Davis Advantage Basic Nursing- Thinking Doing and Caring 3rd Edition Treas Wilkinson Test Bank (1)

www.mynursingtestprep.com1) Ratio of weight lifted divided by body weight 2) Measure of weight pushed divided by BMI 3) Ability of a muscle to perform repeated movements 4) Ability to move a joint through its range of motion ANS: 3 Muscle strength measures the amount of weight a muscle (or group of muscles) can move at one time. This is recorded as a ratio of weight pushed (or lifted) divided by body weight. A woman weighing 132 pounds who is able to lift 72 pounds has a ratio of 72 divided by 132, or 0.55. PTS:1DIF:ModerateREF:dm 884-885 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application 6. Which is one of the greatest concerns with heavy and chronic use of alcohol in teens and young adults? 1) Liver damage 2) Unintentional death 3) Tobacco use 4) Obesity ANS: 2 Heavy and chronic use of alcohol and use of illicit drugs increase the risk of disease and injuries and intentional death (suicide and homicide). Although alcohol as a depressant slows metabolism, chronic alcohol use is more likely associated with poor nutrition, which may or may not lead to obesity. Chronic alcohol use causes damage to liver cells over time in the later years. Alcohol intake is often associated with tobacco and recreational drug use; however, the risk of unintentional injury, such as car accident, suicide, or violence, is more concerning than smoking. PTS:1DIF:EasyREF:p. 879 KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Comprehension 7. A 55-year-old man suffered a myocardial infarction (heart attack) 3 months ago. During his hospitalization, he had stents inserted in two sites in the coronary arteries. He was also placed on a cholesterol-lowering agent and two antihypertensives. What type of care is he receiving? 1) Primary prevention 2) Secondary prevention 3) Tertiary prevention 4) Health promotion ANS: 3 Primary prevention activities are designed to prevent or slow the onset of disease. Activities such as eating healthy foods, exercising, wearing sunscreen, obeying seat-belt laws, and getting immunizations are examples of primary-level interventions. Secondary

www.mynursingtestprep.comprevention activities detect illness so it can be treated in the early stages. Tertiary prevention focuses on stopping the disease from progressing and returning the individual to the pre-illness phase. The patient has an established disease and is receiving care to stop the disease from progressing. PTS:1DIFifficultREF:p. 879 KEY:Nursing process: Planning | Client need: PSI | Cognitive level: Application 8. Health screening activities are designed to: 1) Detect disease at an early stage. 2) Determine treatment options. 3) Assess lifestyle habits. 4) Identify healthcare beliefs. ANS: 1 Health screening activities are designed to detect disease at an early stage so that treatment can begin before there is an opportunity for disease to spread or become debilitating. PTS: 1 DIF: Moderate REF: p. 879 KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Comprehension 9. Which individuals should receive annual lipid screening? 1) All overweight children 2) All adults 20 years and older 3) Persons with total cholesterol greater than 150 mg/dL 4) Persons with HDL less than 40 mg/dL ANS: 1 The American Academy of Pediatrics takes a targeted approach, recommending that overweight children receive cholesterol screening, regardless of family history or other risk factors for cardiovascular disease. The American Heart Association recommends that all adults age 20 years or older have a fasting lipid panel at least once every 5 years. If total cholesterol is 200 mg/dL or greateror HDL is less than 40 mg/dLfrequent monitoring is required. PTS: 1 DIF: Moderate REF: p. 888; Box 27-1 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application 10. A mother of three young children is newly diagnosed with breast cancer. She is intensely committed to fighting the cancer. She believes she can control her cancer to some degree with a positive attitude and feelings of inner strength. Which of the following traits is she demonstrating that is linked to health and healing? 1) Invincibility 2) Hardiness 3) Baseline strength 4)

www.mynursingtestprep.comVulnerability ANS: 2 Research has also demonstrated that in the face of difficult life events, some people develop hardiness rather than vulnerability. Hardiness is a quality in which an individual experiences high levels of stress yet does not fall ill. There are three general characteristics of the hardy person: control (belief in the ability to control the experience), commitment (feeling deeply involved in the activity producing stress), and challenge (the ability to view the change as a challenge to grow). These traits are associated with a strong resistance to negative feelings that occur under adverse circumstances. PTS:1DIF:ModerateREF:p. 887 KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Application Multiple Response Identify one or more choices that best complete the statement or answer the question. 1. The World Health Organizations definition of health includes which of the following? Choose all that apply. 1) Absence of disease 2) Physical well-being 3) Mental well-being 4) Social well-being ANS: 2, 3, 4 The World Health Organization defines health as a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity. PTS:1DIF:EasyREF:p. 878 KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Recall 2. According to Penders health promotion model, which variables must be considered when planning a health promotion program for a client? Choose all that apply. 1) Individual characteristics and experiences 2) Levels of prevention 3) Behavioral outcomes 4) Behavior-specific cognition and affect ANS: 1, 3, 4 Pender identified three variables that affect health promotion: individual characteristics and experiences, behavior-specific cognition and affect, and behavioral outcomes. Levels of prevention were identified by Leavell and Clark; three levels relate to health protection. The levels differ based on their timing in the illness cycle. PTS: 1 DIF: Difficult REF: dm 880-881 KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Comprehension 3. Goals for Healthy People 2020 include which of the following? Choose all that apply. 1) Eliminate health disparities among various groups. 2) Decrease the cost of healthcare related to tobacco use. 3)

www.mynursingtestprep.comIncrease the quality and years of healthy life. 4) Decrease the number of inpatient days annually. ANS: 1, 3 The four overarching goals of Healthy People 2020 are to (1) increase the quality and years of healthy life, free of disease, injury, and premature death; (2) eliminate health disparities and improve health for all groups of people; (3) create physical and social environments for people to live a healthy life; and (4) promote healthy development for people in all stages of life. PTS: 1 DIF: Moderate REF: p. 890 KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Recall 4. The nurse is implementing a wellness program based on data gathered from a group of low-income seniors living in a housing project. He is using the Wheels of Wellness as a model for his planned interventions. Which of the following interventions would be appropriate based on this model? Choose all that apply. 1) Creating a weekly discussion group focused on contemporary news 2) Facilitating a relationship between local pastors and residents of subsidized housing 3) Coordinating a senior tutorial program for local children at the housing center 4) Establishing an on-site healthcare clinic operating one day per week ANS: 1, 2, 3, 4 The Wheels of Wellness model identifies the following dimensions of health: emotional, intellectual, physical, spiritual, social/family, and occupational. A weekly discussion group stimulates intellectual health. A relationship between local pastors and those living in subsidized housing creates a climate for spiritual health. A tutorial program offered by seniors to local children will facilitate occupational health. An on-site healthcare clinic addresses physical health. PTS:1DIFifficultREF:p. 881 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Analysis 5. The nurse working in an ambulatory care program asks questions about the clients locus of control as a part of his assessment because of which of the following? Choose all that apply. 1) People who feel in charge of their own health are the easiest to motivate toward change. 2) People who feel powerless about preventing illness are least likely to engage in health promotion activities. 3) People who respond to direction from respected authorities often prefer a health promotion program supervised by a health provider. 4) People who feel in charge of their own health are less motivated by health promotion activities. ANS: 1, 2, 3 Identifying a persons locus of control helps the nurse determine how to approach a client about health promotion. People who feel powerless about preventing illness are least

www.mynursingtestprep.comlikely to engage in health promotion activities. People who respond to direction from respected authorities often prefer a health promotion program that is supervised by a health provider. Clients who feel in charge of their own health are the easiest to motivate toward positive change. PTS:1DIFifficultREF:p. 888 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Comprehension 6. Health promotion programs assist a person to advance toward optimal health. Which of the following activities might such programs include? Choose all that apply. 1) Disseminating information 2) Changing lifestyle and behavior 3) Prescribing medications to treat underlying disorders 4) Environmental control programs ANS: 1, 2, 4 Health promotion programs may be categorized into four types: disseminating information, programs for changing lifestyle and behavior, environmental control programs, and wellness appraisal and health risk assessment programs. Prescribing medications to treat underlying disorders is an activity that fosters health focused at an individual level rather than at a group program level. PTS:1DIF:ModerateREF:p. 881 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Recall 7. Which of the following actions demonstrate how nurses promote health? 1) Role modeling 2) Educating patients and families 3) Counseling 4) Providing support ANS: 1, 2, 3, 4 Nurses promote health by acting as role models, counseling, providing health education, and providing and facilitating support. PTS:1DIF:EasyREF:dm 891-892 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Comprehension Completion Complete each statement. 1.A middle-aged woman performs breast self-examination monthly. This intervention is considered to be prevention. ANS: secondary Secondary prevention activities detect illness so that it can be treated in the early stages. Health activities such as mammograms, testicular examinations, regular physical examinations, blood pressure and diabetes screenings, and tuberculosis skin tests are examples of secondary interventions. Primary prevention activities are designed to prevent or slow the onset of disease and promote health. Activities such as eating healthy foods, exercising, wearing sunscreen, obeying seat-belt laws, and getting immunizations

www.mynursingtestprep.comare examples of primary-level interventions. Tertiary prevention focuses on stopping the disease from progressing and returning the individual to the pre-illness phase. Chapter 24 Nutrition Identify the choice that best completes the statement or answers the question. 1. Which food provides the body with no usable glucose? 1) Wheat germ 2) Apple 3) White bread 4) White rice ANS: 1 Dietary fiber, such as wheat germ, contains no usable glucose. Apples, white bread, and white rice all contain carbohydrates, which provide usable glucose. PTS: 1 DIF: Easy REF: p. 902; does not specify wheat germ, just indicates that fiber provides no glucose. KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Comprehension 2. Which organ relies almost exclusively on glucose for energy? 1) Liver 2) Heart 3) Pancreas 4) Brain ANS: 4 The brain relies almost exclusively on glucose for energy. The heart and liver do not. The pancreas produces insulin for glucose utilization but does not use glucose. PTS:1DIF:Easy REF: p. 902; ESG 3. A patient with type 1 diabetes mellitus is admitted with hyperglycemia and associated acidosis. The presence of which alternative fuel in the body is responsible for the acidosis? 1) Glycogen 2) Insulin 3) Ketones 4) Proteins x ANS: 3 When fats are converted to ketones for use as alternative fuel, as in diabetic ketoacidosis when glucose cannot by used by the cells, the acidity of the blood rises, leading to the acidosis. Glycogen is converted to glucose to meet energy needs. Insulin, a pancreatic hormone, promotes the movement of glucose into cells for use. Proteins would not be

www.mynursingtestprep.comused for fuel as long as fats were available. PTS:1DIFifficultREF:dm 902, 925 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 4. Which patient is most likely experiencing positive nitrogen balance? A patient admitted: 1) With third-degree burns of his legs. 2) In the sixth month of a healthy pregnancy. 3) From a nursing home who has been refusing to eat. 4) With acute pancreatitis. ANS: 2 A positive nitrogen balance typically exists during pregnancy when new tissues are being formed. Patients with burns, malnutrition, and serious illness commonly experience negative nitrogen balance because tissues are lost. PTS:1DIF:ModerateREF:p. 902 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 5. Which polysaccharide is stored in the liver? 1) Insulin 2) Ketones 3) Glycogen 4) Glucose ANS: 3 Humans store glucose in the liver as polysaccharides, known as glycogen. Glycogen can then be converted back into glucose to meet energy needs through a process known as glycogenolysis. If fats must be used for energy, they are converted directly into ketones. Insulin is a pancreatic hormone that promotes the movement of glucose into cells. PTS: 1 DIF: Moderate REF: p. 902 KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Recall 6. While addressing a community group, the nurse explains the importance of replacing saturated fats in the diet with mono- and polyunsaturated fats. She emphasizes that doing so greatly reduces the risk of which complication? 1) Kidney failure 2) Liver failure 3) Stroke 4) Lung cancer ANS: 3 Replacing saturated fats in the diet with mono- and polyunsaturated fats reduces the risk of heart disease, atherosclerosis, and stroke, not kidney failure, liver failure, or lung cancer.

www.mynursingtestprep.comPTS:1DIF:ModerateREF:p. 903 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Application 7. Patients may be deficient in which vitamin during the winter months? 1) A 2) D 3) E 4) K ANS: 2 The body can synthesize vitamin D from a cholesterol compound in the skin when exposed to adequate sunlight. People at risk for vitamin D deficiency are those who spend little time outdoors, older people, and people who live in an institution (e.g., a nursing home). The deficiency can also occur in the winter at northern and southern latitudes, in people who keep their bodies covered (e.g., traditional Muslim women), and in those who use sunscreen. Also, because breast milk contains only small amounts of vitamin D, breastfed infants who are not exposed to enough sunlight are at risk of the deficiency and rickets. There is no seasonal tie to deficiencies in the other fat-soluble vitamins, A, E, and K. PTS: 1 DIF: Easy REF: p. 905 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall 8. Which nutrient deficiency increases the risk for pressure ulcers? 1) Carbohydrate 2) Protein 3) Fat 4) Vitamin K ANS: 2 Protein is necessary for growth and maintenance of body tissues. Protein deficiency places the patient at risk for skin breakdown and pressure ulcer formation. Carbohydrates are the primary fuel of the body. Fat is a source of energy and contains essential nutrients. Vitamin K aids blood clotting. PTS:1DIF:Moderate REF:p. 902; application is based on principle presented KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application 9. A patient has anemia. An appropriate goal for that the patient would be for him to increase his intake of which nutrient? 1) Calcium 2) Magnesium 3) Potassium 4)

www.mynursingtestprep.comIron ANS: 4 Iron deficiency causes anemia; therefore, the nurse should encourage the patient with anemia to increase his intake of iron. Increasing calcium intake helps prevent osteoporosis. Magnesium supplementation may decrease the risk of hypertension and coronary artery disease in women. Potassium is essential for muscle contraction, acidbase balance, and blood pressure control. PTS:1DIF:EasyREF:p. 907 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application 10. A patient is brought to the emergency department experiencing leg cramps. He is irritable, his temperature is elevated, and his mucous membranes are dry. Based on these findings, the patient most likely has excess levels of which mineral? 1) Sodium 2) Potassium 3) Phosphorus 4) Magnesium ANS: 1 Signs and symptoms associated with sodium excess include thirst, fever, dry and sticky tongue and mucous membranes, restlessness, irritability, and seizures. Findings associated with potassium excess include cardiac arrhythmias, weakness, abdominal cramps, diarrhea, anxiety, and paresthesia. Phosphorus excess leads to tetany and seizures. Magnesium excess causes weakness, nausea, and malaise. PTS:1DIFifficultREF:p. 908 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 11. A patient who was prescribed furosemide (Lasix) is deficient in potassium. Which of the following is an appropriate goal for this patient? The patient will increase his consumption of: 1) Bananas, peaches, molasses, and potatoes. 2) Eggs, baking soda, and baking powder. 3) Wheat bran, chocolate, eggs, and sardines. 4) Egg yolks, nuts, and sardines. ANS: 1 Foods rich in potassium include bananas, peaches, molasses, meats, avocados, milk, shellfish, dates, figs, and potatoes. Eggs, baking soda, and baking powder have high sodium content. Dairy products, beef, pork, beans, sardines, eggs, chicken, wheat bran, and chocolate are rich in phosphorus. Egg yolks, nuts, sardines, dairy products, broccoli, and legumes are rich in calcium. PTS:1DIF:ModerateREF:p. 908 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application 12. During the day shift, a patients temperature measures 97F (36.1C) orally.

www.mynursingtestprep.comAt 2000, the patients temperature measures 102F (38.9C). What effect does this rise in temperature have on the patients basal metabolic rate? 1) Increases the rate by 7% 2) Decreases the rate by 14% 3) Increases the rate by 35% 4) Decreases the rate by 28% ANS: 3 Basal metabolic rate increases 7% for each degree Fahrenheit (0.56C); therefore, this patients temperature rise is an increase of 35%. PTS:1DIFifficultREF:p. 910 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 13. A mother brings her 4-month-old infant for a well-baby checkup. The mother tells the nurse that she would like to start bottle feeding her baby because she cannot keep up with the demands of breastfeeding since returning to work. Which response by the nurse is appropriate? 1) Make sure you give your baby an iron-fortified formula to supplement any stored breast milk you have. 2) You really need to continue breastfeeding your baby. 3) Give your baby formula until he is 6 months old; then you can introduce whole milk. 4) Your baby weighs 14 pounds, so he will require about 36 ounces of formula a day. ANS: 1 The nurse should not make the mother feel guilty about her decision to stop breastfeeding. Instead, she should provide the mother with instruction about bottle feeding. She can give it to supplement any stored breast milk she might have in supply. She should emphasize the importance of giving the baby iron-fortified formula because fetal iron stores become depleted by 4 to 6 months of age. Infants younger than 1 year of age should not receive regular cows milk because it may place a strain on the immature kidneys. Because the baby weighs 14 pounds, he will require about 21 ounces of formula a day (not 36 ounces), based on the nutritional recommendations that infants require 80 to 100 mL of formula or breast milk per kilogram of body weight per day. PTS:1DIF:ModerateREF:p. 912 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Application 14. After instructing a mother about nutrition for a preschool-age child, which statement by the mother would indicate correct understanding of the topic? 1) I usually use dessert only as a reward for eating other foods. 2) I will hide vegetables in casseroles and stews to get my child to eat them. 3) I do not give my child snacks; they simply spoil his appetite for meals. 4) I know that lifelong food habits are developed during this stage of life.

www.mynursingtestprep.comANS: 4 Lifelong food habits are developed during the preschool stage of life. Therefore, the mother should widen the variety of foods she introduces to her child. Desserts should not be used as rewards for eating other foods. This practice can shape an attitude about food that can lead to eating disorders later in life. Preschool-age children often refuse combined foods such as casseroles and stews. Because they are active, preschoolers require nutritious between-meal snacks. PTS: 1 DIF: Moderate REF: p. 913 KEY: Nursing process: Evaluation | Client need: HPM | Cognitive level: Application 15. The nurse is providing nutrition counseling for a patient planning pregnancy. The nurse should emphasize the importance of consuming which nutrient to prevent neural tube defects? 1) Folic acid 2) Calcium 3) Protein 4) Vitamin D ANS: 1 The nurse should emphasize the importance of consuming folic acid even before conception to prevent neural tube defects from developing. Calcium and protein needs also increase during pregnancy; however, their consumption does not prevent neural tube defects. Vitamin D consumption does not prevent neural tube defects. PTS:1DIF:EasyREF:p. 913 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Comprehension 16. A middle-aged patient with a history of alcohol abuse is admitted with acute pancreatitis. This patient will most likely be deficient in which nutrients? 1) Iron 2) B vitamins 3) Calcium 4) Phosphorus ANS: 2 Patients who regularly abuse alcohol may be deficient in many nutrients; however, they are commonly deficient in the B vitamins and folic acid. Vitamin A deficiency can be associated with night blindness in heavy drinkers; vitamin D deficiency leads to softening of the bones. Because some alcoholics are deficient in vitamins A, C, D, E, and K and the B vitamins, they experience delayed wound healing. In particular, because vitamin K, the vitamin needed for blood clotting, is commonly deficient in those who regularly abuse alcohol, those patients can have delayed clotting, resulting in excess bleeding. Deficiencies of other vitamins involved in brain function can cause severe neurological damage. PTS:1DIF:ModerateREF:p. 915 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 17. A patient who underwent surgery 24 hours ago is prescribed a clear liquid

www.mynursingtestprep.comdiet. The patient asks for something to drink. Which item may the nurse provide for the patient? 1) Tea with cream 2) Orange juice 3) Gelatin 4) Skim milk ANS: 3 A clear liquid diet consists of water; tea (without cream); coffee; broth; clear juices, such as apple, grape, or cranberry; popsicles; carbonated beverages; and gelatin. Skim milk, tea with cream, and orange juice are included in a full liquid diet. PTS:1DIF:EasyREF:p. 917 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension 18. A patient with trigeminal neuralgia is prescribed a mechanical soft diet. This diet places the patient at risk for which complication? 1) Dehydration 2) Constipation 3) Hyperglycemia 4) Diarrhea ANS: 2 Because of its lack of fiber, a mechanical soft diet places the patient at risk for constipation. It does not place the patient at risk for dehydration, hyperglycemia, or diarrhea. PTS:1DIF:ModerateREF:p. 917 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 19. Which nutritional goal is appropriate for a patient newly diagnosed with hypertension? The patient will: 1) Limit his intake of protein. 2) Avoid foods containing gluten. 3) Restrict his use of sodium. 4) Limit his intake of potassium-rich foods. ANS: 3 Patients with hypertension should limit their intake of sodium. Those with liver disease should control their protein intake. Patients with renal disease must limit their intake of potassium-rich foods. Patients with celiac disease should avoid foods containing gluten. PTS: 1 DIF: Easy REF: p. 917 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application 20. The nurse notices that a patient has spoon-shaped, brittle nails. This

www.mynursingtestprep.comsuggests that the patient is experiencing Imbalanced Nutrition: Less Than Body Requirements related to deficiency of which of the following nutrients? 1) Iron 2) Vitamin A 3) Protein 4) Vitamin C ANS: 1 Patients with iron deficiency may have spoon-shaped, brittle nails. Other abnormal nail findings include dull nails with transverse ridge (protein deficiency); pale, poor blanching, or mottled nails (vitamin A or C deficiency); splinter hemorrhages (vitamin C deficiency); and bruising or bleeding beneath nails (protein or caloric deficiency). PTS:1DIFifficultREF:p. 920 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Comprehension 21. Which portion of a nutritional assessment must the registered nurse complete? 1) Analyzing the data 2) Obtaining intake and output 3) Weighing the patient 4) Obtaining the history ANS: 1 The registered nurse should review and interpret (analyze) the data collected as part of a nutritional assessment. The registered nurse can delegate height, weight, and intake and output to nursing assistive personnel. History taking can be safely delegated to the licensed practical nurse. PTS:1DIF:ModerateREF:p. 925 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 22. Which laboratory test result most accurately reflects a patients nutritional status? 1) Albumin 2) Prealbumin 3) Transferrin 4) Hemoglobin ANS: 2 Prealbumin levels fluctuate daily and give the best indication of the patients immediate nutritional status. Albumin level is not as accurate because the half-life of albumin is 18 to 21 days, causing a delay in detection of nutritional problems. Transferrin, a protein that binds to iron, has a half-life of 8 to 9 days; therefore, it allows for faster detection of protein deficiency than does albumin. However, transferrin is not as fast as prealbumin. Hemoglobin level reflects iron intake or blood loss.

www.mynursingtestprep.comPTS:1DIF:ModerateREF:p. 925 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall 23. A 52-year-old man has a triceps skinfold thickness of 18 mm, and his weight exceeds the ideal body weight for his height by 23%. Which nursing diagnosis should the nurse identify for this patient? 1) Imbalanced Nutrition: More Than Body Requirements 2) Risk for Imbalanced Nutrition: More Than Body Requirements 3) Imbalanced Nutrition: Less Than Body Requirements 4) Readiness for Enhanced Nutrition ANS: 1 This patient has defining characteristics for the nursing diagnosis Imbalanced Nutrition: More Than Body Requirements: triceps skinfold thickness more than 15 mm in men and weight that is 20% over ideal for height and frame. The patient does not have defining characteristics for the other nursing diagnoses. PTS:1DIF:ModerateREF:p. 929 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 24. A patients 2:1 parenteral nutrition container infuses before the pharmacy prepares the next container. This places the patient at risk for which complication? 1) Sepsis 2) Pneumothorax 3) Hypoglycemia 4) Thrombophlebitis ANS: 3 Because of the high glucose content of 2:1 parenteral nutrition, any interruption in therapy places the patient at risk for hypoglycemia. A PN of this type should not be discontinued abruptly, but rather over several (as many as 48) hours to prevent a sudden drop in blood sugar. Hypoglycemia is unlikely to occur with a 3:1 solution (containing lipids), as the final concentration of glucose is less than 10%. Sepsis is a complication that can occur if a break in aseptic technique occurs during therapy. Pneumothorax can occur as a result of central venous catheter insertion. Central venous catheters are typically employed for parenteral nutrition. Thrombophlebitis is a complication of central venous catheter use. PTS: 1 DIF: Difficult REF: dm 959-960 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 25. Which of the following interventions would help to prevent or relieve persistent nausea? 1) Assess for signs of dehydration. 2) Provide dietary supplements. 3) Have the patient sit in an upright position for 30 minutes after eating. 4)

www.mynursingtestprep.comImmediately remove any food that the patient cannot eat. ANS: 4 Dehydration can occur as a result of continued nausea and vomiting, so the nurse should assess for it. However, this intervention does not prevent nausea. Dietary supplements might help to prevent malnutrition. However, they do not prevent nausea; in fact, they often cause nausea. Having the patient sit upright helps to prevent respiratory aspiration should the patient vomit; it does not prevent or relieve nausea. Odors (even pleasant ones) and even the sight of food can cause nausea, so any uneaten food should be removed immediately from the room. PTS:1DIFifficultREF:p. 928 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application Multiple Response Identify one or more choices that best complete the statement or answer the question. 1. To promote wound healing, the nurse is teaching a patient about choosing foods containing protein. The nurse will evaluate that learning has occurred if the patient recognizes which food(s) as an incomplete protein that should be consumed with a complementary protein? Choose all that apply. 1) Whole grain bread 2) Peanut butter 3) Chicken 4) Eggs ANS: 1, 2 Incomplete protein foods do not provide all of the essential amino acids necessary for protein synthesis. Therefore, the nurse should inform the patient that whole grain bread and peanut butter should be consumed with a complementary protein. For example, they could be eaten together as a peanut butter sandwich. PTS:1DIF:ModerateREF:p. 901 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Comprehension 2. The nurse is teaching a patient about the importance of reducing saturated fats in his diet. The nurse will recognize that learning has occurred if, upon questioning, the patient replies that he should read product labels to eliminate the intake of which saturated fat(s)? Choose all that apply. 1) Palm oil 2) Coconut oil 3) Canola oil 4) Peanut oil ANS: 1, 2 Palm and coconut oils are sources of saturated fat that are contained in many processed foods. The patient should be encouraged to read product labels to eliminate them from his diet. Olive, canola, and peanut oils are unsaturated fats and should be substituted for saturated fats in the diet. PTS: 1 DIF: Moderate REF: p. 901 KEY: Nursing process: Evaluation | Client need: HPM | Cognitive level: Comprehension

www.mynursingtestprep.com3. Which instruction(s) should the nurse give to the patient complaining of constipation? Choose all that apply. 1) Drink at least eight glasses of water or non-caffeinated fluid per day. 2) Include a minimum of four servings of meat per day. 3) Consume a high-fiber diet. 4) Exercise as you feel necessary. ANS: 1, 3 To prevent constipation, the nurse should instruct the patient to consume a high-fiber diet, drink at least eight glasses of water or non-caffeinated fluid per day, exercise regularly, and eat meals on a regular schedule. Caffeine can aggravate constipation. PTS:1DIF:ModerateREF:p. 929 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension 4. Where in the body is glucose stored? Choose all that apply. 1) Brain 2) Liver 3) Skeletal muscles 4) Smooth muscles ANS: 2, 3 Human beings store glucose in liver and skeletal muscle tissue as glycogen. Glycogen is converted back into glucose to meet energy needs. PTS:1DIF:ModerateREF:p. 902 KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Recall 5. For a patient with Risk for Imbalanced Nutrition: Less Than Body Requirements related to Impaired Swallowing, which nursing interventions are appropriate? Choose all that apply. 1) Check inside the mouth for pocketing of food after eating. 2) Provide a full liquid diet that is easy to swallow. 3) Remind the patient to raise the chin slightly to prepare for swallowing. 4) Keep the head of the bed elevated for 30 to 45 minutes after feeding. ANS: 1, 4 The nurse should check for pocketing of food that the patient has not been able to swallow, and should keep the head of the bed elevated for 30 to 45 minutes after feeding. Liquids should be avoided unless thickeners are added. The patient should flex the head forward (tuck the chin) in preparation for swallowing. Chapter 26 Bowel Elimination Identify the choice that best completes the statement or answers the question.

www.mynursingtestprep.com1. When changing a diaper, the nurse observes that a 2-day-old infant has passed a green-black, tarry stool. What should the nurse do? 1) Notify the provider immediately. 2) Do nothing; this is normal. 3) Give the baby sterile water until the mothers milk comes in. 4) Apply a skin barrier cream to the buttocks to prevent irritation. ANS: 2 The nurse should do nothing; this is normal. During the first few days of life, a term newborn passes green-black, tarry stools known as meconium. Stools transition to a yellow-green color over the next few days. After that, the appearance of stools depends upon the feedings the newborn receives. Sterile water does nothing to alter this progression. Meconium stools are more irritating to the buttocks than other stools because they are so sticky and the skin usually must be rubbed to cleanse it. However, meconium leads to skin breakdown like a watery stool does. PTS:1DIF:ModerateREF:p. 968 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Application 2. Considering normal developmental and physical maturation in children, for which age would a goal of Achieves bowel control by the end of this month be most realistic? 1) 18 months 2) • years 3) • years 4) • years ANS: 2 Between ages 2 and 3 years, a child can typically control defecation, thereby making toilet training possible. Nevertheless, some children, especially boys, may not achieve consistent bowel control until somewhat later. PTS:1DIF:ModerateREF:dm 968-969 KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Comprehension 3. The nurse educates a patient about the primary risk factors for irritable bowel syndrome. Which behavior by the patient would be evidence of learning? The patient: 1) Reduces her intake of gluten-containing products. 2) Does not consume foods that contain lactose. 3) Consumes only two servings of caffeinated beverages per day. 4) Takes measures to reduce her stress level. ANS: 4 Stress is a primary factor in the development of irritable bowel syndrome. Other risk

www.mynursingtestprep.comfactors include caffeine consumption and lactose intolerance; however, they are not primary risk factors. Celiac disease is associated with gluten intake. PTS:1DIF:ModerateREF:p. 969 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application 4. Which of the following goals is appropriate for a patient with a nursing diagnosis of Constipation? The patient increases the intake of: 1) Milk and cheese. 2) Bread and pasta. 3) Fruits and vegetables. 4) Lean meats. ANS: 3 The nurse should encourage the patient to increase his intake of foods rich in fiber because they promote peristalsis and defecation, thereby relieving constipation. Low- fiber foods, such as bread, pasta, and other simple carbohydrates, as well as milk, cheese, and lean meat, slow peristalsis. PTS:1DIF:ModerateREF:p. 978 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application 5. A patient is diagnosed with an intestinal infection after traveling abroad. The nurse should encourage the intake of which food to promote healing? 1) Yogurt 2) Pasta 3) Oatmeal 4) Broccoli ANS: 1 Although the patient may have diarrhea, the goal is not to stop the diarrhea, but to eliminate the pathogens from the digestive tract. The active bacteria in yogurt stimulate peristalsis and promote healing of intestinal infections. Pasta is a low-fiber food that slows peristalsis. It does not promote healing of intestinal infections. Oatmeal stimulates peristalsis, but it does not promote healing of intestinal infections. Broccoli stimulates gas production; it is ineffective against intestinal infections. PTS: 1 DIF: Moderate REF: p. 969 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 6. A nurse is teaching wellness to a womens group. The nurse should explain the importance of consuming at least how much fluid to promote healthy bowel function (assume these are 8-ounce servings)? 1) 3 to 4 servings a day 2) 5 to 6 servings a day 3) 7 to 8 servings a day 4)

www.mynursingtestprep.com9 to 10 servings a day ANS: 3 A minimum of 7 to 8 servings of fluid should be consumed each day to promote healthy bowel function. PTS:1DIF:EasyREF:p. 969 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Recall 7. A patient with a skin infection is prescribed cephalexin (an antibiotic) 500 mg orally q 12 hours. The patient complains that the last time he took this medication, he had frequent episodes of loose stools. Which recommendation should the nurse make to the patient? 1) Stop taking the drug immediately if diarrhea develops. 2) Take an antidiarrheal agent, such as diphenoxylate. 3) Consume yogurt daily while taking the antibiotic. 4) Increase your intake of fiber until the diarrhea stops. ANS: 3 Antibiotics such as cephalexin, given to combat infection, decrease the normal flora in the colon that cause diarrhea. Bacterial populations can be maintained by encouraging the patient to consume yogurt daily while taking the drugs. Diarrhea is a common adverse effect of antibiotics; stopping the drug is not necessary. The patient should not be encouraged to take an antidiarrheal agent at this time. Increasing the intake of fiber combats constipation, not diarrhea. PTS:1DIF:ModerateREF:p. 969 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 8. Which collaborative interventions will help prevent paralytic ileus in a patient who underwent right hemicolectomy for colon cancer? 1) Administer morphine 4 mg IV every 2 hours for pain. 2) Administer IV fluids at 125 mL/hr. 3) Insert an indwelling urinary catheter to monitor I&O. 4) Keep the patient NPO until bowel sounds return. ANS: 4 Patients who require bowel surgery typically remain NPO until peristalsis returns, helping to prevent paralytic ileus, a complication that can occur after the bowel is surgically manipulated. Administering morphine promotes comfort but may increase the risk of ileus. Administering IV fluids prevents dehydration but does not directly prevent ileus. Inserting an indwelling urinary catheter prevents urine retention and facilitates monitoring postoperative urine output. PTS: 1 DIF: Moderate REF: p. 969; not stated directly in text KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 9. The nurse in a long-term care facility is teaching a group of residents about increasing dietary fiber. Which foods should she explain are high in fiber? 1) White bread, pasta, and white rice

www.mynursingtestprep.com2) Oranges, raisins, and strawberries 3) Whole milk, eggs, and bacon 4) Peaches, orange juice, and bananas ANS: 2 Oranges, raisins, and strawberries are high in fiber. White bread, pasta, and white rice are carbohydrates. Whole milk, eggs, and bacon are high in cholesterol. Peaches, orange juice, and bananas are sources of potassium. PTS:1DIF:ModerateREF:p. 969 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Comprehension 10. The nurse is assessing a patient who underwent bowel resection 2 days ago. As she auscultates the patients abdomen, she notes low-pitched, infrequent bowel sounds. How should she document this finding? 1) Hyperactive bowel sounds 2) Abdominal bruit sounds 3) Normal bowel sounds 4) Hypoactive bowel sounds ANS: 4 Hypoactive bowel sounds are low-pitched, infrequent, and quiet. An abdominal bruit is a hollow, blowing sound found over an artery, such as the iliac artery. Normal bowel sounds are high pitched with approximately 5 to 35 gurgles occurring every minute. Hyperactive bowel sounds are very high pitched and more frequent than normal bowel sounds. PTS:1DIFifficultREF:p. 972 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 11. The healthcare team suspects that a patient has an intestinal infection. Which action should the nurse take to help confirm the diagnosis? 1) Prepare the patient for an abdominal flat plate. 2) Collect a stool specimen that contains 20 to 30 mL of liquid stool. 3) Administer a laxative to prepare the patient for a colonoscopy. 4) Test the patients stool using a fecal occult test. ANS: 2 To confirm the diagnosis of an infection, the nurse should collect a liquid stool specimen that contains 20 to 30 mL of liquid stool. An abdominal flat plate and a fecal occult blood test cannot confirm the diagnosis. Colonoscopy is not necessary to obtain a specimen to confirm the diagnosis. PTS:1DIF:ModerateREF:dm 974-975 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

www.mynursingtestprep.com12. The nurse is instructing a patient about performing home testing for fecal occult blood. The nurse can conclude that learning occurs if the patient says, For 3 days prior to testing, I should avoid eating: 1) Beef. 2) Milk. 3) Eggs. 4) Oatmeal. ANS: 1 The nurse should instruct the patient to avoid red meat, chicken, fish, horseradish, and certain raw fruits and vegetables for 3 days prior to fecal occult blood testing. PTS: 1 DIF: Moderate REF: dm 989-990 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Comprehension 13. The nurse is instructing a patient about performing home testing for fecal occult blood. The nurse should explain that ingestion of which substance may cause a false- negative fecal occult blood test? 1) Vitamin D 2) Iron 3) Vitamin C 4) Thiamine ANS: 3 Ingestion of vitamin C can produce a false-negative fecal occult blood test; ingestion of vitamin D, iron, and thiamine does not. Iron can lead to a false-positive result. PTS: 1 DIF: Moderate REF: dm 989-990 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension 14. Which action should the nurse take to assess a 2-year-old child for pinworms? 1) Press clear cellophane tape against the anal opening at night to obtain a specimen. 2) Collect a freshly passed stool from a diaper using a wooden specimen blade. 3) Place a smear of stool on a slide and add two drops of reagent. 4) Prepare the patient for a flat plate (x-ray) of the abdomen. ANS: 1 To assess for pinworms, the nurse should press cellophane tape against the childs anal opening during the night or as soon as he awakens. Remove the tape immediately, and place it on a slide. Perineal swabs may also be necessary for microscopic study. Collecting a fresh stool specimen from a diaper describes the method for an infant or toddler. Placing a smear of stool on a slide and adding a reagent describes fecal occult blood testing. An abdominal flat plate is not a method of assessing for pinworms. PTS: 1 DIF: Moderate REF: p. 975

www.mynursingtestprep.comKEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 15. The nurse must irrigate the colostomy of a patient who is unable to move independently. How should the nurse position the patient for this procedure? 1) Semi-Fowlers position 2) Left side-lying position 3) Supine with the head of the bed lowered flat 4) Supine with the head of bed raised to 30 degrees ANS: 2 The nurse should position an immobile patient in a left side-lying position to irrigate his colostomy. Semi-Fowlers, supine with the bed lowered flat, and the supine position with the head of bed elevated to 30 are not appropriate positions for colostomy irrigation. PTS:1DIF:ModerateREF:p. 1008 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 16. A mother of a school-age child seeks healthcare because her child has had diarrhea after being ill with a viral infection. The patient states that after vomiting for 24 hours, his appetite has returned. Which recommendation should the nurse make to this mother? 1) Consume a diet consisting of bananas, white rice, applesauce, and toast. 2) Drink large quantities of water regularly to prevent dehydration. 3) Take loperamide (an antidiarrheal) as needed to control diarrhea. 4) Increase the consumption of raw fruits and vegetables. ANS: 1 The nurse should encourage the patient with diarrhea who has an appetite to consume a diet that consists of bananas, white rice, applesauce, and toast. These foods are easy to digest, provide calories for energy, and help provide a source of calcium. The patient should sip liquids frequently to prevent dehydration; large quantities might worsen diarrhea. Medication, such as loperamide (Imodium), is usually reserved for chronic diarrhea. Raw fruits and vegetables may worsen diarrhea. PTS:1DIF:ModerateREF:p. 978 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 17. Which is a key treatment intervention for the patient admitted with diverticulitis? 1) Antacid 2) Antidiarrheal agent 3) Antibiotic therapy 4) NSAIDs ANS: 3

www.mynursingtestprep.comA key treatment for diverticulitis (an infected diverticulum) is antibiotic therapy; if antibiotic therapy is ineffective, surgery may be necessary. Antacids, antidiarrheal agents, and NSAIDs are not indicated for treatment of diverticulitis. PTS:1DIF:ModerateREF:p. 970 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 18. The nurse assesses a patients abdomen 4 days after abdominal surgery and notes that bowel sounds are absent. This finding most likely suggest which postoperative complication? 1) Paralytic ileus 2) Small bowel obstruction 3) Diarrhea 4) Constipation ANS: 1 Absent bowel sounds on the fourth postoperative day suggests paralytic ileus, a complication associated with abdominal surgery. A small bowel obstruction and diarrhea produce hyperactive bowel sounds. Constipation might be associated with hypoactive bowel sounds. PTS:1DIF:ModerateREF:p. 972 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 19. A patient with a colostomy complains to the nurse, I am noticing really bad odors coming from my pouch. To help control odor, which foods should the nurse advise him to consume? 1) White rice and toast 2) Tomatoes and dried fruit 3) Asparagus and melons 4) Yogurt and parsley ANS: 4 Yogurt, cranberry juice, parsley, and buttermilk may help control odor. White rice and toast (also bananas and applesauce) help control diarrhea. Asparagus, peas, melons, and fish are known to cause odor. Tomatoes, pears, and dried fruit are high-fiber foods that might cause blockage in a patient with an ostomy. PTS:1DIF:ModerateREF:p. 987 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 20. A patient with severe hemorrhoids is incontinent of liquid stool. Which of the following interventions is contraindicated? 1) Apply an indwelling fecal drainage device. 2) Apply an external fecal collection device. 3) Place an incontinence garment on the patient.

www.mynursingtestprep.com4) Place a waterproof pad under the patients buttocks. ANS: 1 An indwelling fecal drainage device is contraindicated for children; for more than 30 consecutive days of use; and for patients who have severe hemorrhoids, recent bowel, rectal, or anal surgery or injury; rectal or anal tumors; or stricture or stenosis. External devices are not typically used for patients who are ambulatory, agitated, or active in bed because the device may be dislodged, causing skin breakdown. External devices cannot be used effectively when the patient has Impaired Skin Integrity because they will not seal tightly. Absorbent products are not contraindicated for this patient unless Impaired Skin Integrity occurs. Even with absorbent products or an external collection device, the nurse should place a waterproof pad under the patient to protect the bed linens. PTS:1DIFifficultREF:p. 1001 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 21. A patient has a colostomy in the descending (sigmoid) colon and wants to control bowel evacuation and possibly stop wearing an ostomy pouch. To help achieve this goal, nurse should teach the patient to: 1) Call the primary care provider if the stoma becomes pale, dusky, or black. 2) Limit the intake of gas-forming foods such as cabbage, onions, and fish. 3) Irrigate the stoma to produce a bowel movement on a schedule. 4) Avoid returning to the use of an ostomy appliance if he becomes ill. ANS: 3 Patients with an ostomy in the descending or sigmoid colon may use colostomy irrigation as a means to control and schedule bowel evacuation and possibly eliminate the need to wear an ostomy pouch. Limiting the intake of gas-forming foods is a good idea from a social perspective; however, it does not help achieve the goal of having regular bowel movements and thus, eliminating the need to wear a pouch. When illness occurs, it may be difficult to control the output, so the patient can use an ostomy appliance. This will not make it more difficult to schedule the bowel movements after the illness passes. PTS:1DIF:ModerateREF:p. 971 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application Multiple Response Identify one or more choices that best complete the statement or answer the question. 1. Which factor(s) place(s) the patient at risk for constipation? Choose all that apply. 1) Sedentary lifestyle 2) High-dose calcium therapy 3) Lactose intolerance 4) Consuming spicy foods ANS: 1, 2 Physical activity stimulates peristalsis and bowel elimination. Therefore, those with a sedentary lifestyle commonly experience constipation. High-dose calcium therapy also

www.mynursingtestprep.compredisposes a patient to constipation. Lactose intolerance and consuming spicy foods are associated with a nursing diagnosis of Diarrhea, not Constipation. PTS:1DIF:ModerateREF:p. 969 KEY: Nursing process: Diagnosis | Client need: HPM | Cognitive level: Comprehension 2. A patient who has been immobile since sustaining injuries in a motor vehicle accident complains of constipation. The nurse encourages him to consume eight to ten 8- ounce servings of fluid daily. Which fluid(s) should the patient avoid because of the diuretic effect? Choose all that apply. 1) Cranberry juice 2) Water 3) Coffee 4) Ginger ale 5) Tea ANS: 3, 5 Coffee, tea, and caffeine-containing sodas should be avoided because caffeine promotes diuresis, placing the patient at further risk for constipation. Water is the preferred fluid; however, fruit juices and decaffeinated sodas are also acceptable. PTS:1DIF:ModerateREF:p. 977 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension 3. The nurse must administer an enema to an adult patient with constipation. Which of the following would be a safe and effective distance for the nurse to insert the tubing into the patients rectum? Choose all that apply. 1) 2 in (5.1 cm) 2) 3 in (7.6 cm) 3) 4 in (10.2 cm) 4) 5 in (12.7 cm) ANS: 2, 3 When administering an enema, the nurse should insert the tubing about 3 to 4 inches into the patients rectum. Two inches would not be effective because it would not place the fluid high enough in the rectum. Five inches is too much. PTS:1DIF:ModerateREF:p. 994 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall Completion 1.When performing an abdominal assessment, what sequence of assessment techniques should the nurse use? Label the steps from A to D, with A being the first step to perform. • Auscultation • Palpation • Percussion •

www.mynursingtestprep.comInspection ANS: D, A, C, B When performing an abdominal assessment, the nurse should follow the sequence: inspection, auscultation, percussion, and palpation. Percussion and palpation may stimulate peristalsis, so the techniques with the least contact should be done first. PTS:1DIF:ModerateREF:p. 972 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall 2.The nurse is collecting a stool specimen. Arrange the following steps in the order in which the nurse should perform them. Label the steps from A to D, with A being the first step to perform. • Have the patient defecate into a special container placed under the toilet seat. • Put on gloves and place the specimen in a specimen container. • Ask the patient to void to empty the bladder. • Place a label on the specimen container. ANS: C, A, B, D The nurse should ask the patient to void and then have him defecate into a special container placed under the toilet seat. Next, the nurse should put on gloves and, using a tongue blade, place the specimen into the container. Finally, she should label the specimen and send it to the laboratory for analysis. PTS: 1 DIF: Difficult REF: dm 989-990 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis 3.When administering an enema, list the following steps in the order in which they should be performed. Label the steps from A to F, with A being the first step to perform. • Document the results of the procedure. • Assess the patient for cramping. • Insert the tubing about 3 to 4 inches into the rectum. • Lubricate the tip of the enema tubing generously. • Raise the container to the correct height and instill the solution at a slow rate. • Encourage the patient to hold the solution for 3 to 15 minutes, depending on the type of enema. ANS: D, C, E, B, F, A You must lubricate the tip before inserting the tubing. You would then insert the tubing and begin instilling the solution before assessing for cramping that the instillation might produce. Only after the solution is instilled would you ask the patient to hold the solution. The last action is to document the results of the procedure, after the procedure is finished. Chapter 25 Urinary Elimination Identify the choice that best completes the statement or answers the question. 1. What is the most significant change in kidney function that occurs with aging? 1) Decreased glomerular filtration rate 2) Proliferation of micro blood vessels to renal cortex 3) Formation of urate crystals 4)

www.mynursingtestprep.comIncreased renal mass ANS: 1 Glomerular filtration rate is the amount of filtrate formed by the kidneys in 1 minute. Renal blood flow progressively decreases with aging primarily because of reduced blood supply through the micro blood vessels of the kidney. A decrease in glomerular filtration is the most important functional deficit caused by aging. Urate crystals are somewhat common in the newborn period. They might indicate that the infant is dehydrated. In older people, they result from too much uric acid in the blood, although this is not related to aging. Renal mass (weight) decreases over time, starting around age 30 to 40. PTS:1DIFifficultREF:p. 1013 KEY:Nursing process: N/A | Client need: PHSI | Cognitive level: Recall 2. While performing a physical assessment, the student nurse tells her instructor that she cannot palpate her patients bladder. Which statement by the instructor is best? You should: 1) Try to palpate it again; it takes practice but you will locate it. 2) Palpate the patients bladder only when it is distended by urine. 3) Document this abnormal finding on the patients chart. 4) Immediately notify the nurse assigned to the care of your patient. ANS: 2 The bladder is not palpable unless it is distended by urine. It is not difficult to palpate the bladder when distended. The nurse should document her finding, but it is not an abnormal finding. It is not necessary to notify the nurse assigned to the patient. PTS:1DIF:EasyREF:p. 1014 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application 3. Which urine specific gravity would be expected in a patient admitted with dehydration? 1) 1.002 2) 1.010 3) 1.025 4) 1.030 ANS: 4 Normal urine specific gravity ranges from 1.010 to 1.025. Specific gravity less than 1.010 indicates fluid volume excess, such as when the patient has fluid overload (too much IV fluid) or when the kidneys fail to concentrate urine. Specific gravity greater than 1.025 is a sign of deficient fluid volume that occurs, for example, as a result of blood loss or dehydration. PTS:1DIF:ModerateREF:p. 1015 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application 4. Which medication class will the primary care provider most likely prescribe to increase urine output in the patient admitted with congestive heart failure? 1) Thiazide diuretic

www.mynursingtestprep.com2) Loop diuretic 3) MAO inhibitor 4) Anticholinergic ANS: 2 A loop diuretic [e.g., Furosemide (Lasix)] increases urine elimination. It works by limiting the reabsorption of water in the renal tubules and is used to reduce congestion in the cardiopulmonary circulation. A thiazide diuretic is used to treat high blood pressure by reducing the amount of sodium and water in the blood vessels. An MAO inhibitor [e.g., phenelzine (Nardil)] is an antidepressant that is used after other medications have proven unsuccessful in lifting symptoms of serious depression. Anticholinergics [e.g., ipratropium (Atrovent)] relax smooth muscle in the airways. Also known as antispasmodics, they reduce airway constriction experienced by those with asthma, for example. is a cholesterol-lowering drug. Although high cholesterol is a leading factor for heart disease, the medication is used to reduce cholesterol in the bloodnot to promote diuresis to reduce the demand on the heart and backflow into the lungs. PTS:1DIF:ModerateREF:p. 1016; not stated directly in the text and requires critical thinking KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application 5. The nurse identifies the nursing diagnosis Urinary Incontinence (Total) in an older adult patient admitted after a stroke. Urinary Incontinence places the patient at risk for which complication? 1) Skin breakdown 2) Urinary tract infection 3) Bowel incontinence 4) Renal calculi ANS: 1 Urine contains ammonia, which may cause excoriation with prolonged contact with the skin. Bowel incontinence, not urinary incontinence, increases the patients risk for urinary tract infection. Immobility and high consumption of calcium-containing foods increase the risk for renal calculi. PTS: 1 DIF: Moderate REF: p. 1021 KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application 6. The nurse is caring for a patient who underwent a bowel resection 2 hours ago. His urine output for the past 2 hours totals 50 mL. Which action should the nurse take? 1) Do nothing; this is normal postoperative urine output. 2) Increase the infusion rate of the patients IV fluids. 3) Notify the provider about the patients oliguria. 4) Administer the patients routine diuretic dose early. ANS: 3 50 mL in 2 hours is not normal output. The kidneys typically produce 60 mL of urine per

www.mynursingtestprep.comhour. Therefore, the nurse should notify the provider when the patient shows diminished urine output (oliguria). Patients who undergo abdominal surgery commonly require increased infusions of IV fluid during the immediate postoperative period. The nurse cannot provide increased IV fluids without a providers order. The nurse should not administer any medications before the scheduled time without a prescription. The provider may hold the patients scheduled dose of diuretic if he determines that the patient is experiencing deficient fluid volume. PTS: 1 DIF: Difficult REF: p. 1025 KEY: Nursing process: Interventions | Client need: PSI| Cognitive level: Application 7. The nurse measures the urine output of a patient who requires a bedpan to void. Which action should the nurse take first? Put on gloves and: 1) Have the patient void directly into the bedpan. 2) Pour the urine into a graduated container. 3) Read the volume with the container on a flat surface at eye level. 4) Observe the color and clarity of the urine in the bedpan. ANS: 1 First, the nurse should put on gloves and have the patient void directly into the bedpan. Next, she should pour the urine into a graduated container, place the measuring device on a flat surface, and read the amount at eye level. She should observe the urine for color, clarity, and odor. Then, if no specimen is required, she should discard the urine in the toilet and clean the container and bedpan. Finally, she should record the amount of urine voided on the patients intake and output record. PTS: 1 DIF: Easy REF: p. 1041 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis 8. The nurse instructs a woman about providing a clean-catch urine specimen. Which of the following statements indicates that the patient correctly understands the procedure? 1) I will be sure to urinate into the hat you placed on the toilet seat. 2) I will wipe my genital area from front to back before I collect the specimen midstream. 3) I will need to lie still while you put in a urinary catheter to obtain the specimen. 4) I will collect my urine each time I urinate for the next 24 hours. ANS: 2 To obtain a clean-catch urine specimen, the nurse should instruct the patient to cleanse the genital area from front to back and collect the specimen midstream. This follows the principle of going from clean to dirty. The nurse should have the ambulatory patient void into a hat (container for collecting the urine of an ambulatory patient) when monitoring urinary output, but not when obtaining a clean-catch urine specimen. A urinary catheter is required for a sterile urine specimen, not a clean-catch specimen. A 24-hour urine collection may be necessary to evaluate some disorders, but a clean-catch specimen is a one-time collection. PTS: 1 DIF: Moderate REF: dm 1043-1044 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Analysis

www.mynursingtestprep.com9. What position should the patient assume before the nurse inserts an indwelling urinary catheter? 1) Modified Trendelenburg 2) Prone 3) Dorsal recumbent 4) Semi-Fowlers ANS: 3 The nurse should have the patient lie supine with knees flexed, feet flat on the bed (dorsal recumbent position). If the patient is unable to assume this position, the nurse should help the patient to a side-lying position. Modified Trendelenburg position is used for central venous catheter insertion. Prone position is sometimes used to improve oxygenation in patients with adult respiratory distress syndrome. Semi-Fowlers position is used to prevent aspiration in those receiving enteral feedings. PTS: 1 DIF: Easy REF: p. 1031 KEY: Nursing process: Interventions | Client need: Physiological Integrity | Cognitive level: Application 10. A patient complains that she passes urine whenever she sneezes or coughs. How should the nurse document this complaint in the patients healthcare record? 1) Transient incontinence 2) Overflow incontinence 3) Urge incontinence 4) Stress incontinence ANS: 4 Stress incontinence is an involuntary loss of urine that occurs with increased intra- abdominal pressure. Activities that typically produce the symptom include sneezing, coughing, laughing, lifting, and exercise. Transient incontinence is a short-term incontinence that is expected to resolve spontaneously. It is typically caused by urinary tract infection or medications, such as diuretics. Overflow incontinence is the loss of urine when the bladder becomes distended; it is commonly associated with fecal impaction, enlarged prostate, and neurological conditions. Urge incontinence is the involuntary loss of urine associated with a strong urge to void. PTS:1DIF:ModerateREF:p. 1018 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis 11. Which outcome is appropriate for the patient who underwent urinary diversion surgery and creation of an ileal conduit for invasive bladder cancer? 1) Patient will resume his normal urination pattern by (target date). 2) Patient will perform urostomy self-care by (target date). 3) Patient will perform self-catheterization by (target date). 4)

www.mynursingtestprep.comPatients urine will remain clear with sufficient volume. ANS: 2 The most appropriate outcome for this patient is the patient will perform urostomy self- care by a specific date. The patient with an ileal conduit is unable to resume a normal urination pattern; urine, along with mucus, drains continuously from the stoma site, so the urine will not be clear. Also, the phrase sufficient volume is too vague for an outcome statement. The patient with a continent urostomy inserts a catheter into the stoma to drain urine. PTS:1DIF:ModerateREF:p. 1039 KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application 12. Which intervention should the nurse take first to promote micturition in a patient who is having difficulty voiding? 1) Insert an indwelling urinary catheter. 2) Notify the provider immediately. 3) Insert an intermittent, straight catheter. 4) Pour warm water over the patients perineum. ANS: 4 The nurse should perform independent nursing measures, such as pouring warm water over the patients perineum before notifying the provider. If nursing measures fail, the nurse should notify the provider. The provider may order an indwelling urinary catheter or a straight catheter to relieve the patients urinary retention. PTS:1DIF:ModerateREF:p. 1028 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Analysis 13. The student nurse asks the provider if she will prescribe an indwelling urinary catheter for a hospitalized patient who is incontinent. The provider explains that catheters should be utilized only when absolutely necessary because: 1) They are the leading cause of nosocomial infection. 2) They are too expensive for routine use. 3) They contain latex, increasing the risk for allergies. 4) Insertion is painful for most patients. ANS: 1 Indwelling urinary catheters should not be routinely used for hospitalized patients with incontinence because they are the leading cause of healthcare-acquired infection (nosocomial). The cost of an indwelling urinary catheter should not deter its use if necessary. Latex-free catheters are available for patients with or at risk for latex allergy. Insertion may be somewhat uncomfortable, but it should not be painful. PTS:1DIF:ModerateREF:p. 1028 KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application 14. A patient who sustained a spinal cord injury will perform intermittent self- catheterization after discharge. After discharge teaching, which statement by the patient would indicate correct understanding of the procedure? 1)

www.mynursingtestprep.comI will need to replace the catheter weekly. 2) I can use clean, rather than sterile, technique at home. 3) I will remember to inflate the catheter balloon after insertion. 4) I will dispose of the catheter after use and get a new one each time. ANS: 2 The nurse should inform the patient that clean technique can be used after discharge. The patient should wash his hands before the procedure, then wash the reusable catheter in soap and water, and rinse and store it in a clean, dry place. It is not necessary for the patient to use a new catheter for each catheterization. The patient should use a straight catheter; therefore, a balloon is not inflated after insertion. Straight catheters are removed immediately after use. PTS: 1 DIF: Moderate REF: p. 1029 KEY: Nursing process: Evaluation | Client need: PSI | Cognitive level: Application 15. The nurse notes that a patients indwelling urinary catheter tubing contains sediment and crusting at the meatus. Which action should the nurse take? 1) Notify the provider immediately. 2) Flush the catheter tubing with saline solution. 3) Replace the indwelling urinary catheter. 4) Encourage fluids that increase urine acidity. ANS: 3 The catheter needs to be changed when sediment collects in the tubing or catheter and crusting at the meatus occurs. It is not necessary to notify the provider immediately. The nurse should not flush the catheter tubing. The patient should be encouraged to consume fluids that increase urine acidity to prevent urinary tract infection; however, it will not help clear the catheter tubing of sediment. PTS:1DIF:ModerateREF:p. 1031 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 16. The surgeon orders hourly urine output measurement for a patient after abdominal surgery. The patients urine output has been greater than 60 mL/hour for the past 2 hours. Suddenly the patients urine output drops to almost nothing. What should the nurse do first? 1) Irrigate the catheter with 30 mL of sterile solution. 2) Replace the patients indwelling urinary catheter. 3) Infuse 500 mL of normal saline solution IV over 1 hour. 4) Notify the surgeon immediately. ANS: 1 If the patients urinary output suddenly ceases, the nurse should irrigate the urinary catheter to assess whether the catheter is blocked. If no blockage is detected, the nurse should notify the surgeon. The surgeon may request that the catheter be changed if irrigation does

www.mynursingtestprep.comnot help or if the tubing is not kinked. However, the nurse should not change a catheter in the immediate postoperative period without consulting with the surgeon. The surgeon may prescribe an IV fluid bolus if the patient is suspected to have a deficient fluid volume. PTS:1DIFifficultREF:p. 1058 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Analysis 17. A patient is admitted with high BUN and creatinine levels, low blood pH, and elevated serum potassium level. Based on these laboratory findings the nurse suspects which diagnosis? 1) Cystitis 2) Renal calculi 3) Enuresis 4) Renal failure ANS: 4 Elevated BUN, creatinine, and serum potassium levels and low blood pH are signs of renal failure. Cystitis is an infection of the bladder and would not result in abnormal renal function. Renal calculi typically produce blood in the urine but do not lead to marked renal dysfunction and failure. Enuresis is involuntary urination, particularly common in children, and does not produce renal dysfunction. The cause of enuresis is often emotional, developmental, or trauma related. PTS:1DIFifficultREF:p. 1023 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis 18. A mother tells the nurse at an annual well-child checkup that her 6-year-old son occasionally wets himself. Which response by the nurse is appropriate? 1) Explain that occasional wetting is normal in children of this age. 2) Tell the mother to restrict her childs activities to avoid wetting. 3) Suggest time out to reinforce the importance of staying dry. 4) Inform the mother that medication is commonly used to control wetting. ANS: 1 The nurse should explain that occasional wetting is normal in children during the early school years. The mother should handle the situation calmly and avoid punishing the child. Medications are occasionally prescribed for nocturnal enuresis when the child is older and not sleeping at home, but not for occasional daytime wetting. PTS:1DIF:ModerateREF:dm 1038-1039 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Application 19. Which task can the nurse safely delegate to the nursing assistive personnel? 1) Palpating the bladder of a patient who is unable to void 2) Administering a continuous bladder irrigation 3) Providing indwelling urinary catheter care

www.mynursingtestprep.com4) Obtaining the patients history and physical assessment ANS: 3 The nurse can safely delegate indwelling urinary catheter care to nursing assistive personnel who are adequately trained to do so. Palpating the bladder, administering continuous bladder irrigation, and obtaining the patients history and physical assessment involve the critical thinking skills of a professional nurse. PTS:1DIF:Moderate REF: p. 1048, 1058; not directly stated in text KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis 20. Which action should the nurse take when beginning bladder training using scheduled voiding? 1) Offer the patient a bedpan every 2 hours while she is awake. 2) Increase the voiding interval by 30 to 60 minutes each week. 3) Frequently ask the patient if she has the urge to void. 4) Increase the frequency between voiding even if urine leakage occurs. ANS: 1 The nurse should offer the patient the bedpan or assist the patient to the bathroom every 2 hours while she is awake. You would encourage the patient to get up once during the night to void, but awakening the patient every 2 hours would lead to fatigue. If the patient adheres to the schedule, the voiding interval should be increased by 15 to 30 minutes each week. Simply asking the patient about the urge to void does not help to manage bladder emptying. PTS:1DIF:ModerateREF:p. 1033 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 21. A patient is prescribed furosemide (Lasix), a loop diuretic, for treatment of congestive heart failure. The patient is at risk for which electrolyte imbalance associated with use of this drug? 1) Hypocalcemia 2) Hypokalemia 3) Hypomagnesemia 4) Hypophosphatemia ANS: 2 Furosemide is a loop diuretic, which causes potassium to pass into the urine. This drug increases the risk for hypokalemia (low potassium); it does not cause hypocalcemia (low calcium in the blood), hypomagnesemia (low blood magnesium), or hypophosphatemia (low blood phosphorous). PTS:1DIF:ModerateREF:p. 1016, not stated directly in the text and requires critical thinking KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Comprehension 22. Which daily urine output is within normal limits for a newborn weighing

www.mynursingtestprep.com8 pounds? 1) 288 mL 2) 180 mL 3) 36 mL 4) 18 mL ANS: 2 A newborn weighing 8 pounds (3.6 kg) should produce 15 to 60 mL of urine per kilogram per day. If the newborn produces 50 mL/kg/day and weighs 3.6 kg, he will produce a total of 180 mL in 24 hours. The other options are not within normal limits and require further assessment. PTS:1DIFifficultREF:p. 1015 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Analysis 23. The nurse is teaching an older female patient how to manage urge incontinence at home. What is the first-line approach to reducing involuntary leakage of urine? 1) Insertion of a pessary 2) Intermittent self-catheterization 3) Bladder training 4) Anticholinergic medication ANS: 3 The goal of bladder training is to enable the patient to hold increasingly greater volumes of urine in the bladder and to increase the interval between voiding. This involves patient teaching, scheduled voiding, and self-monitoring using a voiding diary. In addition to teaching the mechanisms of urination, teach distraction and relaxation strategies to help inhibit the urge to void. Other techniques include deep breathing and guided imagery. A pessary is an incontinence device that is inserted into the vagina to reduce organ prolapse or pressure on the bladder. Clean, intermittent self-catheterization is a good option for managing incontinence that is resistant to conservative measure, such as bladder training, Kegel exercises, lifestyle modification, and medication. Anticholinergic medication can be highly effective for improving urinary incontinence. However, more conservative measures, such as timed voiding and Kegel exercises, are recommended first. PTS:1DIF:ModerateREF:p. 1033 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 24. What is the best technique for obtaining a sterile urine specimen from an indwelling urinary catheter? 1) Use antiseptic wipes to cleanse the meatus prior to obtaining the sample. 2) Briefly disconnect the catheter from the drainage tube to obtain the sample. 3) Withdraw urine through the port using a needleless access device. 4) Obtain the urine specimen directly from the collection bag.

www.mynursingtestprep.comANS: 3 To obtain a specimen from an indwelling catheter, insert the needleless access device with a 20- or 30-mL syringe into the specimen port, and aspirate to withdraw the amount of urine you need. Wiping the meatus with an antiseptic material helps to minimize contamination for a clean-catch voided specimen, not a sample collected from a closed system such as an indwelling catheter system. Never disconnect the catheter from the drainage tube to obtain a sample. Interrupting the system creates a portal of entry for pathogens, thereby increasing the risk of contamination. Do not take the specimen from the collection bag because that urine may be several hours old. PTS: 1 DIF: Moderate REF: p. 1024 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application Multiple Response Identify one or more choices that best complete the statement or answer the question. 1. Which of the following is/are an appropriate goal(s) for a patient with urinary incontinence? Choose all that apply. 1) Increase the intake of citrus fruits. 2) Maintain daily oral fluids to 8 to 10 servings per day. 3) Limit daily caffeine intake to less than 100 mg. 4) Engage in high-impact, aerobic exercise. ANS: 2, 3 The nurse should encourage lifestyle changes such as limiting caffeine intake to fewer than 100 mg per day; limiting intake of alcohol, artificial sweeteners, spicy foods, and citrus fruit; and maintaining daily oral fluid intake to 8 to 10 servings per day. High- impact exercise can be associated with stress incontinence for those with weakened pelvic muscles that support the bladder and urethra. Chapter 27 Sensation, Perception, & Cognition Identify the choice that best completes the statement or answers the question. 1. The nurse checks a patients pupils using a penlight. Which receptors is the nurse stimulating? 1) Chemoreceptors 2) Photoreceptors 3) Proprioceptors 4) Mechanoreceptors ANS: 2 Photoreceptors located in the retina of the eyes detect visible light. Proprioceptors in the skin, muscles, tendons, ligaments, and joint capsules coordinate input to enable an individual to sense the position of the body in space. Chemoreceptors are located in the taste buds and epithelium of the nasal cavity. They play a role in taste and smell. Thermoreceptors in the skin detect variations in temperature. Mechanoreceptors in the skin and hair follicles detect touch, pressure, and vibration.

www.mynursingtestprep.comPTS:1DIF:EasyREF:p. 1068 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 2. Which structure within the brain is responsible for consciousness and alertness? 1) Reticular activating system 2) Cerebellum 3) Thalamus 4) Hypothalamus ANS: 1 The reticular activating system, located in the brainstem, controls consciousness and alertness. The cerebellum maintains muscle tone, coordinates muscle movement, and controls balance. The thalamus is a relay system for sensory stimuli. The hypothalamus controls body temperature. PTS:1DIF:EasyREF:p. 1068 KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Recall 3. The nurse has been teaching a parent about stimuli to develop her infants auditory nervous system. Which behavior by a parent toward the child provides evidence that learning occurred? 1) Cuddling 2) Speaking 3) Feeding 4) Soothing ANS: 2 Exposure to voices, music, and ambient sound helps develop the infants auditory nervous system. Cuddling, feeding, and soothing provide comfort and pleasure and teach the infant about his external environment. PTS:1DIF:EasyREF:p. 1069 KEY: Nursing process: Evaluation | Client need: HPM | Cognitive level: Recall 4. A patient complains to the nurse that since taking a medication he has suffered from excessively dry mouth. What term should the nurse use to document this complaint? 1) Exophthalmos 2) Anosmia 3) Insomnia 4) Xerostomia ANS: 4 The nurse should document excessively dry mouth as xerostomia. Exophthalmos is abnormal bulging of the eyeballs that commonly occurs with thyrotoxicosis. Anosmia is losing the sense of smell. Insomnia is inability to sleep. PTS:1DIF:ModerateREF:p. 1072

www.mynursingtestprep.comKEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension 5. Which nursing diagnosis has the highest priority for a patient with impaired tactile perception? 1) Self-Care Deficit: Dressing and Grooming 2) Impaired Adjustment 3) Risk for Injury 4) Activity Intolerance ANS: 3 The patient with impaired tactile perception is unable to perceive touch, pressure, heat, cold, or pain, placing him at risk for injury. Self-Care Deficit, Impaired Adjustment, and Activity Intolerance are also likely to be appropriate for this patient but are not as high a priority as Risk for Injury. Risk for Injury is directly related to safety, which must always be a priority. PTS: 1 DIF: Moderate REF: p. 1072 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 6. A patient with Parkinsons disease is at risk for which complication? 1) Impaired kinesthesia 2) Macular degeneration 3) Seizures 4) Xerostomia ANS: 1 Patients with Parkinsons disease are at risk for impaired kinesthesia, placing them at risk for falling. Drooling, not excessive dry mouth (xerostomia), is common with Parkinsons disease. Seizures and macular degeneration are not associated with Parkinsons disease. PTS:1DIF:ModerateREF:dm 1074-1075 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 7. The nurse is caring for a patient with dementia who becomes agitated every evening. Which intervention by the nurse is best for calming this patient? 1) Encouraging family members to visit only during the day 2) Applying wrist restraints during periods of agitation 3) Playing soft, calming music during the evening 4) Administering lorazepam (a tranquilizer) ANS: 3 Soft, calming music is sometimes helpful for patients with dementia. Encouraging a family member to sit with the patient might have a calming effect, but the option does not provide for that during the evening when the patient is symptomatic. Applying bilateral wrist restraints might further agitate the patient. Lorazepam will provide sedation but might cause further confusion. PTS:1DIF:ModerateREF:p. 1081

www.mynursingtestprep.comKEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis 8. Which intervention is appropriate for the patient with a nursing diagnosis of Disturbed Sensory Perception: Gustatory? 1) Limit oral hygiene to one time a day. 2) Teach the patient to combine foods in each bite. 3) Assess for sores or open areas in the mouth. 4) Instruct the patient to avoid salt substitutes. ANS: 3 The nurse should assess for sores or open areas in the mouth and provide frequent oral hygiene. The nurse should also teach the patient to eat foods separately to allow the taste of food to be distinguishable. Seasonings, salt substitutes, spices, or lemon may improve the taste of foods, so the patient should not avoid them. PTS:1DIF:ModerateREF:p. 1083 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 9. A patient diagnosed with macular degeneration asks the nurse to explain his condition. Which statement by the nurse best describes macular degeneration? 1) The portion of your eye called the macula, which is responsible for central vision, is damaged. 2) Your lens became cloudy, causing your blurred vision. This cloudiness will increase over time. 3) The pressure in the anterior cavity of your eye became elevated, shifting the position of your lens. 4) Theres an irregular curvature of your cornea, causing your blurred vision. ANS: 1 Macular damage (degeneration) causes diminished central vision. Cataracts are caused by a cloudy lens and result in blurred vision. Glaucoma is pressure in the anterior cavity of the eye, which shifts the lens position. Astigmatism is irregular curvature of the cornea, resulting in blurred vision. PTS:1DIF:ModerateREF:p. 1072 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 10. A patient who sustained a head injury in a motor vehicle accident has damage to the temporal lobe. This injury places the patient at risk for which type of hearing loss? 1) Otosclerosis 2) Conduction deafness 3) Presbycusis 4) Central deafness ANS: 4 Central deafness results from damage to the auditory areas in the temporal lobes.

www.mynursingtestprep.comOtosclerosis is hardening of the bones of the middle ear, especially the stapes. Conduction deafness results when one of the structures that transmits vibrations is affected. Presbycusis is a progressive sensorineural loss associated with aging. PTS:1DIF:ModerateREF:p. 1072 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application 11. A patient comes to the clinic complaining of a taste disturbance. Which medication that the patient is currently prescribed is most likely responsible for this disturbance? 1) Furosemide, a diuretic 2) Phenytoin, an anticonvulsant 3) Glyburide, an antidiabetic 4) Heparin, an anticoagulant ANS: 2 Phenytoin is a medication that has a high incidence of associated taste disturbance. Furosemide, glyburide, and heparin are not implicated in taste disturbances. PTS:1DIF:ModerateREF:p. 1073 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application 12. Which instruction should the nurse be certain to include when providing discharge teaching for a patient who has a serious visual deficit? 1) Install blinking lights to alert an incoming phone call. 2) Have gas appliances inspected regularly to detect gas leaks. 3) Wear properly fitting shoes and socks. 4) Avoid using throw rugs on the floors. ANS: 4 The nurse should instruct the visually impaired patient to avoid using throw rugs on the floors at home. She should instruct the patient with a hearing deficit to install blinking lights to alert him to an incoming phone call. She should instruct the patient with an olfactory deficit to have gas appliances inspected regularly to detect leaks. The patient with a tactile deficit should be instructed to use properly fitting shoes and socks. PTS:1DIF:ModerateREF:p. 1084 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application 13. The nurse must irrigate the ear of a 4-year-old child. How should the nurse pull the pinna to straighten the childs ear canal? 1) Up and back 2) Straight back 3) Down and back 4) Straight upward

www.mynursingtestprep.comANS: 3 The nurse should straighten the ear canal of a small child by pulling the pinna down and back. To straighten the ear canal of an adult, the nurse should pull the pinna up and outward. PTS: 1 DIF: Moderate REF: p. 1086 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 14. Which step should the nurse take first when performing otic irrigation in an adult? 1) Warm the irrigation solution to room temperature. 2) Position the patient so she is sitting with her head tilted away from the affected ear. 3) Straighten the ear canal by pulling up and back on the pinna. 4) Place the tip of the nozzle into the entrance of the ear canal. ANS: 1 The nurse should warm the irrigation solution to room temperature first. Next, the nurse should assist the patient into a sitting position, with the head tilted away from the affected ear; straighten the ear canal by pulling up and back on the pinna; place the tip of the nozzle into the entrance of the ear canal; and direct the stream of irrigating solution gently along the top of the ear canal toward the back of the patients head. Then continue irrigating until the canal is clean. PTS: 1 DIF: Easy REF: p. 1086 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis 15. Which essential oil might the nurse trained in aromatherapy use to uplift and stimulate a patient? 1) Lavender 2) Roman chamomile 3) Rosemary 4) Ylang-ylang ANS: 3 Rosemary is very stimulating and uplifting. Lavender, Roman chamomile, and Ylang- ylang are used to promote relaxation. PTS:1DIF:ModerateREF:p. 1073 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension 16. Which assessment finding is considered an age-related change? 1) Presbycusis 2) Hyperopia 3) Increased sensitivity to touch 4) Increased sensitivity to taste

www.mynursingtestprep.comANS: 1 Presbycusis, the loss of high-frequency tones, is an age-related change. Hyperopia is the ability to see distant objects well; it is not an age-related change. The ability to perceive touch and taste diminishes with age; it does not increase. PTS:1DIF:ModerateREF:p. 1069, 1072 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 17. After sustaining a stroke, the patient lacks attention to the right side of his body. Which nursing diagnosis best describes the patients problem? 1) Disturbed Sensory Perception 2) Unilateral Neglect 3) Risk for Peripheral Vascular Dysfunction 4) Acute Confusion ANS: 2 This patient lacks attention to the right side of his body after sustaining a stroke; therefore, the most appropriate nursing diagnosis is Unilateral Neglect. The patient may also have Disturbed Sensory Perception, Risk for Peripheral Vascular Dysfunction, and Acute Confusion, but they are not the most appropriate for the defined problem. PTS:1DIFifficultREF:p. 1079 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 18. A patient is admitted with an exacerbation of asthma. Which factor places the patient at highest risk for sensory overload? 1) Administering albuterol (a central nervous stimulant) as needed 2) Administering a tranquilizer intravenously every 2 hours as prescribed 3) Delivering oxygen at 6 L/min via nasal cannula 4) Maintaining complete bedrest in a quiet, dimly lit room ANS: 1 Medications that stimulate the central nervous system, such as albuterol, place the patient at risk for sensory overload. A tranquilizer and a quiet darkened room may help the patient to relax, thus preventing sensory overload. If the patients oxygen needs are met with oxygen at 6 L/min via nasal cannula, the patient should not experience sensory overload related to oxygen therapy alone. PTS:1DIFifficultREF:p. 1071 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 19. A patient complains of an impaired sense of smell. Which cranial nerve might have been affected? 1) Trigeminal 2) Glossopharyngeal 3) Olfactory 4)

www.mynursingtestprep.comVagus ANS: 3 The olfactory nerve is responsible for the sense of smell. Damage to this nerve causes an impaired sense of smell. The trigeminal nerve transmits stimuli from the face and head. The glossopharyngeal nerve is responsible for taste. The vagus nerve is responsible for sensations of the throat, larynx, and thoracic and abdominal viscera. PTS: 1 DIF: Moderate REF: p. 1072 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 20. Which intervention is helpful when caring for a patient with impaired vision? 1) Suggest the patient use bright overhead lighting. 2) Advise the patient to avoid wearing sunglasses when outdoors. 3) Do not offer large-print books, as this may embarrass the patient. 4) Place the patients eyeglasses within easy reach. ANS: 4 The nurse should place the patients eyeglasses within easy reach and make sure that they are clean and in good repair. The patient should have sufficient light but avoid bright light, which might cause glare. The patient should be encouraged to wear sunglasses, visors, or hats with brims when outdoors. A magnifying lens or large-print books may be helpful. PTS:1DIF:ModerateREF:p. 1082 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 21. A patient tells the nurse that since taking a medication he has suffered from excessively dry mouth. Which of the following assessments would be needed in order to plan interventions for that symptom? 1) Asking the patient if foods taste different now 2) Checking the patients sense of smell 3) Having the patient stand to check for balance 4) Assessing for a history of seizures ANS: 1 Many medications cause xerostomia (dry mouth), and xerostomia is the most common cause of impaired taste. Impaired sense of smell also affects the sense of taste; however, there is no reason to assume impaired smell in this patient. Balance is related the inner ear and to kinesthetic sense, not to taste and xerostomia. Xerostomia would be related to seizures only if a patient experienced dry mouth as an aura; this would be unusual. Even if this were the case, the information would allow the nurse to plan care for seizures, but not for the symptom of dry mouth. PTS:1DIFifficultREF:p. 1072 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application Multiple Response Identify one or more choices that best complete the statement or answer the question. 1. For a particular patient, it has become essential to minimize the risk of further damage to the auditory nerve. Which of the following medications may need to be discontinued if the patient is taking them? Choose all that are correct.

www.mynursingtestprep.com1) Furosemide, a diuretic 2) Digoxin, a cardiotonic 3) Famotidine, an antacid 4) Aspirin, an analgesic ANS: 1, 4 Aspirin and furosemide may cause ototoxicity, leading to auditory nerve impairment. Digoxin and famotidine do not place the patient at risk for auditory nerve impairment. PTS:1DIFifficultREF:p. 1070 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Comprehension 2. Which factors in a health history place a patient at risk for hearing loss? Choose all that apply. 1) Being an older adult 2) Childhood chickenpox 3) Frequent otitis media 4) Diabetes mellitus ANS: 1, 3 Having had frequent ear infections (otitis media) places a patient at risk for hearing loss because of scarring that may have occurred. Older adults experience a generalized decrease in the number of nerve conduction fibers and structural changes in the ear, which cause hearing loss. Chickenpox and diabetes mellitus do not place the patient at risk for hearing loss. PTS: 1 DIF: Moderate REF: p. 1072 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 3. The nurse caring in the intensive care unit suspects that one of her patients is experiencing sensory overload. Which findings(s) has/have aroused her suspicion? Choose all that apply. 1) Disorientation 2) Restlessness 3) Hallucinations 4) Depression ANS: 1, 2 The patient with sensory overload might exhibit disorientation, confusion, restlessness, decreased ability to perform tasks, anxiety, muscle tension, and muscle tension. Sensory deprivation causes irritability, confusion, depression, heart palpitations, hallucinations, and delusions. PTS:1DIF:ModerateREF:p. 1071 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 4. Which action(s) can the nurse take to prevent sensory overload? Choose all

www.mynursingtestprep.comthat apply. 1) Leave the television on to block out other noises. 2) Minimize unnecessary light in the patients room. 3) Plan care to provide uninterrupted periods of sleep. 4) Speak calmly with a moderate voice volume. ANS: 2, 3, 4 To prevent sensory overload, minimize unnecessary light, plan care to provide uninterrupted periods of sleep, and speak to the patient in a moderate tone of voice using a calm and confident manner. Television can be used to provide sensory stimuli, but not to prevent sensory overload. When used, it should not be left on indiscriminately. PTS:1DIF:ModerateREF:p. 1081 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 5. For an unconscious patient, which of the following interventions are necessary to provide for patient safety? Choose all that apply. 1) Talk to the patient as you provide care. 2) Incorporate more touch in the plan of care. 3) Give frequent eye care if blink reflex is absent. 4) Keep the side rails up and bed in low position. ANS: 3, 4 Safety measures are a priority for unconscious clients. Keep the bed in low position when you are not at the bedside, and keep the side rails up. If the patients blink reflex is absent or her eyes do not close totally, you may need to give frequent eye care to keep secretions from collecting along the lid margins. The eyes may be patched to prevent corneal drying, and lubricating eye drops may be ordered. It is important to talk to the patient because the sense of hearing may still be intact. This provides some stimulation and may help with reality orientation. Providing touch will also help prevent sensory deficit; however, it is not a safety measure. Chapter 28 Pain Identify the choice that best completes the statement or answers the question. 1. A patient suddenly develops right lower-quadrant pain, nausea, vomiting, and rebound tenderness. How should the nurse classify this patients pain? 1) Acute 2) Chronic 3) Intractable 4) Neuropathic ANS: 1 Acute pain typically has a short duration and a rapid onset. Chronic pain lasts longer than

www.mynursingtestprep.com6 months and interferes with daily activities. Intractable pain is chronic and highly resistant to relief. Neuropathic pain is a type of chronic pain that occurs from injury to one or more nerves. PTS:1DIF:EasyREF:p. 1092 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 2. How should the nurse classify pain that a patient with lung cancer is experiencing? 1) Radiating 2) Deep somatic 3) Visceral 4) Referred ANS: 3 Visceral pain is commonly experienced in the abdominal cavity, cranium, or thorax. Lung cancer produces visceral pain. Radiating pain starts at the source and extends to other locations. Deep somatic pain is typically caused by fracture, sprain, arthritis, and bone cancer. Referred pain occurs in an area distant from the original site. PTS:1DIF:ModerateREF:p. 1091 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 3. A patient who underwent a left above-the-knee amputation complains of pain in his left foot. The nurse should document this finding as what type of pain? 1) Psychogenic 2) Phantom 3) Referred 4) Radiating ANS: 2 The nurse should document this finding as phantom pain. Phantom pain is pain that is perceived to originate in an area that has been amputated. Psychogenic pain refers to pain experienced by a person which does not match the symptoms or the apparent source of pain. It is thought to arise from psychological factors and is disproportional to the painful stimuli. Referred pain occurs in an area distant from the original site. Radiating pain starts at the source but extends to other locations. PTS:1DIF:EasyREF:p. 1091 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 4. A patient who sustained a leg laceration in an industrial accident is brought to the emergency department. The area around the laceration is red, swollen, and tender. Which substance is responsible for causing this response? 1) Histamine 2) Prostaglandin 3) Bradykinin

www.mynursingtestprep.com4) Serotonin ANS: 3 Tissue damage causes the release of the substances histamine, bradykinin, and prostaglandin. Bradykinin triggers the release of inflammatory chemicals that cause the injured area to become red, swollen, and tender. Serotonin is a neurotransmitter and is not involved in the inflammatory response. PTS:1DIFifficultREF:p. 1092 KEY: Nursing process: NA | Client need: PHSI | Cognitive level: Application 5. In which process do peripheral nerves carry the pain message to the dorsal horn of the spinal cord? 1) Transduction 2) Transmission 3) Perception 4) Modulation ANS: 2 Peripheral nerves carry the pain message to the dorsal horn of the spinal cord during a process known as transmission. In a process called transduction, specialized nociceptors convert potentially damaging mechanical, thermal, and chemical stimuli into electrical activity that leads to the experience of pain. Perception involves the recognition of pain by the frontal cortex of the brain. During modulation, pain signals can be facilitated or inhibited, and the perception of pain can be changed. PTS:1DIFifficultREF:p. 1092 KEY:Nursing process: NA | Client need: PHSI | Cognitive level: Recall 6. A patient reports that he uses music therapy to help control his chronic pain. Music therapy works by prompting the release of endogenous opioids during which stage of the pain process? 1) Perception 2) Transduction 3) Transmission 4) Modulation ANS: 4 Music therapy can prompt the release of endogenous opioids during the modulation stage, which is the stage of the pain process where the perception of pain changes. It is not during the perception (recognizing the pain sensation), transmission (relaying the pain message), or transduction (converting potentially damaging stimuli into electrical activity leading to pain sensation). PTS:1DIF:ModerateREF:dm 1093, 1100; synthesis of information required KEY:Nursing process: Planning | Client need: PHSI | Cognitive level: Recall 7. The nurse is assessing an intubated patient who returned from coronary artery bypass surgery 3 hours ago. Which assessment finding might indicate that this patient is experiencing pain?

www.mynursingtestprep.com1) Blood pressure 160/82 mm Hg 2) Temperature 100.6F 3) Heart rate 80 beats/min 4) Oxygen saturation 95% ANS: 1 This patient has an elevation in blood pressure which is a physiological finding associated with pain. The patient has a mild temperature elevation, which is a common response to surgery. Heart rate and oxygen saturation are within normal limits. PTS: 1 DIF: Moderate REF: dm 1095-1096 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 8. A patient who sustained rib fractures in a motor vehicle accident is complaining that his pain medication is ineffective. Inadequate pain control places this patient at risk for which complication? 1) Metabolic alkalosis 2) Pneumothorax 3) Pneumonia 4) Hemothorax ANS: 3 Pain associated with rib fractures causes splinting. Splinting often causes the patient to breathe shallowly and avoid deep coughing to expel sputum, which can lead to pneumonia. Rib fractures can also lead to complications such as pneumothorax and hemothorax; however, they do not result from inadequate pain control. Respiratory acidosis, not metabolic alkalosis, may result from the shallow breaths caused by pain and restricted chest wall movement with splinting. PTS:1DIF:ModerateREF:p. 1096 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application 9. When should the nurse assess pain? 1) Whenever a full set of vital signs is taken 2) During the admission interview 3) Every 4 hours for the first 2 days after surgery 4) Only when the patient complains of pain ANS: 1 The nurse should assess pain whenever a full set of vital signs is checked. Moreover, the nurse should assess pain on admission of a patient to the facility, even when pain is not the chief complaint. Patients may have chronic pain that has no association with their reason for seeking care. Pain should be assessed more frequently than every 4 hours in the immediate postoperative period. Pain should be reassessed after any treatment is given to evaluate effectiveness of the treatment. Some patients may not complain of pain unless

www.mynursingtestprep.comthey are specifically asked whether they are in pain. Pain rating scales help to quantify the intensity of pain for the nurse providing analgesia. PTS: 1 DIF: Moderate REF: dm 1096-1098 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 10. Which nursing diagnosis is most appropriate for the patient who returns from the postanesthesia care unit after undergoing right hemicolectomy surgery for colon cancer? 1) Acute pain secondary to surgery 2) Acute pain (abdominal) secondary to surgery for colon cancer 3) Chronic pain secondary to cancer diagnosis 4) Chronic pain (abdominal) secondary to abdominal surgery ANS: 2 The nurse should identify a diagnosis by specifying the location of the pain and any precipitating or etiological factors. This patient is experiencing acute abdominal pain that is related to his surgery for colon cancer; therefore, a nursing diagnosis that specifies the surgery is the most appropriate diagnosis for this patient. In addition, options listing chronic pain are incorrect because the pain is acute, not chronic. PTS: 1 DIF: Moderate REF: p. 1100 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application 11. Which drug might the primary care provider prescribe to help facilitate pain management in a client with chronic pain? 1) Selective serotonin reuptake inhibitor 2) Selective norepinephrine reuptake inhibitor 3) Narcotic analgesic 4) Anti-emetic ANS: 1 The control of depression greatly facilitates pain management, especially for patients experiencing chronic pain. Therefore, the physician may prescribe a selective serotonin uptake inhibitor (antidepressant), such as paroxetine (Paxil), as part of the treatment plan. Selective norepinephrine reuptake inhibitors, such as Atomoxetine (Strattera), are commonly used for attention deficit-hyperactivity disorder. If a narcotic, such as oxycodone (OxyContin), is used for a long time, it may become habit forming (causing mental or physical dependence). Physical dependence may lead to withdrawal side effects when you stop taking the medicine. This is not the first-line therapy for chronic pain. An anti-emetic, such as ondansetron (Zofran), is used to control for nausea and vomiting, which can occur with some analgesic medication. However, the prescriber would more likely change the medication to something the patient tolerates better rather than order an anti-emetic to control the side effect. PTS:1DIFifficultREF:p. 1103; higher-order item, can be inferred from text KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application 12. The nurse administers acetaminophen 325 mg and codeine 30 mg orally to a patient complaining of a severe headache. When should the nurse reassess the patients pain?

www.mynursingtestprep.com1) 15 minutes after administration 2) 60 minutes after administration 3) 90 minutes after administration 4) Immediately before the next dose is due ANS: 2 The nurse should reassess pain in the patient who received an oral pain medication 30 to 60 minutes after administration. The nurse should reassess the patient receiving IV medications 10 to 15 minutes after administration. The nurse should not wait until just before the patient can receive another dose. The patient may require additional pain medication before the next dose is due. PTS:1DIF:ModerateREF:p. 1100 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Application 13. After receiving ibuprofen (Motrin) 800 mg orally for right hip pain, the patient states that his pain is 8 out of 10 on the numerical pain scale. Which action should the nurse take? 1) Use nonpharmacological therapy while waiting 3 more hours before the next dose. 2) Administer an additional 800 mg oral dose of ibuprofen right away. 3) Do nothing because the patients facial expression indicates he is comfortable. 4) Notify the prescriber that the current pain management plan is ineffective. ANS: 4 The nurse should notify the prescriber that the current pain management plan is ineffective. The nurse should not delay treatment for 3 hours when the next dose of medication is due. The nurse cannot administer an extra dose of ibuprofen without a prescribers order to do so. Ibuprofen 800 mg is a maximum dose for most individuals. The nurse should not assume that the patient is not in pain simply because he appears comfortable; pain is what the patient states it is. PTS:1DIF:ModerateREF:dm 1110-1111 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 14. The nurse is teaching a client who sustained an ankle injury about cold application. Which instruction should the nurse include in the teaching plan? 1) Place the cold pack directly on the skin over the ankle. 2) Apply the cold pack to the ankle for 30 minutes at a time. 3) Check the skin frequently for extreme redness. 4) Keep the cold pack in place for at least 24 hours. ANS: 3 The nurse should instruct the patient to cover the cold pack with a washcloth, towel, or