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

www.mynursingtestprep.comfitted sheet before applying it to the ankle to prevent tissue damage. A cold pack should be applied intermittently for the first 24 hours, leaving it in place for no longer than 15 minutes at a time. The patient should check the skin frequently and discontinue the treatment immediately if redness or other signs of tissue irritation occur. PTS:1DIF:ModerateREF:p. 1101 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 15. The nurse plays music for a child with leukemia who is experiencing pain. Which pain management technique is this nurse using? 1) Distraction 2) Guided imagery 3) Sequential muscle relaxation 4) Hypnosis ANS: 1 Music is a form of distraction that has been shown to reduce pain and anxiety by allowing the patient to focus on something other than pain. Guided imagery uses auditory and imaginary processes to help the patient to relax. In sequential muscle relaxation, the patient sits and tenses muscles for 15 seconds and then relaxes the muscles while breathing out. This relaxation technique has also been effective for relieving pain. Hypnosis involves the induction of a deeply relaxed state. PTS:1DIF:EasyREF:dm 1101-1102 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension 16. The nurse uses his hands to direct energy fields surrounding the patients body. After this intervention, the patient states that his pain has lessened. How should the nurse document the intervention? 1) Tactile distraction was performed and appeared effective in reducing pain. 2) Guided imagery was effective to relax the patient and reduce the pain. 3) Therapeutic touch was performed; patient verbalized lessening of pain after treatment. 4) Sequential muscle relaxation was performed; patient states pain is less. ANS: 3 Therapeutic touch focuses on the use of hands to direct energy fields surrounding the body. The nurse should document use of therapeutic touch and its effectiveness in the progress notes after performing the procedure. Tactile distraction involves activities such as massage, hugging a favorite toy, holding a loved one, or stroking a pet. Guided imagery uses auditory and imaginary processes to help the patient to relax. In sequential muscle relaxation, the patient sits and tenses muscles for 15 seconds and then relaxes the muscle while breathing out. This relaxation technique is often effective for relieving pain. PTS:1DIF:ModerateREF:p. 1102 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application 17. A patient prescribed a nonsteroidal anti-inflammatory drug (NSAID), naproxen (Aleve, Naprosyn), for treatment of arthritis complains of stomach upset. What

www.mynursingtestprep.comshould the nurse instruct the patient to do? 1) Notify the prescriber immediately. 2) Take the medication with food. 3) Take the medication with 8 ounces of water. 4) Take the medication before bedtime. ANS: 2 The nurse should instruct the patient to take the medication with food to lessen gastric irritation. Taking the medication with 8 ounces of water will not decrease gastric irritation. Taking the medication just before bedtime may cause gastric reflux, increasing gastric irritation. Although indigestion is an unwanted side effect of naproxen, it is not an emergency that requires the prescriber to be notified immediately. However, prior to giving naproxen, be sure the patient has not had ulcers, stomach bleeding, or severe kidney or liver problems. If so, the patient is not a candidate for treatment with naproxen. PTS:1DIF:ModerateREF:p. 1103 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 18. A patient is prescribed morphine sulfate 4 mg intravenously for postoperative pain. Which action should the nurse take before administering the medication? 1) Monitor the patients respiratory status. 2) Auscultate the patients heart sounds. 3) Check blood pressure in supine and sitting positions. 4) Monitor the patient for psychological drug dependence. ANS: 1 The nurse should assess the patients respiratory status and level of alertness before administering the medication because respiratory depression can be a life-threatening effect. It is not necessary to auscultate heart sounds or to check blood pressure while the patient lies down (supine position) and sits up. Psychological dependence occurs rarely even after long-term prescribed use of morphine. Therefore, it is not necessary to routinely monitor a patient who is receiving morphine for acute postoperative pain for psychological drug dependence. PTS:1DIF:ModerateREF:p. 1104 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application 19. A client reports taking acetaminophen (Tylenol) to control osteoarthritis. Which instruction should the nurse give the patient requiring long-term acetaminophen use? 1) Caution the patient against combining acetaminophen with alcohol. 2) Explain that acetaminophen increases the risk for bleeding. 3) Advise taking acetaminophen with meals to prevent gastric irritation.

www.mynursingtestprep.com4) Explain that physical dependence may occur with long-term oral use. ANS: 1 Even in recommended doses, acetaminophen can cause hepatotoxicity in those who consume alcohol. Therefore, the nurse should caution the patient against combining acetaminophen with alcohol. Aspirin, not acetaminophen, increases the risk for bleeding because it inhibits platelet aggregation. Nonsteroidal anti-inflammatory drugs (NSAIDs), not acetaminophen, cause gastric irritation and should be taken with meals. Opioid analgesics, not acetaminophen, can cause physical dependence. PTS:1DIF:ModerateREF:p. 1103 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 20. Which side effects associated with opioid use may improve after taking a few doses of the drug? 1) Constipation 2) Drowsiness 3) Dry mouth 4) Difficulty with urination ANS: 2 Drowsiness as well as nausea are side effects of opioid therapy that commonly improve after a few doses are administered. Other side effects include constipation, vomiting, dry mouth, and difficulty with urination. These side effects do not typically lessen with use. PTS:1DIF:ModerateREF:p. 1104 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Comprehension 21. A patient develops a respiratory rate 6 breaths/minute after receiving IV hydromorphone (Dilaudid) 2 mg. Which medication should the nurse anticipate administering to this patient after notifying the prescriber of this side effect? 1) Physostigmine (Antilirium) 2) Flumazenil (Romazicon) 3) Naloxone (Narcan) 4) Protamine sulfate ANS: 3 The nurse should anticipate administering naloxone to reverse the respiratory depression associated with opioid use. Flumazenil reverses the central nervous system depressant effects of benzodiazepines. Physostigmine reverses the effects of anticholinergic drugs. Protamine sulfate is the antidote for heparin. PTS:1DIF:ModerateREF:p. 1104 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application 22. Which pain management task can be safely delegated to nursing assistive personnel? 1) Assessing the quality and intensity of the patients pain

www.mynursingtestprep.com2) Evaluating the effectiveness of pain medication 3) Providing a therapeutic back massage 4) Administering oral dose of acetaminophen ANS: 3 The nurse can safely delegate providing a back massage for the patient in pain. However, the nurse should never delegate the responsibility of assessing the patients pain, monitoring the patients response to pain management strategies, administering medications (including over-the-counter preparations), or evaluating the pain management plan. PTS:1DIF:ModerateREF:p. 1100 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 23. Which expected outcome is best for the patient with a nursing diagnosis of Acute Pain related to movement and secondary to surgical resection of a ruptured spleen and possible inadequate analgesia? 1) The patient will verbalize a reduction in pain after receiving pain medication and repositioning. 2) The patient will rest quietly when undisturbed. 3) On a scale of 0 to 10, the patient will rate pain as a 3 while in bed or as a 4 during ambulation. 4) The patient will receive pain medication every 2 hours as prescribed. ANS: 3 A low pain rating is the best expected outcome for the patient with a nursing diagnosis of Acute Pain secondary to surgical resection of a ruptured spleen and possible inadequate analgesia because it is specific and measurable. The patient verbalizing reduced pain is not specific enough. The nurse needs to know how much pain relief is achieved. A numeric score gives a clearer indication of the effectiveness of analgesia. The patient might have experienced a reduction in pain, but his pain level might still be intolerable. Saying the patients pain is relieved because he is resting quietly does not address the pain relief while he is awake. Some patients will sleep in an attempt to cope with pain, so this outcome could lead to inaccurate evaluation. Providing pain medication is a nursing intervention, not an expected outcome. PTS:1DIFifficultREF:p. 1100 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Analysis 24. A patient had a bowel resection 5 days ago. Which request by the patient might alert the nurse that the patient has a history of substance abuse? 1) Oral pain medication once every 6 to 8 hours 2) Patient-controlled analgesic 3) Oral pain medications instead of the IM form 4) Only nonpharmacological pain measures

www.mynursingtestprep.comANS: 2 The patient underwent surgery 5 days ago; if there are no complications, it is unlikely that he would require frequent dosing of analgesic. The nurse should recognize this behavior as a possible indicator of current substance abuse or addiction. Requesting oral pain medications every 6 to 8 hours is a typical behavior for a patient 5 days after surgery. Requesting an oral form of the drug does not indicate substance abuse. PTS:1DIF:EasyREF:dm 1109-1110 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 25. A patient with Raynauds disease receives no symptomatic relief with diltiazem (Cardizem). Which surgical intervention might be a treatment option for this patient to help provide symptomatic relief? 1) Cordotomy 2) Rhizotomy 3) Neurectomy 4) Sympathectomy ANS: 4 Sympathectomy severs the pathways to the sympathetic nervous system. The procedure improves vascular blood supply and eliminates vasospasm. It is effective for treatment of pain associated with vascular disorders, such as Raynauds disease. Cordotomy interrupts pain and temperature sensation below the tract that is severed. This procedure is commonly performed to relieve trunk and leg pain. Rhizotomy interrupts the anterior or posterior nerve route located between the ganglion and the cord. It is commonly used to treat head and neck pain. Neurectomy is used to eliminate intractable localized pain. The pathways of peripheral or cranial nerves are interrupted to block pain transmission. PTS:1DIF:ModerateREF:p. 1108 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Recall 26. Which action should the nurse take first when the patient has a score of 4 on the sedation rating scale? 1) Stimulate the patient. 2) Prepare to administer naloxone (Narcan). 3) Administer a dose of pain medication. 4) Notify the physician immediately. ANS: 1 If the patients score on the sedation rating scale is equal to or greater than 4, the nurse should first stimulate the patient. He should next notify the physician. The nurse should consider administering naloxone, as prescribed, if the patients respiratory rate is less than 8 breaths/minute; if respirations are shallow with marginal or falling oxygen saturation; or if the patient is unresponsive to stimulation. Before the patient receives another dose of pain medication, the dose should most likely be reduced and other potential causes of sedation should be investigated. PTS:1DIFifficultREF:p. 1106 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

www.mynursingtestprep.com27. A patient with a history of mitral valve replacement, hypertension, and type 2 diabetes mellitus undergoes emergency surgery to remove an embolus in her right leg. Which factor contraindicates the use of epidural analgesia in this patient? 1) Anticoagulant therapy 2) Diabetes mellitus 3) Hypertension 4) Embolectomy ANS: 1 Patients who undergo mitral valve replacement typically require long-term anticoagulant therapy. Anticoagulant therapy is a contraindication for epidural analgesia use because of the risk for spinal hematoma and uncontrolled bleeding. Diabetes and hypertension are not contraindications for epidural analgesia. Epidural analgesia is commonly used after embolectomy because certain anesthetic agents, such as bupivacaine, help prevent vasospasm. PTS:1DIFifficultREF:p. 1108 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis 28. After undergoing dural puncture while receiving epidural pain medication, a patient complains of a headache. Which action can help alleviate the patients pain? 1) Encourage the client to ambulate to promote flow of spinal fluid. 2) Offer caffeinated beverages to constrict blood vessels in his head. 3) Encourage coughing and deep breathing to increase CSF pressure. 4) Restrict oral fluid intake to prevent excess spinal pressure. ANS: 2 Treatment for a headache that occurs as a result of dural puncture consists of bedrest, analgesics as prescribed, and liberal hydration. Caffeine and a dark, quiet environment may also be helpful. Headaches will be more severe when the patient is sitting upright or ambulating. Fluid volume deficit will also aggravate a spinal headache after epidural anesthesia. PTS:1DIFifficultREF:p. 1108 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 29. An older adult receiving hospice care has dementia as a result of metastasis to the brain. His bone cancer has progressed to an advanced stage. Why might the client fail to request pain medication as needed? The client: 1) Experiences less pain than in earlier stages of cancer. 2) Cannot communicate the character of his pain effectively. 3) Recalls pain at a later time than when it occurs. 4) Relies on caregiver to provide pain relief without asking.

www.mynursingtestprep.comANS: 2 There is no evidence to suggest that patients with dementia and other forms of cognitive impairment do not experience pain. It is most likely that they cannot effectively communicate the intensity or quality of pain and are therefore at risk for underassessment of pain and inadequate pain relief. Be aware of behavioral cues indicating pain rather than relying on verbal report. Failure to request pain medication is not likely a result of hesitation to ask for it out of habit or reliance on others; rather, it is likely due to inability to effectively express to the caregiver that analgesia is needed. PTS:1DIF:ModerateREF:p. 1095 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Analysis 30. What is typically the most reliable indicator of pain? 1) Patients self-report 2) Past medical history 3) Description by caregiver(s) 4) Behavioral cues ANS: 1 The patients self-report is the most reliable indicator of pain. A patients facial expression, vocalization, posture or position, or other behaviors do not always accurately indicate the intensity or quality of a patients experience of pain. The patient might be trying to hide signs of pain in order to be brave or strong. Sociocultural factors can influence a patients nonverbal expression of pain. Caregivers might not appreciate the extent of pain because pain is an individualized experience. Perception of pain might be heightened if other medical conditions coexist, although this perception is also influenced by other factors, such as past experience with pain and the success or failure of the treatment to produce relief. Emotions, cognitive impairment, developmental stage, communication skills, and mental health disorders, such as depression or anxiety, can influence the perception of pain. PTS:1DIF:ModerateREF:p. 1096 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application Multiple Response Identify one or more choices that best complete the statement or answer the question. 1. A 73-year-old patient admitted after a stroke has expressive aphasia. Which pain intensity scale(s) would be appropriate to use with this patient? Choose all that apply. 1) Visual analog 2) Numerical rating 3) Wong-Baker face rating 4) Simple descriptor ANS: 1, 3 The Wong-Baker face-rating scale uses simple illustrations of faces to depict various levels of pain. The scale was developed for children but has proved effective for adults with communication and cognitive impairments. The visual analog requires patients to point to a location on a line that reflects their pain level. Some patients have difficulty

www.mynursingtestprep.comwith the abstract nature of this scale. When using the numerical rating scale, the patient must choose a number from 0 to 10 to denote his pain level. This scale is sometimes difficult for clients with cognitive impairments, such as expressive aphasia; however, it would be appropriate to try it if the face-rating scale is not available. Patients commonly find the simple descriptor scale difficult to understand. This scale uses a list of adjectives that describe pain intensity. PTS: 1 DIF: Moderate REF: dm 1097-1098 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 2. A patient diagnosed with lung cancer who is receiving morphine (MS Contin) complains of constipation. Which instruction(s) by the nurse might help relieve the patients constipation? Choose all that apply. 1) Be sure the amount of fruit, vegetables, and fiber in your diet is adequate. 2) Drink at least eight 8-ounce glasses of water each day. 3) Avoid using stool softeners because they may become habit forming. 4) Increase your exercise routine to include 1 hour of exercise a day. ANS: 1, 2 The nurse should instruct the patient to be sure the amount of fruit, vegetables, and fiber in his diet is adequate, and increase fluid intake to eight, 8-ounce glasses of water per day. Stool softeners may also be used. The patient should also be encouraged to increase exercise; even walking a short distance may be helpful. It is not necessary to increase exercise to 1 hour of exercise a day. The patient may be physically able to walk only short distances. Chapter 29 Activity & Mobility Identify the choice that best completes the statement or answers the question. 1. A 15-year-old patient complains of left ankle pain after being tackled while playing football. He asks the nurse what tests he needs to have to determine if he has a strain or a fracture. How should the nurse reply? 1) You dont need an x-ray; I can tell by the way your ankle looks and feels whether you have a strain or fracture. 2) Sprains, strains, and fractures have similar symptoms at first; you will need an x-ray of the joint to be certain. 3) We will need to get a venous Doppler study to make sure that there is not a fracture. 4) First, we need to get an MRI to diagnose your injury as a fracture instead of strain or sprain. ANS: 2 Signs and symptoms associated with a sprain, strain, or fracture are the same. An x-ray allows the medical provider to visually observe for any breaks in a bone. An x-ray is a more practical than an MRI to diagnose a fracture. A venous or arterial Doppler is used to detect blood flow. PTS: 1 DIF: Easy REF: p. 1136 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

www.mynursingtestprep.com2. The nurse planning the care for a frail, malnourished, immobile patient recognizes which of the following as the best treatment to protect the patients integument? 1) Offering the patient six small meals a day 2) Assisting the patient to sit in a chair three times a day 3) Turning the patient at least every 2 hours 4) Administering fluid boluses as directed by the healthcare provider ANS: 3 External pressure from lying or sitting in one position compresses capillaries and obstructs blood flow to the skin. Immobile patients confined to a bed should be turned at least every 2 hours to protect their skin and relieve pressure. PTS:1DIF:EasyREF:p. 1137 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Comprehension 3. What action is most important in limiting the nurses risk of back injuries? 1) Use good body mechanics at all times. 2) Work with another nurse or an aide when lifting and turning patients. 3) Avoid manual lifting by using assistive devices as often as possible. 4) Develop a lift team at the clinical site. ANS: 3 Back injuries are the leading cause of injury among nurses. Good body mechanics and teamwork limit the risk of injury. However, the American Nurses Associations (ANA) Handle with Care program advocates the regular use of assistive devices as well as avoiding manual lifting. PTS:1DIFifficultREF:p. 1128 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis 4. The nurse is helping the patient to perform leg exercises after surgery to prevent thrombophlebitis. Which type of muscle is the patient using for these exercises? 1) Skeletal 2) Smooth 3) Cardiac 4) Slow-twitch fibers ANS: 1 Skeletal muscle moves the bones with ligaments. Smooth muscle is found in the digestive tract and other hollow structures, such as the blood vessels and bladder. Cardiac muscle contracts spontaneously and is blood ejected out of the heart. Slow-twitch fibers are a subtype of skeletal muscle cell. Slow-twitch fibers (type I), or red muscle, have a rich blood supply and are rich in mitochondria (the powerhouse of the cell) to give the muscle

www.mynursingtestprep.commore oxygen and energy to sustain aerobic activity. The fast-twitch fibers (type II skeletal muscle type) are known as white muscle. These fibers increase the speed of muscle contraction. PTS:1DIF:EasyREF:p. 1120 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 5. A nurse is caring for a 25-year-old male quadriplegic patient. Which of the following treatments would the nurse perform to decrease the risk of joint contracture and promote joint mobility? 1) Active ROM 2) Turning the patient every 2 hours 3) Passive ROM 4) Administering glucosamine supplements ANS: 3 Passive ROM involves moving the joints through their ROM when the patient is unable to do so for himself. Passive ROM promotes joint mobility. Active ROM would not be possible for a quadriplegic patient. Turning the patient every 2 hours prevents skin breakdown but does not promote mobility or prevent contracture. Glucosamine is a building block for the formation and repair of cartilage. However, there is inconclusive, scientific evidence regarding the benefit of this substance to improve joint function. PTS:1DIF:Moderate REF: dm 1122, 1151; higher-order item, answer can be derived from text KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 6. A nurse is assessing a 74-year-old male patient for an exercise program to be offered at the local hospital. During the evaluation, the nurse notes the following vital signs: P = 72, RR = 16, BP = 132/70. After 3 minutes of moderate-intensity running on the treadmill, the patient becomes short of breath and states, I have to stop. I cant do this anymore. The nurse measures his vital signs again: P = 152, RR = 40, BP = 172/98. She instructs him to rest. Vital signs return to baseline after 15 minutes. The nurse should recognize his symptoms as associated with which of the following? 1) Anxiety 2) Orthostatic hypotension 3) Limited activity tolerance 4) Respiratory distress ANS: 3 To assess for activity tolerance, assess and record vital signs before and after exercise. A rapid change from baseline vital signs or a slow return to baseline indicates limited activity tolerance. Anxiety might primarily exhibit signs of difficulty getting enough air and elevated heart rate and systolic blood pressure. Vitals would resolve when anxiety is reduced and not after exercise. Orthostatic hypotension is a temporary lowering of blood pressure when suddenly standing up. It is not a finding related to exercise. PTS:1DIF:ModerateREF:p. 1138 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis

www.mynursingtestprep.com7. What is the correct method for turning an adult patient who recently sustained a spinal cord injury? 1) Ask the patient to assist with the turn by holding the side rails of the bed. 2) Place a draw sheet under the patient to assist with turning. 3) Request help from another nurse to perform the logrolling technique. 4) Use a mechanical lift for safe turning and protecting the nurses back. ANS: 3 The patients spine should be maintained in straight alignment. Logrolling moves the patients body as a unit and maintains the patients spine in straight alignment. Holding on to the side rail or using a draw sheet or mechanical lift will not keep the spine in alignment. PTS: 1 DIF: Difficult REF: p. 1148 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 8. An older patient with newly diagnosed osteoporosis asks the nurse to explain her health problem. Which of the following is the correct description of osteoporosis? 1) Loss of bone density that increases the risk of fracture 2) Degenerative joint disease that produces pain and decreased function 3) Chronic inflammatory joint disease that must be treated with steroids 4) Acute infection in the bone that must be treated with antibiotics ANS: 1 Osteoporosis is a decrease in total bone density. The internal structure of the bone diminishes, and the bone collapses in on itself. Women experience a rapid decline in bone mass after menopause. Osteoarthritis is a degenerative joint disease. Osteomyelitis is a serious infection in the bone. PTS:1DIF:EasyREF:p. 1135 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension 9. When caring for a patient with osteoporosis, which of the following is the most important action to take to minimize progression of the disease? 1) Take a calcium supplement twice a day. 2) Start a weight-bearing exercise program. 3) Avoid strenuous activity that puts stress on the bones. 4) Schedule regular healthcare checkups. ANS: 2 Osteoporosis causes bones to become porous and weak. Starting a weight-bearing exercise program is the most important aid in promoting bone strength and decreasing the rate of bone loss. Calcium supplementation helps maintain bone density. PTS:1DIF:ModerateREF:p. 1135

www.mynursingtestprep.comKEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application 10. Which course of action taken by her patient with osteoporosis would allow the nurse to know that her teaching was effective? 1) Taking a calcium supplement every day and increasing her phosphorous intake 2) Participating in an aerobic barbell strength class at the gym three times a week 3) Using a wheelchair to reduce the risk of spontaneous fractures to her legs and feet 4) Seeking healthcare by scheduling a follow-up examination with bone density testing ANS: 2 Active participation in a weight-bearing and weight-lifting program demonstrates not only understanding of the treatment of osteoporosis but commitment to an action plan to reduce bone loss that comes with osteoporosis. Calcium supplementation is also part of the treatment for osteoporosis. However, high phosphorous intake lowers calcium levels and would not be appropriate for a client with osteoporosis. Restricting weight-bearing activity to a wheelchair will actually lower bone density. Although follow-up care is appropriate for a client with osteoporosis, it does not indicate commitment to a daily treatment plan. PTS:1DIF:EasyREF:p. 1135 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Analysis 11. Which of the following is true of synarthroses? Joints are: 1) Freely movable. 2) Capable of only limited movement. 3) Immovable. 4) Painful with movement. ANS: 3 Synarthroses joints are immovable joints. The sutures between the cranial bones are considered synarthroses joints. Although these joints have some flexibility in youth to allow for growth, they gradually become rigid and immovable with age. There is no pain associated with synarthroses. PTS:1DIF:ModerateREF:p. 1120 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall 12. A man has been admitted to the hospital unit with a medical diagnosis of chronic obstructive pulmonary disease (COPD). He is receiving supplemental oxygen at 2 L/min via nasal cannula. Which positioning technique will best assist him with his breathing? 1) Fowlers position 2) Sims position 3) Lateral recumbent position 4) Lateral position ANS: 1 Fowlers position is a semi-sitting position in which the head of the bed is elevated 45 to

www.mynursingtestprep.com60 degrees. This position promotes respiratory function by lowering the diaphragm and allowing the greatest chest expansion. Sims position is a side-lying position where the patient is on his left side with left leg extended and right leg flexed. This position is commonly used for rectal examination. Lateral recumbent position is another term describing Sims position. Lateral position simply means side lying. PTS:1DIF:EasyREF:p. 1146 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 13. A nurse has been asked to design an exercise program with the goal of increasing a clients muscular strength and endurance. Which exercise program would specifically focus on meeting that goal? 1) Flexibility training 2) Resistance training 3) Aerobic conditioning 4) Anaerobic conditioning ANS: 2 Resistance training involves movement against resistance, which increases muscular strength and endurance. Most commonly, resistance training refers to weight lifting and isotonic movement. When exercising for strength, the amount of resistance is increased with each exercise. When exercising for endurance, the number of repetitions is increased with each exercise. Flexibility training will not increase muscular strength. Aerobic and anaerobic conditioning may have some benefit on strength and endurance, but their primary focus is cardiovascular conditioning. PTS:1DIF:ModerateREF:p. 1129 KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Analysis 14. In order to achieve balance, body mass must be distributed around which point? 1) Center of body alignment 2) Center of balance 3) Center of gravity 4) Base of support ANS: 3 Balance is achieved when the body is in alignment. To be balanced, a persons line of gravity must pass through his center of gravity, and the center of gravity must be close to his base of support. The center of gravity is the point around which mass is distributed. PTS:1DIF:EasyREF:p. 1121 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Comprehension 15. A frail 78-year-old man is admitted to the hospital after a fall at home resulted in a left hip fracture. After surgery, he is to begin ambulating with a walker but must avoid weight-bearing on his left lower leg. What is the best intervention to help him use his walker? 1)

www.mynursingtestprep.comAerobic exercise with deep breathing 2) Quadriceps and gluteal repetitions 3) Isometric toning of lower legs 4) Arm resistance training ANS: 4 Arm strength is necessary for ambulating with a walker and other assistive devices. Upper body resistance training increases muscles strength and tone, which will aid him in using the walker more easily. Toning the lower body through exercise of the quadriceps and gluteal muscles, although important for regaining strength in general after surgery, does not aid in using a walker. Aerobic exercise with deep breathing produces the greatest benefit to cardiovascular health but does little to improve the upper body strength needed for ambulating with an assistive device. PTS:1DIF:Moderate REF: dm 1152-1156; synthesis of information required; not a direct response to the item KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 16. Identify the most appropriate nursing diagnosis for promoting the safety of a frail, elderly patient after hip replacement surgery who also has a history of emphysema. 1) Impaired Mobility related to weakness 2) Ineffective Breathing Pattern related to disease process 3) Activity Intolerance related to injury 4) Risk for Injury related to medical condition ANS: 4 The patients medical condition places him at an increased Risk for Injury: He is at risk for falls and for further injury to his hip. The patient does have Impaired Mobility; however, his Impaired Mobility puts him at Risk for Injury. A diagnosis of Impaired Mobility would focus the outcomes on improving his mobility rather than protecting him from further injury. We have no data other than a diagnosis of emphysema to indicate that he is experiencing Ineffective Breathing Pattern. He is experiencing Activity Intolerance, but this is not his primary safety risk. A diagnosis of Activity Intolerance would focus the goals on increasing his endurance and conserving his energy. PTS:1DIF:ModerateREF:p. 1140 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Synthesis 17. What would be the most appropriate goal for a frail, elderly patient with a nursing diagnosis of Risk for Injury after hip surgery? 1) Remain free from injury or falls throughout hospital stay. 2) Increase activity tolerance by discharge from hospital. 3) Demonstrate effective breathing when ambulating. 4) Increase mobility by discharge from hospital. ANS: 1

www.mynursingtestprep.comRemaining free from injury or falls is a measurable goal, and it is directly related to the patients nursing diagnosis, Risk for Injury. Increasing activity tolerance and mobility by the time of discharge is not specific and measurable. Additionally, these outcomes do not relate to Risk for Injury. A goal of effective breathing for a frail, elderly patient after hip surgery does not relate to Risk for Injury. PTS:1DIF:EasyREF:p. 1141 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application 18. A 16-year-old was hospitalized 3 weeks ago. He has been confined to bed throughout his hospital stay because of a crushed pelvis. His parents tell the nurse, Our son is just staring off into space; he wont talk to us. We are worried because he has not even listened to his iPod, watched television, or played his video games for 2 days. That is so unlike him. What is the best response the nurse can make? 1) I will inform his doctor and see if we can get your son started on an antidepressant medication. 2) He is at a critical time in his life; teens are often moody, and being in the hospital with an injury will only make that worse. 3) Your son had a major injury; and his immobility might be causing him to feel isolated and depressed. 4) He is bored because he has been in the hospital for 3 weeks; Ill try to find something new for him to do. ANS: 3 Being immobile, whether in the hospital or home, leads to isolation and mood changes. Patients who are in bed for long periods can suffer from psychological changes such as depression, anxiety, hostility, sleep disturbances, and changes in their ability to perform self-care activities. PTS:1DIF:ModerateREF:p. 1137 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis 19. A healthy, 32-year-old man wants to start a fitness program to increase his muscle tone and muscle strength. What advice should the nurse offer him? The United States Department of Health and Human Services recommends: 1) That exercising even once a week is beneficial. 2) 30 minutes or more of moderate-intensity physical activity three times a week. 3) 1 hour, three times a week of moderate-intensity physical activity. 4) 150 to 300 minutes or more of moderate-intensity physical activity per week. ANS: 4 Exercise involves physical activity and increases muscle tone and strength. The U.S. Department of Health and Human Services recommends 150 to 300 minutes or more of moderate- or vigorous-intensity physical activity per week. PTS:1DIF:ModerateREF:p. 1130 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Comprehension

www.mynursingtestprep.com20. A patient fractured her right ulna 8 weeks ago and has just had her cast removed. The orthopedic surgeon prescribes isometric exercises for the right arm. Which of the following exercises comply with the surgeons orders? 1) Place a 5-pound dumbbell in the right hand and squeeze; hold the squeeze position for 6 to 8 seconds, and repeat 5 to 10 times. 2) Grasping the right wrist with the left hand, move the right arm up, down, and side to side; hold each position for 6 to 8 seconds, and repeat 5 to 10 times. 3) Grasping the right wrist with the left hand, pull the right arm across the body; hold this position for 6 to 8 seconds, and repeat 5 to 10 times. 4) Press the right hand against a wall; hold this position for 6 to 8 seconds, and repeat 5 to 10 times. ANS: 4 Isometric exercise involves muscle contraction without motion. Isometric exercises are useful for developing strength. This type of exercise is appropriate for the patient who has had an extremity confined to a cast because muscle atrophy occurs when the muscle is not used. Performing repetitions light weight increases strength but this would stress the healing fracture at this point in the rehabilitation. Pulling an arm across the body improves flexibility but does not benefit the ulna while healing. PTS:1DIFifficultREF:p. 1128 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 21. A woman with a high-risk pregnancy with triplets is in preterm labor; she is on strict bedrest for 5 days. During this time she has not had a bowel movement, although normally, passes stool daily. She describes feeling bloated and uncomfortable. What information should the nurse give the patient when explaining constipation? 1) Immobility often causes constipation. 2) A stool softener daily will relieve the problem. 3) Use of a bedpan results in bloating and constipation. 4) A low-fiber diet will resolve the problem. ANS: 1 Immobility slows peristalsis, which leads to constipation, gas, and difficulty evacuating stools from the rectum. Increasing fiber in the diet often prevents constipation. A stool softener may be ordered if other measures are unsuccessful. Some people do find use of a bedpan difficult. PTS:1DIF:EasyREF:p. 1137 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension 22. A patient is on strict bedrest for 5 days. During this time she has not had a bowel movement, although she normally passes stool daily. She describes feeling bloated and uncomfortable. A nursing diagnosis that would best address a patient who is on bedrest is Constipation related to: 1)

www.mynursingtestprep.comChange in previous pattern. 2) Immobility. 3) Dietary intake. 4) Change in environment. ANS: 2 Immobility slows peristalsis, which leads to constipation, gas, and difficulty evacuating stools from the rectum. Based on the scenario, this nursing diagnosis would specifically address the patients condition. PTS:1DIF:Moderate REF:p. 1137; higher-order item with implied answer KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 23. A 32-year-old with a high spinal cord injury has been admitted to the hospital for antibiotic therapy to treat pneumonia. He lives independently and has developed strong upper-body strength to maximize his independence. Which transfer device should be used when transferring him from the bed to his wheelchair? 1) Mechanical lift 2) Transfer belt 3) Draw sheet 4) Transfer board ANS: 4 A transfer board is used by patients with longstanding mobility problems; it offers them the greatest amount of independence while ensuring safety. Patients using a transfer board should have sufficient upper-body strength to perform the transfer safely. A mechanical lift could be used, but it does not promote independence. A transfer belt is used for clients who are able to stand. A draw sheet is useful for moving a patient in bed rather than from bed to wheelchair. PTS:1DIF:EasyREF:p. 1149 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Comprehension 24. An 82-year-old patient is unsteady on her feet when walking about the room. She reports feeling a little sore but has no complaints of weakness. What is the appropriate piece of equipment to use when helping her ambulate? 1) Crutches 2) Transfer belt 3) Cane 4) Walker ANS: 2 Crutches are commonly used when the patient has an injured lower extremity. A cane or walker is generally used for the patient with a lower extremity injury or weakness. The most appropriate equipment to use would be a transfer belt. A transfer belt allows the patient the greatest amount of independence while ensuring safety.

www.mynursingtestprep.comPTS:1DIF:EasyREF:dm 1149-1150 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 25. The nurse is helping an 82-year-old patient to ambulate in the hallway. Suddenly she states, I feel so light-headed and weak, as her knees begin to buckle. The nurses best action at this time would be to: 1) Assist the patient to slide down his leg as he guides her to a seated or lying position. 2) Grab her under the arms and hold her up as he calls for assistance. 3) Immediately release the transfer device and place a wheelchair behind the patient to prevent a fall. 4) Instruct the patient to grab the rail in the hallway while he calls for assistance. ANS: 1 If a patient becomes weak or begins to fall when walking, do not attempt to hold the patient up. Instead, protect the patient as you guide her to a seated or lying position. Create a wide base of support, and project forward the hip closest to the patient. Assist the patient to slide down your leg as you call for help. Protect the patients head as her body descends. PTS:1DIF:ModerateREF:p. 1152 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 26. According to the U.S. Department of Health and Human Services 2008 Physical Activity Guidelines for Americans, which of the following statements about the benefits of physical activity is correct? 1) The risks of physical activity outweigh the health benefits. 2) Physical activity in excess of recommendations for age is harmful. 3) Combining aerobic and muscle-strengthening activities promotes better health. 4) Lesser amounts of activity provide little to no health benefits. ANS: 3 The combination of aerobic and bone- and muscle-strengthening physical activities leads to health benefits for people of all ethnic groups and ages. Physical activity is safe for almost everyone, and the health benefits of physical activity far outweigh the risks. Additional health benefits are provided by increasing to 300 minutes a week of moderate- intensity aerobic physical activity, or 150 minutes a week of vigorous-intensity physical activity, or an equivalent combination of both. For all individuals, some activity is better than none. PTS:1DIF:EasyREF:p. 1130 KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Comprehension 27. When encouraging a fitness program for older adults, what must the nurse consider? 1) Older adults should engage in 75 to 150 minutes of moderate-intensity physical activity per week. 2)

www.mynursingtestprep.comMore than 150 minutes of moderate-intensity physical activity can be harmful to bones. 3) Structured fitness programs achieve greater health benefits for older adults. 4) Older adults at risk for falling should do activities that maintain or improve balance. ANS: 4 Older adults should do exercises that maintain or improve balance if they are at risk of falling. Older adults should follow the adult guidelines, which are for 150 minutes per week of moderate-intensity or 75 minutes per week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic physical activity. Aerobic activity should be performed in periods of at least 10 minutes, preferably spread throughout the week. If this is not possible because of limiting chronic conditions, older adults should be as physically active as their abilities allow. They should avoid inactivity. Structured calisthenics programs are no more beneficial for achieving health benefits than other forms of moderate- and vigorous-intensity physical activity. Structured fitness programs can become boring for some individuals. A varied routine often improves compliance and consistency of exercise. PTS: 1 DIF: Easy REF: dm 1131-1132 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. Which of the following body systems must interact to produce mobility and locomotion? Choose all that apply. 1) Digestive system 2) Muscles 3) Skeleton 4) Nervous system ANS: 2, 3, 4 Activity and exercise require bodily movement (mobility) and locomotion (self-powered movement from one place to another). Mobility depends on the successful interaction among the skeleton, the muscles, and the nervous system. PTS:1DIF:EasyREF:p. 1119 KEY:Nursing process: N/A | Client need: PHSI | Cognitive level: Recall 2. Which of the following patients would you expect to be at risk for decreased activity? Choose all that apply. 1) Older adult who walks at the mall for physical activity 2) Someone living in a skilled nursing facility 3) Healthy adult who works as a computer programmer 4) Obese child who enjoys video games ANS: 2, 3, 4 The person who lives in a skilled nursing facility might be sedentary because of

www.mynursingtestprep.comadvancing age and other age-associated medical problems that lead to inactivity. With obesity, movement becomes more difficult and strain on joints increases. A sedentary lifestyle, whether adult or child, contributes to obesity; activities, such as computer work and video games, are sedentary and require little physical activity. Physical activity doesnt have to be a structured fitness class but can also be walking, even walking in a mall or neighborhood, just as long as the intensity is moderately vigorous. PTS: 1 DIF: Moderate REF: p. 1119 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Comprehension 3. A patient has started a fitness program. What program features illustrate that he has started a well-rounded program? 1) Flexibility 2) Isometric exercises 3) Resistance training 4) Aerobic conditioning ANS: 1, 3, 4 Flexibility training helps warm up the muscles and prevents injury during exercise. Resistance training increases muscular strength and endurance. Aerobic conditioning affects fitness and body composition. Isometric exercise is an active form of physical activity using opposing resistance where the joints dont move and muscles dont lengthen. Isometrics are done in static positions, rather than moving through a range of motion. PTS:1DIF:ModerateREF:dm 1129-1130 KEY: Nursing process: Evaluation | Client need: HPM | Cognitive level: Comprehension 4. The nurse is instructing a patient about the need to replace fluid before, during, and after exercise in order to avoid dehydration. She should teach the patient to determine the amount of fluid to consume on the basis of: 1) Duration of exercise. 2) Environmental temperature. 3) Level of fitness. 4) Degree of thirst. ANS: 1, 2 Lost fluids must be replaced to decrease the risk of dehydration, regardless of level of fitness. During intense exercise, the body can lose 2 liters of fluid for every hour of exercise. Elevated environmental temperatures also increase the amount of fluid lost through sweating. When athletes drink according to thirst, the risk that they will over- drink and so develop exercise-associated hyponatremia is minimized (Noakes, 2007). On the other hand, exercise can suppress thirst, making it an unreliable signal to replace fluids lost with exercise. PTS:1DIF:Easy REF:p. 1133; answer can be derived from the text KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 5. Which of the following actions represent proper body mechanics for nurses

www.mynursingtestprep.comproviding care as well as teaching patients about safe body movements? Choose all that apply. 1) Stand with the body in alignment and erect posture. 2) Bend at the waist to lift heavy objects from the floor. 3) Use a wide base of support with your feet at shoulder width. 4) Keep objects close to your body when carrying them. ANS: 1, 3, 4 Proper body mechanics involves good body alignment, erect posture, and a wide base of support. To prevent back injury resulting from reaching and straining muscles, carry objects close to the trunk. Bending at the waist to lift objects uses the back muscles and increases the risk of injury. Instead, squat to lower your center of gravity, and use your leg muscles for lifting. Chapter 30 Sexual Health Identify the choice that best completes the statement or answers the question. 1. Which of the following is the most important information to collect at a womens health examination for a 52-year-old woman? 1) Age at first sexual encounter 2) History of PMS 3) Birth control method used 4) Date of last menstrual period ANS: 4 A 52-year-old woman may be experiencing erratic periods of perimenopause. The date of her last menstrual period will help determine her perimenopausal status and guide the discussion of physical, emotional, and sexual changes that commonly occur during a period of declining estrogen production. The nurse will need to determine her menstrual status, which also includes the length and heaviness of flow, the regularity of her cycle, and any change in symptoms associated with menstruation. The nurse will also need to assess for birth control requirements in a heterosexual or bisexual woman. PTS: 1 DIF: Moderate REF: dm 1186-1187; application item, not directly stated in text KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application 2. An 18-year-old high school senior comes to the local family planning clinic requesting birth control pills. When discussing sexual health with the adolescent girl, your first nursing priority would be to do which of the following? 1) Urge the teen to practice healthful sexual behaviors. 2) Inform her about the risk of pregnancy and STIs. 3) Assess the teens knowledge of sexuality and reproduction. 4) Provide detailed information about birth control pills.

www.mynursingtestprep.comANS: 3 You cannot assume that adolescents or young adults have adequate sexual knowledge, and it is difficult for most people to admit a lack of knowledge to a professional. Therefore, when discussing sexual health with a client, the nurse must first assess the clients knowledge and understanding of reproduction and sexuality. PTS: 1 DIF: Difficult REF: p. 1177 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Analysis 3. Which is the first stage of sexual arousal? 1) Desire 2) Excitement 3) Stimulation 4) Orgasm ANS: 1 The sexual response cycle is the sequence of physiological events that occurs when a person becomes sexually aroused. A theorist named Basson identified five stages of physiological events that occur when a person becomes sexually aroused: desire, excitement, plateau, orgasm, and resolution. Desire precedes all other stages of the cycle, but sexual response does not necessarily proceed beyond desire. PTS:1DIF:ModerateREF:dm 1178-1179 KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Recall 4. A 65-year-old widow is being given an annual physical exam. She states she has been dating a widowed man for 9 months and that the relationship is fulfilling in most areas. However, she is unable to have sexual relations because she feels she is cheating on her husband, who died 5 years ago. Her partner is very understanding, although her inability to have sexual relations is becoming a strain on their relationship. What is an appropriate nursing diagnosis for this woman? 1) Sexual Dysfunction related to conflicted sexual orientation 2) Ineffective Sexuality Patterns related to values conflicts 3) Ineffective Sexuality Patterns related to impaired relationship with partner 4) Sexual Dysfunction related to fear of the unknown ANS: 2 The nursing diagnosis Ineffective Sexuality Patterns is used when the patient expresses concerns about her own sexuality, whereas Sexual Dysfunction is used when there is an actual change in sexual function that the patient views as unsatisfying, unrewarding, or inadequate. In this situation, the patient still views herself as being committed to her deceased husband, causing a conflict in values. PTS:1DIFifficultREF:p. 1188 KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis 5. You are caring for a 35-year-old man who tells you that he feels distress about being a male, and ever since he was a young child has thought of himself as a female. He describes the isolation he feels and concern about fitting in socially and at work because of these recurrent thoughts. How would you respond to your patient?

www.mynursingtestprep.com1) Provide information about support groups and other community resources for transsexual people. 2) Reassure him that he is normal, saying there are more people than we know who feel this way. 3) Share with him that you personally have had thoughts like this but have coped with these thoughts. 4) Suggest your patient seek mental healthcare for medication to help him deal with his anxiety. ANS: 1 Those experiencing a sexual identity disorder, such as transsexualism, typically feel overwhelming cultural disapproval and isolation. The lifelong stresses associated with being transsexual penetrate nearly every aspect of life: medically, socially, and emotionally. Competent and responsive healthcare is essential, and nurses can be an especially valuable source of information and support during a time of isolation and emotional inner conflict. Reassuring the patient he is normal discounts his feelings and conveys insensitivity on the part of the nurse as well as a lack of willingness to listen openly. Genuine support and active listening are important for the transsexual person who is struggling with his gender identity. Interjecting your own experiences trivializes the patients experience. The nurses first action is to offer information rather than imply that the patient has a mental health issue requiring anti-anxiety agents. PTS:1DIF:ModerateREF:p. 1174 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 6. Based on a nursing diagnosis of Ineffective Sexuality Patterns related to values conflicts, what would be the most effective nursing intervention for a patient? 1) Educate the patient about sexual orientation and function. 2) Encourage the patient to discuss relationship problems with her partner. 3) Advise the patient to discuss her value conflict with a counselor. 4) Instruct the patient on effective methods to identify fears. ANS: 3 Effective nursing interventions address the etiology of the identified nursing diagnoses. This patient is experiencing a values conflict. Therefore, interventions must address this concern rather than issues, such as fears and relationship problems. The partner might not be the most suitable person for the patient to talk to because she would be too close to the matter; a counselor is trained to discuss sexuality and values conflicts in a professional and objective manner. PTS:1DIF:ModerateREF:p. 1189 KEY: Nursing process: Interventions | Client need: Health Promotion | Cognitive level: Application 7. What do shared touching, celibacy, masturbation, and developing intimate relationships have in common? They are all: 1)

www.mynursingtestprep.comForms of sexuality or sexual orientation. 2) Cues to use in formulating a nursing diagnosis. 3) Important in the development of sexual identity. 4) Forms of sexual expression. ANS: 4 People express their sexuality and gain satisfaction in many ways. Developing intimate relationships, fantasies and erotic dreams, masturbation, shared touching, oralgenital stimulation, anal stimulation or intercourse, sexual intercourse, and celibacy are all forms of sexual expressioneven a lack of activity is an expression of sexuality. PTS:1DIF:ModerateREF:dm 1181-1182 KEY:Nursing process: N/A | Client need: PSI | Cognitive level: Analysis 8. In order to discuss a clients sexual health needs in a comfortable and competent manner, it is most important for a nurse to be able to: 1) Recognize and set aside personal biases or experiences related to sexuality. 2) Perform an accurate and comprehensive physical assessment. 3) Collect an accurate and comprehensive sexual history. 4) Acquire theoretical knowledge of sexual health concerns. ANS: 1 In many cultures, people have been socialized to avoid talking openly about sexuality. As a nurse, you will find that you must discuss a variety of issues that are vital for a clients optimal wellness. Some of these discussions may include sexual concerns, dysfunctions, infections, or behaviors. As you reflect on the issues of human sexuality, you will be challenged to confront your own biases related to sexuality and to set those aside as you work with your clients. Although theoretical knowledge is important, you will be able to use it fully only if you can identify and set aside your own biases. PTS:1DIF:EasyREF:p. 1172 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Comprehension 9. Which of the following statements by a teenage client would indicate that your teaching about detection of STIs has been effective? 1) A healthcare provider can tell if you have an STI just by looking at your genitals. 2) The doctor has to do surgery to biopsy the tissue to find out if a person has an STI. 3) A healthcare provider can tell if you have an STI by getting a detailed sexual history. 4) A genital swab culture can be done at the office or clinic to determine if a person has an STI. ANS: 4 Many STIs have few or no symptoms. To find out if a patient has an STI, you must obtain a swab culture of secretions. For a man, a culture is obtained from the urethra. For a woman, secretions are swabbed near the cervix.

www.mynursingtestprep.comPTS:1DIF:ModerateREF:p. 1183 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application 10. When evaluating the treatment plan for a patient with erectile dysfunction (ED), you would deem the treatment successful if the patient made the following statement: 1) I feel very good about the treatment; I am now comfortable with my sexual orientation. 2) I am happy with the treatment as I can now maintain an erection through orgasm. 3) Now I can communicate my sexual needs to my partner without embarrassment. 4) I now know how to prevent further sexually transmitted infections. ANS: 2 Men with erectile dysfunction have persistent or recurring inability to achieve or maintain an erection sufficient for satisfactory sexual performance. When the patient is maintaining penile erection through orgasm, this is an indication the interventions were successful. ED is not related to sexual orientation or exposure to STIs. Comfort with communicating about sexual needs is helpful for sexual satisfaction but is not the cause of ED. PTS:1DIF:ModerateREF:p. 1185 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application 11. When providing care for a client with concerns about his sexual orientation, you use the PLISSIT model. You recognize that the first step you must take is to: 1) Provide information about sexual orientation and common alterations. 2) Plan time to discuss concerns with the client in a private, comfortable setting. 3) Permit the client to speak openly by communicating an open, accepting attitude. 4) Provide referrals to the client so he can identify resources to assist him in the future. ANS: 3 The PLISSIT model was developed as a guideline for sex therapy. Although basic nursing education does not prepare you to provide sex therapy, the first three PLISSIT steps have been adapted to address sexual knowledge deficits that you are qualified to treat. The first step, P, is to provide permission. Permission means that you communicate an open, accepting attitude so the client feels free to ask questions and express concerns and feelings. PTS:1DIFifficultREF:p. 1196 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Comprehension 12. A 24-year-old woman comes to the clinic to be evaluated for sexually transmitted infections. She states she has no symptoms, but her boyfriend is complaining of a thin, clear discharge and mild discomfort with urination. His doctor advised him that his partner should be treated because this problem may affect her future fertility. What disorder should be assessed for? 1) Chlamydia 2) Trichomoniasis

www.mynursingtestprep.com3) Genital herpes 4) Human papillomavirus ANS: 1 The male partner exhibits symptoms of chlamydia. Women are frequently asymptomatic for chlamydia. As a result, the infection may go untreated and affect future fertility. Trichomoniasis is asymptomatic in men, but women experience a frothy, odorous vaginal discharge. Small blisters on the genitals may be seen with genital herpes. Human papillomavirus produces genital warts. PTS:1DIFifficultREF:p. 1183 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 13. When in the reproductive cycle is there marked growth of ovarian material and regrowth of the endometrium, ending with the release of the ovum? 1) Menstrual phase 2) Follicular phase 3) Luteal phase 4) Fertilization ANS: 2 The luteal phase occurs after the menstrual phase. At this time, the endometrial lining builds back up after being shed with menstruation. Ovarian follicles mature until the ovum is released. The luteal phase occurs after ovulation. In this phase, if fertilization does not occur, progesterone drops and menses begins again. Fertilization occurs at the time of ovulation at which a sperm joins with the mature egg and the endometrium is ripe to support the embryo. PTS:1DIF:ModerateREF:p. 1172 KEY:Nursing process: N/A | Client need: PHSI | Cognitive level: Recall Multiple Response Identify one or more choices that best complete the statement or answer the question. 1. Normal physiological changes in womens sexual responses that occur with aging include which of the following? Choose all that apply. 1) Delayed nipple erection 2) Increased vaginal expansion 3) Reduced vaginal lubrication 4) Reduced labial separation and swelling ANS: 1, 3, 4 As women age, normal physiological responses in sexual behavior include delayed nipple erection, reduced vaginal lubrication, and reduced labial separation and swelling. Vaginal expansion is reduced rather than increased because of decreased estrogen and progesterone levels. PTS:1DIF:ModerateREF:p. 1179

www.mynursingtestprep.comKEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Analysis 2. A 2-year-old boy has come to the well-child clinic with his mother for a checkup. When the nurse asks his mother if she has any concerns, she says, I dont know why he wont quit touching his privates all the time. I have tried sitting him in a chair, smacking his hand, and telling him no, but he continues to do this. I just dont know how to make him stop. How would you best respond to her concerns? Choose all that apply. 1) Give him a little time, and hell grow out of it. Hes just too young to understand right now. 2) How often do you punish him by giving him a time-out or by using physical discipline? 3) Physical punishment is not the best way to modify a childs behavior. 4) It isnt unusual for him to fondle his genitals, as this is part of his exploration of his body. ANS: 2, 3, 4 The first two years of life are highly sensual as infants are nursed, stroked, bathed, and massaged, and they develop their first attachment experience through bonding with the mother. It is not unusual for infants and preschoolers to fondle their genitals and enjoy being nude. This is part of their exploration of their bodies, and parents should not overreact. Although health teaching about normal sexual development of toddlers is important, this mothers comments are a red flag to appropriate discipline. Her exaggerated response using physical reprimands to a 2-year-old child bears further exploration about other potential for physical harm or abuse within the home. The nurse has a responsibility to assess risk to the child for an abusive situation and counsel the mother about alternate methods of dealing with the behavior. PTS:1DIF:ModerateREF:p. 1175 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Application 3. What are common reasons victims of abuse might not report an incident of sexual assault? Choose all that apply. 1) Fear that her abuser would be angry if she reported it and would hurt her again 2) Belief that she was to blame for starting a fight with the abuser 3) Idea that the legal system couldnt prosecute the abuser for the crime 4) Desire to have the incident behind her, as if it never happened in the first place ANS: 1, 2, 3, 4 Reasons for not reporting rape include fear of the assailant, fear of consequences to the assailant, knowledge of the low conviction rate for rapists, the desire to avoid a trial, shame and embarrassment, past sexual history, self-blame, and wanting to move on and not face possible consequences involving pregnancy and sexually transmitted infection. PTS:1DIF:ModerateREF:p. 1184 KEY: Nursing process: Evaluation | Client need: PSI | Cognitive level: Application 4. Which of the following are considered sexual response cycle disorders? Choose all that apply. 1) Arousal disorder 2)

www.mynursingtestprep.comDate rape 3) Orgasmic disorder 4) Low libido ANS: 1, 3, 4 Low libido, arousal disorder, and orgasmic disorder all affect the sexual response cycle. These disorders affect desire, arousal, excitement, and orgasm. Rape occurs when there is nonconsensual vaginal, anal, or oral penetration. It occurs through force, by the threat of bodily harm, or when the victim is incapable of giving consent. Date rape is forced, unwanted sexual intercourse by an acquaintance when the assault occurs during an agreed- upon social encounter. PTS:1DIF:EasyREF:dm 1184-1185 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Comprehension 5. When caring for a woman who was sexually assaulted, what is your best approach for collecting information surrounding the event? Choose all that apply. 1) Use a calm, reassuring voice when asking questions of your patient. 2) Ask only close family members to describe events related to the incident. 3) Provide privacy by asking questions behind a closed curtain. 4) Document the details using the patients own words. ANS: 1, 4 Use a calm, professional approach as you collect sexual data from your patients. This will not only help them to feel more comfortable and confident, but will also yield more honest and complete information. Your patient might have difficulty discussing the events relating to the assault; however, this is a private matter and not a topic to discuss with family members, regardless of the apparent closeness of the relationship. When asking personal questions, provide privacy and be sensitive to your clients cues. A curtain is not secure enough because conversation easily could be overheard. Clear, unambiguous documentation is extremely important because of the criminal nature of sexual crime. Using the patients own words is a way for the nurse to avoid misinterpreting the facts as well as keep from introducing bias or drawing conclusions about the event. PTS:1DIF:ModerateREF:p. 1184; not directly stated in text KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 6. You are caring for a 32-year-old woman who has been sexually assaulted. What nursing interventions are initially most important for this client? 1) Help her to communicate effectively with police about the attack. 2) Obtain permission from your client to test for pregnancy and STIs. 3) Refer your client to a sexual assault support group. 4) Promote and model empathy and support for her family members. ANS: 2, 3 A victim of rape has experienced psychological and physiological trauma. Sexual assault is a risk factor for sexually transmitted infection (STI). Testing for STIs and pregnancy is

www.mynursingtestprep.coma necessary component of the physical care of a victim of sexual violence. Referral to a local sexual assault support group is critical when planning care. A sexual assault nurse examiner (SANE), who is a registered nurse, can assist the client through the physical examination, police interview, and disclosure to family members, all of which are important activities. Chapter 31 Sleep & Rest Identify the choice that best completes the statement or answers the question. 1. A person who is deprived of REM sleep for several nights in succession will usually experience: 1) Extended NREM sleep. 2) Paradoxical sleep. 3) REM rebound. 4) Insomnia. ANS: 3 A person who is deprived of REM sleep for several nights will usually experience REM rebound. The person will spend a greater amount of time in REM sleep on successive nights, generally keeping the total amount of REM sleep constant over time. PTS:1DIF:ModerateREF:p. 1205 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 2. A patient states that many of his friends told him to ask for Valium or Ativan to help him sleep while hospitalized. The nurse knows that nonbenzodiazepines (such as Ambien) are often preferred over benzodiazepines (Ativan or Valium). Why is this? 1) Benzodiazepines are eliminated from the body faster than are nonbenzodiazepines, so they do not provide a full night of sleep. 2) Nonbenzodiazepines cause daytime sleepiness, allowing people to rest throughout the day. 3) Benzodiazepines produce daytime sleepiness and alter the sleep cycle. 4) Nonbenzodiazepines remain in the body longer than do benzodiazepines. ANS: 3 Nonbenzodiazepines (such as Ambien) have a short half-life, which means that they are eliminated from the body quickly and do not cause daytime sleepiness. Ativan is a long- acting benzodiazepine and remains in the body longer than Ambien, often causing daytime sleepiness. PTS: 1 DIF: Moderate REF: p. 1215 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis 3. Which of the following factors has the greatest positive effect on sleep quality? 1) Sleeping hours in synchrony with the persons circadian rhythm 2) Sleeping in a quiet environment 3)

www.mynursingtestprep.comSpending additional time in stage IV of the sleep cycle 4) Napping frequently during the day hours ANS: 1 A circadian rhythm is a biorhythm based on the daynight pattern in a 24-hour cycle. Sleep quality is best when the time at which the person goes to sleep and awakens is in synchrony with his circadian rhythm. Not all people require a quiet environment for sleep. Time spent in stage IV of the sleep cycle is affected by the total time spent asleep. Napping on and off throughout the day might disrupt the natural circadian rhythm with uninterrupted periods of sleep that cycle through the various stages of the sleep cycle. PTS:1DIF:ModerateREF:p. 1204 KEY: Nursing process: N/A| Client need: HPM | Cognitive level: Analysis 4. Which is a major factor regulating sleep? 1) Electrical impulses transmitted to the cerebellum 2) Level of sympathetic nervous system stimulation 3) Amount of sleep a person has become accustomed to 4) Amount of light received through the eyes ANS: 4 The circadian rhythm is a biorhythm based on the daynight pattern in a 24-hour cycle. A persons circadian rhythm is regulated by a cluster of cells in the hypothalamus of the brainstem that respond to changing levels of light. A major factor in regulating sleep is the amount of light received through the eyesnot the typical amount of sleep the person has within a 24-hour period. The autonomic nervous system (rather than central nervous system) controls the involuntary processes of the body, such as sleep, digestion, immune function, and so on. PTS:1DIF:ModerateREF:p. 1204 KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Comprehension 5. Which of the following is the main difference between sleep and rest? 1) In sleep, the body may respond to external stimuli. 2) Short periods of sleep do not restore the body as much as do short periods of rest. 3) Sleep is characterized by an altered level of consciousness. 4) The metabolism slows less during sleep than during rest. ANS: 3 During rest, the mind remains active and conscious; sleep is characterized by altered consciousness. Sleep is a cyclic state of decreased motor activity and perception. A sleeping person is unaware of the environment and does respond selectively to certain external stimuli. However, at rest, the body is disturbed by all external stimuli; sleep restores the body more than does rest. The metabolism decreases more during sleep than during rest. PTS:1DIF:EasyREF:p. 1202 KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Analysis 6. A patient tells you that she has trouble falling asleep at night, even though she is

www.mynursingtestprep.comvery tired. A review of symptoms reveals no physical problems and she takes no medication. She has recently quit smoking, is trying to eat healthier foods, and has started a moderate-intensity exercise program. Her sleep history reveals no changes in bedtime routine, stress level, or environment. Based on this information, the most appropriate nursing diagnosis would be Disturbed Sleep Pattern related to: 1) Increased exercise. 2) Nicotine withdrawal. 3) Caffeine intake. 4) Environmental changes. ANS: 2 Based on the information given, the patient is not experiencing significant stress or change in sleep routine or environment, which commonly lead to insomnia. People who use nicotine tend to have more difficulty falling asleep and are more easily aroused than those who are nicotine free. People who stop smoking often experience temporary sleep disturbances during the withdrawal period. PTS:1DIF:ModerateREF:p. 1208 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 7. Which patient teaching would be most therapeutic for someone with sleep disturbance? 1) Give yourself at least 60 minutes to fall asleep. 2) Avoid eating carbohydrates before going to sleep. 3) Catch up on sleep by napping or sleeping in when possible. 4) Do not go to bed feeling upset about a conflict. ANS: 4 Intense emotion before bedtime can interfere with rest and sleep. Lying awake longer than 30 minutes is counterproductive. Eating a small amount of a complex carbohydrate can aid in falling asleep. Avoid simple sugars because sucrose can lead to a short-term energy boost instead of relaxation. Taking naps during the day and sleeping late on some mornings can actually exacerbate a sleep disturbance. Its better to establish a consistent routine for wake and sleep. The extra sleep during the day can interfere with the bodys readiness for sleep at night. PTS:1DIF:EasyREF:dm 1207-1208 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 8. The expected outcome (goal) for a patient with Disturbed Sleep Pattern is that she will: 1) Limit exercise to 1 hour per day early in the day. 2) Consume only one caffeinated beverage per day. 3) Demonstrate effective guided imagery to aid relaxation. 4)

www.mynursingtestprep.comVerbalize that she is sleeping better and feels less fatigued. ANS: 4 The patient would verbalize that she is sleeping better and feels less fatigued. The expected outcome (goal) is based on the nursing diagnosis, and its achievement should reflect resolution of the problem. The other options are outcomes that demonstrate only that the patient took certain actions. They would not, if achieved, demonstrate that the problem of Disturbed Sleep Pattern had been resolved. PTS:1DIF:ModerateREF:p. 1213 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Analysis 9. When making rounds on the night shift, the nurse observes her patient to be in deep sleep. His muscles are very relaxed. When he arouses as the nurse changes the IV tubing, he is confused. What stage of sleep was the patient most likely experiencing? 1) Stage V 2) Stage IV 3) Stage III 4) REM ANS: 2 Stage IV is the deepest sleep. In this stage, the delta waves are highest in amplitude, slowest in frequency, and highly synchronized. The body, mind, and muscles are very relaxed. It is difficult to awaken someone in stage IV sleep; if awakened, the person may appear confused and react slowly. During this stage, the body releases human growth hormone, which is essential for repair and renewal of brain and other cells. PTS:1DIF:EasyREF:p. 1206 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application 10. What is the purpose of using a sleep diary? 1) Identify sleeprest patterns over a 1-year period. 2) Note the trend in sleepwakefulness patterns over a 2-week period. 3) Note typical sleep habits and most common daily routines. 4) Examine the patterns of sleep during the night and naps during the day. ANS: 2 A sleep diary provides specific information about the patients sleepwakefulness patterns over a certain period of time. It allows identification of trends in sleepwakefulness patterns and associates specific behaviors interfering with sleep. The diary is typically kept for 14 days. PTS: 1 DIF: Moderate REF: p. 1212 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall 11. Patterns of waking behavior that appear during sleep are known as: 1) Parasomnias. 2) Dyssomnias. 3) Insomnia.

www.mynursingtestprep.com4) Hypersomnia. ANS: 1 Parasomnias are patterns of waking behavior that appear during sleep. Sleepwalking, sleep talking, and bruxism are parasomnias. PTS: 1 DIF: Easy REF: p. 1208 KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Comprehension 12. A 6-year-old boy is admitted to the hospital for a surgical procedure associated with a hospital stay. When the nurse asks his mother about the boys sleep patterns, she says, Sometimes he will get out of bed, walk into the kitchen, and get the cereal out of the cabinet. Then he just turns around and goes back to bed. The nurse explains that he is sleepwalking. The best nursing diagnosis for Tad would be: 1) Risk for Insomnia related to sleepwalking. 2) Risk for Fatigue related to sleepwalking. 3) Disturbed Sleep Pattern related to dyssomnia. 4) Risk for Injury related to sleepwalking. ANS: 4 Sleepwalking occurs during stages III and IV of NREM sleep. The sleeper leaves the bed and walks about with little awareness of surroundings. He may perform what appear to be conscious motor activities but does not wake up and has no memory of the event on awakening. The boy is at high risk for injury when sleepwalking because of his lack of awareness of his surroundings. Insomnia is a medical diagnosis rather than a nursing diagnosis. Certainly his sleep pattern is disturbed; however, there is little in the way of independent actions that the nurse could take for either the problem or etiology of this diagnosis, so it would not be useful. The boy does not awaken while sleepwalking and is not likely to experience fatigue from the event. PTS:1DIF:ModerateREF:p. 1213 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis 13. The primary focus of your interventions for a 6-year-old child who sleepwalks would be to: 1) Maintain patient safety during episodes of somnambulation. 2) Administer and teach about medications to suppress stage IV sleep. 3) Encourage the child to verbalize feelings regarding sleep pattern. 4) Provide a quiet environment for nighttime sleep. ANS: 1 Sleepwalking places the patient at Risk for Injury because of his lack of awareness of the surroundings. The nurses primary intervention would be to protect the patient from injury (e.g., falls) while sleepwalking, also called somnambulation. Because the child is only 6 years old, administering and teaching about medications and having him verbalize feelings would not be useful. Providing a quiet environment would likely be ineffective and certainly not the focus of interventions. PTS:1DIF:ModerateREF:p. 1211

www.mynursingtestprep.comKEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 14. From what stage of sleep are people typically most difficult to arouse? 1) NREM, alpha waves 2) NREM, sleep spindles 3) NREM, delta waves 4) REM ANS: 3 Contrary to previous beliefs, stages III and IV of NREM (delta wave) are the deepest stages of sleepnot REM. It is difficult to awaken someone in stage IV slow wave NREM sleep, and if she is awakened, the person may appear confused and react slowly. Stage I NREM is a light sleep from which the sleeper can easily be awakened. Stage II (sleep spindles) is also light sleep; the sleeper in this stage is easily roused. REM sleep is the stage at which most dream activity occurs, as well as more spontaneous awakenings. PTS:1DIF:ModerateREF:p. 1205 KEY:Nursing process: Assessment | Client need: HPM | Cognitive level: Recall 15. During which of the following developmental stages does a person tend to need the most hours of sleep? 1) Toddler 2) Adolescence 3) Middle adulthood 4) Older adulthood ANS: 1 Toddlers (ages 1 to 3 years) require 12 to 14 hours of sleep in a 24-hour period. Adolescents (ages 12 to 18 years) usually need 8 to 9 hours in a 24-hour period. Middle- aged adults (ages 40 to 65 years) typically require 7 hours in a 24-hour period. Older adults (age 65 years and older) often need 5 to 7 hours of sleep in a 24-hour period. PTS:1DIF:EasyREF:p. 1204 KEY:Nursing process: Planning | Client need: HPM | Cognitive level: Comprehension Multiple Response Identify one or more choices that best complete the statement or answer the question. 1. Select the factors known to affect sleep. Choose all that apply. 1) Age 2) Environment 3) Lifestyle 4) State of health 5) Ethnicity ANS: 1, 2, 3, 4 Age, environment, lifestyle, and state of health are factors affecting sleep. Many older

www.mynursingtestprep.comadults sleep less but require more rest. Alcohol, caffeine, nicotine use, and diet are examples of lifestyle factors that affect sleep. When a person is ill, she may sleep more or find that she cannot sleep because of pain or other factors associated with illness. Changes in environment also affect sleep. PTS:1DIF:EasyREF:dm 1207-1208 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Comprehension 2. A mother expresses concern that her 7-year-old has episodes of nocturnal enuresis approximately 3 to 4 times per week. The nurses best response would be which of the following? Choose all that apply. 1) Your daughters bladder is still developing at this point in her life. 2) Be patient; most children outgrow enuresis. 3) Wake your daughter every 4 hours to use the bathroom. 4) You might consider purchasing protective pads for the bed. 5) Try a bed alarm to wake her when she starts wetting the bed at night. ANS: 2, 4 Enuresis is nighttime incontinence past the stage at which toilet training has been well established. Most incidents occur during NREM sleep when the child is difficult to arouse. As the great majority of children outgrow enuresis, the best strategy is patience. In the meantime, protecting the mattress from moisture and odor will help reduce frustration and embarrassment. A bed alarm can be used for older children (typically older than age 10 or 12) who are resistant to other behavioral strategies. PTS:1DIF:ModerateREF:p. 1211 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension 3. The patient is diagnosed with obstructive sleep apnea. Identify the symptoms you would expect the client to exhibit. Choose all that apply. 1) Bruxism 2) Enuresis 3) Daytime fatigue 4) Snoring 5) Drooling ANS: 3, 4 Obstructive sleep apnea is caused by partial airway occlusion (usually by the tongue or palate) during sleep. The patient experiences interrupted sleep as he arouses frequently to clear the airway. As a result, the patient has episodes of snoring and daytime fatigue. Chapter 32 Skin Integrity & Wound Healing Identify the choice that best completes the statement or answers the question. 1. What is the function of the stratum corneum? 1)

www.mynursingtestprep.comProvides insulation for temperature regulation 2) Provides strength and elasticity to the skin 3) Protects the body against the entry of pathogens 4) Continually produces new skin cells ANS: 3 The stratum corneum is the outermost layer of the epidermis and is composed of numerous thicknesses of dead cells. Functioning as a barrier to the environment, it restricts water loss, prevents entry of fluids into the body, and protects the body against the entry of pathogens and chemicals. The subcutaneous layer is composed of adipose and connective tissue that provide insulation, protection, and an energy reserve (adipose). The dermis is composed of irregular fibrous connective tissue that provides strength and elasticity to the skin. The stratum germinativum is the innermost layer of the skin that produces new cells, pushing older cells toward the skin surface. PTS:1DIF:ModerateREF:p. 1223 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 2. Skin integrity and wound healing are compromised in the client who takes blood pressure medications because antihypertensives: 1) Can cause cellular toxicity. 2) Increase the risk of ischemia. 3) Delay wound healing. 4) Predispose to hematoma formation. ANS: 2 Blood pressure medications decrease the amount of pressure required to occlude blood flow to an area, creating a risk for ischemia. Chemotherapeutic agents delay wound healing because of their cellular toxicity. Anticoagulants can lead to extravasation of blood into subcutaneous tissue, predisposing to hematoma formation with minimal pressure or injury. PTS:1DIFifficultREF:p. 1224 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 3. What is the primary difference between acute and chronic wounds? Chronic wounds: 1) Are full-thickness wounds, but acute wounds are superficial. 2) Result from pressure, but acute wounds result from surgery. 3) Are usually infected, whereas acute wounds are contaminated. 4) Exceed the typical healing time, but acute wounds heal readily. ANS: 4 The length of time for healing is the determining factor when classifying a wound as acute or chronic. Acute wounds are expected to be of short duration. Wounds that exceed the anticipated length of recovery are classified as chronic wounds.

www.mynursingtestprep.comPTS:1DIF:EasyREF:p. 1225 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 4. A patient with quadriplegia presents to the outpatient clinic with an ischial wound that extends through the epidermis into the dermis. When documenting the depth of the wound, how would the nurse classify it? 1) Partial-thickness wound 2) Penetrating wound 3) Superficial wound 4) Full-thickness wound ANS: 1 Partial-thickness wounds extend through the epidermis into the dermis. Superficial wounds involve only the epidermal layer of skin. Full-thickness wounds extend into the subcutaneous tissue and beyond. Penetrating is a descriptor sometimes added to indicate that the wound includes internal organs. PTS:1DIF:EasyREF:dm 1226-1227 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 5. A patient underwent abdominal surgery for a ruptured appendix. The surgeon did not surgically close the wound. The wound healing process described in this situation is: 1) Primary intention healing. 2) Secondary intention healing. 3) Tertiary intention healing. 4) Approximation healing. ANS: 2 Secondary intention healing occurs when a wound is left open, and it heals from the inner layer to the surface by filling in with beefy red granulation tissue. Primary intention healing occurs when a wound is surgically closed. Tertiary intention healing occurs when a wound that was previously left open to heal by secondary intention is closed by joining the margins of granulation tissue. Approximation is another word for the joining of wound edges. PTS:1DIF:ModerateREF:p. 1227 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 6. When teaching a patient about the healing process of an open wound after surgery, which of the following points would the nurse make? 1) The patient will need to take antibiotics until the wound is completely healed. 2) Because the patients wound was left open, the wound will likely become infected. 3) The patient will have more scar tissue formation than for a wound closed at surgery. 4) The patient should expect to remain hospitalized until complete wound healing occurs. ANS: 3

www.mynursingtestprep.comBecause the wound edges are not approximated, more scar tissue will form. Although open wounds are more prone to infection, this is not an expected outcome, and antibiotics would not necessarily be needed. A patient with an open wound should not expect an extended hospital stay if wound care can be provided in the home or an outpatient setting. PTS:1DIFifficultREF:p. 1227 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 7. What is the primary goal that the nurse should establish for a patient with an open wound? 1) The wound will remain free of infection throughout the healing process. 2) Client completes antibiotic treatment as ordered. 3) The wound will remain free of scar tissue at healing. 4) Client increases caloric intake throughout the healing process. ANS: 1 Wounds healing by secondary intention are more prone to infection; therefore, the primary goal would be to prevent infection. Antibiotics may not be necessary, and the nurse can expect the formation of scar tissue in this particular situation. There is no evidence presented that the patient needs to increase caloric intake. PTS:1DIF:ModerateREF:p. 1227 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Synthesis 8. While assessing a new wound, the nurse notes red, watery drainage. What type of drainage will the nurse document this as? 1) Sanguineous 2) Serosanguineous 3) Serous 4) Purosanguineous ANS: 2 Serosanguineous drainage, a combination of bloody and serous drainage, is most commonly seen with new wounds. Serous drainage is straw colored, and sanguineous drainage is bloody. Purosanguineous drainage is pus that is red tinged. PTS:1DIF:EasyREF:p. 1229 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 9. Three days after a patient had abdominal surgery, the nurse notes a 4-cm periwound erythema and swelling at the distal end of the incision. The area is tender and warm to the touch. Staples are intact along the incision, and there is no obvious drainage. Heart rate is 96 beats/min and oral temperature is 100.8F (38.2C). The nurse would suspect that the patient has what kind of complication? 1) Infection at the incisional site 2) Dehiscence of the wound 3) Hematoma under the skin 4)

www.mynursingtestprep.comFormation of granulation tissue ANS: 1 Infection is a complication of wound healing that causes warmth, pain, inflammation of the affected area, and changes in vital signs (i.e., elevated pulse and temperature). Dehiscence is the rupture of a suture line, whereas evisceration is the protrusion of internal organs through the rupture. A hematoma is a collection of blood that forms under the skin. It is usually tender or painful to the touch and is usually swollen. Granulation tissue is new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process. It is beefy red in appearance but would not be warm or tender to the touch. PTS:1DIF:ModerateREF:p. 1229 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 10. Which of the following describes the difference between dehiscence and evisceration? 1) With dehiscence, there is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site. 2) Dehiscence is an urgent complication that requires surgery as soon as possible; evisceration is not as urgent. 3) Dehiscence involves the protrusion of internal viscera from the incision site; with evisceration, there is a separation of one or more layers of wound tissue. 4) Dehiscence involves rupture of subcutaneous tissue; evisceration involves damage to dermal tissue. ANS: 1 With dehiscence there is a separation of one or more layers of wound tissue, whereas evisceration involves the protrusion of internal viscera from the incision site. Evisceration is an urgent complication usually requiring immediate surgical intervention. PTS:1DIF:ModerateREF:dm 1229-1230 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 11. The nurse will know that the plan of care for the diabetic client with severe peripheral neuropathy is effective if the client: 1) begins an aggressive exercise program. 2) follows a diet plan of 1,200 calories per day. 3) is fitted for deep-depth diabetic footwear. 4) remains free of foot wounds. ANS: 4 Diabetic clients experiencing difficulty with blood sugar control are prone to the development of peripheral neuropathy, which results in decreased sensation in the feet and lower extremities. Decreased sensation in the feet places the client at increased risk for development of wounds or pressure ulcers in the feet. The nurse will know his plan of care is effective when the clients feet remain free of wounds. An aggressive exercise program would not be appropriate for a client with severely diminished sensation in the feet.

www.mynursingtestprep.comSimilarly, a 1,200-calorie diet would be inadequate for most clients. Being fitted for diabetic footwear is an intervention rather than a goal. PTS:1DIFifficultREF:p. 1232; higher-order item implied from text KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Synthesis 12. Pressure ulcers are directly caused by which of the following conditions at the site? 1) Compromised blood flow 2) Edema 3) Shearing forces 4) Inadequate venous return ANS: 1 Pressure ulcers are caused by unrelieved pressure that compromises blood flow to an area, resulting in ischemia (inadequate blood supply) in the underlying tissue. Friction and shear are extrinsic factors affecting skin integrity, which increases the risk of a client developing a pressure ulcer but is not the direct cause. Inadequate arterial blood flow to an area due to pressure causes the development of a pressure ulcer. Edema leads to compromised skin and tissue integrity, which is more prone to pressure injury. PTS: 1 DIF: Difficult REF: p. 1230 KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Comprehension 13. A patient hospitalized in a long-term rehabilitation facility is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure area on her coccyx measuring 5 cm by 3 cm. The area is covered with 100% eschar. What would the nurse identify this as? 1) Stage II pressure ulcer 2) Stage III pressure ulcer 3) Stage IV pressure ulcer 4) Unstageable pressure ulcer ANS: 4 An eschar is a black, leathery covering made up of necrotic tissue. An ulcer covered in eschar cannot be classified using a staging method because it is impossible to determine the depth. PTS: 1 DIF: Moderate REF: p. 1234 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 14. A client developed a stage IV pressure ulcer to his sacrum 6 weeks ago, and now the ulcer appears to be a shallow crater involving only partial skin loss. What would the nurse now classify the pressure ulcer as? 1) Stage I pressure ulcer, healing 2) Stage II pressure ulcer, healing 3) Stage III pressure ulcer, healing 4)

www.mynursingtestprep.comStage IV pressure ulcer, healing ANS: 4 Reverse staging is not done because as the ulcer heals with granulation tissue and becomes shallower, the lost muscle, subcutaneous fat, and dermis are not replaced. Pressure ulcers maintain their original staging classification throughout the healing process but are accompanied by the modifier healing. PTS: 1 DIF: Moderate REF: p. 1232 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level:Analysis 15. A patient has underlying cardiac disease and requires careful monitoring of his fluid balance. He also has a draining wound. Which of the following methods for evaluating his wound drainage would be most appropriate for assessing fluid loss? 1) Draw a circle around the area of drainage on a dressing. 2) Classify drainage as less or more than the previous drainage. 3) Weigh the patient at the same time each day on the same scale. 4) Weigh dressings before they are applied and after they are removed. ANS: 4 By weighing the dressing before it is applied and after it is removed, the nurse can accurately determine the amount of drainage. Weighing the patient daily would evaluate his overall fluid balance but is not sensitive to fluid loss through the wound. Marking a circle around the wound is useful for determining the extent of drainage seeping out of a wound, but it does not provide information how much fluid is draining. PTS:1DIF:ModerateREF:p. 1238 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Synthesis 16. A patient had a CVA (stroke) 2 days ago, resulting in decreased mobility to her left side. During the assessment, the nurse discovers a stage I pressure area on the patients left heel. What is the initial treatment for this pressure ulcer? 1) Antibiotic therapy for 2 weeks 2) Normal saline irrigation of the ulcer daily 3) Dbridement to the left heel 4) Elevation of the left heel off the bed ANS: 4 Pressure ulcers are caused by pressure to an area that restricts blood flow, causing ischemia to underlying tissue. The primary treatment is to relieve the pressure, thus improving blood flow. Elevating the patients left heel off the bed would relieve pressure to this area. PTS:1DIF:ModerateREF:p. 1231 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 17. Why is the information obtained from a swab culture of a wound limited? 1) A positive culture does not necessarily indicate infection, because chronic wounds are often colonized with bacteria. 2)

www.mynursingtestprep.comA negative culture may not indicate infection, because chronic wounds are often colonized with bacteria. 3) Most wound infections are viral, so the swab culture would not be indicative of a wound infection. 4) A swab culture result does not include bacterial sensitivity information necessary to provide treatment. ANS: 1 The information obtained from a swab culture is limited because a positive culture may not indicate infection. Chronic wounds are often colonized with bacteria, but this does not require antibiotic treatment. A needle aspiration of the wound would provide more definitive information about whether the wound is infected or not and can be performed by a registered nurse. However, the most accurate wound information is obtained by tissue biopsy performed by a specially trained provider. PTS:1DIF:ModerateREF:p. 1242 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 18. For the client with a stage IV pressure ulcer, what would an applicable patient goal/outcome be? 1) Client will maintain intact skin throughout hospitalization. 2) Client will limit pressure to wound site throughout treatment course. 3) Wound will close with no evidence of infection within 6 weeks. 4) Wound will improve prior to discharge as evidenced by a decrease in drainage. ANS: 3 The goal for any wound is for healing to take place with no complications (such as infection). Intact skin throughout hospitalization is not realistic with a stage IV pressure ulcer. Limiting pressure to a wound site is incorrect because total pressure relief must be provided to the area. Improved wound drainage before discharge is not a realistic expectation for a stage IV pressure ulcer. PTS:1DIFifficultREF:p. 1234 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Synthesis 19. A man was involved in a motor vehicle accident yesterday. He is to be sedated for over 2 weeks while breathing with the assistance of a mechanical ventilator. Which of the following would be an appropriate nursing diagnosis for him at this time? 1) Risk for Infection related to subcutaneous injuries 2) Risk for Impaired Skin Integrity related to immobility 3) Impaired Tissue Integrity related to ventilator dependency 4) Impaired Skin Integrity related to ventilator dependency ANS: 2 This patient is at Risk for Impaired Skin Integrity because he is being kept in a sedated state. Thus, he is unable to turn himself to relieve pressure. There is no mention of

www.mynursingtestprep.comsubcutaneous injuries, ruling out Risk for Infection related to subcutaneous injuries. Impaired Tissue Integrity and Impaired Skin Integrity are also incorrect because there is no supporting evidence for these nursing diagnoses. PTS:1DIF:ModerateREF:dm 1235-1237 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis 20. What intervention would be most appropriate for a wound with a beefy red wound bed? 1) Mechanical dbridement 2) Autolytic dbridement 3) Dressing to keep the wound moist and clean 4) Removal of devitalized tissue and a sterile dressing ANS: 3 A red wound indicates active healing, and the best treatment is gentle cleansing and a dressing that will ensure a clean, moist wound environment. Dbridement is not necessary in this situation because there is no devitalized tissue present. PTS: 1 DIF: Moderate REF: p. 1228 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 21. A patient has a stage II pressure ulcer on her right buttock. The ulcer is covered with dry, yellow slough that tightly adheres to the wound. What is the best treatment the nurse could recommend for treating this wound? 1) Dry gauze dressing changed twice daily 2) Nonadherent dressing with daily wound care 3) Hydrocolloid dressing changed as needed 4) Wet-to-dry dressings changed three times a day ANS: 3 A hydrocolloid dressing would conform to this area and form a protective layer against friction and bacterial invasion. It would also promote autolytic dbridement of the slough and absorb the exudate from the autolysis. Dry gauze and nonadherent dressing (e.g., Telfa) would cover the wound but would not aid in removing the slough. A wet-to-dry dressing is a form of mechanical dbridement. It would aid in removing the slough but is nonselective; therefore, it could cause damage to healthy tissue as well. PTS:1DIFifficultREF:dm 1233, 1251, 1277; synthesis required KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 22. The nurse would know care for a stage II pressure ulcer is achieving the desired goal when: 1) The ulcer is completely healed with minimal scarring. 2) The patient reports no pain at the site. 3) A minimal amount of drainage is noted.

www.mynursingtestprep.com4) The wound bed contains 100% granulated tissue. ANS: 4 A healing wound contains granulating tissue. Although pain and drainage are indicators of inflammation, infection, and bleeding, no pain or drainage at the wound site does not indicate proper healing is occurring. A wound can heal leaving a scar. PTS:1DIFifficult REF: p. 1227; higher-order item, answer can be derived from text KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application 23. Your patient has a deep wound on the right hip, with tunneling at the 8 oclock position extending 5 cm. The wound is draining large amounts of serosanguineous fluid and contains 100% red beefy tissue in the wound bed. Of the following, which would be an appropriate dressing choice? 1) Alginate dressing 2) Dry gauze dressing 3) Hydrogel 4) Hydrocolloid dressing ANS: 1 Alginates are highly absorbent and are appropriate for wounds with moderate to large amounts of drainage. They are ideal for wounds with tunneling, as they will conform to fill the tunnel. Gauze and hydrocolloids have limited absorptive ability. Gauze could adhere to the wound bed and cause trauma when removed. A hydrogel would increase the drainage, with the potential of macerating surrounding skin. PTS:1DIF:ModerateREF:p. 1250 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 24. Of the following, which is the best choice for performing wound irrigation? 1) Water jet irrigation 2) 35-cc syringe with a 19-gauge angiocatheter 3) 5-cc syringe with a 23-gauge needle 4) Bulb syringe ANS: 2 A 35-cc syringe with a 19-gauge angiocatheter is the best choice for irrigation because it will deliver the irrigation solution at approximately 8 psi. The water jet irrigation unit and 5-cc syringe with a 23-gauge needle would deliver the solution above the recommended pressure range of 4 to 15 psi. A bulb syringe is not an appropriate choice because there is an increased risk of aspirating drainage from the wound. PTS: 1 DIF: Moderate REF: p. 1246 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 25. Your patient has multiple open wounds that require treatment. When performing dressing changes, you should: 1) Remove all of the soiled dressings before beginning wound treatment.

www.mynursingtestprep.com2) Cleanse wounds from most contaminated to least contaminated. 3) Treat wounds on the patients side first, then the front and back of the patient. 4) Irrigate wounds from least contaminated to most contaminated. ANS: 4 To avoid the possibility of cross-contamination, the wound with the least amount of contamination should be treated first, progressing to the wound with the most contamination. PTS:1DIF:ModerateREF:p. 1249 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Synthesis 26. A patient had abdominal surgery. The incision has been closed by primary intention, and the staples are intact. To provide more support to the incision site and decrease the risk of dehiscence, it would be appropriate to apply which of the following? 1) Steri-Strips 2) Abdominal binder 3) T-binder 4) Paper tape ANS: 2 An abdominal binder provides added support to an incision site and decreases the risk of wound dehiscence. A T-binder is used in the perineal area. Steri-Strips and paper tape would not be needed for an approximated incision that has intact staples, sutures, or surgical glue. PTS:1DIF:EasyREF:p. 1253 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 27. A patient has an area of nonblanchable erythema on his coccyx. The nurse has determined this to be a stage I pressure ulcer. What would be the most important treatment for this patient? 1) Transparent film dressing 2) Sheet hydrogel 3) Frequent turn schedule 4) Enzymatic dbridement ANS: 3 The patient should be placed on a turn schedule to relieve the pressure. If pressure is not relieved, the wound will worsen. A stage I wound is not open, so a dressing is not warranted. Enzymatic dbridement is used to remove slough or eschar in an open wound. A transparent film dressing would protect the area. However, the primary treatment is to relieve the source of pressure. PTS:1DIF:ModerateREF:p. 1244 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis 28. When applying heat or cold therapy to a wound, what should the nurse do? 1) Leave the therapy on each area no longer than 15 minutes.

www.mynursingtestprep.com2) Leave the therapy on each area no longer than 30 minutes. 3) When using heat, ensure the temperature is at least 135F (57.2C) before applying it. 4) When using cold, ensure the temperature is less than 32F (0C) before applying it. ANS: 1 Apply heat or cold therapies intermittently, leaving them on for no more than 15 minutes at a time in an area. This helps prevent tissue injury and also makes the therapy more effective by preventing rebound phenomenon. Temperatures should be kept between 59F and 113F (15C and 45C), depending on the type of therapy chosen and what is comfortable to the patient. Temperatures colder or warmer than those recommended can damage tissue. PTS:1DIF:EasyREF:p. 1254 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 29. A patient has a contaminated right hip wound that requires dressing changes twice daily. The surgeon informs the nurse that when the wound heals a little more he will suture it closed. The nurse recognizes that the surgeon is using which form of wound healing? 1) Primary intention 2) Regenerative healing 3) Secondary intention 4) Tertiary intention ANS: 4 Tertiary intention is a technique used when a wound is clean contaminated or dirty (potentially infected). Initially, the wound is allowed to heal by secondary intention, and when there is no evidence of edema, infection, or foreign matter, granulating tissue is brought together and the wound edges are sutured closed. PTS:1DIF:ModerateREF:p. 1227 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 30. What is a common characteristic of aging skin? 1) Increased permeability to moisture 2) Diminished sweat gland activity 3) Reduced oxygen-free radicals 4) Overproduction of elastin ANS: 2 Aging skin tends to be drier. Sweat gland activity is diminished. The skins connective tissue, collagen, and elastin are reduced, which means the skin loses firmness and so wrinkles. Skin aging also occurs with exposure to oxygen-free radicals that are waste products from chemical reactions in the body as well as with exposure to certain food and

www.mynursingtestprep.comenvironmental sources. An infants skin is thinner and more permeable to moisture in the environment. PTS:1DIF:ModerateREF:p. 1224 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 31. Which client does the nurse recognize as being at greatest risk for pressure ulcers? 1) Infant with skin excoriations in the diaper region 2) Young adult with diabetes in skeletal traction 3) Middle-aged adult with quadriplegia 4) Older adult requiring use of assistive device for ambulation ANS: 3 The client at greatest risk for pressure sores is the one with a lack of sensory perception at the site (e.g., quadriplegia). The infant with disruption to the skin from diaper rash is at risk for skin infection but not for a pressure sore. The young adult with diabetes is at increased risk for delayed wound healing but not likely for a pressure sore because he would shift weight in bed and respond to discomfort of pressure on a bony site. The older adult is normally at risk for pressure injury, but when mobile, even with an assistive device, the risk is minimal. PTS:1DIF:ModerateREF:p. 1224 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 32. The nurse working in the emergency department is preparing heat therapy for one of the patients in the unit. Which one is it most likely to be? Choose all that apply. 1) Is actively bleeding 2) Has swollen, tender insect bite 3) Has just sprained her ankle 4) Has lower back pain ANS: 4 Heat therapy is used to relieve stiffness and discomfort commonly associated with musculoskeletal soreness. Heat causes dilation of the blood vessels and improves delivery of oxygen and nutrients to the tissues. It promotes relaxation and is used to aid in the healing process. Applying heat promotes vasodilation and reduces blood thickness (viscosity) and leaky capillaries, all of which would be harmful to the patient who is actively bleeding. It can lead to a drop in blood pressure. Heat should not be applied to a site with inflammation (insect bite or acute joint injury with swelling) because it can increase edema to the site. A good application for heat therapy is to promote comfort and relaxation to the patient experiencing back pain. PTS:1DIF:ModerateREF:p. 1254 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. Select the process(es) that occur(s) during the inflammatory phase of wound healing. Choose all that apply.

www.mynursingtestprep.com1) Granulation 2) Hemostasis 3) Epithelialization 4) Inflammation ANS: 2, 4 During the inflammatory phase of wound healing, hemostasis and inflammation occur. After an injury, blood vessels constrict to limit blood loss, and platelets migrate to the site and aggregate to stop bleeding. Together, this results in hemostasis. Inflammation follows as a defense against infection at the wound site. PTS: 1 DIF: Moderate REF: p. 1228 KEY:Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall 2. What are two risk assessment tools used in the United States to evaluate a patients risk for pressure ulcers? Choose all that apply. 1) Pressure ulcer healing chart 2) PUSH tool 3) Braden scale 4) Norton scale ANS: 3, 4 The Braden scale is a tool used to predict the risk of developing a pressure sore. Evaluation is based on six areas (indicators): sensory perception, moisture, activity, mobility, nutrition, and friction or shear. The Norton scale is another tool used to assess the risk for pressure ulcers based on the patients physical condition, mental state, activity, mobility, and incontinence. These are the two most used risk assessment tools in the United States. Both of these tools are used to identify persons at high risk of pressure ulcer development. The PUSH tool provides a comprehensive means of reporting the progression of a pressure ulcer. Surface area, exudate, and type of wound tissue are scored and totaled. The Pressure Ulcer Healing Chart is part of the PUSH tool, which is used to monitor the progression of a pressure ulcer. PTS: 1 DIF: Moderate REF: p. 1235 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall 3. Which of the following are examples of nonselective mechanical dbridement methods? Choose all that apply. 1) Wet-to-dry dressings 2) Sharp dbridement 3) Whirlpool 4) Pulsed lavage ANS: 1, 3, 4 Wet-to-dry dressings, sharp dbridement, and pulsed lavage are all forms of mechanical

www.mynursingtestprep.comdbridement. They are nonselective forms, which means that healthy tissue as well as devitalized tissue can be removed with their use. Sharp dbridement is a selective form of dbridement. With sharp dbridement, only devitalized tissue is removed. PTS:1DIF:ModerateREF:p. 1248 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 4. Why is an accurate description of the location of a wound important? Choose all that apply. 1) Influences the rate of healing 2) Determines the appropriate treatment choice 3) Will affect the frequency of dressing changes 4) Affects patient movement and mobility ANS: 1, 4 Wounds in highly vascular areas heal more rapidly than wounds in less vascular regions. Wounds that can be stabilized also heal more readily than those in areas of stress. Treatment choices and frequency of dressing changes will be dependent on the condition of the wound, not the location. Chapter 33 Oxygenation Identify the choice that best completes the statement or answers the question. 1. The nurse is providing care to a pregnant woman in preterm labor. The patient is 32 weeks pregnant. Initially, the patient states, Ive gained 30 pounds. That should be enough for the baby. Everything will be OK if I deliver now. After teaching the patient about fetal development, the nurse will know her teaching is effective if the patient makes which of the following statements? 1) The babys lungs are well developed now, but he will be at increased risk for SIDS if I deliver early. 2) We should try to stop this labor now because the baby will be born with sleep apnea if I deliver this early. 3) If I deliver this early my baby is at risk for respiratory distress syndrome, a condition that can be life threatening. 4) Thanks for reassuring me; I was pretty sure there isnt much risk to the baby this far along in my pregnancy. ANS: 3 Premature infants (younger than 33 weeks gestation) are born before the alveolar surfactant system is fully developed. Therefore, they are at high risk for respiratory distress syndrome (RDS). RDS is characterized by widespread atelectasis (collapse of alveoli), usually related to a deficiency of surfactant that keeps air sacs open. PTS:1DIF:ModerateREF:p. 1297 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application 2. The nurse is caring for a patient who is experiencing dyspnea. Which of

www.mynursingtestprep.comthe following positions would be most effective if incorporated into the patients care? 1) Supine 2) Head of bed elevated 80 3) Head of bed elevated 30 4) Lying on left side ANS: 2 Position affects ventilation. An upright or elevated position pulls abdominal organs down, thus allowing maximum diaphragm excursion and lung expansion. PTS:1DIF:EasyREF:p. 1303 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 3. While a patient is receiving hygiene care, her chest tube becomes disconnected from the water-seal chest drainage system (CDU). Which action should the nurse take immediately? 1) Clamp the chest tube close to the insertion site. 2) Set up a new drainage system, and connect it to the chest tube. 3) Have the patient take and hold a deep breath while the nurse reconnects the tube to the CDU. 4) Place the disconnected end nearest the patient into a bottle of sterile water. ANS: 4 Recollapse of the lung can occur because of loss of negative pressure within the system. This is commonly caused by air leaks, disconnections, or cracks in the bottles or chambers. If any of these occur, the nurse should immediately place the disconnected end nearest the patient into a bottle of sterile water or saline to a depth of 2 cm to serve as an emergency water seal until a new system can be connected. Do not clamp the chest tube because this can rapidly lead to a tension pneumothorax. A new drainage system should be set up to decrease the risk of infection, but the immediate action is to place the disconnected end into a bottle of sterile water. PTS:1DIF:ModerateREF:p. 1322 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis 4. The nurse administers an antitussive/expectorant cough preparation to a patient with bronchitis. Which of the following responses indicates to the nurse that the medication is effective? 1) The amount of sputum the patient expectorates decreases with each dose administered. 2) Cough is completely suppressed, and she is able to sleep through the night. 3) Dry, unproductive cough is reduced, but her voluntary coughing is more productive. 4) Involuntary coughing produces large amounts of thick yellow sputum. ANS: 3 Antitussives are cough suppressants that reduce the frequency of an involuntary, dry,