?
5. With the exposure to an antigen, a nurse explains that the initiator of the inflammatory response is the presence of histamine. What is responsible for releasing histamine?
6. A nurse is bathing a patient who is immunodeficient and has a Cryptococcus infestation. What is the classification of this organism?
7. A mosquito or a fly carries an organism that infects another living organism. What is this mode of transmission of infection?
a. Common vehicle
b. Direct excretion
8. What is the most effective method to control the spread of communicable disease?
a. Isolate the infected person from all contact with noninfected persons.
b. Vigorously petition the community health department to increase spraying.
c. Administer prophylactic antibiotics to the rest of the family.
d. Demonstrate and monitor a return demonstration of a good hand washing technique by the family.
9. An air conditioner duct cleaning is recommended by a home health nurse. What should this precaution prevent the spread of in the patient’s home?
10. A school nurse cautions a group of parents about children playing barefoot on dirt. To what infectious agents can this action expose the children?
Chapter 14: Fluids and Electrolytes
1. A nurse assesses that a patient’s urine has become much more concentrated. What is the most likely cause for the change?
c. Antidiuretic hormone (ADH)
2. When the water absorption in the renal tubules becomes greater than normal, what assessment finding should a nurse anticipate?
a. More concentrated urine
b. Less concentrated urine
c. More alkaline urine
d. Less alkaline urine
3. What process occurs when oxygen is directed out of the arteries and into the capillaries?
a. Active transport
4. A patient’s intravenous (IV) injection has been infusing at a very high rate. What assessment indicates fluid volume overload in this patient?
c. Pulmonary edema
d. Kidney failure
5. A small child is hospitalized with severe metabolic acidosis after ingesting a whole bottle of baby aspirin approximately 8 hours earlier. In addition to providing reassurance to the patient, which nursing action is the most appropriate?
a. Providing IV treatments as ordered but without sodium bicarbonate
b. Frequently assessing the mental and neurologic status
c. Taking daily weights and vital signs
d. Inducing vomiting
6. What is primarily responsible for carrying fluids with nutrients and wastes on a random basis throughout the body?
b. Extracellular fluid
c. Intracellular fluid
7. A nurse clarifies that electrolytes, such as sodium and potassium (K+), break down into smaller particles when dissolved. What are these smaller particles?
8. A nurse assists a patient with dyspnea to sit in a high Fowler position. What process allows gravity to help move oxygen from the pulmonary capillaries into the blood when the patient is in this position?
a. Active transport
9. A nurse evaluates the laboratory reports on electrolyte values carefully to assess the balance between positive and negative ions. What is responsible for the regulation of this process?
10. What is being administered when a nurse hangs an IV bag with Na+, K+, and Cl-?
Chapter 15: Pain Management
1. The length of time that a nurse should leave heat to an injured hip of a patient is no longer than:
a. 15 minutes.
b. 20 minutes.
c. 30 minutes.
d. 1 hour.
2. A patient with an extensive abdominal surgical procedure is assessed by the nurse as having predictable pain. How often should the nurse administer analgesics to this patient to be most effective?
a. As needed (PRN)
b. Once a day
c. Twice a day
d. Around the clock
3. What sympathetic responses to pain might be assessed by the nurse?
a. Increased blood pressure, increased pulse, and increased respiratory rate
b. Decreased blood pressure, decreased pulse, and increased respiratory rate
c. Increased blood pressure, decreased pulse, and increased respiratory rate
d. Decreased blood pressure, decreased pulse, and decreased respiratory rate
4. A health care provider has prescribed both heat and cold treatments for an older adult patient with a leg injury. The nursing care plan reflects secondary diagnoses of peripheral vascular disease (PVD), diabetes, and an allergy to latex. Which of the prescribed treatments should the nurse administer and why?
a. The nurse will use cold treatment because patients with diabetes and a latex allergy cannot tolerate heat.
b. The nurse will use cold treatment for this patient with a fracture because cold will help set the cast.
c. The nurse will use heat treatment because cold is contraindicated for patients with PVD.
d. The nurse will use heat treatment because heat will increase circulation and increase the threat of infection in the injured part.
5. A nurse notices that a patient seems calm and peaceful despite an assessment that the patient’s injuries might be causing severe pain. The patient tells the nurse that using yoga and meditation lessens the perceptions of pain to tolerable levels. Which other alternative intervention should the nurse suggest to help relax this patient for pain relief?
a. Indulging in a favorite food
b. Music by a favorite artist
c. Reading exciting science fiction
d. Self-administration of drugs
6. What intervention of pain control exemplifies the gate control methods of pain relief?
a. Assisting the patient to ambulate
b. Giving a massage
c. Providing an ice cold beverage
d. Instructing the patient in stretching exercises
7. To perform a nursing assessment correctly, a nurse must remember that pain perception involves several central nervous system (CNS) processes. Which are examples of CNS processes?
a. Afferent pathways carry messages to the spinal cord.
b. Efferent pathways stimulate the spinal cord to recognize the location of pain.
c. Nociceptors in the brain stimulate the spinal cord.
d. Pain receptors in muscle, skin, and subcutaneous tissue stimulate efferent pathways.
8. A nurse is teaching a patient how to use a transcutaneous electrical nerve stimulation (TENS) unit and how it works. What is the most appropriate information for the nurse to relay?
a. “The stimulation of the skin seeks to localize the acute pain and will last for several minutes after the unit is applied.”
b. “This unit stimulates both the skin and the underlying tissues to decrease the intensity of the pain.”
c. “The mechanism for use of this unit is well known and can be read.”
d. “During those days when using the TENS unit, no analgesic can be given.”
9. What should greatly reduce postoperative pain for a patient about to undergo a hip replacement?
a. Femoral nerve blocks
b. Extremely deep general anesthesia
c. Practicing leg lifting exercises before surgery
d. Placing an analgesic patch directly over the incision
10. A patient continues to report pain after the administration of the prescribed analgesic. Why should the nurse change the nursing care plan?
a. Patient’s pain threshold has risen.
b. Patient’s pain threshold has lowered.
c. Patient has become addicted.
d. Patient is seeking attention.
Chapter 16: First Aid, Emergency Care, and Disaster Management
1. What do changes in cardiopulmonary resuscitation (CPR) techniques as recommended by the American Heart Association (AHA) include?
a. Compress the chest 100 times a minute.
b. Depress the chest at least1 inch.
c. Before compressions, administer three strong breaths.
d. Elevate the patient’s hips.
2. Standing in a fast-food line, the person in front, while munching on a cookie, begins to cough heavily, takes deep inspirations, and waves his arms around wildly. What should be the nurse’s first action?
a. Start rescue breathing as quickly as possible.
b. Start chest compressions as quickly as possible.
c. Perform abdominal thrusts.
d. Do nothing at this point as long as air is exchanged.
3. What is the initial intervention for an unconscious patient who is not breathing according to one-person CPR principles, as taught and practiced by professional nurses?
a. Lift the jaw to clear the airway.
b. Call for assistance.
c. Start chest compressions.
d. Remove patient clothing to visualize the chest.
4. While ambulating, a patient gasps and drops to the floor unconscious with no pulse or respiration. When is the nurse aware that brain cells begin to die?
a. 1 minute
b. 2 minutes
c. 3 minutes
d. 4 minutes
5. A nurse comes upon a traffic accident. One passenger is lying on the ground by an open door. What should the nurse assess for first?
a. Uncontrolled bleeding
b. Circulation, airway, and breathing (CAB)
c. Abdominal deep wounds
d. Level of consciousness (LOC) and orientation
6. A nurse follows the protocol of SAMPLE when speaking to a victim of a fall in the parking lot of the hospital. What does the P stand for?
a. Pills taken today
b. Personal physician
c. Past illnesses
d. Preference for emergency transportation
7. What instructions should the nurse provide for immediate treatment for epistaxis?
a. “Stand still, lean your head back so that the blood won’t get all over everything, and pinch your nose shut for at least 10 minutes.”
b. “Stand still, lean your head forward, and pinch your nose tightly for at least 10 minutes.”
c. “Sit down on a solid surface, lean your head forward to let the blood run out, and then pinch your nose closed for at least 30 minutes.”
d. “Sit down on a solid surface, lean your head forward so you don’t choke on the blood, and pinch your nose shut for at least 10 minutes.”
8. Which condition may complicate the assessment of an older adult patient with a suspected head injury?
a. Sensory deficits
b. Slowed metabolism
c. Preexisting cerebral dysfunction
d. Decreased pulmonary function
9. A nurse is called on to assist a neighbor who needs first aid. What should the nurse know is the legal responsibility for this action?
a. Is legally bound to help in any way possible
b. Is expected to demonstrate the same skill, knowledge, and care that would be provided by other nurses in the same community with the same credentials
c. Has no legal responsibilities outside the hospital setting and would be held accountable for nothing
d. Can legally perform any aid skill, even those not allowed the nurse in the hospital
10. A nurse comes upon a traffic accident where injured, unconscious people are lying on the highway. What should the nurse be aware of regarding the sanctioning of first-aid interventions in this scenario?
a. Good Samaritan Act
b. Emergency Care Doctrine
c. Fifth Amendment
d. Liability Protection against Malpractice Act
Chapter 17: Surgical Care
1. A postoperative patient is complaining of incisional pain. An order has been given for morphine every 4 to 6 hours as needed (PRN). What should the nurse assess first?
a. Assess for the presence of bowel sounds.
b. Assess pupillary reaction.
c. Ask the patient’s family if she is having pain.
d. Determine when the patient last received pain medication.
2. A nurse is caring for a postoperative patient. What should the nurse ask when assessing for the complication of malignant hyperthermia?
a. “Do you think you might have a fever?”
b. “Do you currently have an infection?”
c. “Has anyone in your family ever had problems with general anesthesia?”
d. “Have you ever had any type of malignancy?”
3. A patient who had a hysterectomy yesterday has not been allowed food or drink by mouth (NPO). The physician has now ordered the patient’s diet to be clear liquids. What should the nurse assess prior to providing this patient with clear liquids?
a. Feelings of hunger
b. Bowel sounds
c. Positive Homans sign
d. Gag reflex
4. Which technique should a nurse implement when changing a postoperative dressing?
a. Enteric isolation
b. Aseptic technique
c. Clean technique
d. Respiratory isolation
5. A nurse is caring for a postoperative patient who has had spinal anesthesia. Which assessment is a priority for this patient?
a. Complaints of a headache
b. Pulse rate of 78 beats/min
c. Voided 300 mL
d. Blood pressure of 126/78 mm Hg
6. What should a nurse ensure that a postoperative patient implement to best prevent deep vein thrombosis (DVT)?
a. Splint the incision.
b. Cough and deep breathe every 2 hours.
c. Regularly remove antiembolism stockings.
d. Ambulate frequently.
7. During a nurse’s preoperative assessment, the nurse notices that a patient is extremely anxious. The patient’s blood pressure is 142/92 mm Hg, the heart rate is 104 beats/min, and respirations are 32 breaths/min. What nursing action should be implemented?
a. Give the preoperative medicine early to help calm the patient.
b. Call the surgical department and cancel the surgery.
c. Notify the anesthesiologist or surgeon.
d. Instruct the patient on possible postoperative complications.
8. A nurse is performing a postoperative assessment on a patient who has just returned from a hernia repair. The patient’s blood pressure is 90/60 mm Hg, and the apical pulse is 108 beats/min. What should be the nurse’s first action?
a. Check the dressing for bleeding.
b. Notify the registered nurse (RN).
c. Document the vital signs.
d. Increase the rate of infusion of intravenous fluids.
9. A postoperative patient who has no previous medical conditions is difficult to arouse when transferred to the surgical unit from the postanesthesia care unit. A nurse monitors the pulse oximeter and gets a reading of 85%. What should be the nurse’s next action?
a. Assess the pulse oximeter reading again in 1 hour.
b. Arouse the patient, have him cough, and encourage deep breathing.
c. Administer a dose of pain medication.
d. Suction fluid from the oral cavity.
10. A nurse has completed giving discharge instructions to a patient after a hernia repair. What verbalization by the patient should lead the nurse to determine that the patient understands the instructions?
a. Go back to work tomorrow.
b. Do not change the dressing until he sees his physician in 2 weeks.
c. Ignore changes in the size of his abdomen.
d. Report fever, redness, swelling, or increased pain at the incision site.
Chapter 18: Intravenous Therapy
1. In an assessment of a patient who has been receiving intravenous (IV) fluids for the past 6 hours, a nurse finds that the pulse is now bounding, the blood pressure is more than 15 mm Hg higher than the last reading, and pedal edema has developed. What should the nurse suspect?
a. Infiltration of the IV site
b. Vascular fluid volume excess
c. Pulmonary air embolism
d. Phlebitis of the leg veins
2. As part of a written standard protocol for the unit, a nurse adds that irrigation of an occluded cannula is not recommended. What is the rationale against performing this procedure?
a. It may damage a venous valve.
b. It may introduce an air embolus into the line.
c. It may cause the patient pain.
d. It may force blood clots into the main bloodstream.
3. What is a major advantage when medication is administered intravenously?
a. Better maintained at a therapeutic blood level
b. Less expensive than oral route
c. Safer than administering by oral or intramuscular route
d. Lower incidence of allergy than other routes
4. How often should intravenous (IV) rounds be performed during a nursing shift?
a. Every 15 minutes
b. Every 30 minutes
c. Every 60 minutes
d. Twice per shift
5. Using an intravenous (IV) infusion system that delivers 60 drops/L, a nurse hangs a 1000-mL bag of 5% dextrose in water (D5W), which the physician has ordered to infuse at 80 mL/hr. It is now 1000. What time should the nurse anticipate the IV will need to be changed?
6. Using an IV infusion system that delivers 60 drops/mL, a nurse hangs a 500-mL bag of normal saline (NS) at 0800. The physician has ordered a rate of 20 mL/hr. What should the nurse set the roller clamp to deliver?
a. 10 gtt/min
b. 20 gtt/min
c. 25 gtt/min
d. 30 gtt/min
7. A physician prescribes a hypertonic intravenous line for an extremely edematous patient. What solution should the nurse anticipate to be prescribed?
a. D5W in NS
b. Lactated Ringer solution
c. D5W in 0.25 NS
d. 10% glucose in water
8. What is the source of calories in IV solutions?
9. What signs of infiltration should be assessed by a nurse?
a. Burning sensation, pain, and puffy
b. Pain, heat, and puffy
c. Burning sensation and no feeling at the site
d. Red streak up the arm
10. A physician orders an infusion of 1000 mL of 5% dextrose in 0.45% NS to be completed in 8 hours. The IV delivery system’s drop factor is 20 gtt. How many mL/hr should the nurse set the electronic infusion pump to deliver the infusion?
a. 125 mL/hr
b. 100 mL/hr
c. 85 mL/hr
d. 42 mL/hr
Chapter 19: Shock
1. What are the four types of shock?
a. Multiple organ, cardiogenic, renal, and anaphylactic
b. Cardiogenic, renal, hypovolemic, and septic
c. Renal, hypervolemic, obstructive shock, and neurogenic
d. Hypovolemic, cardiogenic, obstructive shock, and vasogenic
2. Although several life-supporting systems of the body are involved in the pathophysiologic characteristics of shock, shock itself results from failure of which system?
3. A nurse is assessing a patient who is in shock. What should the nurse be aware that one common sign will be, regardless of the cause of the shock?
a. The skin is cool and dry with cyanotic nail beds.
b. The skin is cool and moist with cyanotic nail beds.
c. The nail beds are reddened, and the skin is moist and warm.
d. The nail beds are reddened, and the skin is dry and warm.
4. What should a nurse assessing a patient in the progressive stage of shock expect to find?
a. Bounding pulse, decreased respirations, and decreased blood pressure
b. Bounding pulse, shallow respirations, and significantly increased blood pressure
c. Thready pulse and deep respirations with decreased blood pressure
d. Thready pulse and irregular respirations with increased blood pressure
5. What should a nurse expect of a patient’s respirations caused by the falling blood pressure and impaired blood circulation during the refractory stage of shock?
a. Rapid and deep
b. Rapid and shallow
c. Slow and deep
d. Slow and shallow
6. A licensed practical/vocational nurse (LPN/LVN) is assisting in developing a nursing care plan for a patient in shock. Which nursing diagnosis should be included?
a. Increased cardiac output, related to hypertension
b. Increased cardiac output, related to hypotension
c. Decreased cardiac output, related to hypovolemia
d. Decreased cardiac output, related to hypertension
7. How does the intraaortic balloon pump (IABP) assist a patient who is in cardiogenic shock to increase cardiac output?
a. Provides generalized vasoconstriction
b. Inflates during the diastole phase
c. Constricts the vena cava
d. Adds hypertonic fluid to the circulating volume
8. A nurse is explaining to a family member the pathophysiologic characteristic of vasogenic shock. What information should the nurse include?
a. The intravascular compartment fills beyond capacity, allowing fluid to leak out, compressing vital organs.
b. The circulating volume causes excessive constriction of the vessels, causing blood pooling.
c. Widely fluctuating blood pressures stimulate vascular collapse, causing severe alterations in peripheral perfusion.
d. Although the circulating volume is intact, excessive vascular dilation causes drastic drops in the blood pressure.
9. A nurse is caring for a patient who has a cervical spine injury and assesses progressive hypotension. What does this signify?
b. Respiratory alkalosis
c. Multiple organ dysfunction syndrome (MODS)
d. Neurogenic shock
10. While shopping in the mall, a nurse sees a lady suddenly fall to the floor. On immediate assessment, the nurse realizes she is not in cardiac arrest and has no need for cardiopulmonary resuscitation (CPR). What should be the immediate actions by the nurse?
a. Check the pulse and respirations and call for a blood pressure cuff.
b. Check the pulse, respirations, skin color, and temperature.
c. Call for help and check the pulse, respiration, and mental status.
d. Ask someone to help place large blankets or coats under her legs and trunk.
Chapter 20: Falls
1. What recommendation should a nurse make to the family of a patient diagnosed with ataxia when preparing discharge to home?
a. Remove all scatter rugs from the home.
b. Rearrange the bedroom furniture.
c. Arrange for someone to stay with the patient 24 hours a day.
d. Purchase oversized shoes so that they are easy to get on.
2. What should be the first intervention when a nurse finds that a patient has fallen?
a. Ask the patient to stand up.
b. Document the fall according to agency policy.
c. Remove or correct the cause of the fall.
d. Assess the circumstances of the fall and any injuries sustained.
3. What should discharge planning for a patient who lives alone and is at high risk for falling include?
a. Cannot go home unless someone is with him all the time
b. Must go to a long-term care facility
c. Can wear devices around the neck that can signal for help
d. Needs to be aware of the dangers of living alone
4. A nurse explains that older adults account for a large percentage of the total deaths resulting from falls. What is this percentage?
5. A nurse is caring for an older adult patient who has undergone a total hip replacement. What is the best action to reduce the risk of further injury?
a. Leave all the lights on in the room at night.
b. Leave the side rails down at all times to enable the patient to get to the bathroom quickly.
c. Keep the call bell and other frequently used items in easy reach.
d. Keep the bed in the high position to discourage the patient from getting out of bed without assistance.
6. A nurse is talking to the family of a patient who has fallen several times. What should be the most important intervention for preventing falls for the nurse to relay to this family?
c. Continuous observation
7. How often should a nurse remove and release restraints when caring for a patient who requires wrist restraints?
a. Once every 8 hours for at least 30 minutes
b. Once every 4 hours for at least 15 minutes
c. Once every 2 hours for at least 10 minutes
d. Once every 1 hour for at least 5 minutes
8. An older adult patient in a long-term care facility is at risk for injury because of confusion. The patient’s gait is stable. What is the best method of restraint to prevent injury to the patient?
a. Geriatric chair
b. Ambularm bracelet
c. Vest restraint
d. Wrist or ankle restraint or both
9. A nurse is admitting a new patient to the nursing unit. When conducting the admission procedure, what is important for the nurse to ask in order to assess the patient’s risk for falling?
a. “How many times have you fallen before?”
b. “How many hours do you sleep at night?”
c. “What are your eating habits?”
d. “Do you smoke?”
10. A patient has asked a nurse to assist him to ambulate to the bathroom. The nurse is aware that the patient is currently taking an antidepressant medication. What action should the nurse implement?
a. Never leave the patient alone in his room.
b. Ask the patient if he could use the bedside commode instead of going to the bathroom.
c. Make suicidal precautions part of the care plan.
d. Ask the patient to sit on the side of the bed for a minute or two before standing and then stand slowly.
AND MUCH MORE