Prioritization Delegation and Assignment 4th Edition LaCharity Test Bank
Table of Contents Chapter 1. Pain ................................
... [Show More] ................................ ..... 1
Chapter 2. Cancer ................................ ................................ ... 9 Chapter 3. Immunologic Problems ................................ .................... 16 Chapter 4. Fluid, Electrolyte, and Acid-Base Balance Problems ............................. 23 Chapter 5. Safety and Infection Control ................................ ................ 30 Chapter 6. Respiratory Problems ................................ ..................... 36 Chapter 7. Cardiovascular Problems ................................ ................... 45 Chapter 8. Hematologic Problems ................................ ..................... 50 Chapter 9. Neurologic Problems ................................ ...................... 55 Chapter 10. Visual and Auditory Problems ................................ .............. 61 Chapter 11. Musculoskeletal Problems ................................ ................. 68 Chapter 12. Gastrointestinal and Nutritional Problems ................................ ... 75 Chapter 13. Diabetes Mellitus ................................ ........................ 81 Chapter 14. Other Endocrine Problems ................................ ................ 88 Chapter 15. Integumentary Problems ................................ .................. 93 Chapter 16. Renal and Urinary Problems ................................ ............... 98 Chapter 17. Reproductive Problems ................................ .................. 105 Chapter 18. Problems in Pregnancy and Childbearing ................................ ... 111 Chapter 19. Pediatric Problems ................................ ...................... 118 Chapter 20. Pharmacology ................................ .......................... 127 Chapter 21. Emergencies and Disasters ................................ ............... 134 Chapter 22. Psychiatric–Mental Health Problems ................................ ....... 140
Chapter 1. Pain MULTIPLE CHOICE 1.A client tells the nurse that she rarely experiences pain, but when she does, she seeks medical attention. The nurse realizes this client understands that pain is important because it:
1. 2. 3. 4.
ANS: 1 1 | P a g e is a protective system.
includes the automatic withdrawal reflex. creates sensitivity to pain.
helps with healing.Pain is a protective system that includes protection from unsafe behaviors by use of reflexes,
memory, and avoidance. Even though the automatic withdrawal reflex is a part of the pain
response, it does not explain why pain is important. Pain does not create sensitivity to pain.
Pain does not help with healing.
PTS: 1 DIF: Analyze REF: Definitions and Implications of Pain
2.A client complains that the bed sheets touching his skin are extremely painful. The
nurse realizes this client is experiencing:
1.
2.
3.
4.
allodynia.
modulation.
kinesthesia.
proprioception.
ANS: 1
Allodynia or hyperalgesia is a state where a slight or nonpainful stimulus is interpreted as
very painful. Kinesthesia is the awareness of movement. Proprioception is the awareness of
body position. Modulation is an influencing factor in the perception of pain.
PTS: 1 DIF: Analyze REF: Peripheral Nervous System
3.A client is complaining of severe abdomen pain. The nurse realizes this client is
experiencing which type of pain?
1.
2.
3.
4.
Neuralgia
Pathological
Somatic
Visceral
ANS: 4
Visceral pain is pain arising from the body organs or gastrointestinal tract. Somatic pain is
pain that originates from the bone, joints, muscles, skin, or connective pain. Neuralgia and
pathological pain are both types of pain that result from injury to a nerve or malfunction of
the neuronal transmission process or due to impaired regulation.
PTS:1DIF:AnalyzeREF:Types of Pain
4.A client, diagnosed with acute appendicitis, is experiencing abdominal pain. The best way
for the nurse to describe this clients pain would be:
1.
2.
3.
4.
chronic.
neuropathic.
referred.
acute.
ANS: 4
Acute pain onset is sudden and of short duration. Chronic pain is a sudden or slow onset of
mild to severe pain that lasts longer than 6 months. Referred pain is the result of the transfer
of visceral pain sensations to a body surface at a distance from the actual origin.
Neuropathic pain is paroxysmal pain that occurs along the branches of a nerve.
2 | P a g ePTS:1DIF:ApplyREF:Types of Pain
5.A client is observed holding a pillow over the abdominal region with both knees flexed
in a side-lying position. Vital signs assessment reveals an elevated blood pressure and
heart rate. Which of the following should the nurse say to this client?
1.
2.
3.
4.
Can I get you anything?
Would you like something for pain?
You look comfortable.
Your blood pressure is up.
ANS: 2
Sympathetic responses to pain include elevated blood pressure and heart rate. And since the
client is hugging a pillow over the abdominal region with both knees flexed in a side-lying
position, the best thing for the nurse to say to this client is Would you like something for
pain? The other responses are incorrect because they do not acknowledge that the client is
experiencing pain.
PTS: 1 DIF: Apply REF: Assessing the Clinical Manifestations of Pain
6.A client experiencing chronic pain asks the nurse why she is not prescribed Demerol like
she received when she had a total knee replacement. Which of the following should the
nurse respond to this client?
1.
2.
3.
4.
You dont need something that strong.
That medication does not exist anymore.
That medication does not last very long.
It can cause you have high blood pressure.
ANS: 3
Meperidine is no longer a major drug for acute or chronic pain due to its short analgesic
duration of 2 to 3 hours and the potential for accumulative toxic effects of its metabolite,
normeperidine. The best response for the nurse to make to the client would be that
medication does not last very long. The other responses are inaccurate.
PTS:1DIF:ApplyREF:Opioid Analgesics
7.A client is informed that a tricyclic antidepressant medication is going to help control
his chronic pain. The nurse would expect the physician to prescribe:
1.
2.
3.
4.
Amitriptyline.
Baclofen.
Gabapentin.
Diazepam.
ANS: 1
Amitriptyline is an antidepressant. Gabapentin is an anticonvulsant. Baclofen is a
muscle relaxant. Diazepam is a benzodiazepine.
PTS: 1 DIF: Analyze REF: Adjuvant Medications
8.A client receiving around-the-clock medication for terminal cancer experiences additional
3 | P a g epain when performing activities of daily living. The nurse realizes this client is experiencing:
1.
breakthrough pain.
2.
3.
4.
intractable pain.
psychosomatic pain.
acute pain.
ANS: 1
Breakthrough pain is commonly seen in the advanced stages of cancer. It is spontaneous,
unpredictable, and can be initiated by certain activities such as during activities of daily
living. Intractable pain is resistant to some or all forms of therapy. Psychosomatic pain is that
which has a psychological origin. The client is diagnosed with terminal cancer. Acute pain has
a sudden onset and resolves within 6 months.
PTS:1DIF:AnalyzeREF:Breakthrough Pain
9.A client recovering from surgery tells the nurse that she is nauseated and is
experiencing an increase in pain. Which of the following does this clients symptoms
suggest to the nurse?
1
.
2
.
3
.
The client is becoming dependent upon the pain medication.
The clients pain threshold is lower when experiencing nausea.
The client is experiencing withdrawal symptoms from pain medication.
4 | P a g e4
.
The client is experiencing referred pain.
ANS: 2
Pain threshold is influenced by nausea, fatigue, and lack of sleep. The client experiencing an
increase in pain during nausea is demonstrating an alteration in the pain threshold. The
client is not becoming dependent upon the pain medication. The client is not experiencing
withdrawal symptoms. The client is also not experiencing referred pain.
PTS: 1 DIF: Analyze REF: Pain Threshold and Pain Tolerance
10.A client with a history of malingering pain tells the nurse that he needs a prescription for
pain medication. Which of the following should the nurse do first to assist this client?
1
.
2
.
3
.
4
.
Ask the physician for a pain medication prescription for the client.
Remind the client that he does not have pain but just wants the medication.
Thoroughly assess the client for pain.
Suggest the client seek counseling for his pain medication-seeking behavior.
ANS: 3
Pain of a psychological origin is when an individual seeks treatment for pain when no actual
pain exists. This is also referred to as malingering or pretending pain. The nurse should not
assume that the pain does not exist but rather should conduct a thorough pain assessment to
rule out an actual physiological problem. The nurse should not immediately ask the physician
for pain medication. The nurse should not remind the client that he does not have pain but
just wants the medication. The nurse should also not suggest the client seek counseling for
pain medication- seeking behavior.
PTS: 1 DIF: Apply REF: Box 16-1 Pain Descriptions
11.The nurse is implementing the five Cs of pain management for a client. Which of
the following is included in this intervention?
1
.
2
.
3
.
4
.
Caring for the client in a holistic manner
Creating a calm environment
Comparing the degree of pain reported with previous episodes
Continuously assessing the clients pain
ANS: 4
The five Cs of pain management include comprehensive assessment, consistent use of
assessment tools, continuous reassessment, customize the plan of care, and collaborate with
other health care providers to plan pain management. The other choices are not included in
5 | P a g ethe five Cs of pain management.
PTS: 1 DIF: Apply REF: Planning and Implementation
12.A client, diagnosed with arthritis, should be instructed to avoid the use of NSAIDs because
of which of the following prescribed medications?
1.
2.
3.
4.
Penicillin
Coumadin
Digoxin
Diazide
ANS: 2
Persons at greatest risk for adverse reactions to NSAIDs include those who are prescribed
warfarin (Coumadin) since the NSAID can increase the effects of the Coumadin and
promote bleeding.
PTS: 1 DIF: Apply REF: Box 16-2 Groups of NSAID Drugs
MULTIPLE RESPONSE
1. Prior to hospitalization, a client had been ingesting high doses of oxycodone. The nurse
suspects the client is experiencing symptoms of withdrawal when which of the following
are assessed? (Select all that apply.)
1.
2.
3.
4.
5.
6.
Muscle twitching and spasms
Restlessness
Increased heart rate
Drop in blood pressure
Increase in blood pressure
Irritability
ANS: 1, 2, 3, 5, 6
Withdrawal symptoms include myoclonus or muscle twitching and spasms, restlessness,
irritability, increased heart rate, and increased blood pressure. A decrease in blood pressure
is not a symptom of narcotic medication withdrawal.
PTS:1DIF:Analyze
REF: Potential and Actual Side Effects of Opioid Analgesics
2. The nurse would be concerned that a client is at risk for developing chronic pain when
which of the following health problems are diagnosed? (Select all that apply.)
1.
2.
3.
Osteoarthritis
Osteoporosis
Heart disease
6 | P a g e4.
5.
6.
Diabetes mellitus
Chronic pulmonary disease
Anemia
ANS: 1, 2, 5
Common health problems associated with chronic pain include osteoarthritis, osteoporosis,
and chronic pulmonary disease. Heart disease, diabetes mellitus, and anemia are not
associated with chronic pain.
PTS:1DIF:AnalyzeREF:Chronic Pain
3. An 84-year-old client is experiencing severe arthritis pain. The nurse realizes that which of
the following pain management approaches would be the most beneficial for this client?
(Select all that apply.)
1.
2.
3.
4.
5.
6.
Avoid NSAIDs.
Utilize morphine or morphine-like medication.
Provide medication through the oral route.
Utilize diazepam.
Suggest Darvocet.
Provide medication through the intramuscular route.
ANS: 1, 2, 3
When providing pain medication to a geriatric client, pain management approaches include
the utilization of morphine or morphine-like medication to control pain and provide
medication using the oral route. NSAIDs should also be avoided because of the risk of
gastrointestinal bleeding. Diazepam should be avoided because of a long half-life. Darvocet
should be avoided because of toxic effects with renal insufficiency. Medication should not be
provided using the intramuscular route because of muscle wasting and loss of fatty tissue
in the elderly client.
PTS: 1 DIF: Apply REF: Geriatric Considerations
4.A client with severe pain from spinal stenosis is prescribed Methadone. The nurse realizes
that the advantages of this medication are what? (Select all that apply.)
1.
2.
3.
4.
5.
6.
Decrease in the need for antidepressant adjuvant medication
Less frequent dosing schedule
Long half-life
Inexpensive
Can be used for intermittent pain
Does not cause respiratory depression
ANS: 1, 2, 4
The advantages of methadone include that it decreases the need for antidepressant
adjuvant medication because it increases the release of serotonin and norepinephrine,
dosing is every 12
hours, and it is inexpensive. Disadvantages of this medication include: it has a long half-life;
7 | P a g eit cannot be used for intermittent pain management; and it does cause respiratory
depression.
PTS:1DIF:AnalyzeREF:Intractable Pain
5.The nurse is using the PAINAID Scale to assess a clients level of pain. Which of the
following are assessed with this pain scale? (Select all that apply.)
1.
2.
3.
4.
5.
6.
Breathing rate
Assign a number to the degree of pain
Negative vocalizations
Assign a facial expression to the degree of pain
Facial expression
Body language
ANS: 1, 3, 5, 6
The PAINAID scale assesses breathing, negative vocalizations, facial expression, body
language, and comfort. The Numerical Rating Scale assigns a number to the degree of pain.
The Wong- Baker FACES Scale assigns a facial expression to the degree of pain.
PTS: 1 DIF: Apply REF: Skills 360: Pain Assessment Tools
6.A client diagnosed with severe arthritis tells the nurse that she always has some degree of
pain. Which of the following could explain this clients poor pain management? (Select all that
apply.)
1.
2.
3.
4.
5.
6.
Client does not appear to be in pain.
Client does not report pain.
Client cannot afford pain medication.
Client is fearful of becoming addicted to pain medication.
Client believes pain medication means the condition is worse.
Client has a high pain tolerance.
ANS: 1, 2, 4, 5
Barriers to pain assessment and management include that the client is not demonstrating
overt signs of pain, and therefore she does not need pain medication; the client does not
report pain, so therefore she does not need pain medication; the client is fearful of becoming
addicted to pain medication; and the client believes pain medication means the condition is
worse. The fact that the client is unable to afford pain medication and is having a high pain
tolerance are not identified barriers to pain assessment and management.
PTS: 1 DIF: Analyze REF: Barrier to Pain Assessment and Pain Management
7.The nurse determines that a client is experiencing chronic pain when which of the
following is assessed? (Select all that apply.)
1.
Suffering
8 | P a g e2.
3.
4.
5.
6.
Fatigue
Sleeplessness
Apathy
Sadness
Anger
ANS: 1, 3, 5
The descriptor triad for chronic pain is suffering, sleeplessness, and sadness. Fatigue, apathy,
and anger do not describe chronic pain.
Chapter 2. Cancer
MULTIPLE CHOICE
1.The nurse realizes that for a cell to become cancer, it needs to progress through four
stages. Which of the following is not a stage of this process?
1.
2.
3.
4.
Initiation
Metastasis
Progression
Stimulation
ANS: 4
The four stages of oncogenesis or carcinogenesis are: 1) initiation, 2) promotion, 3)
progression, and 4) metastasis. Stimulation is not a stage of carcinogenesis.
PTS:1DIF:AnalyzeREF:Carcinogenesis
2.A clients most recent prostate-specific antigen level has decreased since starting
treatment for prostate cancer. The nurse realizes this level would indicate that the client:
1.
2.
3.
4.
no longer has the disease.
has an increase in the severity of the disease process.
is responding to treatment.
should be retested.
ANS: 3
A decrease in a tumor marker is important in the assessment of cancer, monitoring tumor
response during treatment strategies, and diagnosis of recurrence of disease. A decrease in
the prostate-specific antigen level once treatment has begun for prostate cancer would
indicate that the client is responding to treatment. A drop in the level does not mean that
the client no longer has the disease, that the disease is progressing, or that the client needs
to be retested.
PTS:1DIF:AnalyzeREF:Laboratory Tests
3.A clients tumor was staged using the TNM system. The tumor was staged as T4,N1,Mx.
The nurse realizes that this staging means:
9 | P a g e1
.
2
.
3
.
4
.
tumor in situ, minimal node involvement, no presence of metastasis.
large tumor, no node involvement, presence of metastasis.
medium tumor, multiple nodes involvement, no presence of metastasis.
large tumor, single node involvement, unable to assess metastasis.
ANS: 4
The larger the number in the TNM staging system, the increasing involvement or larger size
of the tumor, node, and metastasis. T4 reflects the size of the tumor. N1 describes the
regional node involvement. Mx signals the inability to assess the presence or absence of
distant metastasis.
PTS:1DIF:AnalyzeREF:Staging and Grading
4.Which of the following statements made by a client after receiving instruction
regarding internal radiation would indicate that teaching has been successful?
1
.
2
.
3
.
4
.
My children can come visit me after school.
Individuals will need to keep at least 3 feet away when possible.
I will be sharing a room near the nursing station.
The hospital staff will limit the amount of time in my room.
ANS: 4
General guidelines include assigning the patient to a private room; postradiation precaution
signage; limiting the amount of time in the room; observing a distance of at least 6 feet from
the source when possible; and prohibiting pregnant staff, family, visitors, and children from
interacting or visiting with the patient. The other choices would indicate the need for
additional instruction and are incorrect.
PTS:1DIF:AnalyzeREF:Internal Radiation
5.A client, prescribed to begin chemotherapy, asks the nurse How does chemotherapy
work? Which of the following should the nurse respond to this client?
1.
2.
3.
4.
ANS: 1
Chemotherapy is the use of drugs that prevent, kill, or block the growth and spread of
cancer cells. Some noncancerous cells can be damaged during chemotherapy. External
10 | P a g e
It prevents the process of cell growth and replication.
It kills only cancer cells.
It treats the exposed area only with high-energy rays.
Agents are implanted in an area to inhibit cancer growth.radiation treats an exposed area with high-energy rays. Internal radiation uses implanted
agents.
PTS:1DIF:ApplyREF:Chemotherapy
6.A client is prescribed interferon as part of treatment for cancer. Which of the following
should the nurse instruct the client regarding this medication?
1.
2.
3.
4.
Flu-like symptoms should be reported to the physician.
General fatigue while receiving this medication is common.
Seek emergency care with a high fever.
Side effects are short term and will resolve in a few days.
ANS: 2
Side effects vary by the type of biological agent, including a flu-like illness, high fever,
headache, and general fatigue. These are expected effects and do not need to be reported
to the physician. Side effects of these medications are long term and can vary in intensity
during the course of treatment.
PTS:1DIF:ApplyREF:Biological Therapy
7.A client recovering from bone marrow transplantation is experiencing vomiting, fatigue,
and skin reactions. Which of the following should the nurse do to help this client?
1
.
2
.
3
.
4
.
Prepare to administer platelets as prescribed.
Prepare to administer red blood cells as prescribed.
Limit fluids.
Explain that the client is experiencing expected short-term side effects.
ANS: 4
Clients who undergo bone marrow transplantation may experience short-term side effects,
including nausea, vomiting, fatigue, loss of appetite, mouth sores, hair loss, and skin
reactions. These side effects are not treated with platelets or red blood cells. Limiting fluids
can make the side effects worse.
PTS: 1 DIF: Apply REF: Blood and Bone Marrow Transplantation
8.A client receiving chemotherapy for cancer has a hemoglobin level of 9.7 g/dL. Which of
the following should the nurse anticipate as treatment for this client?
1.
2.
3.
Place client in reverse isolation.
Administer antibiotics as prescribed.
Administer epoetin alfa as prescribed.
11 | P a g e4.
Administer filgrastim as prescribed.
ANS: 3
Treatment for moderate anemia in the client receiving chemotherapy for cancer would
include the administration of epoetin alfa as prescribed. This medication elevates
hemoglobin levels and improves the quality of life for clients. The other choices would be
appropriate for the client diagnosed with neutropenia and not anemia.
PTS: 1 DIF: Apply REF: Anemia
9.A client receiving chemotherapy has a platelet count of 85,000. Which of the following
should the nurse do to assist this client?
1.
2.
3.
4.
Assess for bruising and frank bleeding.
Provide a razor for shaving.
Remind the client to floss before brushing the teeth each day.
Provide NSAIDs as prescribed.
ANS: 1
A platelet count of less than 100,000 indicates thrombocytopenia, and the client should
be assessed for bruising and frank bleeding. The client should avoid the use of a razor,
avoid flossing, and NSAIDs should not be provided since they promote bleeding.
PTS:1DIF:ApplyREF:Thrombocytopenia
10.A client receiving chemotherapy tells the nurse that he is concerned that he may be
developing Alzheimers disease since he is having a new onset of memory loss. Which of
the following should the nurse do to help this client?
1
.
2
.
3
.
4
.
Discuss the clients memory issues with the physician.
Suggest the client use a journal to aid with short-term chemo fog problems.
Assess for signs of pending stroke.
Notify the physician and plan for transferring the client to an intensive care
area.
ANS: 2
Twenty to 50% of cancer clients receiving chemotherapy describe cognitive changes such as
being in a fog. To aid this client, the nurse should suggest the client keep a log or journal to
document activities in order to identify when the fog is more acute. Chemo fog can last up to
2 years after treatment, but it is not permanent. The clients memory issues do not need to be
discussed with a physician. The client is not experiencing a stroke. The client does not need
to be transferred to an intensive care area.
PTS:1DIF:ApplyREF:Cognitive Disorders
11.A client is experiencing nausea and vomiting 1 day after chemotherapy has begun for
cancer treatment. The nurse realizes this clients nausea and vomiting would be considered:
1.
12 | P a g e
anticipatory.2.
3.
4.
acute.
delayed.
chronic.
ANS: 3
Delayed nausea and vomiting occurs more than 24 hours after chemotherapy. Anticipatory
nausea and vomiting occur before, during, or after chemotherapy, and they appear earlier
than expected. Acute nausea and vomiting occur within 24 hours after starting chemotherapy.
Chronic nausea and vomiting affect people with advanced cancer and is not well understood.
PTS: 1 DIF: Analyze REF: GI System
12. The nurse is planning interventions to address the potential problem of mucositis for a
client receiving chemotherapy. Which of the following assessment findings caused the nurse
to identify the client as being at risk for this side effect?
1.
2.
3.
4.
Client prescribed chemotherapy
Client age 50
Client lives alone
Client is fatigued
ANS: 1
High risks for developing mucositis include age younger than 20, hematologic or head and
neck cancer, preexisting oral disease, and chemotherapy and radiation. Age greater than 50,
living arrangements, and level of fatigue do not increase a clients risk of developing
mucositis.
PTS: 1 DIF: Analyze REF: Mucositis
13. Even though a client has completed a course of chemotherapy and has been found to be
cancer free at this time, she continues to experience fatigue. Which of the following should
the nurse instruct this client?
1
.
2
.
3
.
4
.
Fatigue is the first warning sign of cancer and should be reported to
the physician.
Fatigue indicates a poor diet.
Fatigue is caused by poor fluid intake.
Fatigue can persist after treatment ends, but it will eventually improve.
ANS: 4
Fatigue is the most common symptom associated with cancer and cancer treatment.
Fatigue is more often a result of the treatment than the cancer itself. The client should be
informed that
fatigue may persist after cancer therapy is completed, but it will eventually
improve. PTS: 1 DIF: Apply REF: Fatigue
MULTIPLE RESPONSE
13 | P a g e1.A client is diagnosed with cancer. The nurse realizes that which of the following
are characteristics of this type of cell? (Select all that apply.)
1.
2.
3.
4.
5.
6.
Aneuploid
Cohesive
Migratory
Poorly differentiated
Specific morphology
Abnormal chromosomes
ANS: 1, 3, 4, 6
Characteristics of malignant cells include uncontrolled cell division; large, variably
shaped nuclei; anaplasia; poor differentiation; noncohesion; migration; lack of contact
inhibition; aneuploidy; and abnormal chromosomes. Specific morphology and
cohesiveness are characteristics of either benign or normal cells.
PTS:1DIF:AnalyzeREF:Malignant Cells
2.A nurse is teaching at a health fair about the early warning signs of cancer. Which of
the following would the nurse include as early warning signs? (Select all that apply.)
1.
2.
3.
4.
5.
6.
A sore that does not heal
Change in bladder or bowel habits
Family history
Unusual discharge
Obvious change in nevus
Nagging cough
ANS: 1, 2, 4, 5, 6
Early warning signs can be easily remember using the acronym CAUTION: C, change in
bladder or bowel habits; A, a sore that does not heal; U, unusual bleeding or discharge; T,
presence of a lump or thickening; I, indigestion; O, obvious change in a wart or mole; and N, a
nagging cough or hoarseness.
PTS: 1 DIF: Apply REF: Box 15-1 Warning Signs of Cancer
3.A client is experiencing nausea and vomiting related to chemotherapy. Which of the
following strategies can the nurse use to improve nutrition in this client? (Select all that
apply.)
1.
2.
Adding peppermint to foods
Administering ondansetron
14 | P a g e3.
4.
5.
6.
Drinking adequate fluids
Drinking hot beverages
Eating food at room temperature
Sipping ice water
ANS: 1, 2, 3, 5
Strategies to improve nutrition in the client experiencing nausea and vomiting from
chemotherapy include using herbs such as peppermint, administering prescribed anti-
emetics, ensuring an adequate intake of fluids, and ingesting foods at room temperature.
Foods and fluids of extreme temperatures such as hot beverages and ice water should be
avoided by the patient with nausea and vomiting.
PTS: 1 DIF: Apply REF: Chemotherapy: Side Effects
4.A client asks the nurse what he can do to prevent the onset of cancer. The nurse realizes
that which of the following contribute to the development of cancer? (Select all that apply.)
1.
2.
3.
4.
5.
6.
Heredity
Environment
Lifestyle
Stress
Age
Blood pressure
ANS: 1, 2, 3, 5
The factors known to contribute to the development of cancer include heredity, environment,
and lifestyle. Aging has a direct effect on ones risk of developing cancer. The longer one lives,
the greater the risk for developing cancer. Stress and blood pressure are not factors known to
contribute to the development of cancer.
PTS: 1 DIF: Analyze REF: Etiology
5.The nurse is planning to instruct a client on strategies to lessen the impact of lifestyle on
the development of cancer. Which of the following should the nurse include in these
instructions? (Select all that apply.)
1.
2.
3.
4.
5.
6.
Follow a low-fat diet.
Avoid prescribed medications.
Exercise regularly.
Limit sun exposure.
Sleep less than 7 hours each night.
Do not smoke or use any tobacco products.
ANS: 1, 3, 4, 6
Strategies to lessen the impact of lifestyle on the development of cancer include following a low-
fat diet, exercising regularly, limiting sun exposure, and avoiding all use of tobacco
products. Prescribed medications will not lessen the impact of lifestyle on the development
15 | P a g eof cancer. Sleeping less than 7 hours each night will not lessen the impact of lifestyle on the
development of cancer.
PTS: 1 DIF: Apply REF: Lifestyle
6.A client is prescribed a selective estrogen receptor modulator as treatment for ovarian
cancer. Which of the following should the nurse instruct the client regarding side effects of
this medication? (Select all that apply.)
1.
2.
3.
4.
5.
6.
Hot flashes
Blood clots
Drop in blood pressure
Reduce libido
Increased risk of developing other cancer
Weight gain
ANS: 1, 2, 4, 5
Side effects of selective estrogen modulator medications include hot flashes, blood clots, loss
of interest in sex, and a higher risk of other cancers. Drop in blood pressure and weight gain
are not side effects associated with this classification of medication.
Chapter 3. Immunologic Problems
MULTIPLE CHOICE
1.A pregnant client diagnosed with human immunodeficiency virus (HIV) is asking about
her babys risk of infection. Which of the following does put the newborn at risk?
1.
2.
3.
4.
Bottle-feeding
Changing diapers
Kissing the baby
Vaginal birth
ANS: 4
Breastfeeding and vaginal birth put the newborn at risk for HIV. HIV cannot be transmitted
by changing diapers (feces) or kissing the baby (saliva).
PTS:1DIF:Apply
REF: Human Immunodeficiency Virus Infection: Etiology
2.A health care provider has accidentally been stuck with a used needle. The health care
provider is going to be tested for human immunodeficiency virus (HIV). Which of the following
would be the testing schedule for the health care provider?
1.
Tested at 2 months, 4 months, and then at 6 months
16 | P a g e2.
3.
4.
Tested immediately and then again at 2 months
Tested immediately and then again at 6 months
Tested in 6 months and then again in 1 year
ANS: 3
The health care provider should be tested immediately to show if any preexisting infection
exists. Seroconversion usually occurs in 1 to 3 months but can take up to 6 months. Testing
at 2 months is too late to discover a preexisting infection and can be too early to detect a new
infection.
Testing at 6 months or 1 year would not detect a preexisting
infection. PTS:1DIF:Apply
REF: Human Immunodeficiency Virus Infection: Etiology
3. Which of the following CD4+ count would be used to confirm the diagnosis of
acquired immunodeficiency syndrome (AIDS)?
1.
2.
3.
4.
155 cells/mcL
255 cells/mcL
455 cells/mcL
755 cells/mcL
ANS: 1
A CD4+ count of less than 200 cells/mcL is used as a criterion to establish the diagnosis of
AIDS. In cell counts less than 500 to 600 cells/mcL, antiviral therapy should be initiated.
Cell counts greater than 600 cells/mcL are in the normal range.
PTS:1DIF:Analyze
REF:Human Immunodeficiency Virus Infection: Pathophysiology
4. The nurse, planning care for a client diagnosed with human immunodeficiency virus,
realizes that the most common infection that occurs in clients with this health problem is:
1.
2.
3.
4.
cytomegalovirus infection.
Mycobacterium tuberculosis.
Pneumocystis carinii pneumonia.
Streptococcus pneumoniae.
ANS: 3
As the immune system becomes overpowered, opportunistic infections can occur. The most
common infection is Pneumocystis carinii pneumonia. The other infections can also occur,
but they occur less frequently.
PTS:1DIF:Analyze
REF: Human Immunodeficiency Virus Infection: Assessment with Clinical Manifestations
5.A client diagnosed with acquired immunodeficiency syndrome (AIDS) 6 years ago has
a purple lesion located on the inner thigh. This lesion is most likely to be:
17 | P a g e1. 2. 3. 4.
AIDS-related syndrome. Burkitts lymphoma.
cachexia. Kaposis sarcoma.
ANS: 4 Kaposis sarcoma presents as abnormal lesions that appear purple or blue-red in color. They can be found anywhere but are common on the feet, arms, thighs, perineal area, and face. Cachexia is tissue wasting. Burkitts lymphoma is characterized by enlarged lymph nodes. AIDS-related syndrome is a collection of symptoms and infections resulting from the specific damage to the immune system caused by the HIV virus. PTS:1DIF:Analyze REF: Human Immunodeficiency Virus Infection: Assessment with Clinical Manifestations 6.The nurse realizes that which of the following tests can be used to initially identify the presence of human immunodeficiency virus (HIV) antibodies in a client?
1. 2. 3. 4.
Enzyme-linked immunosorbent assay (ELISA) Platelet count
Red blood cell count Western blot
ANS: 1 The ELISA test detects HIV antibodies. The Western blot is used as a confirmatory test to a positive ELISA test. Red blood cell counts and platelet counts are part of standard blood studies. PTS:1DIF:Analyze REF:Human Immunodeficiency Virus Infection: Diagnostic Tests 7.A client diagnosed with acquired immunodeficiency [Show Less]