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Microbiology Chapter 17 Test Bank questions and answers rated A solution
... artificially acquired active immunity What type of immunity results from transfer of antibodies from one individual to a susceptible individual... [Show More] by means of injection? A) innate immunity B) naturally acquired active immunity C) naturally acquired passive immunity D) artificially acquired active immunity E) artificially acquired passive immunity artificially acquired passive immunity What type of immunity results from recovery from mumps? A) innate immunity B) naturally acquired active immunity C) naturally acquired passive immunity D) artificially acquired active immunity E) artificially acquired passive immunity naturally acquired active immunity Which of the following is the best definition of epitope? A) specific regions on antigens that interact with T-cell receptors B) specific regions on antigens that interact with MHC class molecules C) specific regions on antigens that interact with haptens D) specific regions on antigens that interact with antibodies E) specific regions on antigens that interact with perforins specific regions on antigens that interact with haptens Newborns' immunity due to the transfer of antibodies across the placenta is an example of A) innate immunity. B) naturally acquired active immunity. C) naturally acquired passive immunity. D) artificially acquired active immunity. E) artificially acquired passive immunity naturally acquired passive immunity Which of the following statements is NOT a possible outcome of antigen-antibody reaction? A) clonal deletion B) activation of complement C) opsonization D) ADCC E) agglutination clonal deletion Which of the following cells is NOT an APC? A) dentritic cells B) macrophages C) mature B cells D) natural killer cells E) None of the answers is correct; all of these are APCs natural killer cells When an antibody binds to a toxin, the resulting action is referred to as A) agglutination. B) opsonization. C) ADCC. D) apoptosis. E) neutralization neutralization CD4+ T cells are activated by A) interaction between CD4+ and MHC II. B) interaction between TCRs and MHC II. C) cytokines released by dendritic cells. D) cytokines released by B cells. E) complement interaction between CD4+ and MHC II Which of the following recognizes antigens displayed on host cells with MHC II? A) TC cell B) B cell C) TH cell D) natural killer cell E) basophil TH cell The specificity of an antibody is due to A) its valence. B) the H chains. C) the L chains. D) the constant portions of the H and L chains. E) the variable portions of the H and L chains the variable portions of the H and L chains Which of the following is NOT a characteristic of B cells? A) They originate in bone marrow. B) They have antibodies on their surfaces. C) They are responsible for the memory response. D) They are responsible for antibody formation. E) They recognize antigens associated with MHC I they recognize antigens associated with MHC I Which of the following is NOT a characteristic of cellular immunity? A) The cells originate in bone marrow. B) Cells are processed in the thymus gland. C) It can inhibit the immune response. D) B cells make antibodies. E) T cells react with antigens B cells make antibodies Plasma cells are activated by a(n) A) antigen. B) T cell. C) B cell. D) memory cell. E) APC antigen The antibodies found in mucus, saliva, and tears are A) IgG. B) IgM. C) IgA. D) IgD. E) IgE IgA The antibodies found almost entirely and only on the surface of B cells (not secreted from them), and which always exist as monomers, are A) IgG. B) IgM. C) IgA. D) IgD. E) IgE IgD The antibodies that can bind to large parasites are A) IgG. B) IgM. C) IgA. D) IgD. E) IgE IgE In addition to IgG, the antibodies that can fix complement are A) IgM. B) IgA. C) IgD. D) IgE. E) None of the answers is correct IgM Large antibodies that agglutinate antigens are A) IgG. B) IgM. C) IgA. D) IgD. E) IgE IgM The most abundant class of antibodies in serum is A) IgG. B) IgM. C) IgA. D) IgD. E) IgE IgG In Figure 17.1, which letter on the graph indicates the patient's secondary response to a repeated exposure with the identical antigen? A) a B) b C) c D) d E) e c In Figure 17.1, which letter on the graph indicates the highest antibody titer during the patient's response to a second and distinct/different antigen? A) a B) b C) c D) d E) e e In Figure 17.1, the arrow at time (c) indicates A) the time of exposure to the same antigen as at time (a). B) the secondary response. C) the primary response. D) exposure to a new antigen. E) the T-cell response the secondary response [Show Less]
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Pathophysiology Chapter 18- test bank questions and answers. A+
Which of the following structures is most likely to be located in the renal medulla? A) Proximal convoluted tubule B) Glomerulus C) Loop of Henle D) Af... [Show More] ferent arteriole C Which of the following is NOT a function of the kidney? A) Regulation of body fluid concentrations B) Removal of nitrogenous and acidic wastes C) Activation of vitamin D D) Production of albumin D Which of the following describes the normal flow of urine? A) Collecting duct to the renal pelvis to the ureter to the bladder B) Renal pelvis to the urethra to the bladder to the ureter C) Ureter to the renal pelvis to the urethra to the bladder D) Collecting duct to the ureter to the urethra A Which of the following increases glomerular filtration rate? A) Increased plasma osmotic pressure B) Dilation of the efferent arteriole C) Increased hydrostatic pressure in the glomerular capillaries D) Constriction of the afferent arteriole C By what process is water reabsorbed from the filtrate? A) Osmosis B) Active transport C) Cotransport D) Capillary action A Which substance directly controls the reabsorption of water from the collecting ducts? A) Renin B) Aldosterone C) Angiotensin D) Antidiuretic hormone D Under what circumstances do cells in the kidneys secrete renin? A) The urine pH decreases. B) Blood flow in the afferent arteriole decreases. C) Serum potassium levels are high. D) Serum osmotic pressure increases. B Which of the following should be present in the filtrate in the proximal convoluted tubule? A) Plasma proteins B) Erythrocytes C) Sodium ions D) Leukocytes C From the following, choose the substance likely to appear in the urine when the glomerulus is inflamed. A) Albumin B) Urea C) Sodium D) Creatinine A What is the cause of most cases of pyelonephritis? A) An ascending infection by E. coli B) Abnormal immune response, causing inflammation C) Dialysis or other invasive procedure D) Severe pH imbalance of urine A Which disease is manifested by dysuria and pyuria? A) Nephrotic syndrome B) Cystitis C) Glomerulonephritis D) Urolithiasis B Why may acute pyelonephritis and cystitis follow untreated prostatitis? A) Microbes spread through the circulation. B) Antibodies have not yet formed. C) There is no effective treatment. D) There is a continuous mucosa along the involved structures. D Pyelonephritis may be distinguished from cystitis by the presence in pyelonephritis of: A) microbes, leukocytes, and pus in the urine. B) painful micturition. C) urgency and frequency. D) urinary casts and flank pain. D In a case of acute pyelonephritis, what is the cause of flank pain? A) Inflammation, causing ischemia in the tubules B) Inflammation, stretching the renal capsule C) Increasing glomerular permeability, creating an increased volume of filtrate in the kidney D) Microbes irritating the tissues B Which pathophysiological process applies to acute post-streptococcal glomerulonephritis? A) Streptococcal infection affects both the glomerular and tubule functions B) Ischemic damage occurs in the tubules, causing obstruction and decreased glomerular filtration rate (GFR) C) Immune complexes deposit in glomerular tissue, causing inflammation D) Increased glomerular permeability for unknown reasons C What causes the dark urine associated with acute post-streptococcal glomerulonephritis? A) Blood and protein leaking through the capillary into the filtrate B) Proteinuria and microscopic hematuria from the inflammation C) Pyuria from inflammatory exudate D) Bleeding from ulcerations in the kidneys A Renal disease frequently causes hypertension because: A) albuminuria increases vascular volume. B) congestion and ischemia stimulate release of renin. C) antidiuretic hormone (ADH) secretion is decreased. D) damaged tubules absorb large amounts of filtrate. B Urinary casts are present with acute post-streptococcal A) glomerulonephritis because: large numbers of microbes and leukocytes enter the filtrate. B) ruptured capillaries release debris into the tubules. C) normal reabsorption of cells and proteins cannot take place. D) inflamed tubules compress red blood cells (RBCs) and protein into a typical mass. D Which disease would cause an increased ASO titer and elevated serum ASK? A) Nephrotic syndrome B) Acute post-streptococcal glomerulonephritis C) Pyelonephritis D) Polycystic kidney B Why does metabolic acidosis develop with bilateral kidney disease? A) Tubule exchanges are impaired. B) GFR is increased. C) Serum urea is increased. D) More bicarbonate ion is produced. A What is the first indicator in the arterial blood gases of acidosis caused by glomerulonephritis? A) Increased carbonic acid B) Increased bicarbonate ion C) A pH less than 7.35 D) Decreased bicarbonate ion D What would be the long-term effects of chronic infection or inflammation of the kidneys? A) Dehydration and hypovolemia B) Gradual necrosis, fibrosis, and development of uremia C) Sudden anuria and azotemia D) Severe back or flank pain B What factors contribute to headache, anorexia, and lethargy with kidney disease? 1. Increased blood pressure 2. Elevated serum urea 3. Anemia 4. Acidosis A) 1 only B) 2, 4 C) 1, 3, 4 D) 1, 2, 3, 4 D What are the significant signs of nephrotic syndrome? A) Hyperlipidemia and lipiduria B) Pyuria and leucopenia C) Hypertension and heart failure D) Gross hematuria and pyuria A Why does blood pressure often remain near normal in patients with nephrotic syndrome? A) Massive amounts of fluid are lost from the body with polyuria. B) Renin and aldosterone are no longer secreted. C) Tubules do not respond to ADH and aldosterone. D) Hypovolemia results from fluid shift to the interstitial compartment. D Common causes of urolithiasis include all of the following EXCEPT: A) hypercalcemia. B) hyperlipidemia. C) inadequate fluid intake. D) hyperuricemia. B Which of the following results from obstruction of the left ureter by a renal calculus? A) Mild flank pain on the affected side B) Hydronephrosis in both kidneys C) Immediate cessation of urine production D) An attack of renal colic D What does hydronephrosis lead to? A) Ischemia and necrosis in the compressed area B) Multiple hemorrhages in the kidney C) Severe colicky pain radiating into the groin D) Increased GFR A Which of the following does NOT usually result from nephrosclerosis? A) Secondary hypertension B) Chronic renal failure C) Acute renal failure D) Increased renin and aldosterone secretions C Which of the following relates to polycystic kidney disease? A) It affects only one of the kidneys. B) It results in gradual degeneration and chronic renal failure. C) The kidneys are displaced and the ureters are twisted. D) The prognosis is good because there is adequate reserve for normal life. B With severe kidney disease, either hypokalemia or hyperkalemia may occur and cause: A) cardiac arrhythmias. B) encephalopathy. C) hypervolemia. D) skeletal muscle twitch or spasm. A Which of the following indicates the early stage of acute renal failure? A) Polyuria with urine of fixed and low specific gravity B) Hypotension and increased urine output C) Development of decompensated acidosis D) Very low GFR and increased serum urea D What is/are a cause(s) of acute tubule necrosis and acute renal failure? A) Prolonged circulatory shock B) Sudden significant exposure to nephrotoxins C) Crush injuries or burns D) All of the above D [Show Less]
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Test bank for sexual dysfunction questions and answers with verified content
The nurse is instructing a client about the medication sildenafil (Viagra). Which statement on the part of the client indicates that this teaching has b... [Show More] een effective? A. "Viagra works by decreasing blood flow to the penis." B. "I can take Viagra at the same time I take my daily alpha-adrenergic blocker." C. "Viagra should be taken with food." D. "I can take only one pill in a 24-hour period." D. "I can take only one pill in a 24-hour period." Which of the following terms describes involuntary tightening of the pelvic muscles that prevents penetration from occurring? A. Genito-pelvic pain/penetration disorder B. Vaginismus C. Dyspareunia D. Female orgasmic disorder B. Vaginismus The nurse is planning care for a client with female orgasmic disorder. Which of the following elements would least likely be included in the client's plan of care? A. Information on the use of vibrators and other mechanical aids B. Referral to a sex therapist C. Instruction on how to obtain and use vaginal dilators D. Teaching on how to perform pelvic floor exercises C. Instruction on how to obtain and use vaginal dilators A 30-year-old client is concerned that he will become impotent after experiencing difficulty sustaining an erection during a recent sexual encounter. What is the nurse's best response to this client's concerns? A. "A medical diagnosis of erectile dysfunction is not made until a man has experienced erectile difficulties for a period of at least 3 months." B. "An occasional incident like this is normal and common." C. "Erectile dysfunction is the correct term for inability to achieve or sustain an erection." D. "Sexually transmitted infections may result in sexual problems in adults." B. "An occasional incident like this is normal and common." A male client tells the nurse that he has no idea why his wife wants to stay married to him because he has not been able to "perform" sexually since his prostate surgery. Based on the client's statement, which nursing diagnosis would be most appropriate? A. Situational Low Self-Esteem B. Ineffective Coping C. Hormonal Imbalance D. Sexual Dysfunction A. Situational Low Self-Esteem The nurse is teaching a client about sexual activity during the pregnancy. Which of the client statements indicate that this teaching has been successful? A. "Pregnant women are most likely to experience sexual difficulties during the third trimester." B. "It's a good idea to avoid vaginal sex during the last few weeks of pregnancy, so I don't risk hurting the baby." C. "The elevated androgen levels that accompany pregnancy might reduce my desire for sex." D. "Sexual dysfunction is uncommon during pregnancy, although many women suffer from low desire during the postpartum period." A. "Pregnant women are most likely to experience sexual difficulties during the third trimester." A postmenopausal client says to the nurse, "I've lost interest in sex over the past few months, but that's normal for women my age." Based on the client's statement, which nursing diagnosis would be most appropriate? A. Situational Low Self-Esteem B. Readiness for Enhanced Relationship C. Readiness for Enhanced Communication D. Deficient Knowledge D. Deficient Knowledge A client who gave birth 10 weeks ago via cesarean section tells the nurse that she is having difficulty resuming sexual relations with her husband. She reports both reduced desire for sex and pain upon penetration. What is the nurse's best response to this client? A. "Based on the symptoms you're reporting, I'm concerned you might be experiencing a postpartum mood disorder." B. "These problems are common during the postpartum period and usually resolve with time." C. "Are you breastfeeding? If so, switching to formula will help resolve these issues." D. "Most women don't report these sorts of problems unless they've delivered vaginally." B. "These problems are common during the postpartum period and usually resolve with time." The nurse is caring for a client with erectile dysfunction (ED). Which medication(s) should the nurse anticipate being prescribed for this client? Select all that apply. A. Methylphenidate (Ritalin) B. Buspirone (BuSpar) C. Tadalafil (Cialis) D. Sildenafil (Viagra) E. Vardenafil (Levitra) C. Tadalafil (Cialis) D. Sildenafil (Viagra) E. Vardenafil (Levitra) A 45-year-old female client tells the nurse that she has not had any interest in sex for about 8 months. During this time, she has also had difficulty with arousal. Which response by the nurse is best? A. "You are not alone. Lack of interest and arousal is the most common sexual problem reported by female clients." B. "Don't worry; all women go through periods where they are uninterested in sex." C. "A lack of interest in sex is a normal consequence of the aging process, and it often begins around the time a woman enters menopause." D. "It sounds like you might be experiencing female sexual interest/arousal disorder, although your symptoms need to be present for 12 full months before this diagnosis applies." A. "You are not alone. Lack of interest and arousal is the most common sexual problem reported by female clients." A 25-year-old client who is taking fluoxetine (Prozac) to treat depression reports decreased sexual desire since starting the medication. What can the nurse anticipate with regard to changes in the client's pharmacological regimen? A. Immediate discontinuation of fluoxetine therapy B. Addition of bupropion to the client's drug regimen C. Addition of flibanserin to the client's drug regimen D. Replacement of fluoxetine with paroxetine therapy B. Addition of bupropion to the client's drug regimen A nurse is gathering the health history of a client with erectile dysfunction (ED). Which finding(s) could indicate a possible cause for the client's ED? Select all that apply. A. Blood pressure of 118/68 mmHg B. Body mass index (BMI) of 24.5 C. Treatment for type 2 diabetes mellitus for 7 years D. Alcohol intake of 4 to 6 beers each day E. Engaging in moderate exercise twice a week C. Treatment for type 2 diabetes mellitus for 7 years D. Alcohol intake of 4 to 6 beers each day [Show Less]
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Fundamentals Final Test Bank questions and answers ,A+ test 2023
A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dr... [Show More] essing material? A. Discard the dressing in the bedside trash receptacle. B. Dispose of the dressing in a biohazardous waste container. C. Enclose the dressing in a single clear plastic bag and discard in the bedside trash receptacle. B. Dispose of the dressing in a biohazardous waste container. A nurse is caring for a female client who has recurrent kidney stones and is scheduled for an intravenous pyelogram. Which of the following statements should the nurse report to the provider? A. "I drink at least 2 quarts of fluid every day." B. "The last time I voided it was painful and red-tinged." C. "My period ended 2 days ago." D. "I don't eat shellfish because it gives me hives." D. "I don't eat shellfish because it gives me hives." A nurse is preparing to administer 40 mEq of potassium chloride in 45% sodium chloride (NaCl) 500 mL IV to infuse 10 mEq/hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) CALCULATION 125 mL/hr A nurse working for a home agency is assessing an older adult male client. Which of the following findings is the priority for the nurse to address? A. Swollen gums B. Pruritus C. Urinary Hesitancy D. Dysphagia D. Dysphagia A nurse is going to give a presentation about preventing deep-vein thrombosis (DVT). Which of the following should the nurse include as a risk factor for this disorder? (Select all that apply.) BMI of 20 Recent long flight Hypertension High calcium intake Immobility Flights Immobility A nurse is teaching a client who has a prescription of a nasogastric tube (NG) to treat a pyloric obstruction. Which of the following rationales for the use of the nasogastric tube should the nurse include in the teaching? A. Determine the pH of the gastric secretions. B. Supply nutrients via tube feedings. C. Decompress the stomach. D. Administer medications. C. Decompress the stomach. A nurse provides a back massage as a palliative care measure to a client who is unconscious, grimacing, and restless. Which of the following findings should the nurse identify as indicating a therapeutic response? (Select all that apply.) The shoulders droop. The facial muscles relax. The respiratory rate increases. The pulse is within the expected range. The client draws his legs up into a fetal position. The shoulders droop. The facial muscles relax. The pulse is within the expected range. A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect? A. Fatigue B. Hypertension C. Bradycardia D. Diarrhea A. Fatigue A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see? A. pH below 7.35 B. HCO3 above 26 mEq/L C. PaO2 below 70 mmHg D. PaCO2 above 45 mmHg A. pH below 7.35 A hospice nurse is reviewing the prescriptions for a client who is receiving palliative care. Which of the following prescriptions should the nurse expect? (Select all that apply.) Provide skin care with a moisture barrier cream. Administer artificial tear PRN. Obtain vital signs every 2 hr. Perform mouth care every hour. Administer oxygen 2L/min via nasal cannula. Provide skin care with a moisture barrier cream. Administer artificial tear PRN. Perform mouth care every hour. Administer oxygen 2L/min via nasal cannula. A nurse is planning care for a client who is postoperative and at risk of paralytic ileus. Which of the following interventions should the nurse plan to take to promote peristalsis? A. Increase ambulation. B. Decrease fluid intake. C. Increase protein intake. D. Offer the client the bedpan every 2 hr. A. Increase ambulation. A nurse has completed care procedures for a client who requires airborne precautions. Which of the following items of personal protective equipment (PPE) should the nurse remove last? A. Mask B. Gloves C. Gown D. Goggles A. Mask A nurse is providing teaching to an assistive personnel (AP) about caring for clients with restraints. Which of the following statements by the AP indicates an understanding of the teaching? A. "I will tie restraints in double knots." B. "I will tie a restraint to the portion of the bed that moves when the head of the bed is moved." C. "I will ensure that restraints fit tightly against the client." D. "I will put four side rails up if a client is confused." B. "I will tie a restraint to the portion of the bed that moves when the head of the bed is moved." A nurse is teaching a new group of assistive personnel (AP) about the importance of hand hygiene. Which of the following statements should the nurse include? A. "If you wear gloves, you do not have to wash your hands." B. "Rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds." C. "Use an alcohol rub when your hands are visibly soiled." D. "If you don't have an infection, your hands won't infect others." B. "Rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds." A nurse is planning postoperative care for a client who is scheduled for an ileal conduit (urinary diversion) procedure. The nurse should include which of the following in the client's plan of care? (Select all that apply). Notify the provider immediately if mucus is present in the urine. Maintain the client on a fluid restriction. Apply skin barrier around the stoma site. Educate the client that hematuria is expected following the procedure. Monitor hourly urine output. Apply skin barrier around the stoma site. Educate the client that hematuria is expected following the procedure. Monitor hourly urine output. A nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client? A. Contact B. Droplet C. Protective D. Airborne D. Airborne A nurse is caring for a client who is scheduled to have surgery. In preparing the client for surgery, which of the following actions is considered outside the nurse's responsibilities? A. Assuring the current health status of the client. B. Explaining the operative procedure, risks, and benefits. C. Reviewing preoperative laboratory test results. D. Ensuring that a signed surgical consent was completed. B. Explaining the operative procedure, risks, and benefits. A nurse is caring for a client who is postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the client's pan? A. Vital sign management B. The client's self-report of pain intensity. C. Visual observation for nonverbal signs of pain. D. The nature and invasiveness of the surgical procedure. B. The client's self-report of pain intensity. A nurse is working with an assistive personnel (AP) while caring for a surgical client who is 1 day postoperative. Which task should the nurse take responsibility for completing? A. Measuring vital signs. B. Removing the abdominal dressing. C. Helping the client into the shower. D. Ambulating the client in the hallway. B. Removing the abdominal dressing. A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mmHg, and temperature 36.8ºC (98.2ºF). Which of the following actions should the nurse perform? A. Complete a neurological check. B. Administer the prescribed PRN antihypertensive medication. C. Increase the client's fluid intake. D. Hold the client's evening dose of digoxin. A. Complete a neurological check. A nurse is preparing to teach a client who has a low literacy level. Which of the following methods should the nurse plan to include? A. Emphasize four important points at each session. B. Use a passive voice to explain the information. C. Refer to the client in the third person during the session. D. Have short teaching sessions. D. Have short teaching sessions. A nurse is reviewing the medical record for a client who has a health care-associated infection (HAI). The nurse should identify which of the following findings as a risk factor for acquiring an HAI? A. The client had an appendectomy 6 months ago. B. The client has bipolar disorder. C. The client is a male. D. The client is 71 years old. D. The client is 71 years old. A nurse is planning care for a client who is 4 hr postoperative. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) Assist the client to cough and deep breathe every hour. Administer PRN analgesics as needed. Encourage the client to turn every 4 hr. Give the client a back massage. Teach the client relaxation techniques. Assist the client to cough and deep breathe every hour. Administer PRN analgesics as needed. Give the client a back massage. Teach the client relaxation techniques. A nurse is caring for a client who has a new diagnosis of chronic kidney disease. Which of the following statements should the nurse identify as an indication of anticipatory grieving? A. "I know that I will get a kidney transplant. I am a good candidate." B. "I can now eat whatever I want. The dialysis will remove it from my system." C. "I just can't believe that this dialysis is going to ruin my whole life." D. "I know that kidney disease runs in my family, but I can prevent it." C. "I just can't believe that this dialysis is going to ruin my whole life." A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed to receive an enema." Which of the following nursing actions is appropriate at this time? A. Check the client's medical record for the provider's prescription. B. Explain to the client that the provider prescribed the procedure. C. Assure the client that enemas are commonly prescribed for constipation. D. Inform the charge nurse that the client refused the enema. A. Check the client's medical record for the provider's prescription. A nurse is completing discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session? A. Pain B. Hearing loss C. The client's culture D. Motor impairment A. Pain A nurse is caring for an older client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? A. Reposition the client every 3 hr. B. Massage bony prominences to promote circulation. C. Provide the client with a diet high in protein. D. Apply cornstarch to keep the skin dry. C. Provide the client with a diet high in protein. A nurse is teaching a group of middle adult clients about early detection of colorectal cancer. The nurse should include the American Cancer Society recommendation that men and women beginning at age 50 who are at average risk should have a fecal occult blood test (FOBT) and a colonoscopy at which of the following intervals? A. Five years B. Ten years C. One year D. Two years B. Ten years A nurse is providing instructions for a 52-year-old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate? A. "Don't worry, most clients dislike the prep more than the procedure itself." B. "Before the examination, your provider will give you a sedative that will make you sleepy." C. "I know you're anxious, but this procedure is recommended for people your age." D. "After you have signed the consent form, we can talk more about this." B. "Before the examination, your provider will give you a sedative that will make you sleepy." [Show Less]
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Chapter 34: Heart Failure Test Bank questions and answers with verified content
1. While assessing a 68-year-old with ascites, the nurse also notes jugular venous distention (JVD) with the head of the patients bed elevated 45 degrees. ... [Show More] The nurse knows this finding indicates a. decreased fluid volume. b. jugular vein atherosclerosis. c. increased right atrial pressure. d. incompetent jugular vein valves. c. increased right atrial pressure. The jugular veins empty into the superior vena cava and then into the right atrium, so JVD with the patient sitting at a 45-degree angle reflects increased right atrial pressure. JVD is an indicator of excessive fluid volume (increased preload), not decreased fluid volume. JVD is not caused by incompetent jugular vein valves or atherosclerosis. 2. The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best indicator that the treatment has been effective? a. Weight loss of 2 pounds in 24 hours b. Hourly urine output greater than 60 mL c. Reduction in patient complaints of chest pain d. Reduced dyspnea with the head of bed at 30 degrees d. Reduced dyspnea with the head of bed at 30 degrees Because the patients major clinical manifestation of ADHF is orthopnea (caused by the presence of fluid in the alveoli), the best indicator that the medications are effective is a decrease in dyspnea with the head of the bed at 30 degrees. The other assessment data also may indicate that diuresis or improvement in cardiac output has occurred, but are not as specific to evaluating this patients response. 3. Which topic will the nurse plan to include in discharge teaching for a patient with systolic heart failure and an ejection fraction of 33%? a. Need to begin an aerobic exercise program several times weekly b. Use of salt substitutes to replace table salt when cooking and at the table c. Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors d. Importance of making an annual appointment with the primary care provider c. Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors The core measures for the treatment of heart failure established by The Joint Commission indicate that patients with an ejection fraction (EF) <40% receive an ACE inhibitor to decrease the progression of heart failure. Aerobic exercise may not be appropriate for a patient with this level of heart failure, salt substitutes are not usually recommended because of the risk of hyperkalemia, and the patient will need to see the primary care provider more frequently than annually. 4. IV sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to titrate the nitroprusside rate if the patient develops a. ventricular ectopy. b. a dry, hacking cough. c. a systolic BP <90 mm Hg. d. a heart rate <50 beats/minute. c. a systolic BP <90 mm Hg. Sodium nitroprusside is a potent vasodilator, and the major adverse effect is severe hypotension. Coughing and bradycardia are not adverse effects of this medication. Nitroprusside does not cause increased ventricular ectopy. 5. A patient who has chronic heart failure tells the nurse, I was fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating! The nurse will document this assessment finding as a. orthopnea. b. pulsus alternans. c. paroxysmal nocturnal dyspnea. d. acute bilateral pleural effusion. c. paroxysmal nocturnal dyspnea. Paroxysmal nocturnal dyspnea is caused by the reabsorption of fluid from dependent body areas when the patient is sleeping and is characterized by waking up suddenly with the feeling of suffocation. Pulsus alternans is the alternation of strong and weak peripheral pulses during palpation. Orthopnea indicates that the patient is unable to lie flat because of dyspnea. Pleural effusions develop over a longer time period. 6. During a visit to a 78-year-old with chronic heart failure, the home care nurse finds that the patient has ankle edema, a 2-kg weight gain over the past 2 days, and complains of feeling too tired to get out of bed. Based on these data, the best nursing diagnosis for the patient is a. activity intolerance related to fatigue. b. disturbed body image related to weight gain. c. impaired skin integrity related to ankle edema. d. impaired gas exchange related to dyspnea on exertion. a. activity intolerance related to fatigue. The patients statement supports the diagnosis of activity intolerance. There are no data to support the other diagnoses, although the nurse will need to assess for other patient problems. 7. The nurse working on the heart failure unit knows that teaching an older female patient with newly diagnosed heart failure is effective when the patient states that a. she will take furosemide (Lasix) every day at bedtime. b. the nitroglycerin patch is applied when any chest pain develops. c. she will call the clinic if her weight goes from 124 to 128 pounds in a week. d. an additional pillow can help her sleep if she is feeling short of breath at night. c. she will call the clinic if her weight goes from 124 to 128 pounds in a week. Teaching for a patient with heart failure includes information about the need to weigh daily and notify the health care provider about an increase of 3 pounds in 2 days or 3 to 5 pounds in a week. Nitroglycerin patches are used primarily to reduce preload (not to prevent chest pain) in patients with heart failure and should be used daily, not on an as needed basis. Diuretics should be taken earlier in the day to avoid nocturia and sleep disturbance. The patient should call the clinic if increased orthopnea develops, rather than just compensating by further elevating the head of the bed. 8. When teaching the patient with newly diagnosed heart failure about a 2000-mg sodium diet, the nurse explains that foods to be restricted include a. canned and frozen fruits. b. fresh or frozen vegetables. c. eggs and other high-protein foods. d. milk, yogurt, and other milk products. d. milk, yogurt, and other milk products. Milk and yogurt naturally contain a significant amount of sodium, and intake of these should be limited for patients on a diet that limits sodium to 2000 mg daily. Other milk products, such as processed cheeses, have very high levels of sodium and are not appropriate for a 2000-mg sodium diet. The other foods listed have minimal levels of sodium and can be eaten without restriction. 9. The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hydrochlorothiazide (HydroDIURIL). Appropriate instructions for the patient include a. limit dietary sources of potassium. b. take the hydrochlorothiazide before bedtime. c. notify the health care provider if nausea develops. d. skip the digoxin if the pulse is below 60 beats/minute. c. notify the health care provider if nausea develops. Nausea is an indication of digoxin toxicity and should be reported so that the provider can assess the patient for toxicity and adjust the digoxin dose, if necessary. The patient will need to include potassium-containing foods in the diet to avoid hypokalemia. Patients should be taught to check their pulse daily before taking the digoxin and if the pulse is less than 60, to call their provider before taking the digoxin. Diuretics should be taken early in the day to avoid sleep disruption. 10. While admitting an 82-year-old with acute decompensated heart failure to the hospital, the nurse learns that the patient lives alone and sometimes confuses the water pill with the heart pill. When planning for the patients discharge the nurse will facilitate a a. consult with a psychologist. b. transfer to a long-term care facility. c. referral to a home health care agency. d. arrangements for around-the-clock care. c. referral to a home health care agency. The data about the patient suggest that assistance in developing a system for taking medications correctly at home is needed. A home health nurse will assess the patients home situation and help the patient develop a method for taking the two medications as directed. There is no evidence that the patient requires services such as a psychologist consult, long-term care, or around-the-clock home care. 11. Following an acute myocardial infarction, a previously healthy 63-year-old develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about a. digitalis preparations. b. b-adrenergic blockers. c. calcium channel blockers. d. angiotensin-converting enzyme (ACE) inhibitors. d. angiotensin-converting enzyme (ACE) inhibitors. ACE inhibitor therapy is currently recommended to prevent the development of heart failure in patients who have had a myocardial infarction and as a first-line therapy for patients with chronic heart failure. Digoxin therapy for heart failure is no longer considered a first-line measure, and digoxin is added to the treatment protocol when therapy with other medications such as ACE-inhibitors, diuretics, and b-adrenergic blockers is insufficient. Calcium channel blockers are not generally used in the treatment of heart failure. The b- adrenergic blockers are not used as initial therapy for new onset heart failure. 12. A 53-year-old patient with Stage D heart failure and type 2 diabetes asks the nurse whether heart transplant is a possible therapy. Which response by the nurse is most appropriate? a. Because you have diabetes, you would not be a candidate for a heart transplant. b. The choice of a patient for a heart transplant depends on many different factors. c. Your heart failure has not reached the stage in which heart transplants are needed. d. People who have heart transplants are at risk for multiple complications after surgery. b. The choice of a patient for a heart transplant depends on many different factors. Indications for a heart transplant include end-stage heart failure (Stage D), but other factors such as coping skills, family support, and patient motivation to follow the rigorous posttransplant regimen are also considered. Diabetic patients who have well-controlled blood glucose levels may be candidates for heart transplant. Although heart transplants can be associated with many complications, this response does not address the patients question. 13. Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with acute shortness of breath has heart failure? a. Serum troponin b. Arterial blood gases c. B-type natriuretic peptide d. 12-lead electrocardiogram c. B-type natriuretic peptide B-type natriuretic peptide (BNP) is secreted when ventricular pressures increase, as they do with heart failure. Elevated BNP indicates a probable or very probable diagnosis of heart failure. A twelve-lead electrocardiogram, arterial blood gases, and troponin may also be used in determining the causes or effects of heart failure but are not as clearly diagnostic of heart failure as BNP. 14. Which action should the nurse include in the plan of care when caring for a patient admitted with acute decompensated heart failure (ADHF) who is receiving nesiritide (Natrecor)? a. Monitor blood pressure frequently. b. Encourage patient to ambulate in room. c. Titrate nesiritide slowly before stopping. d. Teach patient about home use of the drug. a. Monitor blood pressure frequently. Nesiritide is a potent arterial and venous dilator, and the major adverse effect is hypotension. Because the patient is likely to have orthostatic hypotension, the patient should not be encouraged to ambulate. Nesiritide does not require titration and is used for ADHF but not in a home setting. 15. A patient with heart failure has a new order for captopril (Capoten) 12.5 mg PO. After administering the first dose and teaching the patient about the drug, which statement by the patient indicates that teaching has been effective? a. I will be sure to take the medication with food. b. I will need to eat more potassium-rich foods in my diet. c. I will call for help when I need to get up to use the bathroom. d. I will expect to feel more short of breath for the next few days. c. I will call for help when I need to get up to use the bathroom. Captopril can cause hypotension, especially after the initial dose, so it is important that the patient not get up out of bed without assistance until the nurse has had a chance to evaluate the effect of the first dose. The angiotensin-converting enzyme (ACE) inhibitors are potassium sparing, and the nurse should not teach the patient to purposely increase sources of dietary potassium. Increased shortness of breath is expected with the initiation of b-adrenergic blocker therapy for heart failure, not for ACE inhibitor therapy. ACE inhibitors are best absorbed when taken an hour before eating. 16. A patient who has just been admitted with pulmonary edema is scheduled to receive the following medications. Which medication should the nurse question before giving? a. Furosemide (Lasix) 60 mg b. Captopril (Capoten) 25 mg c. Digoxin (Lanoxin) 0.125 mg d. Carvedilol (Coreg) 3.125 mg d. Carvedilol (Coreg) 3.125 mg Although carvedilol is appropriate for the treatment of chronic heart failure, it is not used for patients with acute decompensated heart failure (ADHF) because of the risk of worsening the heart failure. The other medications are appropriate for the patient with ADHF. 17. A patient with a history of chronic heart failure is admitted to the emergency department (ED) with severe dyspnea and a dry, hacking cough. Which action should the nurse do first? a. Auscultate the abdomen. b. Check the capillary refill. c. Auscultate the breath sounds. d. Assess the level of orientation. c. Auscultate the breath sounds. This patients severe dyspnea and cough indicate that acute decompensated heart failure (ADHF) is occurring. ADHF usually manifests as pulmonary edema, which should be detected and treated immediately to prevent ongoing hypoxemia and cardiac/respiratory arrest. The other assessments will provide useful data about the patients volume status and also should be accomplished rapidly, but detection (and treatment) of pulmonary complications is the priority. 18. A patient with chronic heart failure who is taking a diuretic and an angiotensin-converting enzyme (ACE) inhibitor and who is on a low-sodium diet tells the home health nurse about a 5-pound weight gain in the last 3 days. The nurses priority action will be to a. have the patient recall the dietary intake for the last 3 days. b. ask the patient about the use of the prescribed medications. c. assess the patient for clinical manifestations of acute heart failure. d. teach the patient about the importance of restricting dietary sodium. c. assess the patient for clinical manifestations of acute heart failure The 5-pound weight gain over 3 days indicates that the patients chronic heart failure may be worsening. It is important that the patient be assessed immediately for other clinical manifestations of decompensation, such as lung crackles. A dietary recall to detect hidden sodium in the diet, reinforcement of sodium restrictions, and assessment of medication compliance may be appropriate interventions but are not the first nursing actions indicated. 19. A patient in the intensive care unit with acute decompensated heart failure (ADHF) complains of severe dyspnea and is anxious, tachypneic, and tachycardic. All of the following medications have been ordered for the patient. The nurses priority action will be to a. give IV morphine sulfate 4 mg. b. give IV diazepam (Valium) 2.5 mg. c. increase nitroglycerin (Tridil) infusion by 5 mcg/min. d. increase dopamine (Intropin) infusion by 2 mcg/kg/min. a. give IV morphine sulfate 4 mg. Morphine improves alveolar gas exchange, improves cardiac output by reducing ventricular preload and afterload, decreases anxiety, and assists in reducing the subjective feeling of dyspnea. Diazepam may decrease patient anxiety, but it will not improve the cardiac output or gas exchange. Increasing the dopamine may improve cardiac output, but it will also increase the heart rate and myocardial oxygen consumption. Nitroglycerin will improve cardiac output and may be appropriate for this patient, but it will not directly reduce anxiety and will not act as quickly as morphine to decrease dyspnea. 20. After receiving change-of-shift report on a heart failure unit, which patient should the nurse assessfirst? a. A patient who is cool and clammy, with new-onset confusion and restlessness b. A patient who has crackles bilaterally in the lung bases and is receiving oxygen. c. A patient who had dizziness after receiving the first dose of captopril (Capoten) d. A patient who is receiving IV nesiritide (Natrecor) and has a blood pressure of 100/62 a. A patient who is cool and clammy, with new-onset confusion and restlessness The patient who has wet-cold clinical manifestations of heart failure is perfusing inadequately and needs rapid assessment and changes in management. The other patients also should be assessed as quickly as possible but do not have indications of severe decreases in tissue perfusion. 21. Which assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires the most immediate action by the nurse? a. Oxygen saturation of 88% b. Weight gain of 1 kg (2.2 lb) c. Heart rate of 106 beats/minute d. Urine output of 50 mL over 2 hours a. Oxygen saturation of 88% A decrease in oxygen saturation to less than 92% indicates hypoxemia. The nurse should administer supplemental oxygen immediately to the patient. An increase in apical pulse rate, 1-kg weight gain, and decreases in urine output also indicate worsening heart failure and require nursing actions, but the low oxygen saturation rate requires the most immediate nursing action. 22. A patient has recently started on digoxin (Lanoxin) in addition to furosemide (Lasix) and captopril (Capoten) for the management of heart failure. Which assessment finding by the home health nurse is a priority to communicate to the health care provider? a. Presence of 1 to 2+ edema in the feet and ankles b. Palpable liver edge 2 cm below the ribs on the right side c. Serum potassium level 3.0 mEq/L after 1 week of therapy d. Weight increase from 120 pounds to 122 pounds over 3 days c. Serum potassium level 3.0 mEq/L after 1 week of therapy Hypokalemia can predispose the patient to life-threatening dysrhythmias (e.g., premature ventricular contractions), and potentiate the actions of digoxin and increase the risk for digoxin toxicity, which can also cause life-threatening dysrhythmias. The other data indicate that the patients heart failure requires more effective therapies, but they do not require nursing action as rapidly as the low serum potassium 23. An outpatient who has chronic heart failure returns to the clinic after 2 weeks of therapy with metoprolol (Toprol XL). Which assessment finding is most important for the nurse to report to the health care provider? a. 2+ pedal edema b. Heart rate of 56 beats/minute c. Blood pressure (BP) of 88/42 mm Hg d. Complaints of fatigue c. Blood pressure (BP) of 88/42 mm Hg The patients BP indicates that the dose of metoprolol may need to be decreased because of hypotension. Bradycardia is a frequent adverse effect of b-adrenergic blockade, but the rate of 56 is not unusual with - adrenergic blocker therapy. b-Adrenergic blockade initially will worsen symptoms of heart failure in many patients, and patients should be taught that some increase in symptoms, such as fatigue and edema, is expected during the initiation of therapy with this class of drugs. 24. A patient who is receiving dobutamine (Dobutrex) for the treatment of acute decompensated heart failure (ADHF) has the following nursing interventions included in the plan of care. Which action will be most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Assess the IV insertion site for signs of extravasation. b. Teach the patient the reasons for remaining on bed rest. c. Monitor the patients blood pressure and heart rate every hour. d. Titrate the rate to keep the systolic blood pressure >90 mm Hg. c. Monitor the patients blood pressure and heart rate every hour. An experienced LPN/LVN would be able to monitor BP and heart rate and would know to report significant changes to the RN. Teaching patients, making adjustments to the drip rate for vasoactive medications, and monitoring for serious complications such as extravasation require RN level education and scope of practice. 25. After receiving change-of-shift report on a heart failure unit, which patient should the nurse assess first? a. Patient who is taking carvedilol (Coreg) and has a heart rate of 58 b. Patient who is taking digoxin and has a potassium level of 3.1 mEq/L c. Patient who is taking isosorbide dinitrate/hydralazine (BiDil) and has a headache d. Patient who is taking captopril (Capoten) and has a frequent nonproductive cough b. Patient who is taking digoxin and has a potassium level of 3.1 mEq/L The patients low potassium level increases the risk for digoxin toxicity and potentially fatal dysrhythmias. The nurse should assess the patient for other signs of digoxin toxicity and then notify the health care provider about the potassium level. The other patients also have side effects of their medications, but their symptoms do not indicate potentially life-threatening complications. 1. Based on the Joint Commission Core Measures for patients with heart failure, which topics should the nurse include in the discharge teaching plan for a patient who has been hospitalized with chronic heart failure (select all that apply)? a. How to take and record daily weight b. Importance of limiting aerobic exercise c. Date and time of follow-up appointment d. Symptoms indicating worsening heart failure e. Actions and side effects of prescribed medications a. How to take and record daily weight c. Date and time of follow-up appointment d. Symptoms indicating worsening heart failure e. Actions and side effects of prescribed medications The Joint Commission Core Measures state that patients should be taught about prescribed medications, follow-up appointments, weight monitoring, and actions to take for worsening symptoms. Patients with heart failure are encouraged to begin or continue aerobic exercises such as walking, while self-monitoring to avoid excessive fatigue. [Show Less]
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Pathophysiology Chapter 12- Test Bank questions and answers A+ test
Which of the following actions causes the atrioventricular (AV) valves to close? A) Increased intraventricular pressure B) Depolarization at the AV node ... [Show More] C) Ventricular relaxation and backflow of blood D) Contraction of the atria A When stroke volume decreases, which of the following could maintain cardiac output? A) Decreased peripheral resistance B) Increased heart rate C) Decreased venous return D) General vasodilation B 00:59 01:22 Which of the following describes the pericardial cavity? A) It contains sufficient fluid to provide a protective cushion for the heart. B) It is a potential space containing a very small amount of serous fluid. C) It is lined by the endocardium. D) It is located between the double-walled pericardium and the epicardium. B Which of the following factors greatly improves venous return to the heart during strenuous exercise? A) Rapid emptying of the right side of the heart B) Forceful action of the valves in the veins C) Contraction and relaxation of skeletal muscle D) Peristalsis in the large veins C The function of the baroreceptors is to: A) stimulate the parasympathetic or sympathetic nervous system at the sinoatrial (SA) node as needed. B) adjust blood pressure by changing peripheral resistance. C) sense a change in blood oxygen and carbon dioxide levels. D) signal the cardiovascular control center of changes in systemic blood pressure. D The normal delay in conduction through the AV node is essential for: A) preventing an excessively rapid heart rate. B) limiting the time for a myocardial contraction. C) allowing the ventricles to contract before the atria. D) completing ventricular filling. D Which of the following is a result of increased secretion of epinephrine? A) Increased heart rate and force of contraction B) Decreased stimulation of the SA node and ventricles C) Vasoconstriction in skeletal muscles and kidneys D) Vasodilation of cutaneous blood vessels A Which of the following causes increased heart rate? A) Stimulation of the vagus nerve B) Increased renin secretion C) Administration of beta-blocking drugs D) Stimulation of the sympathetic nervous system D The term preload refers to: A) volume of venous return. B) peripheral resistance. C) stroke volume. D) cardiac output. A Cardiac output refers to: A) the amount of blood passing through either of the atria. B) the volume of blood ejected by a ventricle in one minute. C) the volume of blood ejected by each ventricle in a single contraction. D) the total number of heartbeats in one minute. B Vasodilation in the skin and viscera results directly from: A) decreased blood pressure. B) increased parasympathetic stimulation. C) relaxation of smooth muscle in the arterioles. D) increased stimulation of alpha-adrenergic receptors. C Which of the following are predisposing factors to thrombus formation in the circulation? 1. Decreased viscosity of the blood 2. Damaged blood vessel walls 3. Immobility 4. Prosthetic valves A) 1, 3 B) 2, 4 C) 1, 3, 4 D) 2, 3, 4 D A partial obstruction in a coronary artery will likely cause: A) pulmonary embolus. B) hypertension. C) angina attacks. D) myocardial infarction. C Cigarette smoking is a risk factor in coronary artery disease because smoking: A) reduces vasoconstriction and peripheral resistance. B) decreases serum lipid levels. C) promotes platelet adhesion. D) increases serum HDL levels. C The term arteriosclerosis specifically refers to: A) development of atheromas in large arteries. B) intermittent vasospasm in coronary arteries. C) degeneration with loss of elasticity and obstruction in small arteries. D) ischemia and necrosis in the brain, kidneys, and heart. C A modifiable factor that increases the risk for atherosclerosis is: A) leading a sedentary lifestyle. B) being female and older than 40 years of age. C) excluding saturated fats from the diet. D) familial hypercholesterolemia. A An atheroma develops from: A) a torn arterial wall and blood clots. B) accumulated lipids, cells, and fibrin where endothelial injury has occurred. C) thrombus forming on damaged walls of veins. D) repeated vasospasms. B Low-density lipoproteins (LDL): A) promote atheroma development. B) contain only small amounts of cholesterol. C) transport cholesterol from cells to the liver for excretion. D) are associated with low intake of saturated fats. A Factors that may precipitate an angina attack include all of the following EXCEPT: A) eating a large meal. B) engaging in an angry argument. C) taking a nap. D) shoveling snow on a cold, windy day. C When comparing angina with myocardial infarction (MI), which statement is true? A) Both angina and MI cause tissue necrosis. B) Angina often occurs at rest; MI occurs during a stressful time. C) Pain is more severe and lasts longer with angina than with MI. D) Angina pain is relieved by rest and intake of nitroglycerin; the pain of MI is not. D The basic pathophysiology of myocardial infarction is best described as: A) cardiac output that is insufficient to meet the needs of the heart and body. B) temporary vasospasm that occurs in a coronary artery. C) total obstruction of a coronary artery, which causes myocardial necrosis. D) irregular heart rate and force, reducing blood supply to coronary arteries. C Typical early signs or symptoms of myocardial infarction include: A) brief, substernal pain radiating to the right arm, with labored breathing. B) persistent chest pain radiating to the left arm, pallor, and rapid, weak pulse. C) bradycardia, increased blood pressure, and severe dyspnea. D) flushed face, rapid respirations, left-side weakness, and numbness. B The most common cause of a myocardial infarction is: A) an imbalance in calcium ions. B) an infection of the heart muscle. C) atherosclerosis involving an attached thrombus. D) a disruption of the heart conduction system. C Which of the following confirms the presence of a myocardial infarction? A) A full description of the pain, including the sequence of development B) The presence of elevated serum cholesterol and triglycerides C) Serum isoenzymes released from necrotic cells and an ECG D) Leukocytosis and elevated C-reactive protein C The size of the necrotic area resulting from myocardial infarction may be minimized by all of the following EXCEPT: A) previously established collateral circulation. B) immediate administration of thrombolytic drugs. C) maintaining maximum oxygen supply to the myocardium. D) removing the predisposing factors to atheroma development. D The most common cause of death immediately following a myocardial infarction is: A) cardiac arrhythmias and fibrillation. B) ruptured ventricle or aorta. C) congestive heart failure. D) cerebrovascular accident. A Why does ventricular fibrillation result in cardiac arrest? A) Delayed conduction through the AV node blocks ventricular stimulation. B) Insufficient blood is supplied to the myocardium. C) The ventricles contract before the atria. D) Parasympathetic stimulation depresses the SA node. B The term cardiac arrest refers to which of the following? A) Condition where cardiac output is less than the demand B) A decreased circulating blood volume C) Missing a ventricular contraction D) The cessation of all cardiac function D Which change results from total heart block? A) A prolonged PR interval B) Periodic omission of a ventricular contraction C) A wide QRS wave D) Spontaneous slow ventricular contractions, not coordinated with atrial contraction D Which of the following is most likely to cause left-sided congestive heart failure? A) Incompetent tricuspid heart valve B) Chronic pulmonary disease C) Infarction in the right atrium D) Uncontrolled essential hypertension D The definition of congestive heart failure is: A) cessation of all cardiac activity. B) inability of the heart to pump enough blood to meet the metabolic needs of the body. C) insufficient circulating blood in the body. D) the demand for oxygen by the heart is greater than the supply. B Significant signs of right-sided congestive heart failure include: A) severe chest pain and tachycardia. B) edematous feet and legs with hepatomegaly. C) frequent cough with blood-streaked frothy sputum. D) orthopnea, fatigue, increased blood pressure. B Paroxysmal nocturnal dyspnea is marked by: A) hemoptysis and rales. B) distended neck veins and flushed face. C) bradycardia and weak pulse. D) cardiomegaly. A Compensation mechanisms for decreased cardiac output in cases of congestive heart failure include: A) slow cardiac contractions. B) increased renin and aldosterone secretions. C) decreased erythropoietin secretion. D) fatigue and cold intolerance. B In which blood vessels will failure of the left ventricle cause increased hydrostatic pressure? A) Veins of the legs and feet B) Jugular veins C) Pulmonary capillaries D) Blood vessels of the liver and spleen C In an infant, the initial indication of congestive heart failure is often: A) distended neck veins. B) feeding problems. C) low-grade fever and lethargy. D) frequent vomiting. B A sign of aortic stenosis is: A) increased cardiac output. B) congestion in the liver, spleen, and legs. C) flushed face and headache. D) a heart murmur. D An incompetent mitral valve would cause: A) increased blood to remain in the right atrium. B) hypertrophy of the right ventricle. C) decreased output from the left ventricle. D) decreased pressure in the left atrium. C Which of the following describes the blood flow occurring with a ventricular septal defect? A) From the left ventricle to the right ventricle B) From the right ventricle to the left ventricle C) Increased cardiac output from the left ventricle D) Mixed oxygenated and unoxygenated blood in the systemic circulation A Cyanosis occurs in children with tetralogy of Fallot because: A) more carbon dioxide is present in the circulating blood. B) a large amount of hemoglobin in the general circulation is unoxygenated. C) the pulmonary circulation is overloaded and congested. D) the circulation is sluggish (slow) throughout the system. B The initial effect on the heart in cases of rheumatic fever is: A) infection in the heart by hemolytic streptococci. B) highly virulent microbes causing vegetations on the heart valves. C) septic emboli obstructing coronary arteries. D) acute inflammation in all layers of the heart due to abnormal immune response. D Common signs of rheumatic fever include all of the following EXCEPT: A) arthritis, causing deformity of the small joints in the hands and feet. B) erythematous skin rash and subcutaneous nodules. C) epistaxis, tachycardia, and fever. D) elevated ASO titer and leukocytosis. A Rheumatic heart disease usually manifests in later years as: A) swollen heart valves and fever. B) cardiac arrhythmias and heart murmurs. C) thrombus formation and septic emboli. D) petechial hemorrhages of the skin and mucosa. B Septic emboli, a common complication of infective endocarditis, are a result of the fact that: A) vegetations are loosely attached and fragile. B) the valves are no longer competent. C) cardiac output is reduced. D) heart contractions are irregular. A Which of the following applies to subacute infective endocarditis? A) A microbe of low virulence attacks abnormal or damaged heart valves. B) Virulent microbes invade normal heart valves. C) No permanent damage occurs to the valves. D) Prophylactic medication does not prevent infection. A Pericarditis causes a reduction in cardiac output as a result of which of the following? A) Delays in the conduction system, interfering with cardiac rhythm B) Weak myocardial contractions due to friction rub C) Excess fluid in the pericardial cavity, which decreases ventricular filling D) Incompetent valves, which allow regurgitation of blood C Pericarditis may be caused by: 1. infection. 2. abnormal immune responses. 3. injury. 4. malignant neoplasm. A) 1, 2 B) 3, 4 C) 1, 3, 4 D) 1, 2, 3, 4 D A source of an embolus causing an obstruction in the brain could be the: A) femoral vein. B) pulmonary vein. C) carotid artery. D) coronary artery. C The basic pathophysiological change associated with essential hypertension is: A) development of lipid plaques in large arteries. B) recurrent inflammation and fibrosis in peripheral arteries. C) degeneration and loss of elasticity in arteries. D) increased systemic vasoconstriction. D Uncontrolled hypertension is most likely to cause ischemia and loss of function in the: A) kidneys, brain, and retinas of the eye. B) peripheral arteries in the legs. C) aorta and coronary arteries. D) liver, spleen, and stomach. A When is a diagnosis of essential hypertension likely to be considered in young or middle-aged individuals? A) Blood pressure remains consistently above 140/90 B) Blood pressure fluctuates between 130/85 and 180/105 C) Blood pressure increases rapidly and is unresponsive to medication D) Chronic kidney disease leads to consistently elevated blood pressure A Atherosclerosis in the iliac or femoral arteries is likely to cause which of the following? 1. Gangrenous ulcers in the legs 2. Strong rapid pulses in the legs 3. Intermittent claudication 4. Red, swollen legs A) 1, 2 B) 1, 3 C) 2, 3 D) 2, 4 B The term intermittent claudication refers to: A) sensory deficit in the legs due to damage to nerves. B) chest pain related to ischemia. C) ischemic muscle pain in the legs, particularly with exercise. D) dry, cyanotic skin with superficial ulcers. C What is the primary reason for amputation of gangrenous toes or feet in patients with peripheral vascular disease? A) It promotes more rapid healing of ulcerated areas. B) It improves circulation to other areas. C) It prevents spread of infection and reduces pain. D) It reduces swelling in the peripheral areas. C An echocardiogram is used to demonstrate any abnormal: A) activity in the conduction system. B) movement of the heart valves. C) change in central venous pressure. D) blood flow in coronary arteries. B A friction rub is associated with: A) infectious endocarditis. B) arrhythmias. C) pericarditis. D) an incompetent aortic valve. C A dissecting aortic aneurysm develops as: A) a dilation or bulge that develops at one point on the aortic wall. B) a thrombus that accumulates at a point in the aortic wall. C) a section of the aorta that weakens and dilates in all directions. D) a tear in the intimal lining, which allows blood flow between layers of the aortic wall. D The outcome for many aortic aneurysms is: A) early diagnosis and repair. B) thrombus formation and pulmonary embolus. C) rupture and hemorrhage. D) pressure on adjacent organs or structures. C Which factor predisposes to varicose veins during pregnancy? A) Compressed pelvic veins B) Stenotic valves in leg veins C) Thrombus formation D) Insufficient muscle support for veins A Phlebothrombosis is more likely to cause pulmonary emboli than is thrombophlebitis because: A) platelets attach to the inflamed wall. B) thrombus forms in a vein and is less firmly attached. C) leg cramps require massage. D) systemic signs of inflammation require treatment. B Shock is defined as: A) failure of the heart to supply sufficient blood to body cells. B) general hypoxia, causing damage to various organs. C) decreased circulating blood and tissue perfusion. D) loss of blood, causing severe hypoxia. C Shock follows a myocardial infarction when: A) the stress response causes general vasodilation. B )fluid is lost into ischemic tissues. C) heart valves are damaged. D) a large portion of the myocardium is damaged. D What are the early signs of circulatory shock? 1. Pale moist skin 2. Loss of consciousness 3. Anxiety and restlessness 4. Rapid strong pulse A) 1, 2 B) 1, 3 C) 1, 4 D) 3, 4 B A compensation for shock would include: A) increased heart rate and oliguria. B) lethargy and decreased responsiveness. C) warm, dry, flushed skin. D) weak, thready pulse. A Why does anaphylactic shock cause severe hypoxia very quickly? A) Generalized vasoconstriction reduces venous return. B) Bronchoconstriction and bronchial edema reduce airflow. C) Heart rate and contractility are reduced. D) Metabolic rate is greatly increased. B A prolonged period of shock is likely to cause: A) damage to, and increased permeability of, pulmonary capillaries. B) increased permeability of the glomerular capillaries of the kidneys. C) increased pH of blood and body fluids. D) increased systemic vasoconstriction. A What would indicate decompensated acidosis related to shock? A) Serum bicarbonate level below normal B) PCO2 above normal C) Serum pH below normal range D) Urine pH of 4.5 C With shock, anaerobic cell metabolism and decreased renal blood flow cause: A) metabolic alkalosis. B) metabolic acidosis. C) decreased serum potassium. D) increased serum bicarbonate. B The classic early manifestation(s) of left-sided congestive heart failure is/are ____, whereas the early indicator(s) of right-sided failure is/are _______. A) palpitations and periodic chest pain; shortness of breath on exertion B) swelling of the ankles and abdomen; chest pain C) shortness of breath on exertion or lying down; swelling of the ankles D) coughing up frothy sputum; hepatomegaly and splenomegaly C The cause of essential hypertension is considered to be: A) chronic renal disease. B) excessive intake of saturated fats and salt. C) sedentary lifestyle. D) idiopathic. D Which of the following is considered to be the most dangerous arrhythmia? A) Tachycardia B) Bradycardia C) Ventricular fibrillation D) Second-degree heart block C Which of the following is NOT true of the drug nitroglycerin? A) It decreases myocardial workload by causing systemic vasodilation. B) It may be administered sublingually, transdermally, or by oral spray. C) Dizziness or syncope may follow a sublingual dose. D) It strengthens the myocardial contraction. D Confirmation of the diagnosis of a myocardial infarction would include: 1. specific changes in the ECG. 2. marked leukocytosis and increased erythrocyte sedimentation rate (ESR). 3. elevation of cardiac isoenzymes in serum. 4. a pattern of pain. A) 1, 2 B) 1, 3 C) 2, 4 D) 3, 4 B Which of the following statements regarding aneurysms is true? A) Aneurysms are always caused by congenital malformations. B) The greatest danger with aneurysms is thrombus formation. C) Manifestations of aneurysms result from compression of adjacent structures. D) Aneurysms involve a defect in the tunica media of veins. C The most common factor predisposing to the development of varicose veins is: A) trauma. B) congenital valve defect in the abdominal veins. C) infection. D) increased venous pressure. D In the period immediately following a myocardial infarction, the manifestations of pallor and diaphoresis, rapid pulse, and anxiety result from: A) onset of circulatory shock. B) the inflammatory response. C) release of enzymes from necrotic tissue. D) heart failure. A [Show Less]
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Ch 32 Personality Disorder Test Bank 100% accurate answers ,A+ test
1. During an assessment interview, a client diagnosed with antisocial personality disorder spits, curses, and refuses to answer questions. Which is the mos... [Show More] t appropriate nursing statement to address this behavior? A. You are very disrespectful. You need to learn to control yourself. B. I understand that you are angry, but this behavior will not be tolerated. C. What behaviors could you modify to improve this situation? D. What anti-personality-disorder medications have helped you in the past? ANS: B The appropriate nursing statement is to reflect the clients feeling while setting firm limits on behavior. Clients diagnosed with antisocial personality disorder have a low tolerance for frustration, see themselves as victims, and use projection as a primary ego defense mechanism. Antidepressants and anxiolytics are used for symptom relief; however, there are no specific medications targeted for the treatment of a personality disorder. 2. A client diagnosed with antisocial personality disorder comes to a nurses station at 11:00 p.m., requesting to phone a lawyer to discuss filing for a divorce. The unit rules state that no phone calls are permitted after 10:00 p.m. Which nursing reply is most appropriate? A. Go ahead and use the phone. I know this pending divorce is stressful. B. You know better than to break the rules. Im surprised at you. C. It is after the 10:00 p.m. phone curfew. You will be able to call tomorrow. D. The decision to divorce should not be considered until you have had a good nights sleep. ANS: C The most appropriate response by the staff is to restate the unit rules in a calm, assertive manner. Because of the probability of manipulative behavior in this client population, it is imperative to maintain consistent application of rules. 3. A client diagnosed with paranoid personality disorder becomes violent on a unit. Which nursing intervention is most appropriate? A. Provide objective evidence that violence is unwarranted. B. Initially restrain the client to maintain safety. C. Use clear, calm statements and a confident physical stance. D. Empathize with the clients paranoid perceptions. ANS: C The most appropriate nursing intervention is to use clear, calm statements and to assume a confident physical stance. A calm attitude avoids escalating the aggressive behavior and provides the client with a feeling of safety and security. It may also be beneficial to have sufficient staff on hand to present a show of strength. 4. A highly emotional client presents at an outpatient clinic appointment wearing flamboyant attire, spiked heels, and theatrical makeup. Which personality disorder should a nurse associate with this assessment data? A. Compulsive personality disorder B. Schizotypal personality disorder C. Histrionic personality disorder D. Manic personality disorder ANS: C The nurse should associate histrionic personality disorder with this assessment data. Individuals diagnosed with histrionic personality disorder tend to be self-dramatizing, attention seeking, overly gregarious, and seductive. They often use manipulation and exhibitionism as a means of gaining attention. 5. A client diagnosed with borderline personality disorder brings up a conflict with the staff in a community meeting and develops a following of clients who unreasonably demand modification of unit rules. How can the nursing staff best handle this situation? A. Allow the clients to apply the democratic process when developing unit rules. B. Maintain consistency of care by open communication to avoid staff manipulation. C. Allow the client spokesperson to verbalize concerns during a unit staff meeting. D. Maintain unit order by the application of autocratic leadership. ANS: B The nursing staff can best handle this situation by maintaining consistency of care by open communication to avoid staff manipulation. Clients diagnosed with borderline personality disorder can exhibit negative patterns of interaction, such as clinging and distancing, splitting, manipulation, and self-destructive behaviors. 6. Which nursing approach should be used to maintain a therapeutic relationship with a client diagnosed with borderline personality disorder? A. Being firm, consistent, and empathetic, while addressing specific client behaviors B. Promoting client self-expression by implementing laissez-faire leadership C. Using authoritative leadership to help clients learn to conform to societal norms D. Overlooking inappropriate behaviors to avoid promoting secondary gains ANS: A The best nursing approach when working with a client diagnosed with borderline personality disorder is to be firm, consistent, and empathetic while addressing specific client behaviors. Individuals diagnosed with borderline personality disorder always seem to be in a state of crisis and can often have negative patterns of interaction, such as manipulation and splitting. 7. Which adult client should a nurse identify as exhibiting the characteristics of a dependent personality disorder? A. A physically healthy client who is dependent on meeting social needs by contact with 15 cats B. A physically healthy client who has a history of depending on intense relationships to meet basic needs C. A physically healthy client who lives with parents and relies on public transportation D. A physically healthy client who is serious, inflexible, perfectionistic, and depends on rules to provide security ANS: C A physically healthy adult client who lives with parents and relies on public transportation exhibits signs of dependent personality disorder. Dependent personality disorder is characterized by a pervasive and excessive need to be taken care of that leads to submissive and clinging behavior. 8. A pessimistic client expresses low self-worth, has much difficulty making decisions, avoids positions of responsibility, and has a behavioral pattern of suffering in silence. Which underlying cause of this clients personality disorder should a nurse recognize? A. Nurturance was provided from many sources, and independent behaviors were encouraged. B. Nurturance was provided exclusively from one source, and independent behaviors were discouraged. C. Nurturance was provided exclusively from one source, and independent behaviors were encouraged. D. Nurturance was provided from many sources, and independent behaviors were discouraged. ANS: B Nurturance provided from one source and discouragement of independent behaviors can attribute to the etiology of dependent personality disorder. Dependent behaviors may be rewarded by a parent who is overprotective and discourages autonomy. 9. Family members of a client ask a nurse to explain the difference between schizoid and avoidant personality disorders. Which is the appropriate nursing reply? A. Clients diagnosed with avoidant personality disorder desire intimacy but fear it, and clients diagnosed with schizoid personality disorder prefer to be alone. B. Clients diagnosed with schizoid personality disorder exhibit odd, bizarre, and eccentric behavior, whereas clients diagnosed with avoidant personality disorder do not. C. Clients diagnosed with avoidant personality disorder are eccentric, and clients diagnosed with schizoid personality disorder are dull and vacant. D. Clients diagnosed with schizoid personality disorder have a history of psychotic thought processes, whereas clients diagnosed with avoidant personality disorder remain based in reality. ANS: A The nurse should educate the family that clients diagnosed with avoidant personality disorder desire intimacy but fear it, whereas clients diagnosed with schizoid personality disorder prefer to be alone. Avoidant personality disorder is characterized by an extreme sensitivity to rejection, which leads to social isolation. Schizoid personality disorder is characterized by a profound deficit in the ability to form personal relationships. 10. During an interview, which client statement indicates to a nurse that a potential diagnosis of schizotypal personality disorder should be considered? A. I really dont have a problem. My family is inflexible, and every relative is out to get me. B. I am so excited about working with you. Have you noticed my new nail polish, Ruby Red Roses? C. I spend all my time tending my bees. I know a whole lot of information about bees. D. I am getting a message from the beyond that we have been involved with each other in a previous life. ANS: D The nurse should assess that a client who states that he or she is getting a message from the beyond indicates a potential diagnosis of schizotypal personality disorder. Individuals with schizotypal personality disorder are aloof and isolated and behave in a bland and apathetic manner. The individual experiences magical thinking, ideas of reference, illusions, and depersonalization as part of daily life. 11. A nursing instructor is teaching students about clients diagnosed with histrionic personality disorder and the quality of their relationships. Which student statement indicates that learning has occurred? A. Their dramatic style tends to make their interpersonal relationships quite interesting and fulfilling. B. Their interpersonal relationships tend to be shallow and fleeting, serving their dependency needs. C. They tend to develop few relationships because they are strongly independent but generally maintain deep affection. D. They pay particular attention to details, which can frustrate the development of relationships. ANS: B The instructor should evaluate that learning has occurred when the student describes clients diagnosed with histrionic personality disorder as having shallow, fleeting interpersonal relationships that serve their dependency needs. Histrionic personality disorder is characterized by colorful, dramatic, and extroverted behavior. These individuals also have difficulty maintaining long-lasting relationships. 12. Which nursing diagnosis should a nurse identify as appropriate when working with a client diagnosed with schizoid personality disorder? A. Altered thought processes R/T increased stress B. Risk for suicide R/T loneliness C. Risk for violence: directed toward others R/T paranoid thinking D. Social isolation R/T inability to relate to others ANS: D An appropriate nursing diagnosis when working with a client diagnosed with schizoid personality disorder is social isolation R/T inability to relate to others. Clients diagnosed with schizoid personality disorder appear cold, aloof, and indifferent to others. They prefer to work in isolation and are unsociable. 13. When planning care for a client diagnosed with borderline personality disorder, which self-harm behavior should a nurse expect the client to exhibit? A. The use of highly lethal methods to commit suicide B. The use of suicidal gestures to evoke a rescue response from others C. The use of isolation and starvation as suicidal methods D. The use of self-mutilation to decrease endorphins in the body ANS: B The nurse should expect that a client diagnosed with borderline personality disorder might use suicidal gestures to evoke a rescue response from others. Repetitive, self-mutilative behaviors are common in clients diagnosed with borderline personality disorders. These behaviors are generated by feelings of abandonment following separation from significant others. 14. Which client situation should a nurse identify as reflective of the impulsive behavior that is commonly associated with borderline personality disorder? A. As the day shift nurse leaves the unit, the client suddenly hugs the nurses arm and whispers, The night nurse is evil. You have to stay. B. As the day shift nurse leaves the unit, the client suddenly hugs the nurses arm and states, I will be up all night if you dont stay with me. C. As the day shift nurse leaves the unit, the client suddenly hugs the nurses arm, yelling, Please dont go! I cant sleep without you being here. D. As the day shift nurse leaves the unit, the client suddenly shows the nurse a bloody arm and states, I cut myself because you are leaving me. ANS: D The clients statement I cut myself because you are leaving me reflects impulsive behavior that is commonly associated with the diagnosis of borderline personality disorder. Repetitive, self-mutilative behaviors are common and are generated by feelings of abandonment following separation from significant others. 15. Which nursing diagnosis should be prioritized when providing care to a client diagnosed with paranoid personality disorder? A. Risk for violence: directed toward others R/T suspicious thoughts B. Risk for suicide R/T altered thought C. Altered sensory perception R/T increased levels of anxiety D. Social isolation R/T inability to relate to others ANS: A The priority nursing diagnosis for a client diagnosed with paranoid personality disorder should be risk for violence: directed toward others R/T suspicious thoughts. Clients diagnosed with paranoid personality disorder have a pervasive distrust and suspiciousness of others that may result in hostile actions to protect self. They are often tense and irritable, which increases the likelihood of violent behavior. 16. Using a behavioral approach, which nursing intervention is most appropriate when caring for a client diagnosed with borderline personality disorder? A. Seclude the client when inappropriate behaviors are exhibited. B. Contract with the client to reinforce positive behaviors with unit privileges. C. Teach the purpose of antianxiety medications to improve medication compliance. D. Encourage the client to journal feelings to improve awareness of abandonment issues. ANS: B The most appropriate nursing intervention from a behavioral perspective is to contract with the client to reinforce positive behaviors with unit privileges. Behavioral strategies offer reinforcement for positive change. 17. A nurse tells a client that the nursing staff will start alternating weekend shifts. Which response should a nurse identify as characteristic of clients diagnosed with obsessive-compulsive personality disorder? A. You really dont have to go by that schedule. Id just stay home sick. B. There has got to be a hidden agenda behind this schedule change. C. Who do you think you are? I expect to interact with the same nurse every Saturday. D. You cant make these kinds of changes! Isnt there a rule that governs this decision? ANS: D The nurse should identify that a client diagnosed with obsessive-compulsive personality disorder would have a difficult time accepting change. This disorder is characterized by inflexibility and lack of spontaneity. Individuals diagnosed with this disorder are very serious, formal, over-disciplined, perfectionistic, and preoccupied with rules. 18. Looking at a slightly bleeding paper cut, the client screams, Somebody help me, quick! Im bleeding. Call 911! A nurse should identify this behavior as characteristic of which personality disorder? A. Schizoid personality disorder B. Obsessive-compulsive personality disorder C. Histrionic personality disorder D. Paranoid personality disorder ANS: C The nurse should identify this behavior as characteristic of histrionic personality disorder. Individuals diagnosed with this disorder tend to be self-dramatizing, attention seeking, over-gregarious, and seductive. 19. Which reaction to a compliment from another client should a nurse identify as a typical response from a client diagnosed with avoidant personality disorder? A. Interpreting the compliment as a secret code used to increase personal power B. Feeling the compliment was well deserved C. Being grateful for the compliment but fearing later rejection and humiliation D. Wondering what deep meaning and purpose are attached to the compliment ANS: C The nurse should identify that a client diagnosed with avoidant personality disorder would be grateful for the comment but would fear later rejection and humiliation. Individuals with avoidant personality disorder are extremely sensitive to rejection and are often awkward and uncomfortable in social situations. 20. Which client symptoms should lead a nurse to suspect a diagnosis of obsessive-compulsive personality disorder? A. The client experiences unwanted, intrusive, and persistent thoughts. B. The client experiences unwanted, repetitive behavior patterns. C. The client experiences inflexibility and lack of spontaneity when dealing with others. D. The client experiences obsessive thoughts that are externally imposed. ANS: C The nurse should suspect a diagnosis of obsessive-compulsive personality disorder when a client experiences inflexibility and lack of spontaneity. Individuals diagnosed with this disorder are very serious and formal and have difficulty expressing emotions. They are perfectionistic and preoccupied with rules. 21. Which client is a nurse most likely to admit to an inpatient facility for self-destructive behaviors? A. A client diagnosed with antisocial personality disorder B. A client diagnosed with borderline personality disorder C. A client diagnosed with schizoid personality disorder D. A client diagnosed with paranoid personality disorder ANS: B The nurse should expect that a client diagnosed with borderline personality disorder would be most likely to be admitted to an inpatient facility for self-destructive behaviors. Clients diagnosed with this disorder often exhibit repetitive, self-mutilative behaviors. Most gestures are designed to evoke a rescue response. 22. When planning care for clients diagnosed with personality disorders, what should be the anticipated treatment outcome? A. To stabilize pathology with the correct combination of medications B. To change the characteristics of the dysfunctional personality C. To reduce inflexibility of personality traits that interfere with functioning and relationships D. To decrease the prevalence of neurotransmitters at receptor sites ANS: C The outcome of treatment for clients diagnosed with personality disorders should be to reduce inflexibility of personality traits that interfere with functioning and relationships. Personality disorders are often difficult and, in some cases, seem impossible to treat. 23. The nurse plans to confront a client about secondary gains related to extreme dependency on her spouse. Which nursing statement would be most appropriate? A. Do you believe dependency issues have been a lifelong concern for you? B. Have you noticed any anxiety during times when your husband makes decisions? C. What do you know about individuals who depend on others for direction? D. How have the specifics of your relationship with your spouse benefited you? ANS: D When a client goes to excessive lengths to obtain nurturance and support from others, the client is seeking secondary gains. Secondary gains provide clients the support and attention that they might not otherwise receive. 24. The nurse should recognize which factors that distinguish personality disorders from psychosis? A. Functioning is more limited in personality disorders than in psychosis. B. Major disturbances of thought are absent in personality disorders. C. Personality disordered clients require hospitalization more frequently. D. Personality disorders do not affect family relationships as much as psychosis. ANS: B Major disturbances of thought are absent in personality disorders and are a classic symptom of psychosis. 25. Which client statement would demonstrate a common characteristic of Cluster B personality disorder? A. I wish someone would make that decision for me. B. I built this building by using materials from outer space. C. Im afraid to go to group because it is crowded with people. D. I didnt have the money for the ring, so I just took it. ANS: D Antisocial personality disorder is included in the Cluster B personality disorders. In this disorder there is a pervasive pattern of disregard for and violation of the rights of others. 26. When a client on an acute care psychiatric unit demonstrates behaviors and verbalizations indicating a lack of guilt feelings, which nursing intervention would help the client to meet desired outcomes? A. Provide external limits on client behavior. B. Foster discussions of rationales for behavioral change. C. Implement interventions consistently by only one staff member. D. Encourage the client to involve self in care. ANS: A Because the client, due to a lack of guilt, cannot or will not impose personal limits on maladaptive behaviors, these limits must be delineated and enforced by staff. [Show Less]
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Ricci Chapter 20 - Test Bank - 4th Edition questions and answers with complete top solutions
1. The nurse is teaching a pregnant woman with type 1 diabetes about her diet during pregnancy. Which client statement indicates that the nurse's teaching... [Show More] was successful? A. "I'll basically follow the same diet that I was following before I became pregnant." B. "Because I need extra protein, I'll have to increase my intake of milk and meat." C. "Pregnancy affects insulin production, so I'll need to make adjustments in my diet." D. "I'll adjust my diet and insulin based on the results of my urine tests for glucose." Answer: C Rationale: In pregnancy, placental hormones cause insulin resistance at a level that tends to parallel growth of the fetoplacental unit. Nutritional management focuses on maintaining balanced glucose levels. Thus, the woman will probably need to make adjustments in her diet. Protein needs increase during pregnancy, but this is unrelated to diabetes. Blood glucose monitoring results typically guide therapy. 2. A pregnant woman with diabetes at 10 weeks' gestation has a glycosylated hemoglobin (HbA1c) level of 13%. At this time the nurse should be most concerned about which possible fetal outcome? A. congenital anomalies B. incompetent cervix C. placenta previa D. placental abruption (abruptio placentae) Answer: A Rationale: A HbA1c level of 13% indicates poor glucose control. This, in conjunction with the woman being in the first trimester, increases the risk for congenital anomalies in the fetus. Elevated glucose levels are not associated with incompetent cervix, placenta previa, or placental abruption (abruptio placentae). 3. A nurse is conducting a review class for a group of perinatal nurses working at the local clinic. The clinic sees a high population of women who are HIV positive. After discussing the recommendations for antiretroviral therapy with the group, the nurse determines that the teaching was successful when the group identifies which rationale as the underlying principle for the therapy? A. reduction in viral loads in the blood B. treatment of opportunistic infections C. adjunct therapy to radiation and chemotherapy D. can cure acute HIV/AIDS infections Answer: A Rationale: Drug therapy is the mainstay of treatment and is important in reducing the viral load as much as possible. Antiretroviral agents do not treat opportunistic infections and are not adjunctive therapy. There is no cure for HIV/AIDS. 4. Assessment of a pregnant woman and her fetus reveals tachycardia and hypertension. There is also evidence suggesting vasoconstriction. The nurse would question the woman about use of which substance? A. marijuana B. alcohol C. heroin D. cocaine Answer: D Rationale: Cocaine use produces vasoconstriction, tachycardia, and hypertension in both the mother and fetus. The effects of marijuana are not yet fully understood. Alcohol ingestion would lead to cognitive and behavioral problems in the newborn. Heroin is a central nervous system depressant. 5. When teaching a class of pregnant women about the effects of substance use during pregnancy, the nurse would include which effect? A. low-birthweight infants B. excessive weight gain C. higher pain tolerance D. longer gestational periods Answer: A Rationale: Substance use during pregnancy is associated with low birth weight infants, preterm labor, abortion, intrauterine growth restriction, abruptio placentae, neurobehavioral abnormalities, and long-term childhood developmental consequences. Excessive weight gain, higher pain tolerance, and longer gestational periods are not associated with substance use. 6. A client who is HIV-positive is in her second trimester and remains asymptomatic. She voices concern about her newborn's risk for the infection. Which statement by the nurse would be most appropriate? A. "You'll probably have a cesarean birth to prevent exposing your newborn." B. "Antibodies cross the placenta and provide immunity to the newborn." C. "Wait until after the infant is born, and then something can be done." D. "Antiretroviral medications are available to help reduce the risk of transmission." Answer: D Rationale: Drug therapy is the mainstay of treatment for pregnant women infected with HIV. The goal of therapy is to reduce the viral load as much as possible; this reduces the risk of transmission to the fetus. Decisions about the method of birth should be based on the woman's viral load, duration of ruptured membranes, progress of labor, and other pertinent clinical factors. The newborn is at risk for HIV because of potential perinatal transmission. Waiting until after the infant is born may be too late. 7. When preparing a schedule of follow-up visits for a pregnant woman with chronic hypertension, which schedule would be most appropriate? A. monthly visits until 32 weeks, then bi-monthly visits B. bi-monthly visits until 28 weeks, then weekly visits C. monthly visits until 20 weeks, then bi-monthly visits D. bi-monthly visits until 36 weeks, then weekly visits Answer: B Rationale: For the woman with chronic hypertension, antepartum visits typically occur every 2 weeks until 28 weeks' gestation and then weekly to allow for frequent maternal and fetal surveillance. 8. A woman with a history of asthma comes to the clinic for evaluation for pregnancy. The woman's pregnancy test is positive. When reviewing the woman's medication therapy regimen for asthma, which medication would the nurse identify as problematic for the woman now that she is pregnant? A. ipratropium B. albuterol C. salmeterol D. Prednisone Answer: D Rationale: Oral corticosteroids such as prednisone are not preferred for the long-term treatment of asthma during pregnancy. Inhaled steroids are the choice for maintenance medications to reduce inflammation that leads to bronchospasm. Common ones prescribed include beclomethasone and salmeterol. Rescue agents such as albuterol or ipratropium provide immediate symptomatic relief by reducing acute bronchospasm. 9. A pregnant woman is diagnosed with iron-deficiency anemia and is prescribed an iron supplement. After teaching her about her prescribed iron supplement, which statement indicates successful teaching? A. "I should take my iron with milk." B. "I should avoid drinking orange juice." C. "I need to eat foods high in fiber." D. "I'll call the primary care provider if my stool is black and tarry." Answer: C Rationale: Iron supplements can lead to constipation, so the woman needs to increase her intake of fluids and high-fiber foods. Milk inhibits absorption and should be discouraged. Vitamin Ccontaining fluids such as orange juice are encouraged because they promote absorption. Ideally the woman should take the iron on an empty stomach to improve absorption, but many women cannot tolerate the gastrointestinal discomfort it causes. In such cases, the woman should take it with meals. Iron typically causes the stool to become black and tarry; there is no need for the woman to notify her primary care provider. 10. The nurse is assessing a newborn of a woman who is suspected of abusing alcohol. Which newborn finding would provide additional evidence to support this suspicion? A. wide, large eyes B. thin upper lip C. protruding jaw D. elongated nose Answer: B Rationale: Newborn characteristics suggesting fetal alcohol spectrum disorder include thin upper lip, small head circumference, small eyes, receding jaw, and short nose. Other features include a low nasal bridge, short palpebral fissures, flat midface, epicanthal folds, and minor ear abnormalities. 11. After teaching a group of nurses working at the women's health clinic about the impact of pregnancy on the older woman, which statement by the group indicates that the teaching was successful? A. "The majority of women who become pregnant over age 35 experience complications." B. "Women over the age of 35 who become pregnant require a specialized type of assessment." C. "Women over age 35 and are pregnant have an increased risk for spontaneous abortions." D. "Women over age 35 are more likely to have a substance use disorder." Answer: C Rationale: Whether childbearing is delayed by choice or by chance, women starting a family at age 35 or older are not doing so without risk. Women in this age group may already have chronic health conditions that can put the pregnancy at risk. In addition, numerous studies have shown that increasing maternal age is a risk factor for infertility and spontaneous abortions, gestational diabetes, chronic hypertension, postpartum hemorrhage, preeclampsia, preterm labor and birth, multiple pregnancy, genetic disorders and chromosomal abnormalities, placenta previa, fetal growth restriction, low Apgar scores, and surgical births (Dillion et al. 2019). However, even though increased age implies increased complications, most women today who become pregnant after age 34, have healthy pregnancies and healthy newborns. Nursing assessment of the pregnant woman over age 35 is the same as that for any pregnant woman. Women of this age have the same risk for a substance use disorder as any other age group. 12. A nurse is conducting an in-service presentation to a group of perinatal nurses about sexually transmitted infections and their effect on pregnancy. The nurse determines that the teaching was successful when the group identifies which infection as being responsible for ophthalmia neonatorum? A. syphilis B. gonorrhea C. chlamydia D. HPV Answer: B Rationale: Infection with gonorrhea during pregnancy can cause ophthalmia neonatorum in the newborn from birth through an infected birth canal. Infection with syphilis can cause congenital syphilis in the neonate. Infection with chlamydia can lead to conjunctivitis or pneumonia in the newborn. Exposure to HPV during birth is associated with laryngeal papillomas. 13. A nurse is preparing a presentation for a group of young adult pregnant women about common infections and their effect on pregnancy. When describing the infections, which infection would the nurse include as the most common congenital and perinatal viral infection in the world? A. rubella B. hepatitis B C. cytomegalovirus D. parvovirus B19 Answer: C Rationale: Although rubella, hepatitis B, and parovirus B19 can affect pregnant women and their fetuses, cytomegalovirus (CMV) is the most common congenital and perinatal viral infection in the world. CMV is the leading cause of congenital infection, with morbidity and mortality at birth and sequelae. Each year approximately 1% to 7% of pregnant women acquire a primary CMV infection. Of these, about 30% to 40% transmits infection to their fetuses. 14. A pregnant woman asks the nurse, "I'm a big coffee drinker. Will the caffeine in my coffee hurt my baby?" Which response by the nurse would be most appropriate? A. "The caffeine in coffee has been linked to birth defects." B. "Caffeine has been shown to restrict growth in the fetus." C. "Caffeine is a stimulant and needs to be avoided completely." D. "If you keep your intake to less than 200 mg/day, you should be okay." Answer: D Rationale: The effect of caffeine intake during pregnancy on fetal growth and development is still unclear. A recent study found that caffeine intake of no more than 200 mg/day during pregnancy does not affect pregnancy duration and the condition of the newborn. Birth defects have not been linked to caffeine consumption, but maternal coffee consumption decreases iron absorption and may increase the risk of anemia during pregnancy. It is not known if there is a correlation between high caffeine intake and miscarriage due to lack of sufficient studies. 15. A neonate born to a mother who was abusing heroin is exhibiting signs and symptoms of withdrawal. Which signs would the nurse assess? Select all that apply. A. low whimpering cry B. hypertonicity C. lethargy D. excessive sneezing E. overly vigorous sucking F. tremors Answer: B, D, F Rationale: Signs and symptoms of withdrawal, or neonatal abstinence syndrome, include: irritability, hypertonicity, excessive and often high-pitched crying, vomiting, diarrhea, feeding disturbances, respiratory distress, disturbed sleeping, excessive sneezing and yawning, nasal stuffiness, diaphoresis, fever, poor sucking, tremors, and seizures. 16. A nurse has been invited to speak at a local high school about adolescent pregnancy. When developing the presentation, the nurse would incorporate information related to which aspects? Select all that apply. A. peer pressure to become sexually active B. rise in teen birth rates over the years. C. Asian Americans as having the highest teen birth rate D. loss of self-esteem as a major impact E. about half occurring within a year of first sexual intercourse Answer: A, D Rationale: Adolescent pregnancy has emerged as one of the most significant social problems facing our society. Early pregnancies among adolescents have major health consequences for mothers and their infants. The latest estimates show that approximately 1 million teenagers become pregnant each year in the United States, accounting for 13% of all U.S. births, but the rates have been declining in the last several years. Teen birth rates in the United States have declined but remain high,especially among African American and Hispanic teenagers and adolescents in southern states. The most important impact lies in the psychosocial area as it contributes to a loss of self-esteem, a destruction of life projects, and the maintenance of the circle of poverty. Moreover, about half of all teen pregnancies occur within 6 months of first having sexual intercourse. About one in four teen mothers under age 18 have a second baby within 2 years after the birth of the first baby. 17. A nurse is counseling a pregnant woman with rheumatoid arthritis about medications that can be used during pregnancy. The nurse would emphasize the need to avoid which medication at this time? A. hydroxychloroquine B. nonsteroidal anti-inflammatory drugs C. glucocorticoid D. methotrexate Answer: D Rationale: Methotrexate is contraindicated during pregnancy. For rheumatoid arthritis, medications are limited to hydroxychloroquine, glucocorticoids, and NSAIDS. 18. A nurse is preparing a teaching program for a group of pregnant women about preventing infections during pregnancy. When describing measures for preventing cytomegalovirus infection, which measure would the nurse include as a priority? A. frequent handwashing B. immunization C. prenatal screening D. antibody titer screening Answer: A Rationale: Most women are asymptomatic and do not know they have been exposed to CMV. Prenatal screening for CMV infection is not routinely performed. Since there is no therapy that prevents or treats CMV infections, nurses are responsible for educating and supporting childbearing-age women at risk for CMV infection. Stressing the importance of good handwashing and use of sound hygiene practices can help to reduce transmission of the virus. There is no immunization for CMV. Antibody titer levels would be useful for identifying women at risk for rubella. 19. A pregnant woman comes to the clinic for her first evaluation. The woman is screened for hepatitis B (HBV) and tests positive. The nurse would anticipate administering which agent? A. HBV immune globulin B. HBV vaccine C. acylcovir D. valacyclovir Answer: A Rationale: If a woman tests positive for HBV, expect to administer HBV immune globulin. The newborn will also receive HBV vaccine within 12 hours of birth. Acyclovir or valacyclovir would be used to treat herpes simplex virus infection. 20. After teaching a pregnant woman with iron deficiency anemia about nutrition, the nurse determines that the teaching was successful when the woman identifies which foods as being good sources of iron in her diet? Select all that apply. A. dried fruits B. peanut butter C. meats D. milk E. white bread Answer: A, B, C Rationale: Foods high in iron include meats, green leafy vegetables, legumes, dried fruits, whole grains, peanut butter, bean dip, whole-wheat fortified breads, and cereals. 21. A pregnant woman with gestational diabetes comes to the clinic for a fasting blood glucose level. When reviewing the results, the nurse determines that the woman is achieving good glucose control based on which result? A. 88 mg/dL B. 100 mg/dL C. 110 mg/dL D. 120 mg/dL Answer: A Rationale: For a pregnant woman with diabetes, the ADA and ACOG recommend maintaining a fasting blood glucose level below 95 mg/dL, with postprandial levels below 140 mg/dL at 1 hour, below 120 mg/dL at 2 hours. 22. A nurse is conducting a program for pregnant women with gestational diabetes about reducing complications. The nurse determines that the teaching was successful when the group identifies which factor as being most important in helping to reduce complications associated with pregnancy and diabetes? A. stability of the woman's emotional and psychological status B. degree of blood glucose control achieved during the pregnancy C. reduction in retinopathy risk by frequent ophthalmologic evaluations D. control of blood urea nitrogen (BUN) levels for optimal kidney function Answer: B Rationale: Therapeutic management for the woman with diabetes focuses on tight glucose control, thereby minimizing the risks to the mother, fetus, and neonate. The woman's emotional and psychological status is highly variable and may or may not affect the pregnancy. Evaluating for long-term diabetic complications such as retinopathy or nephropathy, as evidenced by laboratory testing such as BUN levels, is an important aspect of preconception care to ensure that the mother enters the pregnancy in an optimal state. 23. A nurse is providing care to several pregnant women at different weeks of gestation. The nurse would expect to screen for group B streptococcus infection in the client who is at: A. 16 weeks' gestation. B. 28 weeks' gestation. C. 32 weeks' gestation. D. 36 weeks' gestation. Answer: D Rationale: Pregnant women between 36 and 37 weeks' gestation should be universally screened for GBS infection during a prenatal visit and if positive, receive appropriate intrapartum antibiotic prophylaxis. 24. A woman with a history of systemic lupus erythematosus comes to the clinic for evaluation. The woman tells the nurse that she and her partner would like to have a baby but that they are afraid her lupus will be a problem. Which response would be most appropriate for the nurse to make? A. "It's probably not a good idea for you to get pregnant since you have lupus." B. "Be sure that your lupus is stable or in remission for 6 months before getting pregnant." C. "Your lupus will not have any effect on your pregnancy whatsoever." D. "If you get pregnant, we'll have to add quite a few medications to your normal treatment plan. Answer: B Rationale: The time at which the nurse comes in contact with the woman in her childbearing life cycle will determine the focus of the assessment. If the woman is considering pregnancy, it is recommended that she postpone conception until the disease has been stable or in remission for 6 months. Active disease at time of conception and history of renal disease increase the likelihood of a poor pregnancy outcome (Cunningham et al., 2018). In particular, if pregnancy is planned during periods of inactive or stable disease, the result is often giving birth to healthy full-term babies without increased risks of pregnancy complications. Nonetheless, pregnancies with most autoimmune diseases are still classified as high risk because of the potential for major complications. Preconception counseling should include the medical and obstetric risks of spontaneous abortion, stillbirth, fetal death, fetal growth restriction, preeclampsia, preterm labor, and neonatal death and the need for more frequent visits for monitoring the condition. Treatment of SLE in pregnancy is generally limited to NSAIDs (e.g., ibuprofen), prednisone, and an antimalarial agent, hydroxychloroquine. During pregnancy in the woman with SLE, the goal is to keep drug therapy to a minimum. 25. A nurse is conducting a presentation for a group of pregnant women about measures to prevent toxoplasmosis. The nurse determines that additional teaching is needed when the group identifies which measure as preventive? A. washing raw fruits and vegetables before eating them B. cooking all meat to an internal temperature of 125° F (52° C) C. wearing gardening gloves when working in the soil D. avoiding contact with a cat's litter box Answer: B Rationale: Meats should be cooked to an internal temperature of 160° F (71° C). Other measures to prevent toxoplasmosis include peeling or thoroughly washing all raw fruits and vegetables before eating them, wearing gardening gloves when in contact with outdoor soil, and avoiding the emptying or cleaning of a cat's litter box. 26. A pregnant client with iron-deficiency anemia is prescribed an iron supplement. After teaching the woman about using the supplement, the nurse determines that more teaching is needed based on which client statement? A. "Taking the iron supplement with food will help with the side effects." B. "I will need to avoid coffee and tea when I take this supplement." C. "I will take the iron with milk instead of orange or grapefruit juice." D. "If I happen to miss a dose, I will take it as soon as I remember." Answer: C Rationale: The pregnant client should take the iron supplement with vitamin C-containing fluids such as orange juice, which will promote absorption, rather than milk, which can inhibit iron absorption. Taking iron on an empty stomach improves its absorption, but many women cannot tolerate the gastrointestinal discomfort it causes. In such cases, the woman is advised to take it with meals. The woman also needs instruction about adverse effects, which are predominantly gastrointestinal and include gastric discomfort, nausea, vomiting, anorexia, diarrhea, metallic taste, and constipation. Taking the iron supplement with meals and increasing intake of fiber and fluids helps overcome the most common side effects. If the woman misses a dose, she should take a dose as soon as she remembers. 27. A client in her first trimester comes to the clinic for an evaluation. Assessment reveals reports of fatigue, anorexia, and frequent upper respiratory infections. The client's skin is pale and the client is slightly tachycardic. The client also reports drinking about 6 cups of coffee on average each day. A diagnosis of iron-deficiency anemia is suspected. The client is scheduled for laboratory testing and the results are as follows: • Hemoglobin 11.5 g/dL (115 g/L) • Hematocrit 35% (0.35) • Serum iron 32 μg/dL (5.73 μmol/L) • Serum ferritin 90 ng/dL (90 μg/L) Which laboratory finding would the nurse correlate with the suspected diagnosis? A. Hemoglobin B. Hematocrit C. Serum iron level D. Serum ferritin level Answer: D Rationale: Laboratory tests for iron-deficiency anemia usually reveal low hemoglobin (less than 11 g/dL or 110 g/L), low hematocrit (less than 35% or 0.35), low serum iron (less than 30 μg/dL or 5.37 μmol/L), microcytic and hypochromic cells, and low serum ferritin (less than 100 ng/dL or 100 μg/L). The client's hemoglobin, hematocrit, and serum iron levels are borderline low normal, but the client's serum ferritin is below 100 ng/dL (100 μg/L), helping to support the diagnosis. 28. A young adult woman comes to the clinic for a routine check-up. During the visit, the woman who works in a day care facility tells the nurse that she and her partner are considering having a baby. "We are concerned that I might be exposed to common childhood illnesses." The woman undergoes testing and finds out that she is not immune from chickenpox. Based on this information, which information would the nurse give to the client? A. "You will need to be vaccinated now and wait at least 1 month before getting pregnant." B. "It is very likely that you will need to quit your job if you do get pregnant." C. "Because chickenpox is so rare nowadays, there is nothing to worry about." D. "You will need to take a leave of absence during winter and spring months." Answer: A Rationale: Preconception counseling is important for preventing chickenpox (varicella). A major component of counseling involves determining the woman's varicella immunity. Vaccination is the cornerstone of prevention. The vaccine is administered if needed. Varicella vaccine is a live attenuated viral vaccine. It should be administered to all adolescents and adults 13 years of age and older who do not have evidence of varicella immunity. Therefore, the woman should be vaccinated now before she becomes pregnant and then wait at least 1 month before getting pregnant. The varicella vaccine is contraindicated for pregnant women because the effects of the vaccine on the fetus are unknown. There is no need for the woman to quit her job once she is immunized nor does she need to take a leave of abscence during the winter and spring months when the incidence is highest. Chickenpox does occur and is highly contagious. Maternal varicella can be transmitted to the fetus through the placenta, leading to congenital varicella syndrome if the mother is infected during the first half of pregnancy via an ascending aorta. 29. A nurse is obtaining a medication history from a pregnant client with a history of systemic lupus erythematosus (SLE). Which medication(s) would the nurse expect the woman to report to be currently using? Select all that apply. A. Ibuprofen B. Hydroxychloroquine C. Methotrexate D. Leflunomide E. Prednisone Answer: A, B, E Rationale: Treatment of SLE in pregnancy is generally limited to NSAIDs like ibuprofen, prednisone, and an antimalarial agent, hydroxychloroquine. Methotrexate and leflunomide are used to treat rheumatoid arthritis but are contraindicated for use in pregnancy because of the potential for fetal toxicity. 30. The nurse reviews the medical record of a woman who has come to the clinic for an evaluation. The client has a history of mitral valve prolapse and is listed as risk class II. During the visit, the woman states, "We want to have a baby, but I know I am at higher risk. But what is my risk, really?" Which response by the nurse would be appropriate? A. "If you do get pregnant, you will need to be seen by a cardiologist every other month for monitoring." B. "Your risk during pregnancy is small, but you should see your cardiologist first before getting pregnant." C. "Your heart disease would put too much strain on your heart if you were to get pregnant." D. "Your pregnancy would be uneventful, but you would need specialized care for labor and birth." Answer: B Rationale: Typically, a woman with class I or II cardiac disease can go through a pregnancy without major complications. For class I disease, there is no detectable increased risk of maternal mortality and no increase or a mild increase in morbidity. For class II disease, there is a small increased risk of maternal mortality or moderate increase in morbidity and cardiac consultation should occur every trimester. It is best to have the woman see her cardiologist before becoming pregnant. A woman with class III disease needs frequent visits with the cardiac care team throughout pregnancy. There is a significantly increased risk of maternal mortality or severe morbidity and cardiologist consult should occur every other month with prenatal care and delivery occurring at an appropriate level hospital. A woman with class IV disease is typically advised to avoid pregnancy. 31. A pregnant woman with chronic hypertension is entering her second trimester. The nurse is providing anticipatory guidance to the woman about measures to promote a healthy outcome. The nurse determines that the teaching was successful based on which client statement(s)? Select all that apply. A. "I will need to schedule follow-up appointments every 2 weeks until I reach 32 weeks' gestation." B. "I should try to lie down and rest on my left side for about an hour each day." C. "I will start doing daily counts of my baby's activity at about 24 weeks' gestation." D. "I will need to have an ultrasound at each visit beginning at 28 weeks' gestation." E. "I should take my blood pressure frequently at home and report any high readings." Answer: B, C, E Rationale: The woman with chronic hypertension will be seen more frequently (every 2 weeks until 28 weeks' gestation and then weekly until birth) to monitor her blood pressure and to assess for any signs of preeclampsia. At approximately 24 weeks' gestation, the woman will be instructed to document fetal movement. At this same time, serial ultrasounds will be prescribed to monitor fetal growth and amniotic fluid volume. The woman should also have daily periods of rest (1 hour) in the left lateral recumbent position to maximize placental perfusion and use home blood pressure monitoring devices frequently (daily checks would be preferred), reporting any elevations. [Show Less]
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Pathophysiology Chapter 1- Test Bank 100% accurate answers, latest 2023
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Ch 13 Crisis Intervention Test Bank questions and answers, verified
1. Crises occur when an individual: A. Is exposed to a precipitating stressor B. Perceives a stressor to be threatening C. Has no support system D. E... [Show More] xperiences a stressor & perceives coping strategies to be ineffective Answer: D 2. Amanda's mobile home was destroyed in a tornado. She received only minor injuries but is experiencing disabling anxiety in the aftermath of the event. What is this type of crisis called? A. Crisis resulting from traumatic stress B. Maturational/developmental crisis C. Dispositional crisis D. Crisis of anticipated life transitions Answer: A 1. A mother is concerned about her ability to perform in her new role. She is quite anxious and refuses to leave the postpartum unit. To offer effective client care, a nurse should recognize which information about this type of crisis? A. This type of crisis is precipitated by unexpected external stressors. B. This type of crisis is precipitated by preexisting psychopathology. C. This type of crisis is precipitated by an acute response to an external situational stressor. D. This type of crisis is precipitated by normal life-cycle transitions that overwhelm the client. ANS: D The nurse should understand that this type of crisis is precipitated by normal life-cycle transitions that overwhelm the client. Reassurance and guidance should be provided as needed, and the client should be referred to services that can provide assistance. 2. A wife brings her husband to an emergency department after an attempt to hang himself. He is a full-time student and works 8 hours at night to support his family. He states, I cant function any longer under all this stress. Which type of crisis is the client experiencing? A. Maturational/developmental crisis B. Psychiatric emergency crisis C. Anticipated life transition crisis D. Traumatic stress crisis ANS: B The nurse should determine that the client is experiencing a psychiatric emergency crisis. Psychiatric emergencies occur when crisis situations result in severe impairment, incompetence, or inability to assume personal responsibility. 3. A client comes to a psychiatric clinic, experiencing sudden extreme fatigue and decreased sleep and appetite. The client works 12 hours a day and rates anxiety as 8/10 on a numeric scale. What correctly written long-term outcome is realistic in addressing this clients crisis? A. The client will change his or her type A personality traits to more adaptive ones by week 1. B. The client will list five positive self-attributes. C. The client will examine how childhood events led to an overachieving orientation. D. The client will return to previous adaptive levels of functioning by week 6. ANS: D The nurse should identify that a realistic long-term outcome for this client would be to return to previous adaptive levels of functioning. The nurse should work with the client to develop attainable outcomes that reflect the immediacy of the situation. To be correctly written, an outcome must be client-centered, specific, measurable, realistic, and contain a time frame. 4. A high school student has learned that she cannot graduate. Her boyfriend will be attending a college out of state that she planned to also attend. She is admitted to a psychiatric unit after overdosing on Tylenol. Which is the correctly written priority nursing diagnosis for this client? A. Ineffective coping R/T situational crisis AEB powerlessness B. Anxiety R/T fear of failure C. Risk for self-directed violence R/T hopelessness D. Risk for low self-esteem R/T loss events AEB suicidal ideations ANS: C The priority nursing diagnosis for this client is Risk for self-directed violence R/T hopelessness. Nurses should prioritize diagnoses and outcomes on the basis of potential safety risk to the client and/or others. Nursing diagnoses should be correctly written to include evidence if actual and no evidence if the diagnosis is determined to be potential. 5. After threatening to jump off a bridge, a client is brought to an emergency department by police. To assess for suicide potential, which question should a nurse ask first? A. Are you currently thinking about harming yourself? B. Why do you want to harm yourself? C. Have you thought about the consequences of your actions? D. Who is your emergency contact person? ANS: A The nurse should first assess the client for current suicidal thoughts to minimize risk of harm and provide appropriate interventions. A suicidal client is experiencing a psychiatric emergency. The crisis team should prioritize safety by assessing the client for thoughts of self-harm. 6. An involuntarily committed client, when offered a dinner tray, pushes it off the bedside table onto the floor. Which intervention should a nurse prioritize to address this behavior? A. Initiate forced medication protocol. B. Help the client to explore the source of anger. C. Ignore the act to avoid reinforcing the behavior. D. With staff support and a show of solidarity, set firm limits on the behavior. ANS: D The most appropriate nursing intervention is to set firm limits on the behavior. Pushing food onto the floor does not warrant forced medication because the behavior is not a direct safety concern. Exploring the source of anger may be appropriate after the client has gained emotional control. Ignoring the act may further upset the client and does not reinforce appropriate behavior. 7. A college student who was nearly raped while jogging completes a series of appointments with a rape crisis nurse. At the final session, which client statement most clearly suggests that the goals of crisis intervention have been met? A. You've really been helpful. Can I count on you for continued support? B. I don't work out anymore. C. I'm really glad I didn't go home. It would have been hard to come back. D. I carry mace when I jog. It makes me feel safe and secure. ANS: D The nurse should evaluate that the client who has developed adaptive coping strategies has achieved the goals of crisis intervention. 8. A despondent client, who has recently lost her husband of 30 years, tearfully states, Ill feel a lot better if I sell my house and move away. Which nursing reply is most appropriate? A. I'm confident you know what's best for you. B. This may not be the best time for you to make such an important decision. C. Your children will be terribly disappointed. D. Tell me why you want to make this change. ANS: B During crisis intervention, the nurse should guide the client through a problem-solving process. The nurse should help the individual confront the source of the problem, encourage the individual to discuss changes he or she would like to make, and encourage exploration of feelings about aspects of the crisis that cannot be changed. The nurse should also assist the client in determining whether any changes are realistic and if timing of change is appropriate. This response encourages the client to think through what may be an impulsive decision. 9. An inpatient client with a known history of violence suddenly begins to pace. Which client behavior should alert a nurse to escalating anger and aggression? A. The client requests prn medications. B. The client has a tense facial expression and body language. C. The client refuses to eat lunch. D. The client sits in group therapy with back to peers. ANS: B The nurse should assess that tense facial expressions and body language may indicate that a clients anger is escalating. The nurse should conduct a thorough assessment of the clients past and current violent behaviors and develop interventions for de-escalation. 10. What is the best nursing rationale for holding a debriefing session with clients and staff after clients have witnessed a peer being taken down after a violent outburst? A. To reinforce unit rules with the client population B. To create protocols for the future release of tensions associated with anger C. To process feelings and concerns related to the witnessed intervention D. To discuss the client problems that led to inappropriate expressions of anger ANS: C The nurse should determine that the purpose for holding a debriefing session with clients and staff after clients have witnessed a peer being taken down after a violent outburst is to process feelings and concerns related to the witnessed intervention. 11. Which of the following nursing statements and/or questions represent appropriate communication to assess an individual in crisis? Select all that apply. A. Tell me what happened. B. What coping methods have you used, and did they work? C. Describe to me what your life was like before this happened. D. Lets focus on the current problem. E. Ill assist you in selecting functional coping strategies. ANS: A, B, C In the assessment phase, the nurse should gather information regarding the precipitating stressor and the resulting crisis. Focusing on the current problem and selecting functional coping strategies are nursing interventions rather than assessments. 12. Which of the following are effective interventions that a nurse should utilize when caring for an inpatient client who expresses anger inappropriately? Select all that apply. A. Maintain a calm demeanor. B. Clearly delineate the consequences of the behavior. C. Use therapeutic touch to convey empathy. D. Set limits on the behavior. E. Teach the client to avoid I statements related to expression of feelings. ANS: A, B, D The nurse should determine that when working with an inpatient client who expresses anger inappropriately, it is important to maintain a calm demeanor, clearly define the consequences, and set limits on the behavior. The use of therapeutic touch may not be appropriate and could escalate the clients anger. [Show Less]
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