Adult Health

Test Bank

MULTIPLE CHOICE

	1.	The nurse reviews the health record of a client with melasma. The nurse would anticipate that this client will exhibit:
1.	Skin that is uniformly dark in color	
2.	Very pale skin with little pigmentation	
3.	Patches of skin that have loss of pigmentation	
4.	Blotchy brown macules across the cheeks and forehead	

ANS:	4

Rationale: Melasma is a condition caused by hormonal influences on melanin production and is noted by the appearance of blotchy brown macules across the cheeks and forehead. “Skin that is uniformly dark in color” describes vitiligo. “Very pale skin with little pigmentation” and “patches of skin that have loss of pigmentation” refer to normal variations in skin color.

Test-Taking Strategy: To answer this question correctly, you must be familiar with the various terms used when discussing skin structures and functions. “Skin that is uniformly dark in color” describes vitiligo. “Very pale skin with little pigmentation” and “patches of skin that have loss of pigmentation” refer to normal variations in skin color. Review the description of melasma if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Integumentary
MSC:	Integrated Process: Nursing Process—Assessment

	2.	The client with cellulitis of the lower leg has had cultures done on the affected area. The nurse reviewing the results of the culture report interprets that which of the following organisms is not part of the normal flora of the skin?
1.	Escherichia coli	
2.	Candida albicans	
3.	Staphylococcus aureus	
4.	Staphylococcus epidermidis	

ANS:	1

Rationale: E. coli is normally found in the intestines and is a common source of infection of wounds and the urinary system. C. albicans, S. aureus, and S. epidermis are part of the normal flora of the skin.

Test-Taking Strategy: To answer this question correctly, you must be familiar with the normal microorganisms that inhabit the skin. Note that the question asks for the organism that is not part of normal flora. Remember that E. coli is normally found in the intestines. Review basic skin structures if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Integumentary
MSC:	Integrated Process: Nursing Process—Assessment

	3.	The client complains of chronic pruritus. Which of the following diagnoses would the nurse expect to support this client’s complaint?
1.	Anemia	
2.	Renal failure	
3.	Hypothyroidism	
4.	Diabetes mellitus	

ANS:	2

Rationale: Clients with renal failure often have pruritus, or itchy skin. This is because of impaired clearance of waste products by the kidneys. The client who is markedly anemic is likely to have pale skin. Hypothyroidism may lead to complaints of dry skin. Clients with diabetes mellitus are at risk for skin infections and skin breakdown.

Test-Taking Strategy: Focus on the subject, chronic pruritus. Remember that clients with renal failure often experience this problem. If this question was difficult, review the common causes of pruritus.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Integumentary
MSC:	Integrated Process: Nursing Process—Assessment

	4.	A client being seen in an ambulatory clinic for an unrelated complaint has a butterfly rash noted across the nose. The nurse interprets that this finding is consistent with early manifestations of which of the following disorders?
1.	Hyperthyroidism	
2.	Pernicious anemia	
3.	Cardiopulmonary disorders	
4.	Systemic lupus erythematosus (SLE)	

ANS:	4

Rationale: An early sign of SLE is the appearance of a butterfly rash across the nose. Hyperthyroidism often leads to moist skin and increased perspiration. Pernicious anemia is exhibited by pale skin. Severe cardiopulmonary disorders may lead to clubbing of the fingers.

Test-Taking Strategy: To answer this question accurately, you must be familiar with the impact of systemic conditions on the skin. Remember that SLE causes a characteristic butterfly rash. If this question was difficult, review the disorders identified in the options and the associated skin conditions that occur in each disorder.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Integumentary
MSC:	Integrated Process: Nursing Process—Assessment

	5.	The nurse notes that the older adult client has a number of bright, ruby-colored, round lesions scattered on the trunk and thighs. The nurse correctly interprets the finding as alterations in blood vessels of the skin and defines them as:
1.	Purpura	
2.	Venous star	
3.	Cherry angioma	
4.	Spider angioma	

ANS:	3

Rationale: A cherry angioma occurs with increasing age and has no clinical significance. It is noted by the appearance of small, bright, ruby-colored round lesions on the trunk and/or extremities. Purpura results from hemorrhage into the skin. A venous star results from increased pressure in veins, usually in the lower legs, and has an irregularly shaped bluish center with radiating branches. Spider angiomas have a bright red center, with legs that radiate outward. These are commonly seen in those with liver disease or vitamin B deficiency, although they can occur occasionally without underlying pathology.

Test-Taking Strategy: To answer this question accurately, you must be familiar with the various alterations in vascularity that can occur in the skin. Note the relationship of the words “ruby” in the question and “cherry” in the correct option. If you had difficulty with this question, review the various skin alterations identified in each of the options.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Integumentary
MSC:	Integrated Process: Nursing Process—Assessment

	6.	The client has been diagnosed with paronychia. The nurse understands that this is a disorder of the:
1.	Nails	
2.	Hair follicles	
3.	Pilosebaceous glands	
4.	Epithelial layer of skin	

ANS:	1

Rationale: Paronychia is a fungal infection that is most often caused by Candida albicans. This results in inflammation of the nail fold, with separation of the fold from the nail plate. The area is generally tender to touch, with purulent drainage. Disorders of the hair follicles include folliculitis, furuncles, and carbuncles. Disorders of the pilosebaceous glands include acne vulgaris and seborrheic dermatitis. There are a variety of disorders involving the epithelial skin.

Test-Taking Strategy: To answer this question accurately, you must be familiar with a variety of skin disorders and their causes. Remember that paronychia is a nail disorder. If this question was difficult, review the characteristics of paronychia.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Integumentary
MSC:	Integrated Process: Nursing Process—Assessment

	7.	The client is diagnosed with a full-thickness burn. The nurse understands that which of the following structural areas of the skin is involved?
1.	Epidermis only	
2.	Epidermis and deeper dermis	
3.	Epidermis and upper layer of dermis	
4.	Epidermis, entire dermis, and epithelial portion of subcutaneous fat	

ANS:	4

Rationale: A full-thickness burn involves the epidermis, entire dermis, and epithelial portion of subcutaneous fat layer. “Epidermis only” describes a superficial burn. “Epidermis and deeper dermis” describes a partial-thickness burn, and “epidermis, entire dermis, and epithelial portion of subcutaneous fat” describes a deep partial-thickness burn.

Test-Taking Strategy: To answer this question accurately, you must be familiar with the classification of burn depth and the associated skin structures affected. Noting the words “full-thickness” will direct you to “epidermis, entire dermis, and epithelial portion of subcutaneous fat.” If this question was difficult, review the types of burn injuries.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Integumentary
MSC:	Integrated Process: Nursing Process—Assessment

	8.	A client who suffered carbon monoxide poisoning from working on an automobile in a closed garage has a carbon monoxide level of 15%. The nurse would anticipate observing which sign or symptom?
1.	Coma	
2.	Flushing	
3.	Dizziness	
4.	Tachycardia	

ANS:	2

Rationale: The signs and symptoms worsen as the carbon monoxide level rises in the bloodstream. Impaired visual acuity occurs at 5% to 10%, whereas flushing and headache are seen at 11% to 20%. Nausea and impaired dexterity appear at levels of 21% to 30%, and a 31% to 40% level is accompanied by vomiting, dizziness, and syncope. Levels of 41% to 50% cause tachypnea and tachycardia, and those higher than 50% result in coma and death.

Test-Taking Strategy: Knowledge of the various manifestations of carbon monoxide poisoning is needed to answer this question. Remember that flushing is noted at levels of 11% to 20%. If you had difficulty with this question, review the manifestations associated with carbon monoxide poisoning.

PTS:	1
DIF:	Level of Cognitive Ability: Analyzing
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Integumentary
MSC:	Integrated Process: Nursing Process—Assessment

	9.	A client is admitted to the hospital with cellulitis of the lower leg. The nurse would anticipate which of the following therapies to be prescribed?
1.	Intermittent heat lamp treatments	
2.	Alternating hot and cold compresses	
3.	Warm compresses to the affected area	
4.	Cold compresses to the affected area	

ANS:	3

Rationale: Warm compresses may be used to decrease the discomfort, erythema, and edema that accompany cellulitis. Definitive treatment includes antibiotic therapy after appropriate cultures have been done. Other supportive measures are also used to manage such symptoms as fatigue, fever, chills, headache, or myalgia. Heat lamps are not used because of the risk of burns, and moist heat is most useful in treating this disorder.

Test-Taking Strategy: Use knowledge of the disease process and concepts related to heat and cold therapy to answer this question. Eliminate “alternating hot and cold compresses” and “cold compresses to the affected area” first, because cold therapy would cause vasoconstriction rather than vasodilation. Choose correctly between “intermittent heat lamp treatments” and “warm compresses to the affected area,” knowing that moist heat decreases the discomfort, erythema, and edema that accompanies cellulitis. If you had difficulty with this question, review the treatment associated with cellulitis.

PTS:	1
DIF:	Level of Cognitive Ability: Analyzing
REF:	Monahan, F., Sands, J., Marek, J., Neighbors, M., & Green, C. (2007). Phipps' medical-surgical nursing: health and illness perspectives (8th ed.). St. Louis: Mosby.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Integumentary
MSC:	Integrated Process: Nursing Process—Planning

	10.	The nurse has instructed the client in the correct technique for breast self-examination (BSE). For a portion of the examination, the client will lie down. If the client were to examine the right breast, the nurse would tell the client to place a pillow:
1.	Under the left scapula	
2.	Under the left shoulder	
3.	Under the right shoulder	
4.	Under the small of the back	

ANS:	3

Rationale: The nurse would instruct the client to lie down and place a towel or pillow under the shoulder on the side of the breast to be examined. If the right breast is to be examined, the pillow would be placed under the right shoulder, and vice versa. Therefore “under the left scapula,” “under the left shoulder,” and “under the small of the back” are incorrect.

Test-Taking Strategy: Use the process of elimination, and visualize this procedure. This will direct you to “under the right shoulder.” If you are unfamiliar with the procedure for performing BSE, review this important self-examination.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Health Promotion and Maintenance
TOP:	Content Area: Adult Health/Oncology
MSC:	Integrated Process: Teaching and Learning

	11.	The nurse would identify that which of the following foods should be increased in the diet to help decrease the risk of cancer development?
1.	Bacon	
2.	Broccoli	
3.	Bologna	
4.	Broiled beef	

ANS:	2

Rationale: Broccoli is a cruciferous vegetable, which is helpful in reducing the risk of cancer. Other cruciferous vegetables are cauliflower, Brussels sprouts, and cabbage. Red meat (“bacon”) and meats with nitrites (“bologna” and “broiled beef”) can increase the risk of developing cancer.

Test-Taking Strategy: Remember that options that are comparable or alike are not likely to be correct. With this in mind, note that each incorrect option lists a meat, whereas the correct choice is a cruciferous vegetable. Review dietary risk factors for cancer if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Nix, S. (2009). Williams’ basic nutrition and diet therapy (13th ed.). St. Louis: Mosby.
OBJ:	Client Needs: Health Promotion and Maintenance
TOP:	Content Area: Adult Health/Oncology
MSC:	Integrated Process: Nursing Process—Implementation

	12.	The nurse would include which of the following in a list of the most helpful foods for the vegan client wishing to increase foods high in vitamin A?
1.	Peas	
2.	Carrots	
3.	Potatoes	
4.	Green beans	

ANS:	2

Rationale: Foods that are high in vitamin A include carrots, green leafy vegetables, and yellow vegetables. The other vegetables are high in vitamins but do not necessarily have the highest amount of vitamin A.

Test-Taking Strategy: Note the strategic words “most helpful.” To answer this question accurately, you must be aware of the type of foods that are naturally high in vitamin A. Remember that carrots are high in vitamin A. If you had difficulty with this question, review foods that are in this vitamin group.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Peckenpaugh, N. (2010). Nutrition essentials and diet therapy (11th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Health Promotion and Maintenance
TOP:	Content Area: Adult Health/Oncology
MSC:	Integrated Process: Nursing Process—Implementation

	13.	According to the American Cancer Society, fecal occult blood testing should be done annually after the age of _____ years.
1.	30 	
2.	40 	
3.	50 	
4.	60 	

ANS:	3

Rationale: Fecal occult blood testing for colorectal cancer should be done annually for both men and women after the age of 50 years. The other options are incorrect.

Test-Taking Strategy: To answer this question correctly, you must be familiar with the recommendations for cancer screening published by the American Cancer Society. This would allow you to eliminate each of the incorrect options easily. Review these cancer prevention guidelines.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Health Promotion and Maintenance
TOP:	Content Area: Adult Health/Oncology
MSC:	Integrated Process: Nursing Process—Implementation

	14.	A 27-year-old female client is undergoing evaluation of lumps in her breasts. In determining whether the client could have fibrocystic breast disorder, the nurse should ask the client whether the breast lumps seem to become more prominent or troublesome at which of the following times?
1.	After menses	
2.	Before menses	
3.	During menses	
4.	At any time, regardless of the menstrual cycle	

ANS:	2

Rationale: The nurse assesses the client with fibrocystic breast disorder for worsening of symptoms (breast lumps, painful breasts, and possible nipple discharge) before the onset of menses. This is associated with cyclical hormone changes. Therefore “after menses,” “during menses,” and “at any time, regardless of the menstrual cycle” are incorrect.

Test-Taking Strategy: Note the strategic words “more prominent or troublesome.” This implies that there is a predictable variation in symptoms. Use knowledge of the effects of hormonal variations to select the correct option. Review fibrocystic breast disorder if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Oncology
MSC:	Integrated Process: Nursing Process—Assessment

	15.	The nurse is assigned to the care of a client scheduled for surgery for a right colon tumor. Which of the following is the most characteristic manifestation of cancer at this site?
1.	Frequent diarrhea	
2.	Crampy gas pains	
3.	Flat, ribbon-like stools	
4.	Dull abdominal pain exacerbated by walking	

ANS:	4

Rationale: Characteristic symptoms of right colon tumors include vague, dull, abdominal pain exacerbated by walking, and dark red- or mahogany-colored blood mixed in the stool. The symptoms described in the other options are associated with left colon tumors.

Test-Taking Strategy: Knowledge regarding the signs of right and left colon tumors is required to answer this question. Note, however, that “crampy gas pains” and “dull abdominal pain exacerbated by walking” describe different patterns of pain. This may suggest to you that one of the two is correct. If you are not familiar with the differences between right and left colon tumors, review this content.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Oncology
MSC:	Integrated Process: Nursing Process—Assessment

	16.	A client has undergone abdominal perineal resection for a bowel tumor. The nurse interprets that the client’s colostomy is beginning to function if which of the following signs is noted?
1.	Absent bowel sounds	
2.	The passage of flatus	
3.	Blood drainage from the colostomy	
4.	The client’s ability to tolerate food	

ANS:	2

Rationale: Following abdominal perineal resection, a colostomy should begin to function within 72 hours after surgery, although it may take up to 5 days. The nurse should monitor for a return of peristalsis by listening for bowel sounds and checking for the passage of flatus. Absent bowel sounds indicate that peristalsis has not returned. The client would remain NPO until bowel sounds return and the colostomy is functioning. Bloody drainage is not expected from a colostomy.

Test-Taking Strategy: Note the strategic words “beginning to function.” These strategic words should assist in eliminating “absent bowel sounds.” Knowledge of general postoperative measures will assist in eliminating “the client’s ability to tolerate food.” Focus on the subject of the question to make your final selection. Review postoperative care of a client following abdominal perineal resection if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Analyzing
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Oncology
MSC:	Integrated Process: Nursing Process—Assessment

	17.	A nurse assessing a postoperative ureterostomy client will interpret that the stoma has normal characteristics if the stoma is:
1.	Dry	
2.	Pale	
3.	Dark-colored	
4.	Red and moist	

ANS:	4

Rationale: Following ureterostomy, the stoma should be red and moist. A dry stoma may indicate fluid volume deficit. A pale stoma may indicate an inadequate vascular supply. Any darkness or duskiness of the stoma may mean loss of vascular supply and must be corrected immediately to prevent necrosis.

Test-Taking Strategy: Knowledge of normal stoma characteristics is needed to answer this question. Remember that a red and moist stoma is an expected finding. If you had difficulty with this question, review expected and unexpected findings following ureterostomy.

PTS:	1
DIF:	Level of Cognitive Ability: Analyzing
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Renal
MSC:	Integrated Process: Nursing Process—Assessment

	18.	The nurse monitoring the oncological client for early signs of vena cava syndrome would include assessment for which of the following?
1.	Cyanosis	
2.	Arm edema	
3.	Periorbital edema	
4.	Mental status changes	

ANS:	3

Rationale: Vena cava syndrome occurs when the superior vena cava is compressed or obstructed by tumor growth. Early signs and symptoms generally occur in the morning and include edema of the face, especially around the eyes, and client complaints of tightness of a shirt or blouse collar. As the compression worsens, the client experiences edema of the hands and arms. Mental status changes and cyanosis are late signs.

Test-Taking Strategy: To answer this question accurately, you must be familiar with vena cava syndrome and its manifestations. Note the strategic word “early” in the question. This will assist in directing you to the correct option. If you are unfamiliar with vena cava syndrome, review the signs of this oncological emergency.

PTS:	1
DIF:	Level of Cognitive Ability: Analyzing
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Oncology
MSC:	Integrated Process: Nursing Process—Assessment

	19.	The nurse understands that which of the following hormones is directly responsible for maintaining the free or unbound portion of serum calcium within normal limits?
1.	Thyroid hormone	
2.	Parathyroid hormone	
3.	Follicle-stimulating hormone	
4.	Adrenocorticotropic hormone	

ANS:	2

Rationale: Parathyroid hormone is responsible for maintaining serum calcium and phosphorous levels within normal range. Thyroid hormone is responsible for maintaining a normal metabolic rate in the body. Follicle-stimulating hormone and adrenocorticotropic hormone are produced by the anterior pituitary gland. They are responsible for growth and maturation of the ovarian follicle and stimulation of the adrenal glands, respectively.

Test-Taking Strategy: Basic knowledge of physiology associated with the parathyroid gland is needed to answer this question. This gland is responsible for maintaining the important balance of calcium and phosphorus in the body. Review the function of the parathyroid gland if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Endocrine
MSC:	Integrated Process: Nursing Process—Assessment

	20.	The client with an endocrine disorder complains of weight loss and diarrhea, and says that he can “feel his heart beating in his chest.” The nurse interprets that which of the following glands is most likely responsible for these symptoms?
1.	Thyroid	
2.	Pituitary	
3.	Parathyroid	
4.	Adrenal cortex	

ANS:	1

Rationale: The thyroid gland is responsible for a number of metabolic functions in the body, including metabolism of nutrients (such as fats and carbohydrates). Increased metabolic function places a demand on the cardiovascular system for a higher cardiac output. Thus, a client with increased activity of the thyroid gland exhibits weight loss from higher metabolic rate and increased pulse rate. 

Test-Taking Strategy: Use knowledge of the function of the thyroid gland to answer this question. Remember that the thyroid gland is responsible for metabolic function. This will assist in directing you to “thyroid.” If you had difficulty answering this question, review the function of the thyroid gland.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Endocrine
MSC:	Integrated Process: Nursing Process—Assessment

	21.	The client is experiencing an episode of hypoglycemia. The nurse understands that the physiological mechanism that should take place to combat this decrease in the blood glucose level is:
1.	Decreased cortisol release	
2.	Increased insulin secretion	
3.	Decreased epinephrine release	
4.	Increased glucagon secretion	

ANS:	4

Rationale: Glucagon is secreted from the alpha cells in the pancreas in response to declining blood glucose levels. At the same time, hypoglycemia triggers increased cortisol release, increased epinephrine release, and decreased secretion of insulin. “Decreased cortisol release,” “increased insulin secretion,” and “decreased epinephrine release” are not physiological mechanisms that take place to combat the decrease in the blood glucose level. 

Test-Taking Strategy: To answer this question accurately, you must be familiar with how each of the hormones listed is affected by blood glucose levels. Thinking about the pathophysiology of hypoglycemia will direct you to “increased glucagon secretion.” If this question was difficult, review this physiological mechanism.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Endocrine
MSC:	Integrated Process: Nursing Process—Assessment

	22.	The client with diabetes experiences breakdown of fats for conversion to glucose. The nurse determines that this response is occurring if the client has elevated levels of which of the following substances?
1.	Glucose	
2.	Ketones	
3.	Glucagon	
4.	Lactic dehydrogenase	

ANS:	2

Rationale: Ketones are a byproduct of fat metabolism. When this process occurs to the extreme, it is termed ketoacidosis. “Glucose,” “glucagon,” and “lactic dehydrogenase” are incorrect.

Test-Taking Strategy: Knowledge of the pathophysiology of glucose metabolism is needed to answer this question. Remember that ketones are a byproduct of fat metabolism. If this question was difficult, review the physiological process of fat breakdown.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Endocrine
MSC:	Integrated Process: Nursing Process—Assessment

	23.	The client with diabetes mellitus is being tested to determine long-term diabetic control. Which of the following results would the nurse expect to see if the client’s long-term control is within acceptable limits?
1.	Glycosylated hemoglobin of 6%	
2.	Fasting blood glucose level of 150 mg/dL	
3.	Presence of ketones in the urine	
4.	Presence of albumin in the urine	

ANS:	1

Rationale: This measurement of glycosylated hemoglobin (Hb A1c) detects glucose binding on the red blood cell (RBC) membrane and is expressed as a percentage. It measures glucose for the life of the RBC, which is 120 days. The fasting blood glucose level should be lower than 130 mg/dL. The urine should be free of both ketones and urine.

Test-Taking Strategy: Specific knowledge of the effects of an increased blood glucose level in the body is necessary to answer this question. Noting the words “long-term” will direct you to “glycosylated hemoglobin of 6%.” Review the alterations in normal physiology that occur with diabetes mellitus if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Analyzing
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Endocrine
MSC:	Integrated Process: Nursing Process—Assessment

	24.	The nurse is caring for a client with a dysfunctional thyroid gland and is concerned that the client will exhibit signs of thyroid storm. Which of the following is an early indicator of this complication?
1.	Hyperreflexia	
2.	Constipation	
3.	Bradycardia	
4.	Low-grade temperature	

ANS:	1

Rationale: Clinical manifestations of thyroid storm include a fever as high as 106° F, hyperreflexia, abdominal pain, diarrhea, dehydration rapidly progressing to coma, severe tachycardia, extreme vasodilation, hypotension, atrial fibrillation, and cardiovascular collapse.

Test-Taking Strategy: To answer this question correctly, you must be familiar with the clinical manifestations of thyroid storm. This condition is a rare but potentially fatal hypermetabolic state. Remembering the description of thyroid storm will direct you to the correct option. If you are unfamiliar with thyroid storm, review this content.

PTS:	1
DIF:	Level of Cognitive Ability: Analyzing
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Endocrine
MSC:	Integrated Process: Nursing Process—Assessment

	25.	The client is undergoing an oral glucose tolerance test. The nurse interprets that the client’s results are not compatible with diabetes mellitus if the glucose level is lower than which of the following cutoff values after 120 minutes (2 hours)?
1.	80 mg/dL	
2.	110 mg/dL	
3.	140 mg/dL	
4.	160 mg/dL	

ANS:	3

Rationale: The normal reference values for oral glucose tolerance tests are lower than 140 mg/dL at 120 minutes; lower than 200 mg/dL at 30, 60, and 90 minutes; and lower than 115 mg/dL in the fasting state. The other values are not part of the reference ranges.

Test-Taking Strategy: To answer this question correctly, you must be familiar with the normal values for this screening test for diabetes. Think about the physiology associated with diabetes mellitus and the procedure for this test to answer correctly. Noting the words “not compatible with diabetes mellitus” will assist in answering correctly. Review this test if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Pagana, K., & Pagana, T. (2009). Mosby’s diagnostic and laboratory test reference (9th ed.). St. Louis: Mosby.OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Endocrine
MSC:	Integrated Process: Nursing Process—Assessment

	26.	A client who visits the physician’s office for a routine physical reports new onset of intolerance to cold. Knowing that this is a frequent complaint associated with hypothyroidism, the nurse continues to assess for which of the following?
1.	Weight loss and thinning skin	
2.	Complaints of weakness and lethargy	
3.	Increased heart rate and respiratory rate	
4.	Diaphoresis and increased hair growth	

ANS:	2

Rationale: Weakness and lethargy are common complaints associated with hypothyroidism. Other common symptoms include weight gain, bradycardia, decreased respiratory rate, dry skin, and hair loss.

Test-Taking Strategy: Focus on the client’s diagnosis. Recalling the pathophysiology associated with hypothyroidism will direct you to “complaints of weakness and lethargy.” Review this disorder if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Analyzing
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Endocrine
MSC:	Integrated Process: Nursing Process—Assessment

	27.	The nurse is caring for a client diagnosed with suspected acute pancreatitis. When reviewing the client’s laboratory results, the nurse determines that which of these findings will support the diagnosis?
1.	Elevated serum lipase level	
2.	Elevated serum bilirubin level	
3.	Decreased serum trypsin level	
4.	Decreased serum amylase level	

ANS:	1

Rationale: The serum lipase level is elevated in the presence of pancreatic cell injury. Serum trypsin and amylase levels are also elevated in pancreatic injury. Although bilirubin can be elevated in the client with pancreatitis, it is secondary to the hepatobiliary obstructive process.

Test-Taking Strategy: Focusing on the client’s diagnosis and its pathophysiology will direct you to “elevated serum lipase level.” If this question was difficult, review tests for diagnosing acute pancreatitis.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Gastrointestinal
MSC:	Integrated Process: Nursing Process—Assessment

	28.	A nurse is caring for a client postoperatively following creation of a colostomy. Which of the following nursing diagnoses should the nurse include in the plan of care?
1.	Sexual dysfunction	
2.	Disturbed body image	
3.	Fear	
4.	Imbalanced nutrition: more than body requirements	

ANS:	2

Rationale: Disturbed body image relates to loss of bowel control, the presence of a stoma, the release of fecal material onto the abdomen, the passage of flatus, odor, and the need for an appliance (external pouch). There are no data in the question to support “sexual dysfunction” and “fear.” A risk for “imbalanced nutrition: less than body requirements” is the more likely nursing diagnosis.

Test-Taking Strategy: Use the process of elimination. Use the data presented in the question to assist in selecting the correct option. There are no data in the question to support sexual dysfunction” and “fear.” Reading “imbalanced nutrition: less than body requirements” carefully will assist in eliminating this option. Review care to the client following a colostomy creation if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Analyzing
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Psychosocial Integrity
TOP:	Content Area: Adult Health/Gastrointestinal
MSC:	Integrated Process: Nursing Process—Planning

	29.	The client is experiencing blockage of the common bile duct. Which of the following food selections made by the client indicates the need to plan for further diet teaching?
1.	Rice	
2.	Whole milk	
3.	Broiled fish	
4.	Baked chicken	

ANS:	2

Rationale: Bile acids or bile salts are produced by the liver to emulsify or break down fats. Blockage of the common bile duct impedes the flow of bile from the gallbladder to the duodenum, thus preventing breakdown of fatty intake. Knowledge of this should direct you to “whole milk.” Dairy products, such as whole milk, ice cream, butter, and cheese, are high in cholesterol and fat and should be avoided.

Test-Taking Strategy: Note the strategic words “need to plan for further diet teaching.” These words indicate a negative event query and ask you to select an option that is an incorrect food item. Knowledge of carbohydrate and protein contents of various foods will also assist you with eliminating options “rice,” “broiled fish,” and “baked chicken.” If you had difficulty with this question, review the physiology of digestion.

PTS:	1
DIF:	Level of Cognitive Ability: Evaluating
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Gastrointestinal
MSC:	Integrated Process: Teaching and Learning

	30.	The nurse is reviewing laboratory test results for the client with liver disease and notes that the client’s albumin level is low. Which of the following nursing actions is focused on the consequence of low albumin levels?
1.	Evaluating for asterixis	
2.	Inspecting for petechiae	
3.	Palpating for peripheral edema	
4.	Evaluating for decreased level of consciousness	

ANS:	3

Rationale: Albumin is responsible for maintaining the osmolality of the blood. When there is a low albumin level, there is decreased osmotic pressure, which in turn can lead to peripheral edema. “Evaluating for asterixis,” “inspecting for petechiae,” and “evaluating for decreased level of consciousness” are incorrect and are not associated with a low albumin level.

Test-Taking Strategy: To answer this question accurately, you must be familiar with the function of various substances produced by the liver. “Evaluating for asterixis” and “evaluating for decreased level of consciousness” can be eliminated because neuromuscular disturbances (such as asterixis and altered levels of consciousness) are the consequence of reabsorbed toxic substances. Eliminate “inspecting for petechiae” because petechiae are the result of hematological dysfunction secondary to liver disease. If needed, review the physiology of the liver and the function of albumin.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Gastrointestinal
MSC:	Integrated Process: Nursing Process—Implementation

	31.	Discharge teaching for a client recovering from an attack of chronic pancreatitis should include which of the following instructions?
1.	Alcohol should be consumed in moderation.	
2.	Avoid caffeine, because it may aggravate symptoms.	
3.	Diet should be high in carbohydrates, fats, and proteins.	
4.	Frothy fatty stools indicate that enzyme replacement is working.	

ANS:	2

Rationale: Knowing that caffeinated beverages, such as coffee, tea, and soda, will worsen symptoms, such as pain, will direct you to select “Avoid caffeine, because it may aggravate symptoms.” Alcohol can precipitate an attack of chronic pancreatitis and needs to be avoided. The recommended diet is moderate carbohydrates, low fat, and high protein. Frothy fatty stools indicate that the replacement enzyme dose needs to be increased.

Test-Taking Strategy: “Alcohol should be consumed in moderation” can be immediately eliminated because alcohol can precipitate another attack and needs to be avoided. “Diet should be high in carbohydrates, fats, and proteins” can be eliminated because the recommended diet is moderate carbohydrates, low fat, and high protein. Finally, frothy fatty stools indicate that the enzyme dose needs to be increased, so “frothy fatty stools indicate that enzyme replacement is working” can be eliminated. Review home care instructions for the client with chronic pancreatitis if you had difficulty answering this question.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Gastrointestinal
MSC:	Integrated Process: Teaching and Learning

	32.	A client returns to the nursing unit after undergoing an esophagogastroduodenoscopy (EGD). Which of the following reflects appropriate intervention by the nurse?
1.	Allow the client unassisted bathroom privileges.	
2.	Keep the client lying flat in bed in the supine position.	
3.	Withhold oral fluids until the client’s gag reflex has returned.	
4.	Tell the client to report a sore throat immediately, because it is a serious complication.	

ANS:	3

Rationale: In preparation for the passage of the endoscope, an anesthetic is sprayed to inactivate the gag reflex and thus facilitate passage of the tube. It may take 1 to 2 hours for the anesthetic spray to wear off and for the gag reflex to return. “Allow the client unassisted bathroom privileges,” “keep the client lying flat in bed in the supine position,” and “tell the client to report a sore throat immediately, because it is a serious complication” are incorrect.

Test-Taking Strategy: Apply knowledge of endoscopic procedures of the upper gastrointestinal tract to assist you with selecting the correct option. Because the client will receive conscious sedation for the procedure and anesthetic spray to the throat, postprocedure safety precautions must be maintained. This includes assistance to the bathroom and head of the bed elevation to prevent aspiration of oral secretions. A sore throat is common postprocedure and may persist for a few days but is not a cause for alarm. Review these postprocedural instructions if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Pagana, K., & Pagana, T. (2009). Mosby’s diagnostic and laboratory test reference (9th ed.). St. Louis: Mosby.
OBJ:	Client Needs: Safe and Effective Care Environment
TOP:	Content Area: Adult Health/Gastrointestinal
MSC:	Integrated Process: Nursing Process—Implementation

	33.	The nurse is assisting the physician during a colonoscopy procedure. The nurse helps the client to assume which of the following positions for the procedure?
1.	Left Sims	
2.	Lithotomy	
3.	Knee chest	
4.	Right Sims	

ANS:	1

Rationale: The client is placed in the left Sims position for the procedure. This position uses the client’s anatomy to the best advantage for introducing the colonoscope. The left Sims position would also be used for giving the client an enema while lying down. Therefore “lithotomy,” “knee chest,” and “right Sims” are incorrect.

Test-Taking Strategy: Using concepts related to gastrointestinal (GI) anatomy to answer this question will help you eliminate “right Sims.” When answering such factual questions as these, remember the guiding principles and attempt to visualize the procedure to help you select the correct option. Knowledge and visualization of “lithotomy” and “knee chest” positions will help you eliminate these options. Review this procedure if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Gastrointestinal
MSC:	Integrated Process: Nursing Process—Implementation

	34.	The client is scheduled for oral cholecystography. For the evening meal prior to the test, the nurse provides a list of foods from which diet type?
1.	Liquid	
2.	Fat-free	
3.	Low-protein	
4.	High-carbohydrate	

ANS:	2

Rationale: Normal dietary intake of fat should be maintained during the days preceding the test to empty bile from the gallbladder. A low-fat or fat-free diet is prescribed on the evening before the test. This prevents contraction of the gallbladder and allows for accumulation of the contrast substance needed for x-ray visualization during the testing procedure. Therefore “liquid,” “low-protein,” and “high-carbohydrate” are incorrect.

Test-Taking Strategy: Knowledge that an oral cholecystogram is an x-ray of the gallbladder will assist in directing you to the correct option. Think about the function of the gallbladder and its interaction with fat intake to assist in selecting “fat-free.” Review preprocedural care for oral cholecystography if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Monahan, F., Sands, J., Marek, J., Neighbors, M., & Green, C. (2007). Phipps' medical-surgical nursing: health and illness perspectives (8th ed.). St. Louis: Mosby.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Gastrointestinal
MSC:	Integrated Process: Nursing Process—Implementation

	35.	In which of the following optimal positions should the nurse plan to place the client after bolus feeding using a nasogastric tube?
1.	Head of bed (HOB) flat, with client supine for at least 60 minutes	
2.	HOB elevated 45 to 60 degrees, with client supine for 15 minutes	
3.	HOB elevated 10 degrees, with client in the left lateral position for 60 minutes	
4.	HOB elevated 30 to 45 degrees, with client in the right lateral position for 60 minutes	

ANS:	4

Rationale: Aspiration is a possible complication associated with nasogastric tube feeding. The HOB should be elevated 30 to 45 degrees for 30 to 60 minutes following bolus tube feeding to prevent vomiting and aspiration. The right lateral position uses gravity to facilitate gastric emptying, which also will reduce the risk of vomiting. The flat supine position should be avoided for the first 30 minutes after a tube feeding.

Test-Taking Strategy: There are three components to each option: the level of elevation of the head, the client’s position, and the duration. Remember that for an option to be correct, the entire option must be correct. Note also the strategic word “optimal.” This tells you that more than one option may be partially or totally correct. Eliminate “head of bed (HOB) flat, with client supine for at least 60 minutes” because it could result in aspiration. Eliminate “HOB elevated 45 to 60 degrees, with client supine for 15 minutes” because of the brief time frame. Use knowledge of gastrointestinal (GI) tract anatomy and principles of gravity to choose between the two remaining options. Review this procedure if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed.). St. Louis: Mosby.
OBJ:	Client Needs: Safe and Effective Care Environment
TOP:	Content Area: Adult Health/Gastrointestinal
MSC:	Integrated Process: Nursing Process—Planning

	36.	The client receiving a cleansing enema complains of pain and cramping. The nurse takes which of the following corrective actions?
1.	Discontinue the enema.	
2.	Reassure the client, and continue the flow.	
3.	Raise the enema bag so that the solution can be completed quickly.	
4.	Clamp the tubing for 30 seconds, and restart the flow at a slower rate.	

ANS:	4

Rationale: Enema fluid should be administered slowly. If the client complains of fullness or pain, stop the flow for 30 seconds and restart at a slower rate. This action decreases the likelihood of intestinal spasm and premature ejection of the solution. Therefore “discontinue the enema,” “reassure the client, and continue the flow,” and “raise the enema bag so that the solution can be completed quickly” are incorrect actions.

Test-Taking Strategy: Use knowledge of the basic procedure for enema administration to answer this question. Discontinuation of the enema may result in inadequate evacuation of the bowel, so “discontinue the enema” is incorrect. Eliminate “reassure the client, and continue the flow” because it disregards the client’s complaint. Raising the height of the enema bag will increase the rate of flow and further aggravate the client’s symptoms, so “raise the enema bag so that the solution can be completed quickly” can be eliminated. Review the procedure for administering an enema if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed.). St. Louis: Mosby.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Gastrointestinal
MSC:	Integrated Process: Nursing Process—Implementation

	37.	A client presents to the urgent care center with complaints of abdominal pain and vomits bright red blood. Which of the following is the priority action taken by the nurse?
1.	Take the client’s vital signs.	
2.	Perform a complete abdominal assessment.	
3.	Obtain a thorough history of the recent health status.	
4.	Prepare to insert a nasogastric tube and test pH and occult blood.	

ANS:	1

Rationale: The nurse should take the client’s vital signs first to determine whether the client is hypovolemic or in shock from blood loss; this also provides a baseline blood pressure and pulse by which to gauge the effectiveness of treatment. Signs and symptoms of shock include low blood pressure, rapid weak pulse, increased thirst, cold clammy skin, and restlessness.

Test-Taking Strategy: The strategic word in the question is “priority.” This tells you that more than one or all of the options may be partially or totally correct. Although all the options may be applicable to the care of this client, use principles of priority setting to answer the question. A client with an acute upper gastrointestinal (GI) bleed is at risk for shock. From the options provided, taking the client’s vital signs is the nursing action that will provide information about the status of the client’s circulating volume status. Review care to the client with a GI bleed if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Gastrointestinal
MSC:	Integrated Process: Nursing Process—Implementation

	38.	The client with frequent upper respiratory infections (URIs) asks the nurse why food doesn’t seem to have any taste during illness. The nurse understands that this is because of which of the following?
1.	Anorexia is triggered by the infectious organism.	
2.	Blocked nasal passages impair the senses of smell and taste.	
3.	The infection blocks sensation from the taste buds of the tongue.	
4.	The client’s medication therapy has caused changes in the normal flora of the mouth.	

ANS:	2

Rationale: When nasal passages become blocked because of URIs, the client has impaired senses of taste and smell. This occurs because one of the normal functions of the nose is to stimulate appetite through smell. The other options are incorrect.

Test-Taking Strategy: To answer this question accurately, recall the functions of the nose. The strategic words are “doesn’t seem to have any taste.” Use knowledge of anatomy and physiology to make your selection. If this question was difficult, review the effects of an URI.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Respiratory
MSC:	Integrated Process: Nursing Process—Assessment

	39.	The nurse providing instructions to the client using an incentive spirometer tells the client to sustain the inhaled breath for 3 seconds. When the client asks the nurse about the rationale for this action, the nurse explains that the primary benefit is to:
1.	Dilate the major bronchi.	
2.	Maintain inflation of the alveoli.	
3.	Increase surfactant production.	
4.	Enhance ciliary action in the tracheobronchial tree.	

ANS:	2

Rationale: Sustained inhalation helps maintain inflation of terminal bronchioles and alveoli, thereby promoting better gas exchange. Routine use of such devices such an incentive spirometer can help prevent atelectasis and pneumonia in clients at risk. “Dilate the major bronchi,” “increase surfactant production,” and “enhance ciliary action in the tracheobronchial tree” are not reasons for sustaining inflation.

Test-Taking Strategy: Recall anatomy and physiology of respiration to answer this question. Knowing that the alveoli are the most distal part of the respiratory tree helps you choose this option as the area to obtain the benefit from maximum sustained inhalation. If this question was difficult, review this essential information, which forms the basis for selected areas of respiratory care.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Respiratory
MSC:	Integrated Process: Nursing Process—Implementation

	40.	The nurse understands that increasing the flow of oxygen to more than 2 L/min in the client with chronic obstructive pulmonary disease (COPD) could be harmful because it:
1.	Is drying to nasal mucosal passages	
2.	Decreases diaphragmatic excursion and depth	
3.	Increases the risk of pneumonia and atelectasis	
4.	Decreases the client’s oxygen-based respiratory drive	

ANS:	4

Rationale: Normally, respiratory rate varies with the amount of carbon dioxide present in the blood. In clients with COPD, this natural process becomes ineffective after exposure to high carbon dioxide levels for prolonged periods of time. Instead, the level of oxygen provides the respiratory stimulus. The client with COPD cannot increase oxygen levels independently because this could severely decrease the respiratory drive, leading to respiratory failure.

Test-Taking Strategy: Use knowledge of basic respiratory physiology to answer this question. Remember that the client with COPD should not increase the flow of oxygen to more than 2 L/min, because this could severely decrease the respiratory drive. Review the importance of oxygen and carbon dioxide tensions in the bloodstream if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Respiratory
MSC:	Integrated Process: Nursing Process—Implementation

	41.	The nurse participating in a client care conference with other health team members is discussing the condition of a client with adult respiratory distress syndrome (ARDS). The physician states that because of fluid in the alveoli, surfactant production is falling. The nurse understands that the consequence of insufficient surfactant is:
1.	Atelectasis and viral infection	
2.	Bronchoconstriction and stridor	
3.	Collapse of alveoli and decreased compliance	
4.	Decreased ciliary action and retained secretions	

ANS:	3

Rationale: Surfactant is a phospholipid produced in the lungs that decreases surface tension in the lungs. This prevents the alveoli from sticking together and collapsing at the end of exhalation. When alveoli collapse, the lungs become “stiff” due to decreased compliance. Common causes of decreased surfactant production are ARDS and atelectasis. Viral infection may be one reason a client develops atelectasis. “Atelectasis and viral infection,” “bronchoconstriction and stridor,” and “decreased ciliary action and retained secretions” are incorrect. 

Test-Taking Strategy: The strategic words are “consequence” and “insufficient surfactant.” These tell you that the correct option is a result of inadequate surfactant. Use knowledge of concepts related to respiratory physiology to answer correctly. If this question was difficult, review the physiology of ARDS.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Respiratory
MSC:	Integrated Process: Nursing Process—Assessment

	42.	The nurse caring for a client with chronic obstructive pulmonary disease (COPD) anticipates which of the following arterial blood gas (ABG) findings?
1.	pH, 7.40; PaO2, 90 mm Hg; CO2, 39 mEq/L; HCO3, 23 mEq/L	
2.	pH, 7.32; PaO2, 85 mm Hg; CO2, 57 mEq/L; HCO3, 26 mEq/L	
3.	pH, 7.47; PaO2, 82 mm Hg; CO2, 30 mEq/L; HCO3, 31 mEq/L	
4.	pH, 7.31; PaO2, 95 mm Hg; CO2, 22 mEq/L; HCO3, 19 mEq/L	

ANS:	2

Rationale: The client with COPD will exist in a state of respiratory acidosis. “pH, 7.32; PaO2, 85 mm Hg; CO2, 57 mEq/L; HCO3, 26 mEq/L” and “pH, 7.31; PaO2, 95 mm Hg; CO2, 22 mEq/L; HCO3, 19 mEq/L” reflect an acidotic pH. “pH, 7.32; PaO2, 85 mm Hg; CO2, 57 mEq/L; HCO3, 26 mEq/L” demonstrates increased CO2. Increased CO2 acts as an acid in the body, and is elevated in the client with COPD because of an inability to exhale well and eliminate CO2. Therefore, with a rise in CO2, there is a corresponding fall in pH. The other options are incorrect.

Test-Taking Strategy: Remember that a client with COPD will exist in a state of respiratory acidosis. Also recall that there is an inverse relationship between pH and the CO2 in the body. As CO2 rises, pH falls; as CO2 falls, pH rises. This concept forms the basis for the primary concepts of acid-base balance and respiratory disorders. Review the acid-base findings in the client with COPD if this question was difficult.

PTS:	1
DIF:	Level of Cognitive Ability: Analyzing
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Respiratory
MSC:	Integrated Process: Nursing Process—Assessment

	43.	The chest x-ray report for a client states that the client has a left apical pneumothorax. The nurse would monitor the status of breath sounds in that area by placing the stethoscope:
1.	Near the lateral 12th rib	
2.	Just under the left-sided clavicle	
3.	In the fifth intercostal space	
4.	Posteriorly, under the left-sided scapula	

ANS:	2

Rationale: For the client with a left apical pneumothorax, the nurse would place the stethoscope just under the left clavicle. The apex of the lung is the rounded uppermost part of the lung. All the other options are incorrect.

Test-Taking Strategy: Knowledge of anatomical landmarks is needed to answer this basic question. Noting the client’s diagnosis and the strategic words “left apical” will direct you to “just under the left-sided clavicle.” If needed, review assessment of the client with a left apical pneumothorax.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Respiratory
MSC:	Integrated Process: Nursing Process—Assessment

	44.	The nurse would determine that tracheal suctioning is needed if which of the following is noted?
1.	Arterial oxygen level of 90 mm Hg	
2.	Congested breath sounds in the lung fields	
3.	Two hours elapsed since the last suctioning	
4.	Respiratory rate of 18 breaths/min, up from 16 breaths/min	

ANS:	2

Rationale: Suctioning is indicated only when the client has adventitious breath sounds or has accumulation of secretions. It is not performed routinely according to time elapsed since the last suctioning (“two hours elapsed since the last suctioning”). Arterial blood gas results and respiratory rate (“arterial oxygen level of 90 mm Hg” and “respiratory rate of 18 breaths/min, up from 16 breaths/min”) are not good indicators of the need for suctioning because they may be influenced by a number of other factors in addition to the need for suctioning.

Test-Taking Strategy: “Arterial oxygen level of 90 mm Hg” and “respiratory rate of 18 breaths/min, up from 16 breaths/min” represent normal data and are therefore eliminated first. Choose correctly between the last two options, knowing that adventitious breath sounds are the more accurate indicator or that suctioning is not done by schedule. Review suctioning procedure if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Analyzing
REF:	Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed.). St. Louis: Mosby.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Respiratory
MSC:	Integrated Process: Nursing Process—Assessment

	45.	The client with chronic obstructive pulmonary disease (COPD) is experiencing exacerbation of the disease. The nurse would determine that which of the following documented in the client’s record is an expected finding with this client?
1.	Increased oxygen saturation with ambulation	
2.	Hyperinflation of lungs documented by chest x-ray	
3.	A widened diaphragm documented by chest x-ray	
4.	A shortened expiratory phase of the respiratory cycle	

ANS:	2

Rationale: The clinical manifestations of COPD are several, including hypoxemia; hypercapnia; dyspnea on exertion and at rest; oxygen desaturation with exercise; use of accessory respiratory muscles; and prolonged exhalation. Chest x-ray results indicate a hyperinflated chest and may indicate a flattened diaphragm if the disease is advanced.

Test-Taking Strategy: Use the process of elimination after reading each option carefully. Eliminate “increased oxygen saturation with ambulation” because the reverse is true, even in the client with no respiratory disorder. Eliminate “a widened diaphragm documented by chest x-ray” because it is the opposite of what happens with exacerbation. Eliminate “a shortened expiratory phase of the respiratory cycle” because the client with COPD has a prolonged expiratory phase. Review the clinical manifestations of COPD if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Analyzing
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Respiratory
MSC:	Integrated Process: Nursing Process—Assessment

	46.	The nurse is caring for a postoperative client who has lost a significant amount of blood because of complications during a surgical procedure. Which of the following assessment findings would be indicative of further fluid volume deficit?
1.	Pulse rate increases from 100 beats/min to 136 beats/min	
2.	+4 edema noted in lower extremities	
3.	Blood pressure rises from 116/68 to118/74 mm Hg	
4.	Crackles auscultated from lung bases to apices	

ANS:	1

Rationale: The cardiac output is determined by the volume of the circulating blood, the pumping action of the heart, and the tone of the vascular bed. An increase in the pulse rate compensates for decreases in fluid volume. “+4 edema noted in lower extremities” and “crackles auscultated from lung bases to apices” may be noted in fluid overload. A low blood pressure is expected in a postoperative client who lost a significant amount of blood.

Test-Taking Strategy: To answer this question accurately, you must be familiar with the physiology of the cardiovascular system and the inherent means of compensation available in that system. Eliminate “Blood pressure rises from 116/68 to118/74 mm Hg” because a further decrease in fluid volume will result in a decrease in blood pressure. Eliminate “+4 edema noted in lower extremities” and “crackles auscultated from lung bases to apices” because they are indicative of an increase in fluid volume. Review the findings in a fluid volume deficit if this question was difficult.

PTS:	1
DIF:	Level of Cognitive Ability: Analyzing
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Cardiovascular
MSC:	Integrated Process: Nursing Process—Assessment

	47.	The nurse is preparing to take an apical pulse on an assigned client. The nurse places the diaphragm of the stethoscope at which cardiac site?
1.	Aortic area	
2.	Mitral area	
3.	Tricuspid area	
4.	Pulmonic area	

ANS:	2

Rationale: The diaphragm of the stethoscope is placed directly over the skin at the mitral area (the fifth intercostal space left midclavicular line) to listen to the apical pulse. S1 (lub) and S2 (dub) should be distinguished. The pulse should be counted for a full minute. Therefore “aortic area,” “tricuspid area,” and “pulmonic area” are incorrect sites.

Test-Taking Strategy: Use knowledge of anatomy of the heart to answer this question. Noting the subject, apical pulse, will direct you to the correct option. If you had difficulty with this question, review the cardiac sites for auscultation of heart sounds.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Health Promotion and Maintenance
TOP:	Content Area: Adult Health/Cardiovascular
MSC:	Integrated Process: Nursing Process—Assessment

	48.	The nurse reading the operative record of a client who had cardiac surgery notes that the client’s cardiac output immediately after surgery was 3.2 L/min. Evaluation of the cardiac output results leads the nurse to make which of the following conclusions?
1.	The cardiac output is above the normal range.	
2.	The cardiac output is in the high-normal range.	
3.	The cardiac output is in the low-normal range.	
4.	The cardiac output is below the normal range.	

ANS:	4

Rationale: The normal cardiac output for the adult can range from 4 to 7 L/min. Therefore a cardiac output of 3.2 L/min is below normal range.

Test-Taking Strategy: To answer this question accurately, you must be familiar with the normal range of values for cardiac output. Remember that the normal adult range is 4 to 7 L/min. Review cardiac output measures if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Cardiovascular
MSC:	Integrated Process: Nursing Process—Evaluation

	49.	The nurse is listening to a 56-year-old client’s apical heart rate before giving digoxin (Lanoxin) and notes that the heart rate is 48 beats/min. Which of the following would be an appropriate course of action taken by the nurse?
1.	Withhold the digoxin, and reevaluate the heart rate in 4 hours.	
2.	Administer half the prescribed dose to avoid a further decrease in heart rate.	
3.	Withhold the digoxin; assess for signs of decreased cardiac output and digoxin toxicity.	
4.	Administer the digoxin; the heart rate would be considered normal because of the client’s age.	

ANS:	3

Rationale: The normal heart rate is 60 to 100 beats/min in an adult. If the nurse notes a heart rate that is less than 60 beats/min, the nurse would not administer the digoxin and would further evaluate the client for signs and symptoms of digoxin toxicity. When clients are bradycardic, they may have symptoms of decreased cardiac output so this would also be assessed.

Test-Taking Strategy: Eliminate “withhold the digoxin, and reevaluate the heart rate in 4 hours” because although the digoxin should be withheld the client needs more immediate reassessment of the apical heart rate. Eliminate “administer half the prescribed dose to avoid a further decrease in heart rate” because giving half the prescribed dose can decrease the heart rate even further and because this action would require a physician’s prescription. “Administer the digoxin; the heart rate would be considered normal because of the client’s age” can be eliminated because this is not an expected finding related to the client’s age. Review the normal parameters related to the heart rate and the effects of digoxin if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Cardiovascular
MSC:	Integrated Process: Nursing Process—Implementation

	50.	The nurse is assisting in admitting a client who has a diagnosis of hypothermia. The nurse anticipates that this client will exhibit which of the following vital signs?
1.	Increased heart rate and increased blood pressure	
2.	Increased heart rate and decreased blood pressure	
3.	Decreased heart rate and increased blood pressure	
4.	Decreased heart rate and decreased blood pressure	

ANS:	4

Rationale: The heart rate and blood pressure are decreased because the metabolic needs of the body are reduced with hypothermia. With fewer metabolic needs, the workload of the heart decreases. Therefore “increased heart rate and increased blood pressure,” “Increased heart rate and decreased blood pressure,” and “decreased heart rate and increased blood pressure” are incorrect.

Test-Taking Strategy: Remember that the metabolic needs of the body are reduced in hypothermia. This will direct you to “decreased heart rate and decreased blood pressure.” Review the effects of hypothermia if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Cardiovascular
MSC:	Integrated Process: Nursing Process—Assessment

	51.	A client has been admitted with left-sided heart failure. When planning care for the client, interventions should be focused around reduction of which specific problem associated with this type of heart failure?
1.	Ascites	
2.	Pedal edema	
3.	Bilateral lung crackles	
4.	Jugular vein distention	

ANS:	3

Rationale: The client with heart failure may present with different symptoms, depending on whether the right or the left side of the heart is failing. Adventitious breath sounds, such as crackles, are an indicator of decreased left-sided heart function. Peripheral edema, jugular vein distention, and ascites all can be present because of insufficiency of the pumping action of the right side of the heart.

Test-Taking Strategy: Read each option carefully, recalling that the symptoms of heart failure appear in the circulatory areas behind the failing chamber. The correct option is the one that relates to the pulmonary system, because blood flows into the left side of the heart from the lungs. Review the problems associated with left-sided heart failure if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Analyzing
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Cardiovascular
MSC:	Integrated Process: Nursing Process—Planning

	52.	A client with angina complains that the anginal pain is prolonged, severe, and occurs at the same time each day, most often in the morning. On further assessment, a nurse notes that the pain occurs in the absence of precipitating factors. How would the nurse best describe this type of anginal pain?
1.	Stable angina	
2.	Unstable angina	
3.	Variant angina	
4.	Nonanginal pain	

ANS:	3

Rationale: Stable angina is induced by exercise and relieved by rest or nitroglycerin tablets. Unstable angina occurs at lower levels of activity than those that previously precipitated the angina. Unstable angina also occurs at rest; is less predictable; and is often a precursor of myocardial infarction. Variant angina, or Prinzmetal’s angina, is prolonged and severe and occurs at the same time each day, usually in the morning.

Test-Taking Strategy: Use the process of elimination, focusing on the data in the question. Think about the characteristic of the various types of angina. Noting the strategic words “occurs at the same time each day” will direct you to “variant angina.” If you had difficulty with this question, review the characteristics of the various types of angina.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Monahan, F., Sands, J., Marek, J., Neighbors, M., & Green, C. (2007). Phipps' medical-surgical nursing: health and illness perspectives (8th ed.). St. Louis: Mosby.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Cardiovascular
MSC:	Integrated Process: Nursing Process—Assessment

	53.	A client’s total cholesterol level is 344 mg/dL, low-density lipoprotein cholesterol (LDL-C) level is 164 mg/dL, and high-density lipoprotein cholesterol (HDL-C) level is 30 mg/dL. Based on analysis of the data, how should the nurse direct client teaching?
1.	The client should maintain the current dietary regimen but increase activity levels.	
2.	Results are inconclusive unless the triglyceride level is also screened, so teaching is not indicated at this time.	
3.	The client is at high risk for cardiovascular disease, and measures to modify all identified risk factors should be taught.	
4.	The client is at low risk for cardiovascular disease, so the client should be encouraged to continue to follow the current regimen.	

ANS:	3

Rationale: In the absence of documented cardiovascular disease, the desired goal is to have the total cholesterol level lower than 200 mg/dL. A desired LDL-C level for all individuals is lower than 100 mg/dL, and a desirable HDL-C level is higher than 40 mg/dL. Because the client’s levels are outside the range for all three values to a significant degree, the client is at high risk for developing cardiovascular disease and requires teaching on risk factor reduction.

Test-Taking Strategy: Use knowledge of normal values for serum cholesterol and lipoprotein levels to answer this question. The question does not indicate that the client has documented heart disease, so the standard recommended values apply. Knowing that the total cholesterol should be lower than 200 mg/dL helps you choose your answer correctly. Review the risk factors for cardiovascular disease if you had difficulty answering this question.

PTS:	1
DIF:	Level of Cognitive Ability: Analyzing
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Health Promotion and Maintenance
TOP:	Content Area: Adult Health/Cardiovascular
MSC:	Integrated Process: Nursing Process—Planning

	54.	The ambulatory care nurse measures the blood pressure of a client and finds it to be 156/94 mm Hg. Which of the following areas is unnecessary to emphasize when providing client education for blood pressure control?
1.	Instruct the client to limit protein intake.	
2.	Teach the client to avoid adding salt to foods.	
3.	Discuss the rationale for reducing or maintaining weight.	
4.	Stress the importance of a regular exercise program.	

ANS:	1

Rationale: Obesity and sodium intake are modifiable risk factors for hypertension. These are of the utmost importance because they can be changed or modified by the individual through a regular exercise program and careful monitoring of sodium intake. Protein intake has no relationship to hypertension.

Test-Taking Strategy: Focus on the strategic words “unnecessary to emphasize” in the question. This will assist in directing you to “instruct the client to limit protein intake.” Review client education for risk factor reduction for hypertension if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Health Promotion and Maintenance
TOP:	Content Area: Adult Health/Cardiovascular
MSC:	Integrated Process: Teaching and Learning

	55.	The nurse identifies that a client is having occasional premature ventricular contractions (PVCs) on the cardiac monitor. The nurse reviews the client’s laboratory results and determines that which of the following results would be consistent with the observation?
1.	Serum sodium level of 150 mEq/L	
2.	Serum chloride level of 95 mEq/L	
3.	Serum calcium level of 11.5 mg/dL	
4.	Serum potassium level of 2.8 mEq/L	

ANS:	4

Rationale: The nurse assesses the client’s serum laboratory study results for hypokalemia. The client may experience PVCs in the presence of hypokalemia, because this electrolyte imbalance increases the electrical instability of the heart. The electrolyte imbalances mentioned in the other options do not have this effect.

Test-Taking Strategy: Focus on the data in the question. Recalling that a low potassium level causes cardiac irritability will direct you to “serum potassium level of 2.8 mEq/L.” If this question was difficult, review the effects of electrolyte imbalances on the cardiac system.

PTS:	1
DIF:	Level of Cognitive Ability: Analyzing
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Cardiovascular
MSC:	Integrated Process: Nursing Process—Assessment

	56.	The client who has had intracranial surgery is experiencing diabetes insipidus. The nurse understands that the client is experiencing which of the following problems?
1.	Water intoxication	
2.	Excess production of dopamine	
3.	Excess production of angiotensin II	
4.	Insufficient production of antidiuretic hormone (ADH)	

ANS:	4

Rationale: Diabetes insipidus results from insufficient ADH production, which in this case was because of head injury. This causes the kidneys to excrete large volumes of urine. Water intoxication represents the opposite problem of that experienced with diabetes insipidus. “Excess production of dopamine” and “excess production of angiotensin II” are not associated with diabetes insipidus.

Test-Taking Strategy: Focus on the client’s diagnosis. Recalling the pathophysiology of diabetes insipidus will direct you to “insufficient production of antidiuretic hormone (ADH).” Review this disorder if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Renal
MSC:	Integrated Process: Nursing Process—Assessment

	57.	The client is admitted to the hospital with a tentative diagnosis of bladder cancer. The nurse expects the client history to reveal which of the following earliest manifestations of the disease?
1.	Proteinuria and dysuria	
2.	Hematuria with no pain	
3.	Painful urination and hematuria	
4.	Pyuria and palpable abdominal mass	

ANS:	2

Rationale: The earliest signs and symptoms of bladder cancer are hematuria that is not accompanied by pain. The hematuria is intermittent at first. Later symptoms include hematuria with dysuria and frequency because of bladder irritation. Pyuria and proteinuria are not part of the clinical picture. A mass is usually not palpable.

Test-Taking Strategy: The strategic word in the question is “earliest.” Begin to answer this question by eliminating “pyuria and palpable abdominal mass” first, because pyuria would be caused by infection. Knowing that pain and discomfort are later signs helps you eliminate “proteinuria and dysuria” and “painful urination and hematuria” next. This leaves “hematuria with no pain” as correct. The client usually presents with intermittent painless hematuria. Review the early manifestations of bladder cancer if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Analyzing
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Renal
MSC:	Integrated Process: Nursing Process—Assessment

	58.	The client with glomerulonephritis has developed acute renal failure (ARF) as a complication. The nurse would expect to note which of the following abnormal findings documented on the client’s medical record?
1.	Decreased cardiac output	
2.	Hypertension	
3.	Bradycardia	
4.	Decreased central venous pressure	

ANS:	2

Rationale: ARF caused by glomerulonephritis is classified as an intrinsic or intrarenal cause of renal failure. It is commonly manifested by hypertension, tachycardia, oliguria, lethargy, edema, and other signs of fluid overload. ARF from a prerenal cause is characterized by decreased blood pressure, tachycardia, decreased cardiac output, and decreased central venous pressure. Bradycardia is not part of the clinical picture for any form of renal failure.

Test-Taking Strategy: Begin to answer this question by recalling that renal failure is accompanied by fluid overload. This would guide you to eliminate “decreased central venous pressure” first. Because fluid overload increases the workload of the heart as a pump (tachycardia), “bradycardia” may be eliminated next. Choose correctly between the remaining two options after recalling that hypertension accompanies ARF because of intrarenal causes, whereas decreased cardiac output accompanies ARF because of prerenal causes. Review the manifestations of glomerulonephritis if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Analyzing
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Renal
MSC:	Integrated Process: Nursing Process—Assessment

	59.	The client has been diagnosed with pyelonephritis. The nurse interprets that which of the following health problems has placed the client at risk for this disorder?
1.	Diabetes mellitus	
2.	Intravenous (IV) contrast medium	
3.	Orthostatic hypotension	
4.	Coronary artery disease	

ANS:	1

Rationale: Pyelonephritis is most commonly caused by entry of bacteria, obstruction, or reflux. Risk factors associated with pyelonephritis include diabetes mellitus, hypertension, chronic renal calculi, chronic cystitis, overuse of analgesics, structural abnormalities of the urinary tract, presence of urinary stones, and indwelling or frequent urinary catheterization.

Test-Taking Strategy: Recall that pyelonephritis is an infection in the kidneys that usually occurs as a result of other urinary problems. Because there is no option addressing a urinary association, evaluate each of the options from the perspective of the one that could cause renal complications. This should allow you to eliminate each of the incorrect options systematically. Although IV contrast medium is excreted by the kidneys and could cause renal failure, it is not known to cause kidney infections. Review the risk factors associated with pyelonephritis if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Analyzing
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Renal
MSC:	Integrated Process: Nursing Process—Assessment

	60.	The nurse has a prescription to collect a 24-hour urine specimen from a client. The nurse should avoid which of the following errors in technique when implementing this procedure?
1.	Do not remove urine from the collection container for other specimens.	
2.	Place the specimen in the appropriate container necessary for the test.	
3.	Ask the client to save a sample voided at the end of the collection time.	
4.	Ask the client to void, save the specimen, and note the start time.	

ANS:	4

Rationale: Because the 24-hour urine test is a timed quantitative determination, the test must be started with an empty bladder. Therefore, the first urine is discarded. Fifteen minutes prior to the end of the collection time, the client should be asked to void, and this specimen is added to the collection. The urine sample should be placed in the appropriate container and may be refrigerated or placed on ice to prevent changes in the urine. Because this is a quantitative determination of constituents in the urine, no urine should be removed from the container.

Test-Taking Strategy: The strategic word is “avoid,” which tells you that the correct option is an incorrect nursing action. Recalling that this test is a timed quantitative determination of output will direct you to “ask the client to void, save the specimen, and note the start time.” Review the procedure for collecting a 24-hour urine collection if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Renal
MSC:	Integrated Process: Nursing Process—Implementation

	61.	The nurse who is collecting data from the client notes that the client’s left-sided eyelid is drooping. The nurse documents that the client is exhibiting which of the following conditions?
1.	Ptosis	
2.	Arcus senilis	
3.	Abnormal corneal reflex	
4.	Blockage of the lacrimal duct	

ANS:	1

Rationale: Ptosis is a sagging of the upper lid of the eye so that it covers part of the pupil. It can be caused by edema, third cranial nerve disorders, or neuromuscular disorders. It is not caused by blockage of the lacrimal duct (tear duct). Arcus senilis is an age-related change, characterized by formation of a yellow-gray ring around the periphery of the cornea surrounding the iris. The corneal reflex is the blink reflex.

Test-Taking Strategy: Recall the normal anatomy and physical examination findings of the eye. Noting the word “drooping” in the question will direct you to “ptosis.” If this question was difficult, review the description of ptosis.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Eye
MSC:	Integrated Process: Communication and Documentation

	62.	The nurse is attempting to inspect the lacrimal apparatus of the client’s eye. Because of its anatomical location, the nurse should do which of the following?
1.	Retract the upper eyelid, and ask the client to look down.	
2.	Retract the upper eyelid, and ask the client to look up.	
3.	Retract the lower eyelid, and ask the client to look up.	
4.	Retract the lower eyelid, and ask the client to look down.	

ANS:	1

Rationale: The lacrimal apparatus consists of the lacrimal gland (in the upper lid over the outer canthus) and the secretory ducts, which direct tears to the lacrimal sac in the inner canthus. The nurse examines part of this apparatus by retracting the upper eyelid and asking the client to look down. Abnormal findings would include edema and tenderness. The other statements are incorrect.

Test-Taking Strategy: Recall the normal anatomy of the eye and visualize the procedure for checking the lacrimal apparatus. This will direct you to “retract the upper eyelid, and ask the client to look down.” If this question was difficult, review this assessment procedure.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Health Promotion and Maintenance
TOP:	Content Area: Adult Health/Eye
MSC:	Integrated Process: Nursing Process—Assessment

	63.	The nurse conducting an eye examination notes that the client exhibits rapid, involuntary, oscillating movements of the eyeball when looking at the nurse. The nurse documents this finding as:
1.	Nystagmus	
2.	Photophobia	
3.	Unequal pupils	
4.	Impaired consensual response	

ANS:	1

Rationale: Nystagmus is characterized by the presence of involuntary, rapid eye movements and is an abnormal finding caused by disease or as a side effect of some medications. Unequal pupils are noted by direct examination of pupil size and reaction to light and are abnormal in most cases. Consensual response is a normal finding that is noted when one pupil contracts, even though the other pupil has a light shone into it. Photophobia is an abnormal sensation and is seen as a sensitivity of the client to light.

Test-Taking Strategy: Recall the normal anatomy and physical examination findings of the eye. Focusing on the words “oscillating movements of the eyeball” will direct you to “nystagmus.” If this question was difficult, review the description of nystagmus.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Eye
MSC:	Integrated Process: Nursing Process—Assessment

	64.	The nurse who is assessing the client’s eyes notes that the pupil gets larger when looking at an object in the distance and gets smaller when looking at a near object. The nurse documents this finding as:
1.	Myopia	
2.	Hyperopia	
3.	Photophobia	
4.	Accommodation	

ANS:	4

Rationale: Accommodation is the expected change in pupil size when changing gaze from a near object to a far one, and back again. The pupils dilate when looking at the far object and constrict when looking at the near one. Photophobia is an abnormal sensitivity to light. Myopia (nearsightedness) and hyperopia (farsightedness) are disturbances in visual acuity.

Test-Taking Strategy: Focus on the data in the question, and note the relationship between the data and the definition of accommodation. If this question was difficult, review the definition of accommodation.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Eye
MSC:	Integrated Process: Nursing Process—Assessment

	65.	The nurse suspects the client may be experiencing dysfunction in the area of the semicircular canals of the ear if the client experiences:
1.	Disturbance in balance	
2.	Conduction hearing loss	
3.	Tinnitus	
4.	Sensorineural hearing loss	

ANS:	1

Rationale: The semicircular canals function to aid the client’s sense of balance. These canals do not relate to hearing function or the presence of tinnitus.

Test-Taking Strategy: Eliminate “conduction hearing loss” and “sensorineural hearing loss” first because they are comparable or alike. For the remaining options, it is necessary to know that the semicircular canals function to aid the client’s sense of balance. Review the function of the semicircular canals if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Ear
MSC:	Integrated Process: Nursing Process—Assessment

	66.	A client is experiencing blockage of the eustachian tubes. Which of the following activities by the client may forcibly open the eustachian tube?
1.	Performing the Valsalva maneuver	
2.	Tapping the side of the head lightly	
3.	Using cotton-tipped applicators in the ears	
4.	Chewing food using exaggerated mouth movements	

ANS:	1

Rationale: Performing the Valsalva maneuver increases pressure in the nasopharynx and may help open a blocked eustachian tube. The actions described in the other options will not accomplish this.

Test-Taking Strategy: Focus on the subject, forcibly opening the eustachian tube. Thinking about the anatomy and physiology of the eustachian tube and focusing on the subject will direct you to “performing the Valsalva maneuver.” If needed, review the interventions used to resolve blocked eustachian tubes.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Ear
MSC:	Integrated Process: Teaching and Learning

	67.	A nurse is caring for a client diagnosed with Ménière’s disease. The nurse plans care, understanding that this disorder is characterized by:
1.	Dizziness	
2.	Blurred vision	
3.	Hemianopsia	
4.	Photophobia	

ANS:	1

Rationale: Ménière’s disease is a disorder of the inner ear characterized by a dizziness and loss of balance. This requires the addition of safety to the care plan. “Blurred vision,” “hemianopsia,” and “photophobia” are incorrect.

Test-Taking Strategy: Focus in the client’s diagnosis. Recalling the pathophysiology of Ménière’s disease will direct you to “dizziness.” Review nursing care for this disorder if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Ear
MSC:	Integrated Process: Nursing Process—Planning

	68.	The client has a cerebellar lesion. The nurse would plan to obtain which of the following for use by this client?
1.	Walker	
2.	Slider board	
3.	Raised toilet seat	
4.	Adaptive eating utensils	

ANS:	1

Rationale: The cerebellum is responsible for balance and coordination. A walker provides stability for the client during ambulation. A raised toilet seat is useful if the client has sufficient mobility or ability to flex the hips. A slider board is used in transferring a client with weak or paralyzed legs from a bed to stretcher or wheelchair. Adaptive eating utensils are beneficial if the client has partial paralysis of the hand.

Test-Taking Strategy: To answer this question correctly, it is essential to recall that the cerebellum controls balance and coordination. This would help you eliminate “slider board” and “raised toilet seat” first. To help you choose between the remaining two options, recall that adaptive eating utensils are useful with loss of fine motor coordination, such as with stroke. The walker would help the client maintain balance. Review care of the client with a cerebellar lesion if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Safe and Effective Care Environment
TOP:	Content Area: Adult Health/Neurological
MSC:	Integrated Process: Nursing Process—Planning

	69.	The client has sustained damage to Wernicke’s area in the temporal lobe from a brain attack (stroke). Which of the following should the nurse anticipate when caring for this client?
1.	The client will be unable to recall past events.	
2.	The client will demonstrate difficulty articulating words.	
3.	The client will have difficulty understanding language.	
4.	The client will have difficulty moving one side of the body.	

ANS:	3

Rationale: Wernicke’s area consists of a small group of cells in the temporal lobe the function of which is the understanding of language. The hippocampus is responsible for the storage of memory (“the client will be unable to recall past events”). Damage to Broca’s area is responsible for aphasia (“the client will demonstrate difficulty articulating words”). The motor cortex in the precentral gyrus controls voluntary motor activity (“the client will have difficulty moving one side of the body”).

Test-Taking Strategy: To answer this question correctly, you must recall the specific functions of various areas of the brain. Remember that Wernicke’s area is responsible for understanding language. If this question was difficult, review the function of Wernicke’s area.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Neurological
MSC:	Integrated Process: Nursing Process—Assessment

	70.	The nurse is preparing to administer a prescribed antibiotic to a client with bacterial meningitis. The nurse understands that the selection of an antibiotic to treat meningitis is based on which of the following?
1.	It has a long half-life.	
2.	It acts within minutes to hours.	
3.	It is able to cross the blood-brain barrier.	
4.	It can be easily excreted in the urine.	

ANS:	3

Rationale: A primary consideration regarding medications to treat bacterial meningitis is the ability of the medication to cross the blood-brain barrier. If the medication cannot cross, it will not be effective. The duration, onset, and excretion of the medication (“it has a long half-life,” “it acts within minutes to hours,” and “it can be easily excreted in the urine”) are also of general concern but apply to all medications and not specifically to those that are used to treat meningitis.

Test-Taking Strategy: Focus on the client’s diagnosis. Recalling the pathophysiology associated with meningitis will direct you to “it is able to cross the blood-brain barrier.” Also note the relationship of the diagnosis and the words “blood-brain barrier” in “it is able to cross the blood-brain barrier.” Review meningitis and its treatment if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Neurological
MSC:	Integrated Process: Nursing Process—Planning

	71.	The client who is experiencing an inferior wall myocardial infarction has had a drop in heart rate into the 50 to 56 beats/min range. The client is also complaining of nausea. The nurse interprets that these symptoms are because of stimulation of which cranial nerve (CN)?
1.	Vagus (CN X)	
2.	Hypoglossal (CN XII)	
3.	Spinal accessory (CN XI)	
4.	Glossopharyngeal (CN IX)	

ANS:	1

Rationale: The vagus nerve is responsible for sensations in the thoracic and abdominal viscera. It is also responsible for the decrease in heart rate because approximately 75% of all parasympathetic stimulation is carried by the vagus nerve. CN IX is responsible for taste in the posterior two thirds of the tongue, pharyngeal sensation, and swallowing. CN XI is responsible for neck and shoulder movement. CN XII is responsible for tongue movement.

Test-Taking Strategy: Focus on the data in the question, and note the relationship between the data and “vagus (CN X).” Also recalling the function of the vagus nerve will direct you to the correct option. If this question was difficult, review the functions of the cranial nerves.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Neurological
MSC:	Integrated Process: Nursing Process—Assessment

	72.	The client is being scheduled for a positron emission tomography (PET) scan. The nurse provides which of the following explanations to the client?
1.	“The test uses magnetic fields to produce images.”	
2.	“The test provides cross-sectional views of the brain.”	
3.	“The test detects abnormal glucose metabolism in the brain.”	
4.	“The test views bones of the skull, nasal sinuses, and vertebrae.”	

ANS:	3

Rationale: The PET scan can detect abnormal brain tissue metabolism. A radionuclide is attached to a glucose component and is injected as an intravenous bolus. The computer records the chemical activity in the brain following injection. “The test uses magnetic fields to produce images,” “the test provides cross-sectional views of the brain,” and “the test views bones of the skull, nasal sinuses, and vertebrae” describe magnetic resonance imaging (MRI), computer tomography (CT) scanning, and radiography, respectively.

Test-Taking Strategy: Specific knowledge about this diagnostic test and use of the process of elimination will direct you to “The test detects abnormal glucose metabolism in the brain.” Remember that the PET scan can detect abnormal brain tissue metabolism. Review this neurological test if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Neurological
MSC:	Integrated Process: Nursing Process—Implementation

	73.	The nurse is caring for a client who is scheduled to have electroencephalography. The nurse determines that the client is ready for the procedure after noting which of the following?
1.	The client’s hair has been shampooed.	
2.	The client has not had any breakfast.	
3.	The client has had two cups of coffee with breakfast.	
4.	The morning dose of an anticonvulsant has been administered.	

ANS:	1

Rationale: Preprocedure care for electroencephalography involves client teaching about the procedure, shampooing the client’s hair, and providing a light meal and fluids to prevent hypoglycemia (which could alter electroencephalographic results). Medications, such as antidepressants, tranquilizers, and anticonvulsants, are withheld for 24 to 48 hours before the procedure, as determined by the physician. Stimulants, such as coffee, tea, cola, alcohol, and cigarettes, are also withheld for 12 hours prior to the test.

Test-Taking Strategy: Focus on the name of the test and think about the procedure involved in performing this test. This will direct you to “the client’s hair has been shampooed.” Review this neurological test if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Neurological
MSC:	Integrated Process: Nursing Process—Assessment

	74.	The nurse should ask the client to do which of the following when testing the function of the spinal accessory nerve (CN XI)?
1.	Swallow a sip of water.	
2.	Elevate the shoulders.	
3.	Open the mouth and say “ah.”	
4.	Vocalize the sounds “la-la,” “mi-mi,” and “kuh-kuh.”	

ANS:	2

Rationale: The spinal accessory nerve has only a motor component. This cranial nerve is assessed by asking the client to elevate the shoulders, which may be done with or without resistance. It can also be assessed by asking the client to turn the head from one side to the other, resist attempts to pull the chin toward midline, and push the head forward against resistance. The incorrect options are assessed as part of glossopharyngeal nerve (CN IX) and vagus nerve (CN X) testing, which are done together.

Test-Taking Strategy: Focus on the subject, the spinal accessory nerve. Recalling the function of this nerve and that it has only a motor component will direct you to “elevate the shoulders.” Review the cranial nerves and neurological assessment if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Health Promotion and Maintenance
TOP:	Content Area: Adult Health/Neurological
MSC:	Integrated Process: Nursing Process—Assessment

	75.	The nurse is assessing the client’s muscle strength and notes that when asked, the client cannot maintain his or her hands in a supinated position with the arms extended and eyes closed. How would the nurse correctly document this finding on the medical record?
1.	Client is demonstrating ataxia.	
2.	Client is exhibiting pronator drift.	
3.	Client examination reveals hyperreflexia.	
4.	Client appears to have nystagmus.	

ANS:	2

Rationale: Pronator drift occurs when a client cannot maintain his or her hands in a supinated position with the arms extended and eyes closed. This assessment may be done to detect small changes in muscle strength that might not otherwise be noted. Ataxia is a disturbance in gait. Hyperreflexia is an excessive reflex action. Nystagmus is characterized by fine, involuntary eye movements. It can occur with neurological disease or as a side effect of selected medications. 

Test-Taking Strategy: To answer this question accurately, you must be familiar with common abnormal findings related to neurological assessment. Note the relationship of the assessment finding in the question and the words “pronator drift” in “client is exhibiting pronator drift.” If you had difficulty with this question, review the assessment procedures for testing muscle strength.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Neurological
MSC:	Integrated Process: Nursing Process—Assessment

	76.	The nurse is testing the client for graphesthesia and asks the client to close his eyes. Which of the following would the nurse have the client do?
1.	Identify three objects placed in the hand, one at a time.	
2.	Identify three numbers or letters traced in the client’s palm.	
3.	Identify the smallest distance between two skin pricks after pricking the skin with two pins at varying distances.	
4.	State whether one or two skin pricks are felt, after applying sharp stimuli bilaterally to symmetrical areas of the client’s skin.	

ANS:	2

Rationale: Graphesthesia is the ability to recognize the form of written symbols. The nurse can assess for this by tracing symbols, such as numbers, in the client’s palm. “Identify three objects placed in the hand, one at a time” tests for stereognosis, which is the ability to identify the form of common objects using the sense of touch. “Identify the smallest distance between two skin pricks after pricking the skin with two pins at varying distances” and “state whether one or two skin pricks are felt, after applying sharp stimuli bilaterally to symmetrical areas of the client’s skin” test for extinction phenomenon and two-point stimulation, respectively.

Test-Taking Strategy: This question is difficult, because you must be familiar with common methods of testing for proprioception. Focusing on the subject of the question and recalling the definition of graphesthesia will direct you to “identify three numbers or letters traced in the client’s palm.” If you are unfamiliar with these data collection techniques, review this content.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Health Promotion and Maintenance
TOP:	Content Area: Adult Health/Neurological
MSC:	Integrated Process: Nursing Process—Assessment

	77.	The nurse plans care for the older adult female client with a diagnosis of osteoporosis knowing that the client is at greatest risk for which of the following?
1.	Fractures	
2.	Phosphatemia	
3.	Hypocalcemia	
4.	Muscle atrophy	

ANS:	1

Rationale: Osteoporosis is a disorder that results in a loss of bone mass. The client with osteoporosis is most likely to suffer fractures as a result of this disorder. “Phosphatemia,” “hypocalcemia,” and “muscle atrophy” are not associated with this disorder.

Test-Taking Strategy: Note the strategic words “greatest risk.” To answer this question accurately, you must know that osteoporosis results in loss of bone mass, which makes the client more prone to fractures. If this question was difficult, review the pathophysiology of this disorder.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Musculoskeletal
MSC:	Integrated Process: Nursing Process—Planning

	78.	The clinical picture of the client with osteitis deformans (Paget’s disease) includes back and leg pain, a crouched forward posture, and legs that bow outward. The nurse plans care, knowing that these manifestations are caused by disturbances of which of the following?
1.	Muscle metabolism and growth	
2.	Bone resorption and regeneration	
3.	Nervous system impulse transmission	
4.	Joint integrity and synovial fluid production	

ANS:	2

Rationale: Paget’s disease is characterized by skeletal deformities caused by abnormal bone resorption, followed by abnormal regeneration. It is not caused by problems with muscles, joints, or nervous system functioning.

Test-Taking Strategy: To answer this question correctly, you must be familiar with Paget’s disease and the anatomical structures affected. Remember that Paget’s disease is characterized by abnormal bone resorption and regeneration. If this question was difficult, review the pathophysiology of this disease process.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Musculoskeletal
MSC:	Integrated Process: Nursing Process—Planning

	79.	The nurse understands that the most significant rationale for the application of heat to an area of contusion 72 hours after the injury is to:
1.	Prevent abscess formation.	
2.	Promote muscle relaxation.	
3.	Reabsorb blood from the injured tissue.	
4.	Reduce the likelihood of strain as a complication.	

ANS:	3

Rationale: The primary benefit from applying heat to a contusion is to speed up the rate of absorption of blood that has hemorrhaged into the affected soft tissue. Although heat also promotes muscle relaxation, this is not the intended benefit of this therapy in treating a contusion. Heat is not applied to reduce abscess formation or prevent muscle strain.

Test-Taking Strategy: Use the process of elimination. Think about the effects of heat and use knowledge of what happens to tissue with contusion. This will assist in directing you to the correct option. Review care to the client with a contusion if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Musculoskeletal
MSC:	Integrated Process: Nursing Process—Implementation

	80.	The nurse is assisting in performing a physical assessment of a right-handed client’s musculoskeletal system. Which of the following would be an abnormal finding?
1.	Presence of fasciculations	
2.	Muscle strength of normal power	
3.	Symmetrical movements bilaterally	
4.	Hypertrophy of right upper arm of 1 cm	

ANS:	1

Rationale: Fasciculations are fine muscle twitches that are not normally present. Hypertrophy, or increased muscle size, on the client’s dominant side of up to 1 cm is considered normal. Muscle strength is graded from (paralysis) to (normal power). Symmetrical muscle movement is a normal finding.

Test-Taking Strategy: “Muscle strength of normal power” and “symmetrical movements bilaterally” should be eliminated first because they are normal findings. To choose correctly between the remaining two options, you must know that slight hypertrophy is normal on the dominant side, whereas fasciculations are not. Review basic physical assessment findings of the musculoskeletal system if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Analyzing
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Musculoskeletal
MSC:	Integrated Process: Nursing Process—Assessment

	81.	The nurse explaining the procedure of indium imaging to a client with a bone infection would include which of the following?
1.	Indium is injected into the bloodstream and outlines the extent of the blood supply to the bone.	
2.	Indium is injected into the bloodstream and collects in normal bone but not in infected areas.	
3.	Some of the client’s white blood cells are tagged with indium, which will later accumulate in infected bone.	
4.	Some of the client’s red blood cells are tagged with indium, which will later accumulate in normal bone.	

ANS:	3

Rationale: For indium imaging, a sample of the client’s blood is collected, and the leukocytes (white blood cells) are tagged with indium. The leukocytes are then reinjected into the client. They accumulate in infected areas of bone and can be detected with scanning. No special preparation or aftercare is necessary.

Test-Taking Strategy: To answer this question accurately, you must be familiar with this specific procedure. Use knowledge that leukocytes migrate to an area of infection to answer this question. This will help eliminate the incorrect options. Review this procedure if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Musculoskeletal
MSC:	Integrated Process: Nursing Process—Implementation

	82.	The client was admitted to the hospital 2 hours ago following multiple fractures to the pelvis and soft tissue injury to the abdomen. Diagnostic studies have ruled out perforation of abdominal organs. The nurse places highest priority on monitoring this client for which of the following changes in vital signs?
1.	Fever, bradycardia	
2.	Fever, hypertension	
3.	Tachycardia, hypotension	
4.	Bradycardia, hypertension	

ANS:	3

Rationale: Clients who experience fractures of the femur, pelvis, thorax, and spine are at risk for hypovolemic shock. Bone fragments can damage blood vessels, leading to hemorrhage into the abdominal cavity and, in the case of a fractured femur, into the thigh. This can occur with closed fractures as well as open fractures. Signs of hypovolemic shock include tachycardia and hypotension.

Test-Taking Strategy: Begin to answer this question by noting that the client was admitted just 2 hours ago. This helps you eliminate “fever, bradycardia” and “fever, hypertension” because infection does not develop this quickly. To choose correctly between the last two options, you must know that the client is at risk for hypovolemic shock and the accompanying signs and symptoms. Review the signs of hypovolemic shock if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Analyzing
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Musculoskeletal
MSC:	Integrated Process: Nursing Process—Assessment

	83.	Which of the following teaching points is the priority when the nurse is teaching the client about caring for a plaster cast?
1.	The cast gives off heat as it dries.	
2.	The client can bear weight on the cast in 1 hour.	
3.	A stockinette and soft padding are put over the leg area before casting.	
4.	Immediately report any increase in drainage or interruption in cast integrity.	

ANS:	4

Rationale: Increases in drainage or interruption in cast integrity will affect healing and could lead to osteomyelitis. To apply a cast, the skin is washed and dried well. A stockinette is placed smoothly and evenly over the area to be casted, followed by a roll of padding. The plaster is then rolled onto the padding, and the edges are trimmed or smoothed if needed. A plaster cast gives off heat as it dries. A plaster cast can tolerate weight-bearing once it is dry, which varies from 24 to 72 hours, depending on the nature and thickness of the cast.

Test-Taking Strategy: Note the strategic word “priority.” Recalling that drainage is a sign of infection will direct you to “immediately report any increase in drainage or interruption in cast integrity.” Review the principles of cast care and the client teaching points if you had difficulty with his question.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Musculoskeletal
MSC:	Integrated Process: Teaching and Learning

	84.	The nurse caring for a client who has undergone kidney transplantation is monitoring the client for organ rejection. The nurse understands that in cases in which the recipient rejects transplanted organs, the cells of the transplanted organs are seen by the body as a(n):
1.	T cell	
2.	B cell	
3.	Antibody	
4.	Foreign antigen	

ANS:	4

Rationale: In cases in which transplanted organs are rejected by the recipient, the transplanted organs are seen by the body as foreign antigens. Antibodies are produced to act against a specific antigen. B and T lymphocytes are responsible for cellular and humoral immunity.

Test-Taking Strategy: Knowledge regarding the action and purpose of each of the items listed in the options is required to answer this question. Noting that the subject of the question is rejection of a transplanted organ will assist in directing you to “a foreign antigen.” If you had difficulty with this question, review the types of immune responses.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Immune
MSC:	Integrated Process: Nursing Process—Assessment

	85.	A client is admitted to the hospital with a diagnosis of parasitic worms. The nurse understands that the primary cell type that will attack these foreign particles is:
1.	Basophils	
2.	Neutrophils	
3.	Eosinophils	
4.	Dendritic cells	

ANS:	3

Rationale: Eosinophils attack and destroy foreign particles that have been coated with antibodies of the IgE class. Their usual target is helminths (parasitic worms). Basophils mediate immediate hypersensitivity reactions. Dendritic cells perform the same antigen-presenting task as the macrophages. Neutrophils phagocytize foreign particles, such as bacteria.

Test-Taking Strategy: Knowledge regarding the primary immune-related actions of specific cell types is required to answer this question. Remember that eosinophils attack and destroy foreign particles. If you are unfamiliar with these functions, review this content.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Copstead-Kirkhorn, L., & Banasik, J. (2010). Pathophysiology (4th ed.). St. Louis: Mosby.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Immune
MSC:	Integrated Process: Nursing Process—Assessment

	86.	Tetanus toxoid is prescribed for a client who has sustained a foot laceration from a piece of metal while walking barefoot on the beach. The nurse understands that the toxoid is a(n):
1.	Attenuated bacterium	
2.	Nonattenuated virus	
3.	Toxin produced by bacteria that has been altered so that it is no longer toxic	
4.	Specific antibody that will prevent infection through an antigen-antibody reaction	

ANS:	3

Rationale: Toxoids are toxins produced by bacteria that have been altered so that they are no longer toxic but their important antigenic receptor sites remain intact, enabling antibodies to be produced against the antigen-producing toxin. Therefore “attenuated bacterium,” “nonattenuated virus,” and “specific antibody that will prevent infection through an antigen-antibody reaction” are incorrect descriptions.

Test-Taking Strategy: Knowledge regarding the characteristics of a toxoid is required in this question. Remember that a toxoid is a toxin produced by bacteria that has been altered. If you are unfamiliar with toxoids, review this content.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Monahan, F., Sands, J., Marek, J., Neighbors, M., & Green, C. (2007). Phipps' medical-surgical nursing: health and illness perspectives (8th ed.). St. Louis: Mosby.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Immune
MSC:	Integrated Process: Nursing Process—Assessment

	87.	The nursing instructor is questioning a nursing student about the organs of the immune system and asks the student where Kupffer’s cells are located. The student responds correctly by stating that these types of cells are located in the:
1.	Liver	
2.	Tonsils	
3.	Spleen	
4.	Bone marrow	

ANS:	1

Rationale: The liver contains a large number of macrophages called Kupffer’s cells. These cells help filter blood by phagocytizing microorganisms and other foreign particles that pass through the liver. “Tonsils,” “spleen,” and “bone marrow” are incorrect.

Test-Taking Strategy: Knowledge regarding the organs associated with the immune system and their specific components is required to answer this question. Remember that Kupffer’s cells are located in the liver. If you are unfamiliar with these organs in the immune system, review this content.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Immune
MSC:	Integrated Process: Teaching and Learning

	88.	The nursing student understands that the primary purpose of neutrophils in the inflammatory response is to:
1.	Dilate the blood vessels.	
2.	Increase fluids at the site of injury.	
3.	Phagocytize any potentially harmful agents.	
4.	Produce permeability of the blood vessels.	

ANS:	3

Rationale: In the inflammatory response, neutrophils appear in the area of injury in 30 to 60 minutes. Their primary purpose is to phagocytize (ingest and destroy) any potentially harmful agents, such as microorganisms. “Dilate the blood vessels,” “increase fluids at the site of injury,” and “produce permeability of the blood vessels” are incorrect.

Test-Taking Strategy: Knowledge regarding the inflammatory response and physiological process that occurs is required to answer this question. Remember that neutrophils phagocytize. If you are unfamiliar with the inflammatory response, review this content.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Copstead-Kirkhorn, L., & Banasik, J. (2010). Pathophysiology (4th ed.). St. Louis: Mosby.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Immune
MSC:	Integrated Process: Teaching and Learning

	89.	The nursing student correctly describes the process of phagocytosis as:
1.	The initial reaction in the inflammatory response	
2.	A protein produced in response to a viral infection	
3.	A process required for the production of antibodies	
4.	A process whereby a particle is ingested and digested by a cell	

ANS:	4

Rationale: Phagocytosis, an important nonspecific immune response, is a process in which the particle is ingested and digested by a cell. The other options are incorrect.

Test-Taking Strategy: Knowledge regarding the definition of phagocytosis is required to answer this question. Remember that phagocytosis is a process involving ingestion and digestion by a cell. Review this term if you are unfamiliar with it.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Copstead-Kirkhorn, L., & Banasik, J. (2010). Pathophysiology (4th ed.). St. Louis: Mosby.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Immune
MSC:	Integrated Process: Teaching and Learning

	90.	The nurse is receiving a client from the postanesthesia care unit following left above-knee amputation. The priority nursing action at this time is which of the following?
1.	Elevate the foot of the bed.	
2.	Position the stump flat on the bed.	
3.	Put the bed in a reverse Trendelenburg’s position.	
4.	Keep the stump flat, with the client lying on his or her operative side.	

ANS:	1

Rationale: Edema of the stump is controlled by elevating the foot of the bed for the first 24 hours after surgery. After the first 24 hours, the stump is placed flat on the bed to reduce hip contracture. Edema is also controlled by stump wrapping techniques.

Test-Taking Strategy: The subject of the question is correct positioning of the stump immediately following surgery. Use principles of gravity and edema control to answer this question. If you had difficulty with this question, review postoperative positioning following amputation.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Musculoskeletal
MSC:	Integrated Process: Nursing Process—Implementation

	91.	The nurse is providing instructions to a client and family regarding home care following cataract removal from the left eye. The nurse would plan to teach the client which of the following pieces of information about positioning in the postoperative period?
1.	Lower the head between the knees 3 times a day.	
2.	Bend below the waist as often as possible.	
3.	Avoid sleeping on the left side.	
4.	Sleep only on the left side.	

ANS:	3

Rationale: Following cataract surgery, the client should not sleep on the side of the body that was operated on. Clients should also avoid bending below the level of the waist so as not to increase intraocular pressure.

Test-Taking Strategy: Remember that options that are comparable or alike are not likely to be correct. With this in mind, eliminate “lower the head between the knees 3 times a day” and “bend below the waist as often as possible” first. Choose correctly between the two remaining options, using knowledge of positioning following eye surgery and principles related to gravity and edema formation. Review care to the client following cataract surgery if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Eye
MSC:	Integrated Process: Teaching and Learning

	92.	The nurse caring for a client following craniotomy who has a supratentorial incision understands that the client should most likely be maintained in which of the following positions?
1.	Prone position	
2.	Supine position	
3.	Semi-Fowler’s position	
4.	Dorsal recumbent position	

ANS:	3

Rationale: In supratentorial surgery (surgery above the brain’s tentorium), the client’s head is usually elevated 30 degrees to promote venous outflow through the jugular veins. The client’s head or the head of the bed is not lowered in the acute phase of care after supratentorial surgery. An exception to this position is the client who has undergone evacuation of a chronic subdural hematoma, but a physician’s prescription is required for positions other than those involving head elevation. Additionally, the physician’s prescription regarding positioning is always checked and agency procedures are always followed.

Test-Taking Strategy: Knowledge regarding supratentorial surgery and craniotomy is required to answer this question. Remember that with supratentorial surgery the head should be kept up. If you had difficulty with this question, review positioning following craniotomy surgery.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Neurological
MSC:	Integrated Process: Nursing Process—Implementation

	93.	The nurse is teaching a client with chronic airflow limitation (CAL) about positions that help breathing during dyspneic episodes. Which position, assumed by the client, would indicate that the client needs additional teaching regarding positioning?
1.	Sitting up and leaning on a table	
2.	Standing and leaning against a wall	
3.	Sitting up with elbows resting on knees	
4.	Lying on his or her back in a low Fowler’s position	

ANS:	4

Rationale: The client should use the positions outlined in “sitting up and leaning on a table,” “standing and leaning against a wall,” and “sitting up with elbows resting on knees.” These allow for maximal chest expansion and decreased use of accessory muscles of respiration. The client should not lie on his or her back because it reduces movement of a large area of the client’s chest wall. Sitting is better than standing, whenever possible. If no chair is available, then leaning against a wall while standing allows accessory muscles to be used for breathing rather than posture control.

Test-Taking Strategy: Note the strategic words “needs additional teaching” in the question. These words indicate a negative event query and the need to select the incorrect position. Note that “sitting up and leaning on a table,” “standing and leaning against a wall,” and “sitting up with elbows resting on knees” are comparable or alike in that they are all upright positions. Review care to the client with CAL if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Evaluating
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Respiratory
MSC:	Integrated Process: Teaching and Learning

	94.	The nurse is assisting the physician with insertion of a chest tube. The nurse notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this observation, the nurse takes which of the following actions?
1.	Ensure that suction is turned on.	
2.	Reinforce the occlusive dressing.	
3.	Encourage the client to breathe deeply.	
4.	Document the accurate functioning of the tube.	

ANS:	4

Rationale: The presence of fluctuation of the fluid level in the water seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if a dependent loop exists, if the suction is not working properly, or if the lung has reexpanded. There is no need to ask the client to breathe deeply or to reinforce the dressing. The suction should be turned on if prescribed, but there are no data in the question to indicate this physician’s prescription.

Test-Taking Strategy: Knowledge about closed-chest drainage systems is required to answer this question. Note that the question contains the strategic words “based on this observation.” This tells you that the correct option is the one that is a direct action taken based on the water seal fluctuation. Recalling that fluctuation is normal will direct you to “document the accurate functioning of the tube.” If you had difficulty with this question, review expected and unexpected findings in the care of a client with a chest tube.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Respiratory
MSC:	Integrated Process: Nursing Process—Implementation

	95.	The physician is about to remove a chest tube from a client. After the dressing is removed and the sutures have been cut, the nurse assisting the physician asks the client to:
1.	Breathe in and out quickly.	
2.	Exhale immediately.	
3.	Take a deep breath.	
4.	Perform the Valsalva maneuver.	

ANS:	4

Rationale: When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath, exhale, and bear down). The tube is then quickly withdrawn, and an airtight dressing is taped in place. The pleura seals itself off, and the wound heals in less than 1 week.

Test-Taking Strategy: Knowledge of correct procedure for chest tube removal is required to answer this question. Visualize the procedure as you read each option. This will direct you to “perform the Valsalva maneuver.” If you had difficulty with this question, review the procedure for removing a chest tube.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Respiratory
MSC:	Integrated Process: Nursing Process—Implementation

	96.	The nurse is assisting in caring for the client immediately after removal of the endotracheal tube. Which of the following findings should be reported to the health care physician immediately?
1.	Stridor	
2.	Lung congestion	
3.	Respiratory rate of 26 breaths/min	
4.	Occasional pink-tinged sputum	

ANS:	1

Rationale: The nurse reports the presence of stridor to the physician immediately. This is a high-pitched coarse sound that is heard with the stethoscope over the trachea. It indicates airway edema and places the client at risk for airway obstruction. Congestion (“lung congestion”) and a respiratory rate of 26 breaths/min (“respiratory rate of 26 breaths/min”) are abnormal, but additional data are needed to determine whether these pose a serious problem at this time. Occasional pink-tinged sputum may be expected at this time.

Test-Taking Strategy: To answer this question accurately, recall that the prime danger after removal of an artificial airway is the client’s ability to maintain a patent airway and breathe independently. With this in mind, eliminate each of the incorrect options because they have lower priority as risk factors to the client. Because stridor indicates laryngeal edema and possible airway obstruction, it is the symptom that must be reported immediately. Review care to the client following removal of an endotracheal tube if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Analyzing
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Respiratory
MSC:	Integrated Process: Nursing Process—Assessment

	97.	A client with liver cancer who is receiving chemotherapy tells the nurse that some foods on the meal tray taste bitter. The nurse would try to limit which of the following foods that are most likely to have this taste for the client?
1.	Pork	
2.	Custard	
3.	Potatoes	
4.	Cantaloupe	

ANS:	1

Rationale: Chemotherapy may cause distortion of taste. Frequently, beef and pork are reported to taste bitter or rancid. The nurse can promote client nutrition by helping the client choose alternative sources of protein in the diet, such as mild-tasting fish, cold chicken, turkey, eggs, or cheese. “Custard,” “potatoes,” and “cantaloupe” are not likely to cause distortion of taste.

Test-Taking Strategy: The subject of the question is optimal management of a change in taste sensation. To answer this question accurately, you must be able to identify the most troublesome foods. Remember that meats can cause a distortion in taste. If you had difficulty with this question, review interventions related to nutrition in the client receiving chemotherapy.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Nix, S. (2009). Williams’ basic nutrition and diet therapy (13th ed.). St. Louis: Mosby.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Oncology
MSC:	Integrated Process: Nursing Process—Implementation

	98.	The client with hypertension has been prescribed a low-sodium diet. The nurse teaching this client about foods that are allowed should plan to include which of the following in a list provided to the client?
1.	Tomato soup	
2.	Boiled shrimp	
3.	Instant oatmeal	
4.	Summer squash	

ANS:	4

Rationale: Foods that are lower in sodium are fruits and vegetables (“summer squash”) because they do not contain physiological saline. Highly processed or refined foods (“tomato soup” and “instant oatmeal”) are higher in sodium unless they are specifically noted as “low sodium.” Saltwater fish and shellfish are higher in sodium.

Test-Taking Strategy: Begin to answer this question by eliminating “boiled shrimp” as being highest in sodium. Eliminate the other incorrect options because they are processed foods. Review the foods that are high and low in sodium if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Peckenpaugh, N. (2010). Nutrition essentials and diet therapy (11th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Cardiovascular
MSC:	Integrated Process: Teaching and Learning

	99.	The client has been diagnosed with gout. In developing a teaching plan for this client, the nurse should include a list that identifies which of the following foods to be avoided?
1.	Chicken liver	
2.	Carrots	
3.	Tapioca	
4.	Chocolate	

ANS:	1

Rationale: Liver and other organ meats should be omitted from the diet of a client who has gout because of their high purine content. Purines are a form of protein. The food items identified in the other options contain negligible amounts of purines and may be consumed freely by the client with gout.

Test-Taking Strategy: Focus on the pathophysiology of the client’s diagnosis and the subject, foods high in purine. Remember that organ meats are high in purines. Review foods high in purine if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Musculoskeletal
MSC:	Integrated Process: Teaching and Learning

	100.	The client with a history of gastrointestinal upset has been diagnosed with acute diverticulitis. The nurse gives the client suggestions for foods to aid in symptom management that are in which of the following diet types?
1.	A low-fat diet	
2.	A low-fiber diet	
3.	A high-fiber diet	
4.	A high-carbohydrate diet	

ANS:	2

Rationale: A low-fiber diet places less strain on the intestines because this type of diet is easier to digest. Clients should avoid high-fiber foods when experiencing acute diverticulitis. As the attack resolves, fiber can be gradually added to the diet.

Test-Taking Strategy: Note the strategic word “acute” and that the diagnosis in the question refers to an inflammation in the colon. With this in mind, you should select the diet that would be least irritating to intestinal mucosa. This will direct you to “a low-fiber diet.” If you had difficulty with this question, review the diet prescribed for acute diverticulitis.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Gastrointestinal
MSC:	Integrated Process: Nursing Process—Implementation

	101.	The nurse is caring for the client with cirrhosis. As part of dietary teaching to minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the material if the client states to increase intake of which of the following?
1.	Pork	
2.	Milk	
3.	Chicken	
4.	Broccoli	

ANS:	1

Rationale: Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in the vitamin. Other good sources include peanuts, asparagus, and whole grain and enriched cereals.

Test-Taking Strategy: Note the strategic words “best understanding” in the question. This may indicate that more than one option may be a food that contains thiamine. Knowledge regarding food items high in thiamine is required to answer this question. If you are unfamiliar with these foods, review these food items.

PTS:	1
DIF:	Level of Cognitive Ability: Evaluating
REF:	Nix, S. (2009). Williams’ basic nutrition and diet therapy (13th ed.). St. Louis: Mosby.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Gastrointestinal
MSC:	Integrated Process: Nursing Process—Evaluation

	102.	The client is resuming a diet after hemigastrectomy. To minimize complications, the nurse would tell the client to avoid doing which of the following?
1.	Lying down after eating	
2.	Drinking liquids with meals	
3.	Eating six small meals per day	
4.	Excluding concentrated sweets in the diet	

ANS:	2

Rationale: The client who has had a hemigastrectomy is at risk for dumping syndrome. This client should be placed on a diet that is high in protein, moderate in fat, and high in calories. The client should avoid drinking liquids with meals. Frequent small meals are encouraged, and the client should avoid concentrated sweets.

Test-Taking Strategy: Note the strategic word “avoid” in the question. This word indicates a negative event query and the need to select the incorrect action. Use the process of elimination, selecting “drinking liquids with meals” as the item that will contribute to the problems associated with dumping syndrome. If you had difficulty with this question, review the diet pattern changes needed to manage this disorder.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Gastrointestinal
MSC:	Integrated Process: Nursing Process—Implementation

MULTIPLE RESPONSE

	1.	The older adult client has been lying in a supine position for the last 3 hours. The nurse who is repositioning this client would be most concerned with examining which of the following bony prominences of the client? Select all that apply.
1.	Heels	
2.	Ankles	
3.	Elbows	
4.	Sacrum	
5.	Back of the head	
6.	Greater trochanter	

ANS:	1, 3, 4, 5

Rationale: When the client is lying supine, the heels, sacrum, and back of the head are all at risk, as well as the elbows and scapulae. The greater trochanter and ankles are at greater risk of skin breakdown from excessive pressure when the client is in the side-lying position.

Test-Taking Strategy: To answer this question accurately, you must be familiar with which skin areas underlie bony prominences and their importance with various client positions. Noting the strategic word “supine” in the question will direct you to the correct options. If this question was difficult, review the risks associated with skin breakdown.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed.). St. Louis: Mosby.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Integumentary
MSC:	Integrated Process: Nursing Process—Assessment

	2.	The client is having a diagnostic workup for colorectal cancer. Which of the following factors in the client’s history will place the client at increased risk of this type of cancer? Select all that apply.
1.	A high-fiber diet	
2.	A diet high in fats	
3.	Minimal alcohol intake	
4.	A diet high in carbohydrates	
5.	A history of inflammatory bowel disease	
6.	Maternal grandfather who had a history of heart disease	

ANS:	2, 4, 5

Rationale: A high-fiber diet actually lessens the chances of developing colorectal cancer. This type of cancer most often occurs in populations with diets low in fiber and high in refined carbohydrates, fats, and meats. Other risk factors include a family history of the disease, rectal polyps, and active inflammatory disease of at least 10 years’ duration.

Test-Taking Strategy: Eliminate “a high-fiber diet” because it helps prevent colon cancer and “maternal grandfather who had a history of heart disease” because a family history of heart disease is not related to bowel cancer. “A history of inflammatory bowel disease” is important because a history of any disorder that interrupts bowel wall integrity places the client at risk. Foods high in fats and carbohydrates are low in fiber and thus may place the client at increased risk. A minimal alcohol intake is not associated with cancer. Review the risk factors associated with colorectal cancer if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Analyzing
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Health Promotion and Maintenance
TOP:	Content Area: Adult Health/Oncology
MSC:	Integrated Process: Nursing Process—Assessment

	3.	The nurse teaching a group of adults about cancer warning signs presents to the group a list of the seven possible warning signs of cancer that is used by the American Cancer Society. What should this list include? Select all that apply.
1.	Areas of alopecia	
2.	Sores that do not heal	
3.	Nagging cough or hoarseness	
4.	Indigestion or difficulty swallowing	
5.	Change in bowel or bladder habits	
6.	Absence or decreased frequency of menses	

ANS:	2, 3, 4, 5

Rationale: Each of the seven warning signs of cancer begins with a letter from the word “CAUTION.” Areas of alopecia occur following cancer chemotherapy. Absence of menses is not one of the signs.

Test-Taking Strategy: To answer this question accurately, you must be familiar with the seven warning signs of cancer. Remembering the word “CAUTION” will assist in answering correctly. Because it is so important to teach the public about general early recognition of cancer, memorize these if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Health Promotion and Maintenance
TOP:	Content Area: Adult Health/Oncology
MSC:	Integrated Process: Teaching and Learning

	4.	A client is admitted to the hospital with a diagnosis of Addison’s disease. The nurse would monitor for which of the following problems associated with this disease? Select all that apply.
1.	Edema	
2.	Obesity	
3.	Syncope	
4.	Hirsutism	
5.	Hypotension	
6.	Muscle weakness	

ANS:	3, 5, 6

Rationale: Common manifestations of Addison’s disease include postural hypotension from fluid loss, syncope, muscle weakness, anorexia, nausea and vomiting, abdominal cramps, weight loss, depression, and irritability. “Syncope,” “obesity,” and “hirsutism” do not occur with this disease.

Test-Taking Strategy: Knowledge regarding the clinical manifestations associated with Addison’s disease is required to answer this question. Think about the pathophysiology associated with this disorder to answer correctly. If you had difficulty with this question, review this endocrine disorder.

PTS:	1
DIF:	Level of Cognitive Ability: Analyzing
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Endocrine
MSC:	Integrated Process: Nursing Process—Assessment

	5.	The client has been diagnosed with Cushing’s syndrome. The nurse would monitor this client for which of the following expected signs of this disorder? Select all that apply.
1.	Anorexia	
2.	Weight loss	
3.	Hypertension	
4.	Dizziness	
5.	Moon facies	
6.	Truncal obesity	

ANS:	3, 5, 6

Rationale: The client with Cushing’s syndrome may exhibit a number of different manifestations. These could include moon facies, truncal obesity, and a “buffalo hump” fat pad. Other signs include hypokalemia, peripheral edema, hypertension, increased appetite, and weight gain. Dizziness is not part of the clinical picture for this disorder.

Test-Taking Strategy: To answer this question correctly, recall that Cushing’s syndrome is a disorder characterized by excess cortisol. With this in mind, analyze each of the manifestations to see if they are compatible with this alteration. Review the clinical manifestations associated with Cushing’s syndrome if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Analyzing
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Endocrine
MSC:	Integrated Process: Nursing Process—Assessment

	6.	The client with liver dysfunction has low serum levels of fibrinogen and a prolonged prothrombin time (PT). Based on these findings, which of the following actions are planned to promote client safety? Select all that apply.
1.	Monitor potassium levels.	
2.	Monitor for symptoms of fluid retention.	
3.	Provide the client with a soft toothbrush.	
4.	Instruct the client to use an electric razor.	
5.	Weigh client daily, and monitor trends.	
6.	Monitor all secretions for frank or occult blood.	

ANS:	3, 4, 6

Rationale: Fibrinogen is produced by the liver and is necessary for normal clotting. The client who has insufficient levels is at risk for bleeding. The prothrombin time is prolonged when one or more of the clotting factors (II, V, VII, or X) is deficient, so the client’s risk for bleeding is also increased. “Provide the client with a soft toothbrush,” “instruct the client to use an electric razor,” and “monitor all secretions for frank or occult blood” are measures that provide for client safety and monitor for bleeding.

Test-Taking Strategy: Specific knowledge of the substances produced by the liver is needed to answer this question, as well as knowledge of laboratory abnormalities found in liver dysfunction. Eliminate “monitor potassium levels,” “monitor for symptoms of fluid retention,” and “weigh client daily, and monitor trends” because these actions are directed toward fluid and electrolyte disturbances that can occur with liver dysfunction. Review this content area if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Applying
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Safe and Effective Care Environment
TOP:	Content Area: Adult Health/Gastrointestinal
MSC:	Integrated Process: Nursing Process—Implementation

	7.	The nurse is doing volunteer work in a homeless shelter. The nurse monitors the individuals in the shelter for which of the following initial symptoms of tuberculosis (TB)? Select all that apply.
1.	Fatigue	
2.	Lethargy	
3.	Chest pain	
4.	Low-grade fever	
5.	Morning cough	
6.	Labored breathing	

ANS:	1, 2, 4, 5

Rationale: The symptoms of TB include a slight morning cough, fatigue, lethargy, and low-grade fever. The other symptoms listed are advanced (not initial) symptoms.

Test-Taking Strategy: Note the strategic word “initial” in the question and think about the pathophysiology associated with this disorder. This should easily direct you to the correct options. If you are unfamiliar with the signs associated with TB, review this important disease process.

PTS:	1
DIF:	Level of Cognitive Ability: Analyzing
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Respiratory
MSC:	Integrated Process: Nursing Process—Assessment

	8.	The nurse notes that the client’s serum calcium level is 6.0 mg/dL. Which of the following assessment findings would be anticipated in this client? Select all that apply.
1.	Tetany	
2.	Constipation	
3.	Renal calculi	
4.	Hypotension	
5.	Prolonged QT interval	
6.	Positive Chvostek’s sign	

ANS:	1, 4, 5, 6

Rationale: The normal serum calcium level is 8.6 to 10 mg/dL; thus, the client’s results are reflective of hypocalcemia. A low serum calcium level could lead to severe ventricular dysrhythmias and prolonged QT and ST intervals on the electrocardiogram. Calcium is needed by the heart for contraction. When the serum calcium level is decreased, cardiac contractility is decreased and the client will experience hypotension. The most common manifestations of hypocalcemia are caused by overstimulation of the nerves and muscles; therefore, tetany and presence of Chvostek’s sign would be expected.

Test-Taking Strategy: Begin to answer this question by recalling the normal serum calcium level in the body. Apply knowledge of the effects of low and high serum calcium levels on excitable tissues to assist you with answering this question. Knowing that the level is low helps you eliminate “constipation” and “renal calculi,” which could result from hypercalcemia. Review the effect of calcium on myocardial and neuromuscular function if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Analyzing
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Cardiovascular
MSC:	Integrated Process: Nursing Process—Assessment

	9.	The nurse notes during assessment and history taking that the older client exhibits visual changes. Which of the following are normal age-related changes of the eye? Select all that apply.
1.	Ptosis	
2.	Photophobia	
3.	Corneal thickening	
4.	Decreased visual acuity	
5.	Decreased tolerance of glare	
6.	Decreased peripheral vision	

ANS:	4, 5, 6

Rationale: Normal age-related visual changes include decreases in visual acuity, peripheral vision, and tolerance of glare, and difficulty in adapting to dark and light. “Ptosis,” “photophobia,” and “corneal thickening” are not normal age-related changes. 

Test-Taking Strategy: Focus on the subject, age-related changes. This will direct you to “decreased visual acuity,” “decreased tolerance of glare,” and “decreased peripheral vision.” If this question was difficult, review the age-related visual changes.

PTS:	1
DIF:	Level of Cognitive Ability: Analyzing
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Eye
MSC:	Integrated Process: Nursing Process—Assessment

	10.	The nurse caring for a client admitted to the hospital with acute back pain understands that this problem can be most likely caused by which of the following? Select all that apply.
1.	Scoliosis	
2.	Twisting of the spine	
3.	Hyperflexion of the spine	
4.	Sciatic nerve inflammation	
5.	Herniation of an intervertebral disk	
6.	Degeneration of the vertebral posterior facet joints	

ANS:	2, 3, 5

Rationale: Acute back pain is sudden in onset and is usually precipitated by injury to the lower back, such as with hyperflexion, twisting, or disk herniation. Degenerative vertebral changes, sciatica, and scoliosis are more likely to cause chronic back pain, which can be more insidious in onset and may also be accompanied by degeneration of the intervertebral disk.

Test-Taking Strategy: The strategic words in the question are “most likely” and “acute back pain.” Use knowledge of the vertebral spine structures and mechanisms of injury to make your selection. You could also choose correctly by recalling that the term “acute” is often associated with a problem that is sudden in onset. Review the causes of acute back pain if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Musculoskeletal
MSC:	Integrated Process: Nursing Process—Assessment

	11.	The client who sustained a severe sprain of the ankle is told by the physician that the pain experienced is caused by muscle spasm and swelling in the area of the injury. Which of the following interventions should the nurse anticipate will be included in the client’s plan of care? Select all that apply.
1.	Ice bags	
2.	Elevation	
3.	Heating pad	
4.	Range-of-motion exercises	
5.	Compression by an elastic bandage	
6.	Maintaining the affected extremity in a dependent position	

ANS:	1, 2, 5

Rationale: Reflex spasm of local muscles and swelling caused by rupture of local capillary beds can best be treated by remembering the acronym RICE, which stands for rest, ice, compression, and elevation. Heat, a dependent position, and range-of-motion exercises are contraindicated because they would increase swelling.

Test-Taking Strategy: Focus on the injury. Recalling the acronym RICE will direct you to the correct options. Review the interventions for a severe ankle sprain if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Musculoskeletal
MSC:	Integrated Process: Nursing Process—Planning

	12.	The nurse collecting data related to the client’s risk factors associated with osteoporosis would include which of the following? Select all that apply.
1.	Thin body build	
2.	Smoking history	
3.	Postmenopausal age	
4.	Chronic corticosteroid use	
5.	Family history of osteoporosis	
6.	High intake of dairy products	

ANS:	1, 2, 3, 4, 5

Rationale: A high intake of dairy products is not associated with osteoporosis, because dairy products are high in calcium. Other than low calcium intake, other risk factors for osteoporosis include a thin body frame, sedentary lifestyle, cigarette smoking, excessive alcohol intake, chronic illness, long-term use of corticosteroids, postmenopausal age, and a family history of osteoporosis.

Test-Taking Strategy: Knowledge regarding the risk factors associated with osteoporosis is required to answer this question. Thinking about the pathophysiology associated with osteoporosis and recalling that a high intake of dairy products is not associated with osteoporosis will easily direct you to all choices except “high intake of dairy products.” Review these risk factors if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Analyzing
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Musculoskeletal
MSC:	Integrated Process: Nursing Process—Assessment

	13.	The student nurse is assisting with an assessment of a client’s level of consciousness using the Glasgow Coma Scale. The student understands that which of the following categories of client functioning are included in this assessment? Select all that apply.
1.	Eye opening	
2.	Best verbal response	
3.	Best motor response	
4.	Pupil size and reaction	
5.	Reflex response	

ANS:	1, 2, 3

Rationale: Assessment of pupil size and reaction and reflex response are not part of the Glasgow Coma Scale. The three categories included are eye opening, best verbal response, and best motor response. Pupil assessment and reflex response is a necessary part of total assessment of the neurological status of a client but is not part of this particular scale. Many standardized neurological assessment forms include the pupillary response on the same page, but separate from the Glasgow Coma Scale data.

Test-Taking Strategy: To answer this question accurately, you must be familiar with the various components of the Glasgow Coma Scale. Remember that the three categories included are eye opening, best verbal response, and best motor response. Review this neurological assessment tool if you had difficulty with this question.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Neurological
MSC:	Integrated Process: Nursing Process—Assessment

COMPLETION

	1.	An adult client trapped in a burning house has suffered burns to the back of the head, upper half of the posterior trunk, and the back of both arms. Using the rule of nines, what does the nurse determine the extent of the burn injury to be? (Enter the answer in the space provided.)
Answer: __________%

ANS:	22.5

Rationale: According to the rule of nines, the posterior side of the head equals 4.5%, the back of both arms equals 9%, and the upper half of the posterior trunk equals 9%, totaling 22.5%.

Test-Taking Strategy: Knowledge regarding the rule of nines is required to answer this question. The entire head equals 9%, each entire arm equals 9% (both arms 18%), the anterior or posterior torso each equals 18% (36% for the entire torso), each entire leg equals 18% (both legs equals 36%), and the perineum equals 1%. Remember that 9 (head), 18 (arms), 36 (thorax), 36 (legs), totals 99. If you had difficulty with this question, review the rule of nines.

PTS:	1
DIF:	Level of Cognitive Ability: Understanding
REF:	Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.
OBJ:	Client Needs: Physiological Integrity
TOP:	Content Area: Adult Health/Integumentary
MSC:	Integrated Process: Nursing Process—Assessment