Details of TEST BANK MEDICAL SURGICAL NURSING Concepts for Interprofessional 9TH EDITION IgnataviciusContents
Chapter 01: Overview of Professional
... [Show More] Nursing Concepts for Medical- Surgical Nursing ............................. 2 Chapter 02: Overview of Health Concepts for Medical-Surgical Nursing ................................ ......... 8 Chapter 03: Common Health Problems of Older Adults................................ ....................... 13 Chapter 04: Assessment and Care of Patients with Pain ................................ ...................... 20 Chapter 05: Genetic Concepts for Medical-Surgical Nursing ................................ ................... 33 Chapter 06: Rehabilitation Concepts for Chronic and Disabling Health Problems ................................ . 38 Chapter 07: End-of-Life Care ................................ ................................ ............. 45 Chapter 08: Concepts of Emergency and Trauma Nursing ................................ .................... 51 Chapter 09: Care of Patients with Common Environmental Emergencies ................................ ....... 57 Chapter 10: Concepts of Emergency and Disaster Preparedness ................................ ............... 64 Chapter 11: Assessment and Care of Patients with Fluid and Electrolyte Imbalances ............................. 70 Chapter 12: Assessment and Care of Patients with Acid-Base Imbalances ................................ ...... 78 Chapter 13: Infusion Therapy ................................ ................................ ............. 85 Chapter 14: Care of Preoperative Patients ................................ ................................ .. 96 Chapter 15: Care of Intraoperative Patients ................................ ............................... 105 Chapter 16: Care of Postoperative Patients ................................ ................................ 112 Chapter 17: Inflammation and Immunity ................................ ................................ .. 119 Chapter 18: Care of Patients with Arthritis and Other Connective Tissue Diseases .............................. 125 Chapter 19: Care of Patients with HIV Disease ................................ ............................. 141 Chapter 20: Care of Patients with Hypersensitivity (Allergy) and Autoimmunity ................................ 150 Chapter 21: Cancer Development ................................ ................................ ........ 155 Chapter 22: Care of Patients with Cancer................................ ................................ .. 159 Chapter 23: Care of Patients with Infection ................................ ................................ 169 Chapter 24: Assessment of the Skin, Hair, and Nails ................................ ........................ 176 Chapter 25: Care of Patients with Skin Problems ................................ ........................... 181 Chapter 26: Care of Patients with Burns ................................ ................................ .. 198 Chapter 27: Assessment of the Respiratory System ................................ ......................... 214 Chapter 28: Care of Patients Requiring Oxygen Therapy or Tracheostomy ................................ ...... 221 Chapter 29: Care of Patients with Noninfectious Upper Respiratory Problems ................................ .. 227 Chapter 30: Care of Patients with Noninfectious Lower Respiratory Problems ................................ .. 233 Chapter 31: Care of Patients with Infectious Respiratory Problems ................................ ........... 246 Chapter 32: Care of Critically Ill Patients with Respiratory Problems ................................ ......... 257 Chapter 33: Assessment of the Cardiovascular System ................................ ...................... 270 Chapter 34: Care of Patients with Dysrhythmias ................................ ........................... 280 Chapter 35: Care of Patients with Cardiac Problems ................................ ........................ 289 Chapter 36: Care of Patients with Vascular Problems ................................ ....................... 300 Chapter 37: Care of Patients with Shock ................................ ................................ .. 313 Chapter 38: Care of Patients with Acute Coronary Syndromes ................................ ............... 320 Chapter 39: Assessment of the Hematologic System ................................ ........................ 330 Chapter 40: Care of Patients with Hematologic Problems ................................ .................... 334 Chapter 41: Assessment of the Nervous System ................................ ............................ 347
1 | P a g eChapter 42: Care of Patients with Problems of the CNS: The Brain ................................ ........... 357
Chapter 43: Care of Patients with Problems of the CNS: The Spinal Cord ................................ ...... 368
Chapter 44: Care of Patients with Problems of the Peripheral Nervous System ................................ . 378
Chapter 45: Care of Critically Ill Patients with Neurologic Problems ................................ .......... 384
Chapter 46: Assessment of the Eye and Vision ................................ ............................. 398
Chapter 47: Care of Patients with Eye and Vision Problems ................................ ................. 401
Chapter 48: Assessment and Care of Patients with Ear and Hearing Problems ................................ .. 407
Chapter 49: Assessment of the Musculoskeletal System ................................ ..................... 414
Chapter 50: Care of Patients with Musculoskeletal Problems ................................ ................ 419
Chapter 51: Care of Patients with Musculoskeletal Trauma ................................ .................. 427
Chapter 52: Assessment of the Gastrointestinal System ................................ ..................... 439
Chapter 53: Care of Patients with Oral Cavity Problems ................................ ..................... 445
Chapter 54: Care of Patients with Esophageal Problems ................................ ..................... 449
Chapter 55: Care of Patients with Stomach Disorders ................................ ....................... 458
Chapter 56: Care of Patients with Noninflammatory Intestinal Disorders ................................ ...... 465
Chapter 57: Care of Patients with Inflammatory Intestinal Disorders ................................ ......... 475
Chapter 58: Care of Patients with Liver Problems ................................ .......................... 486
Chapter 59: Care of Patients with Problems of the Biliary System and Pancreas ................................ 494
Chapter 60: Care of Patients with Malnutrition: Undernutrition and Obesity ................................ .... 503
Chapter 61: Assessment of the Endocrine System ................................ .......................... 512
Chapter 62: Care of Patients with Pituitary and Adrenal Gland Problems ................................ ...... 518
Chapter 63: Care of Patients with Problems of the Thyroid and Parathyroid Glands ............................. 526
Chapter 64: Care of Patients with Diabetes Mellitus ................................ ........................ 533
Chapter 65: Assessment of the Renal/Urinary System ................................ ...................... 556
Chapter 66: Care of Patients with Urinary Problems ................................ ........................ 564
Chapter 67: Care of Patients with Kidney Disorders ................................ ........................ 576
Chapter 68: Care of Patients with Acute Kidney Injury and Chronic Kidney Disease ............................. 583
Chapter 69: Assessment of the Reproductive System ................................ ....................... 595
Chapter 70: Care of Patients with Breast Disorders ................................ ......................... 599
Chapter 71: Care of Patients with Gynecologic Problems ................................ .................... 606
Chapter 72: Care of Patients with Male Reproductive Problems ................................ .............. 613
Chapter 73: Care of Transgender Patients ................................ ................................ . 622
Chapter 74: Care of Patients with Sexually Transmitted Diseases ................................ ............. 626
Chapter 01: Overview of Professional Nursing Concepts for Medical- Surgical Nursing
MULTIPLE CHOICE
1. A nurse wishes to provide client-centered care in all interactions. Which action by
the nurse best demonstrates this concept?
a. Assesses for cultural influences affecting health care
b. Ensures that all the clients basic needs are met
c. Tells the client and family about all upcoming tests
d. Thoroughly orients the client and family to the room
ANS: A
Competency in client-focused care is demonstrated when the nurse focuses on communication,
2 | P a g eculture, respect compassion, client education, and empowerment. By assessing the effect of the
clients culture on health care, this nurse is practicing client-focused care. Providing for basic
needs does not demonstrate this competence.
Simply telling the client about all upcoming tests is not providing empowering education.
Orienting the client and family to the room is an important safety measure, but not directly
related to demonstrating client-centered care.
DIF: Understanding/Comprehension REF: 3
KEY: Patient-centered care| culture MSC: Integrated Process:
Caring NOT: Client Needs Category: Psychosocial Integrity
2. A nurse is caring for a postoperative client on the surgical unit. The clients blood pressure
was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse is
best?
a. Call the Rapid Response Team.
b. Document and continue to monitor.
c. Notify the primary care provider.
d. Repeat blood pressure measurement in 15 minutes.
ANS: A
The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating
before they suffer either respiratory or cardiac arrest. Since the client has manifested a
significant change, the nurse should call the RRT. Changes in blood pressure, mental status, heart
rate, and pain are particularly significant.
Documentation is vital, but the nurse must do more than document. The primary care
provider should be notified, but this is not the priority over calling the RRT. The clients
blood pressure should be reassessed frequently, but the priority is getting the rapid care to
the client.
DIF: Applying/Application REF: 3
KEY: Rapid Response Team (RRT)| medical
emergencies MSC: Integrated Process: Communication
and Documentation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. A nurse is orienting a new client and family to the inpatient unit. What information does the
nurse provide to help the client promote his or her own safety?
a. Encourage the client and family to be active partners.
b. Have the client monitor hand hygiene in caregivers.
c. Offer the family the opportunity to stay with the client.
d. Tell the client to always wear his or her armband.
ANS: A
Each action could be important for the client or family to perform. However, encouraging the
client to be active in his or her health care as a partner is the most critical. The other actions are
very limited in scope and do not provide the broad protection that being active and involved
does.
DIF: Understanding/Comprehension REF: 3
KEY: Patient safety
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
4. A new nurse is working with a preceptor on an inpatient medical-surgical unit. The
preceptor advises the student that which is the priority when working as a professional
nurse?
a. Attending to holistic client needs
b. Ensuring client safety
3 | P a g ec. Not making medication errors
d. Providing client-focused care
ANS: B
All actions are appropriate for the professional nurse. However, ensuring client safety is the
priority. Up to 98,000 deaths result each year from errors in hospital care, according to the 2000
Institute of Medicine report. Many more clients have suffered injuries and less serious outcomes.
Every nurse has the responsibility to guard the clients safety.
DIF: Understanding/Comprehension REF: 2
KEY: Patient safety
MSC: Integrated Process: Nursing Process: Intervention
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
5. A client is going to be admitted for a scheduled surgical procedure. Which action does the
nurse explain is the most important thing the client can do to protect against errors?
a. Bring a list of all medications and what they are for.
b. Keep the doctors phone number by the telephone.
c. Make sure all providers wash hands before entering the room.
d. Write down the name of each caregiver who comes in the room.
ANS: A
Medication errors are the most common type of health care mistake. The Joint Commissions
Speak Up campaign encourages clients to help ensure their safety. One recommendation is for
clients to know all their medications and why they take them. This will help prevent medication
errors.
DIF: Applying/Application REF: 4
KEY: Speak Up campaign| patient safety MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
6. Which action by the nurse working with a client best demonstrates respect for autonomy?
a. Asks if the client has questions before signing a consent
b. Gives the client accurate information when questioned
c. Keeps the promises made to the client and family
d. Treats the client fairly compared to other clients
ANS: A
Autonomy is self-determination. The client should make decisions regarding care. When the nurse
obtains a signature on the consent form, assessing if the client still has questions is vital,
because without full information the client cannot practice autonomy. Giving accurate
information is practicing with veracity.
Keeping promises is upholding fidelity. Treating the client fairly is providing social justice.
DIF: Applying/Application REF: 4
KEY: Autonomy| ethical principles MSC: Integrated Process: Caring
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
7. A student nurse asks the faculty to explain best practices when communicating with a person
from the lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) community. What
answer by the faculty is most accurate?
a. Avoid embarrassing the client by asking questions.
b. Dont make assumptions about their health needs.
c. Most LGBTQ people do not want to share information.
d. No differences exist in communicating with this population.
ANS: B
Many members of the LGBTQ community have faced discrimination from health care providers
4 | P a g eand may be reluctant to seek health care. The nurse should never make assumptions about the
needs of members of this population. Rather, respectful questions are appropriate. If
approached with sensitivity, the client with any health care need is more likely to answer
honestly.
DIF: Understanding/Comprehension REF: 4
KEY: LGBTQ| diversity
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Psychosocial Integrity
8. A nurse is calling the on-call physician about a client who had a hysterectomy 2 days ago and
has pain that is unrelieved by the prescribed narcotic pain medication. Which statement is part
of the SBAR format for communication?
a. A: I would like you to order a different pain medication.
b. B: This client has allergies to morphine and codeine.
c. R: Dr. Smith doesnt like nonsteroidal anti-inflammatory meds.
d. S: This client had a vaginal hysterectomy 2 days ago.
ANS: B
SBAR is a recommended form of communication, and the acronym stands for Situation,
Background, Assessment, and Recommendation. Appropriate background information includes
allergies to medications the on-call physician might order. Situation describes what is happening
right now that must be communicated; the clients surgery 2 days ago would be considered
background. Assessment would include an analysis of the clients problem; asking for a different
pain medication is a recommendation. Recommendation is a statement of what is needed or
what outcome is desired; this information about the surgeons preference might be better placed
in background.
DIF: Applying/Application REF: 5
KEY: SBAR| communication
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
9. A nurse working on a cardiac unit delegated taking vital signs to an experienced
unlicensed assistive personnel (UAP). Four hours later, the nurse notes the clients blood
pressure is much higher than previous readings, and the clients mental status has changed.
What action by the nurse would most likely have prevented this negative outcome?
a. Determining if the UAP knew how to take blood pressure
b. Double-checking the UAP by taking another blood pressure
c. Providing more appropriate supervision of the UAP
d. Taking the blood pressure instead of delegating the task
ANS: C
Supervision is one of the five rights of delegation and includes directing, evaluating, and
following up on delegated tasks. The nurse should either have asked the UAP about the vital
signs or instructed the UAP to report them right away. An experienced UAP should know how
to take vital signs and the nurse should not have to assess this at this point. Double-checking
the work defeats the purpose of delegation. Vital signs are within the scope of practice for a UAP
and are permissible to delegate. The only appropriate answer is that the nurse did not provide
adequate instruction to the UAP.
DIF: Applying/Application REF: 6
KEY: Supervision| delegation| unlicensed assistive
personnel MSC: Integrated Process: Communication
and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
10. A nurse is talking with a client who is moving to a new state and needs to find a new doctor
and hospital there. What advice by the nurse is best?
5 | P a g ea. Ask the hospitals there about standard nurse-client ratios.
b. Choose the hospital that has the newest technology.
c. Find a hospital that is accredited by The Joint Commission.
d. Use a facility affiliated with a medical or nursing school.
ANS: C
Accreditation by The Joint Commission (TJC) or other accrediting body gives assurance that the
facility has a focus on safety. Nurse-client ratios differ by unit type and change over time. New
technology doesnt necessarily mean the hospital is safe. Affiliation with a health professions
school has several advantages, but safety is most important.
DIF: Understanding/Comprehension REF:
2 KEY: The Joint Commission (TJC)|
accreditation
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
11. A newly graduated nurse in the hospital states that, since she is so new, she cannot
participate in quality improvement (QI) projects. What response by the precepting nurse is
best?
a. All staff nurses are required to participate in quality improvement here.
b. Even being new, you can implement activities designed to improve care.
c. Its easy to identify what indicators should be used to measure quality.
d. You should ask to be assigned to the research and quality committee.
ANS: B
The preceptor should try to reassure the nurse that implementing QI measures is not out of
line for a newly licensed nurse. Simply stating that all nurses are required to participate does not
help the nurse understand how that is possible and is dismissive. Identifying indicators of quality
is not an easy, quick process and would not be the best place to suggest a new nurse to start.
Asking to be assigned to the QI committee does not give the nurse information about how to
implement QI in daily practice.
DIF: Applying/Application REF: 6
KEY: Quality improvement
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
MULTIPLE RESPONSE
1. A nurse is interested in making interdisciplinary work a high priority. Which actions by
the nurse best demonstrate this skill? (Select all that apply.)
a. Consults with other disciplines on client care
b. Coordinates discharge planning for home safety
c. Participates in comprehensive client rounding
d. Routinely asks other disciplines about client progress
e. Shows the nursing care plans to other disciplines
ANS: A, B, C, D
Collaborating with the interdisciplinary team involves planning, implementing, and evaluating
client care as a team with all other disciplines included. Simply showing other caregivers the
nursing care plan is not actively involving them or collaborating with them.
DIF: Applying/Application REF: 4
KEY: Collaboration| interdisciplinary team
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
2. A nurse manager wishes to ensure that the nurses on the unit are practicing at their highest
6 | P a g elevels of competency. Which areas should the manager assess to determine if the nursing staff
demonstrate competency according to the Institute of Medicine (IOM) report Health
Professions Education: A Bridge to Quality? (Select all that apply.)
a. Collaborating with an interdisciplinary team
b. Implementing evidence-based care
c. Providing family-focused care
d. Routinely using informatics in practice
e. Using quality improvement in client care
ANS: A, B, D, E
The IOM report lists five broad core competencies that all health care providers should practice.
These include collaborating with the interdisciplinary team, implementing evidence-based practice,
providing client-focused care, using informatics in client care, and using quality improvement in
client care.
DIF: Remembering/Knowledge REF: 3
KEY: Competencies| Institute of Medicine (IOM)
MSC: Integrated Process: Nursing Process:
Assessment
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
3. The nurse utilizing evidence-based practice (EBP) considers which factors when planning
care? (Select all that apply.)
a. Cost-saving measures
b. Nurses expertise
c. Client preferences
d. Research findings
e. Values of the client
ANS: B, C, D, E
EBP consists of utilizing current evidence, the clients values and preferences, and the nurses
expertise when planning care. It does not include cost-saving measures.
DIF: Remembering/Knowledge
REF: 6 KEY: Evidence-based
practice (EBP)
MSC: Integrated Process: Nursing Process: Planning
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
4. A nurse manager wants to improve hand-off communication among the staff. What actions by
the manager would best help achieve this goal? (Select all that apply.)
a. Attend hand-off rounds to coach and mentor.
b. Conduct audits of staff using a new template.
c. Create a template of topics to include in report.
d. Encourage staff to ask questions during hand-off.
e. Give raises based on compliance with reporting.
ANS: A, B, C, D
A good tool for standardizing hand-off reports and other critical communication is the SHARE
model. SHARE stands for standardize critical information, hardwire within your system, allow
opportunities to ask questions, reinforce quality and measurement, and educate and coach.
Attending hand-off report gives the manager opportunities to educate and coach. Conducting
audits is part of reinforcing quality. Creating a template is hardwiring within the system.
Encouraging staff to ask questions and think critically about the information is allowing
opportunities to ask questions. The manager may need to tie raises into compliance if the staff
is resistive and other measures have failed, but this is not part of the SHARE model.
DIF: Applying/Application REF: 5
7 | P a g eKEY: SHARE| hand-off
communication
MSC: Integrated Process: Nursing Process: Intervention
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
Chapter 02: Overview of Health Concepts for Medical-Surgical Nursing
MULTIPLE CHOICE
1. Acid-base balance occurs when the pH level of the blood is between:
a. 7.3 and 7.5
b. 7.35 and 7.45
c. 7.4 and 7.5
d. 7.25 and 7.35
ANS: B
Acid-base balance is the maintenance of arterial blood pH between 7.35 and 7.45 through
hydrogen ion production and elimination.
DIF: Understanding/Comprehension REF:
13 KEY: Assessment
MSC: Physiological Adaptation | Fluid and Electrolyte
Imbalances NOT: Describe common fluid, electrolyte, and
acid-base imbalances.
2. The nurse would expect a patient with respiratory acidosis to have an excessive amount of
a. Hydrogen ions.
b. Bicarbonate.
c. Oxygen.
d. Phosphate.
ANS: A
Respiratory acidosis occurs when the arterial blood pH level falls below 7.35 and is caused by
either too many hydrogen ions in the body (respiratory acidosis) or too little bicarbonate
(metabolic acidosis). Excessive oxygen and phosphate are not characteristic of respiratory
acidosis.
DIF: Understanding/Comprehension REF:
13 KEY: Assessment
MSC: Physiological Adaptation | Fluid and Electrolyte
Imbalances NOT: Describe common fluid, electrolyte, and
acid-base imbalances.
3. The best way for an individual to maintain acid-base balance is to
a. avoid or quit smoking.
b. exercise regularly.
c. eat healthy and well-balanced meals.
d. All of the above.
ANS: D
Maintaining a healthy lifestyle is the best way to maintain acid-base balance. For example, most
cases of COPD can be prevented by avoiding or quitting smoking, while regular exercise and a
healthy diet can decrease the incidence of type-2 diabetes.
DIF: Patient education REF:
14 KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
8 | P a g e4. The process to control cellular growth, replication, and differentiation to maintain homeostasis is called:
a. cellular regulation.
b. cellular impairment.
c. cellular reproduction.
d. cellular tumor.
ANS: A
Cellular Regulation is the term used to describe both the positive and negative aspects of cellular function
within the body.
DIF: Understanding/Comprehension REF:
14 KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
5. A defining characteristic of malignant (cancerous) cells is:
a. they cannot spread to other tissues or organs.
b. they can invade healthy cells, tissues, and organs.
c. they are not usually a health risk.
d. none of the above.
ANS: B
Malignant (cancerous) cells have no comparison to the original cells from which they are
derived, and they have the ability to invade healthy cells, tissues, and other organs through
tumor formation and invasion. On the other hand, Benign cells do not have the ability to spread
to other tissues or organs.
DIF: Understanding/Comprehension REF:
14 KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
6. Specialized cells that circulate in the body to promote clotting are called:
a. anticoagulants.
b. proteins.
c. emboli.
d. platelets.
ANS: D
Clotting is a complex, multi-step process through which blood forms a protein-based clot to
prevent excessive bleeding. Platelets (thrombocytes) are the specialized cells that circulate in the
blood and are activated when an injury occurs. Once activated, these cells become sticky, causing
them to clump together to form a temporary, localized, solid plug.
DIF: Understanding/Comprehension REF:
15 KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
7. An increase in platelet stickiness can lead to:
a. hypercoagulability
b. thromobocytopenia
c. embolus
d. atrial fibrillation
ANS: A
Hypercoagulability refers to an increase in clotting ability caused by an excess of platelets or
excessive plately stickiness, which can impair blood flow. The opposite end of the spectrum
9 | P a g einvolves an inability to form adequate clots, which often occurs when there is an inadequate
number of circulating platelets or a reduction in platelet stickiness.
DIF: Understanding/Comprehension REF:
15 KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
8. Signs and symptoms of
a. arterial
b. venous
c. partial
d. atrial
ANS: B
Venous thrombosis is a clot formation in either superficial or deep veins, usually in the leg, and
can be observed locally.
DIF: Understanding/Comprehension REF:
16 KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
9. A serious condition which is not locally observable and is typically manifested by decreased
blood flow to a distal extremity is known as
thrombosis.
a. arterial
b. venous
c. partial
d. atrial
ANS: A
Arterial thrombosis is manifested by decreased blood flow (perfusion) to a distal extremity or
internal organ. For example, the distal leg can become pale and cool in the case of a femoral
arterial clot due to blockage of blood to the leg. This is an emergent condition and requires
immediate intervention.
DIF: Understanding/Comprehension REF:
16 KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
10. A high-level thinking process that allows an individual to make decisions and judgments is known as:
a. amnesia
b. personality
c. reasoning
d. memory
ANS: C
Reasoning is the high-level cognitive thinking process that helps individuals make decisions
and judgments. Personality is the way an individual feels and behaves, while Memory is the
ability of an individual to retain and recall information. Amnesia refers to a loss of memory
caused by brain trauma, congenital disorders, or acute health problems.
DIF: Understanding/Comprehension REF:
16 KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Psychosocial Integrity
10 | P a g e
thromobsis include localized redness, swelling, and warmth:11. A form of inadequate cognition in older adults which is manifested by an acute, fluctuating
confusional state is known as:
a. dementia
b. delerium
c. amnesia
d. depression
ANS: B
Delerium is the form of acute, fluctuating confusion which lasts from a few hours to less than 1
month and that may be treatable. Dementia is a chronic state of confusion that may last from a
few months to many years and that may not be reversible. Amnesia refers to a loss of memory
caused by brain trauma, congenital disorders, or acute health problems.
DIF: Understanding/Comprehension REF:
16 KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Psychosocial Integrity
12. The most common causes of decreased comfort for a patient are pain and
a. light-headedness
b. nausea
c. emotional stress
d. depression
ANS: C
Pain and emotional stress are the two leading causes of discomfort for a patient. For example,
patients who are having surgery are often anxious and feel stressed about the procedure. This
emotional stress may negatively impact the outcome of surgery.
DIF: Understanding/Comprehension REF:
17 KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Safe and Effective Care Environment
13. The inability to pass stool is known as
a. constipation
b. obstipation
c. diarrhea
d. incontinence
ANS: B
Obstipation is the inability to pass stool during bowel elimination. Constipation refers to the
condition where stool can be hard, dry, and difficult to pass through the rectum. Diarrhea is at
the opposite end of the continuum from constipation, and occurs when stool is watery and
without solid form. Elimination is the general term to describe the excretion of waste from the
body by the gastrointestinal tract and by the urinary system.
DIF: Understanding/Comprehension REF:
18 KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
14. Hypokalemia can occur in patients with prolonged diarrhea and is caused by a decrease in:
a. calcium
b. magnesium
c. sodium
d. potassium
ANS: D
11 | P a g e
.
.Hypokalemia occurs when there is a decrease in serum potassium. It can be a life-threatening
condition because it often causes rhythm abnormalities. An excess of potassium is referred to as
Hyperkalemia.
DIF: Understanding/Comprehension REF:
18 KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
15. The minimum hourly urinary output in a patient should be at least:
a. 5 mL per hour
b. 10 mL per hour
c. 30 mL per hour
d. 60 mL per hour
ANS: C
30 mL per hour is the minimum hourly urinary output in a normal healthy adult. A decrease in
urinary output i a sign of diminished kidney activity and fluid deficit.
DIF: Understanding/Comprehension REF:
20 KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
16. The best indicator of fluid volume changes in the body is:
a. skin dryness
b. weight changes
c. blood pressure
d. pulse rate
ANS: C
Changes in weight are the best indicator of fluid volume changes in the body. Monitoring blood
pressure, checking pulse rate and quality, and assessing skin and mucous membranes for dryness
are strong secondary indicators.
DIF: Understanding/Comprehension REF:
20 KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
17. Immunity which occurs when antibodies are passed from the mother to the fetus through
the placenta or through breast milk is called:
a. natural passive
b. artifical passive
c. natural active
d. artifical active
ANS: A
Artifical passive immunity occurs via a specific transfusion. Natural active immunity occurs when
an antigen enters the body and the body creates antibodies to fight off the antigen. Artifical active
immunity occurs via vaccination or immunization.
DIF: Understanding/Comprehension REF:
21-22 KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
18. A major serum protein that is below normal in patients who have inadequate nutrition is:
12 | P a g ea. Albumin
b. Globulin
c. Fibrinogen
d. Transferrin
ANS: A
A serum laboratory test to measure Albumin is the most common assessment for generalized
malnutrition.
DIF: Understanding/Comprehension REF:
25 KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
Chapter 03: Common Health Problems of Older Adults
MULTIPLE CHOICE
1. A nurse working with older adults in the community plans programming to improve morale
and emotional health in this population. What activity would best meet this goal?
a. Exercise program to improve physical function
b. Financial planning seminar series for older adults
c. Social events such as dances and group dinners
d. Workshop on prevention from becoming an abuse victim
ANS: A
All activities would be beneficial for the older population in the community. However, failure in
performing ones own activities of daily living and participating in society has direct effects on
morale and life satisfaction. Those who lose the ability to function independently often feel
worthless and empty. An exercise program designed to maintain and/or improve physical
functioning would best address this need.
DIF: Applying/Application REF: 32
KEY: Independence| autonomy| older adult
MSC: Integrated Process: Nursing Process:
Planning NOT: Client Needs Category:
Psychosocial Integrity
2. A nurse caring for an older client on a medical-surgical unit notices the client reports frequent
constipation and only wants to eat softer foods such as rice, bread, and puddings. What
assessment should the nurse perform first?
a. Auscultate bowel sounds.
b. Check skin turgor.
c. Perform an oral assessment.
d. Weigh the client.
ANS: C
Poorly fitting dentures and other dental problems are often manifested by a preference for soft
foods and constipation from the lack of fiber. The nurse should perform an oral assessment to
determine if these problems exist. The other assessments are important, but will not yield
information specific to the clients food preferences as they relate to constipation.
DIF: Applying/Application REF:
30 KEY: Nutrition| dentures|
older adult
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort
3. A nursing faculty member working with students explains that the fastest growing
13 | P a g esubset of the older population is which group? a. Elite old b. Middle old c. Old old d. Young old
ANS: C The old old is the fastest growing subset of the older population. This is the group comprising those 85 to 99 years of age. The young old are between 65 and 74 years of age; the middle old are between 75 and 84 years of age; and the elite old are over 100 years of age.
DIF: Remembering/Knowledge REF: 29 KEY: Adulthood| aging| old old MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance
4. A nurse is working with an older client admitted with mild dehydration. What teaching does the nurse provide to best address this issue?
a. Cut some sodium out of your diet. b. Dehydration can cause incontinence. c. Have something to drink every 1 to 2 hours. [Show Less]