Medical Surgical Nursing 3rd Australian Edition by LeMone – Test Bank

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Chapter 5: Chronic Illness and Older Adults

Test Bank

 

MULTIPLE CHOICE

 

  1. When caring for a patient with type 2 diabetes who has been hospitalized with severe hyperglycemia, which topic will be most important to include in discharge teaching?
a. Effect of endogenous insulin on transportation of glucose into cells
b. Function of the liver in formation of glycogen and gluconeogenesis
c. Impact of the patient’s family history on likelihood of developing diabetes
d. Symptoms indicating that the patient should contact the health care provider

 

 

ANS:  D

One of the tasks for patients with chronic illnesses is to prevent and manage a crisis. The patient needs instruction on recognition of symptoms of hyperglycemia and appropriate actions to take if these symptoms occur. The other information also may be included in patient teaching, but is not as essential in the patient’s self-management of the illness.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. Which question will provide the most useful information when the nurse is performing a comprehensive geriatric assessment of an older adult who is being assessed for admission to an assisted-living facility?
a. “Have you had any recent infections?”
b. “How frequently do you see a doctor?”
c. “Do you have a history of heart disease?”
d. “Are you able to prepare your own meals?”

 

 

ANS:  D

The patient’s functional abilities, rather than the presence of acute or chronic illness, are more useful in determining how well the patient might adapt to an assisted-living situation. The other questions also will provide helpful information but are not as useful in providing a basis for determining patient needs or for developing interventions for the older patient.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Assessment

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse is planning care for an alert and active 85-year-old patient who takes multiple medications for chronic cardiac and respiratory disease and lives with a daughter who works during the day. Which nursing diagnosis is most appropriate?
a. Risk for injury related to drug-drug interactions
b. Social isolation related to weakness and fatigue
c. Compromised family coping related to the patient’s many care needs
d. Caregiver role strain related to need to adjust family employment schedule

 

 

ANS:  A

The patient’s age and multiple medications indicate a risk for injury caused by interactions between the multiple drugs being taken and a decreased drug metabolism rate. The patient data do not indicate problems with social isolation, caregiver role strain, or compromised family coping.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Diagnosis

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. To obtain the most complete information when doing an assessment for an 81-year-old patient, the nurse will
a. interview both the patient and the primary patient caregiver.
b. use a geriatric assessment instrument to evaluate the patient.
c. review the patient’s chart for the history of medical problems.
d. ask the patient to write down medical problems and medications.

 

 

ANS:  B

The most complete information about the patient will be obtained through the use of an assessment instrument specific to the geriatric population, which includes information about both medical diagnoses and treatments and about functional health patterns and abilities. A review of the chart, interviews of the patient and caregiver, and written information by the patient will all be included in a comprehensive geriatric assessment.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Assessment

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. When developing the plan of care for an older adult who is hospitalized for an acute illness, the nurse should
a. use a standardized geriatric nursing care plan.
b. minimize activity level during hospitalization.
c. plan for transfer to a long-term care facility after the hospitalization.
d. consider the preadmission functional abilities when setting patient goals.

 

 

ANS:  D

The plan of care for older adults should be individualized and based on the patient’s current functional abilities. A standardized geriatric nursing care plan will not address individual patient needs and strengths. A patient’s need for discharge to a long-term care facility is variable. Activity level should be designed to allow the patient to retain functional abilities while hospitalized and also to allow any additional rest needed for recovery from the acute process.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. When caring for an older adult who lives in a rural area, the nurse will plan to
a. assess the patient for chronic diseases that are unique to rural areas.
b. ensure transportation to appointments with the health care provider.
c. suggest that the patient move to an urban area for better health care.
d. obtain adequate medications for the patient to last for 4 to 6 months.

 

 

ANS:  B

Transportation can be a barrier to accessing health services in rural areas. There are no chronic diseases unique to rural areas. Because medications may change, the nurse should help the patient plan for obtaining medications through alternate means such as the mail or delivery services, not by purchasing large quantities of the medications. The patient living in a rural area may lose the benefits of a familiar situation and social support by moving to an urban area.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Planning

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. When the nurse is working in the outpatient clinic, which nursing action will be most helpful in decreasing the risk for drug-drug interactions in an older adult patient?
a. Teach the patient to have all prescriptions filled at the same pharmacy
b. Instruct the patient to avoid taking over-the-counter (OTC) medications.
c. Make a medication schedule for the patient as a reminder about when to take each medication.
d. Have the patient bring all the medications, supplements, and herbs to every health care appointment.

 

 

ANS:  D

The most information about drug use and possible interactions is obtained when the patient brings all prescribed medications, OTC medications, and supplements to every health care appointment. The patient should discuss the use of any OTC medications with the health care provider and obtain all prescribed medications from the same pharmacy, but use of supplements and herbal medications also need to be considered in order to prevent drug-drug interactions. Use of a medication schedule will help the patient take medications as scheduled but will not prevent drug-drug interactions.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. Which action will the nurse take when planning for discharge of a 68-year-old patient who will need daily assistance with activities such as shopping and transportation?
a. Write to the state Medicaid office.
b. Contact the Area Agency on Aging.
c. Provide documentation to Medicare.
d. Communicate with the patient’s insurer.

 

 

ANS:  B

Funding from the federal Administration on Aging is funneled through local Area Agencies on Aging to provide community services to older adults. Medicare, Medicaid, and insurers provide funding for specific medical services, but not for need such as shopping or transportation.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Planning

MSC:  NCLEX: Safe and Effective Care Environment

 

  1. A 78-year-old patient with multiple health problems complains of having “no energy” and feeling increasingly weak. The patient has had an 11-pound weight loss over the last year. The nurse should initially
a. ask the patient about daily dietary intake.
b. schedule regular range-of-motion exercise.
c. discuss long-term care placement with the patient.
d. describe normal changes with aging to the patient.

 

 

ANS:  A

In the frail elderly patient, nutrition is frequently compromised, and the nurse’s initial action should be to assess the patient’s nutritional status. Active range-of-motion may be helpful in improving the patient’s strength and endurance, but nutritional assessment is the priority because the patient has had a significant weight loss. The patient may be a candidate for long-term care placement, but more assessment is needed before this can be determined. The patient’s assessment data are not consistent with normal changes associated with aging.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Assessment

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. When admitting an 88-year-old patient to the hospital, the nurse should plan to
a. speak slowly and loudly while facing the patient.
b. obtain a detailed medical history from the patient.
c. interview the patient before the physical assessment.
d. determine whether the patient uses glasses or hearing aids.

 

 

ANS:  D

Assistive devices should be in place before assessing the patient to minimize anxiety and confusion. When a patient is acutely ill, the physical assessment should be accomplished first to detect any physiologic changes that require immediate action. Not all older patients have hearing deficits, and it is insensitive of the nurse to speak loudly and slowly to all older patients. To avoid tiring the patient, much of the medical history can be obtained from medical records.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Planning

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse is planning discharge for an alert, homeless 70-year-old with a chronic foot infection. The most appropriate intervention by the nurse is to
a. teach the patient how to assess and care for the foot infection.
b. refer to social services for further assessment of patient needs.
c. schedule the patient to return to outpatient services for foot care.
d. give the patient written information about shelters and meal sites.

 

 

ANS:  B

A multidisciplinary approach, including social services, is needed when caring for homeless adults. Even with appropriate education, a homeless individual may not be able to maintain adequate foot care because of a lack of supplies or a suitable place to accomplish care. Older homeless individuals are less likely to use shelters or meal sites. A homeless person may fail to keep appointments for outpatient services because of factors such as fear of institutionalization or lack of transportation.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Implementation

MSC:  NCLEX: Safe and Effective Care Environment

 

  1. The home health nurse is caring for a 71-year-old patient who lives alone and is taking seven different prescribed medications for chronic health problems. To ensure medication compliance, which nursing intervention is best?
a. Use a marked pillbox to set up the patient’s medications.
b. Discuss the option of moving to an assisted-living facility.
c. Remind the patient about the importance of taking medications.
d. Visit the patient daily to administer the prescribed medications.

 

 

ANS:  A

Since forgetting to take medications is a common cause of medication errors in older adults, the use of medication reminder devices is helpful when older adults have multiple medications to take. There is no indication that the patient needs to move to assisted living or that the patient does not understand the importance of medication compliance. Home health care is not designed for the patient who needs ongoing assistance with activities of daily living (ADLs) or instrumental ADLs (IADLs).

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. Which information obtained by the home health nurse when making a visit to an 88-year-old with mild forgetfulness is of concern?
a. The patient tells the nurse that a close friend recently died.
b. The patient has lost 10 pounds (4.5 kg) during the last month.
c. The patient is cared for by a daughter during the day and stays with a son at night.
d. The patient’s son uses a marked pillbox to set up the patient’s medications weekly.

 

 

ANS:  B

A 10-pound weight loss may be an indication of elder neglect or depression and requires further assessment by the nurse. The use of a marked pillbox and planning by the family for 24-hour care are appropriate for this patient. It is not unusual that an 88-year-old would have friends who have died.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. Which information about a 77-year-old patient who is being assessed by the home health nurse is of most concern?
a. The patient organizes medications in a marked pillbox “so I don’t forget them.”
b. The patient uses three different medications for chronic heart and joint problems.
c. The patient says, “I don’t go on my daily walks since I had pneumonia 3 months ago.”
d. The patient tells the nurse, “I prefer to manage my life without much help from others.”

 

 

ANS:  C

Inactivity and immobility lead rapidly to loss of function in older adults. The nurse should develop a plan to prevent further deconditioning and restore function for the patient. Self-management is appropriate for independently living older adults. On average, a 70-year-old takes seven different medications; the use of three medications is not unusual for a 78-year-old. The use of memory devices to assist with safe medication administration is recommended for older adults.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Assessment

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. When admitting a 79-year-old patient who has urinary urgency and a possible urinary tract infection (UTI), the nurse should first
a. assess the patient’s orientation.
b. inspect for abdominal distention.
c. question the patient about hematuria.
d. invite the patient to use the bathroom.

 

 

ANS:  D

Before beginning the assessment of an older patient with a UTI and urgency, the nurse should have the patient empty the bladder because bladder fullness or discomfort will distract from the patient’s ability to provide accurate information. The patient may seem disoriented if distracted by pain or urgency. The physical assessment data are obtained after the patient is as comfortable as possible.

 

DIF:    Cognitive Level: Application           OBJ:   Special Questions: Prioritization

TOP:   Nursing Process: Assessment           MSC:  NCLEX: Physiological Integrity

 

  1. Which of these patients assigned to the nurse is most likely to need planning for long-term nursing management?
a. 22-year-old with appendicitis who has had an emergency appendectomy
b. 56-year-old with bilateral knee osteoarthritis who weighs 350 lbs (159 kg)
c. 34-year-old with cholecystitis who has had a laparoscopic cholecystectomy
d. 62-year-old with acute sinusitis who will require antibiotic therapy for 5 days

 

 

ANS:  B

The patient’s osteoarthritis is a chronic problem that will require planning for long-term interventions such as physical therapy and nutrition counseling. The other patients have acute problems that are not likely to require long-term management.

 

DIF:    Cognitive Level: Application           OBJ:   Special Questions: Multiple Patients

TOP:   Nursing Process: Planning               MSC:  NCLEX: Physiological Integrity

 

  1. When a hospitalized older patient is at risk of falling because of acute confusion and weakness, which action should the nurse take first?
a. Utilize a bed alarm system on the patient’s bed.
b. Administer the prescribed PRN sedative medication.
c. Ask the health care provider to order a vest restraint.
d. Place the patient in a “geri-chair” near the nurse’s station.

 

 

ANS:  A

The use of the least restrictive restraint alternative is required. Physical or chemical restraints may be necessary, but the nurse’s first action should be an alternative such as a bed alarm.

 

DIF:    Cognitive Level: Application           OBJ:   Special Questions: Prioritization

TOP:   Nursing Process: Implementation     MSC:  NCLEX: Safe and Effective Care Environment

 

  1. The nurse suspects that elder abuse may be occurring when a confused and agitated 76-year-old patient with a broken arm is brought to the emergency department by a family member. Which of these actions should the nurse take first?
a. Notify an elder protective services agency about the possible abuse.
b. Make a referral for a home assessment visit by the home health nurse.
c. Have the family member stay in the waiting area while the patient is assessed.
d. Ask the patient how the injury occurred and observe the family member’s reaction.

 

 

ANS:  C

The initial action should be assessment and interviewing of the patient. The patient should be interviewed alone because the patient will be unlikely to give accurate information if the abuser is present. If abuse is occurring, the patient should not be discharged home for a later assessment by a home health nurse. The nurse needs to collect and document physiologic data before notifying the elder protective services agency.

 

DIF:    Cognitive Level: Application           OBJ:   Special Questions: Prioritization

TOP:   Nursing Process: Assessment           MSC:  NCLEX: Physiological Integrity

 

MULTIPLE RESPONSE

 

  1. Which nursing actions will the nurse take to assess for possible malnutrition in a 69-year-old patient (select all that apply)?
a. Observe for depression.
b. Review laboratory results.
c. Assess teeth and oral mucosa.
d. Ask about transportation needs.
e. Determine food likes and dislikes.

 

 

ANS:  A, B, C, D

The laboratory results, especially albumin and cholesterol levels, may indicate chronic poor protein intake or high-fat/cholesterol intake. Transportation impacts patients’ ability to shop for groceries. Depression may lead to decreased appetite. Oral sores or teeth in poor condition may decrease the ability to chew and swallow. Food likes and dislikes are not necessarily associated with malnutrition.

 

DIF:    Cognitive Level: Application           OBJ:   Special Questions: Alternate Item Format

TOP:   Nursing Process: Assessment           MSC:  NCLEX: Health Promotion and Maintenance

 

 

 

 

Chapter 31: Nursing Management: Hematologic Problems

Test Bank

 

MULTIPLE CHOICE

 

  1. A patient with anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patient’s laboratory findings to include
a. normal red blood cell (RBC) indices.
b. a hematocrit (Hct) of 38%.
c. a hemoglobin (Hb) of 8.6 g/dL (86 g/L).
d. an RBC count of 4,500,000/mL.

 

 

ANS:  C

The patient’s clinical manifestations indicate moderate anemia, which is consistent with an Hb of 6 to 10 g/dL. The other values are all within the range of normal.

 

DIF:    Cognitive Level: Comprehension     TOP:   Nursing Process: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. Which menu choice indicates that the patient understands the nurse’s teaching about best dietary choices for iron-deficiency anemia?
a. Omelet and whole wheat toast
b. Cantaloupe and cottage cheese
c. Strawberry and banana fruit plate
d. Cornmeal muffin and orange juice

 

 

ANS:  A

Eggs and whole grain breads are high in iron. The other choices are appropriate for other nutritional deficiencies, but are not the best choice for a patient with iron-deficiency anemia.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Evaluation

MSC:  NCLEX: Physiological Integrity

 

  1. A patient who is receiving methotrexate develops a megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of
a. iron.
b. folic acid.
c. cobalamin (vitamin B12).
d. ascorbic acid (vitamin C).

 

 

ANS:  B

Methotrexate use can lead to folic acid deficiency. Supplementation with oral folic acid supplements is the usual treatment. The other nutrients would not correct folic acid deficiency, although they would be used to treat other types of anemia.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. A 52-year-old patient has a new diagnosis of pernicious anemia. After teaching the patient about pernicious anemia, the nurse determines that the patient understands the disorder when the patient states,
a. “I need to start eating more red meat or liver.”
b. “I will stop having a glass of wine with dinner.”
c. “I will need to take a proton pump inhibitor like omeprazole (Prilosec).”
d. “I would rather use the nasal spray than have to get injections of vitamin B12.”

 

 

ANS:  D

Since pernicious anemia prevents the absorption of vitamin B12, this patient requires injections or intranasal administration of cobalamin. Alcohol use does not cause cobalamin deficiency. Proton pump inhibitors decrease the absorption of vitamin B12. Eating more foods rich in vitamin B12 is not helpful because the lack of intrinsic factor prevents absorption of the vitamin.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Evaluation

MSC:  NCLEX: Physiological Integrity

 

  1. A patient is hospitalized for treatment of severe hemolytic anemia. An appropriate nursing action for the patient is to
a. provide a diet high in vitamin K.
b. place the patient on protective isolation.
c. alternate periods of rest and activity.
d. teach the patient how to avoid injury.

 

 

ANS:  C

Nursing care for patients with anemia should alternate periods of rest and activity to encourage activity without causing undue fatigue. There is no indication that the patient has a bleeding disorder, so a high vitamin K diet or teaching about how to avoid injury is not needed. Protective isolation might be used for a patient with aplastic anemia, but it is not indicated for hemolytic anemia.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. After the nurse has finished teaching a patient about taking oral ferrous sulfate, which patient statement indicates that additional instruction is needed?
a. “I will call the doctor if my stools start to turn black.”
b. “I will take a stool softener if I feel constipated occasionally.”
c. “I should take the iron with orange juice about an hour before eating.”
d. “I should increase my fluid and fiber intake while I am taking the iron tablets.”

 

 

ANS:  A

It is normal for the stools to appear black when a patient is taking iron and the patient should not call the doctor about this. The other patient statements are correct.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Evaluation

MSC:  NCLEX: Physiological Integrity

 

  1. A patient is admitted to the hospital with idiopathic aplastic anemia. Which of these collaborative problems will the nurse include when developing the care plan?
a. Potential complication: seizures
b. Potential complication: infection
c. Potential complication: neurogenic shock
d. Potential complication: pulmonary edema

 

 

ANS:  B

Because the patient with aplastic anemia has pancytopenia, the patient is at risk for infection and bleeding. There is no increased risk for seizures, neurogenic shock, or pulmonary edema.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. A patient is admitted to the hospital with a sickle cell crisis. While caring for the patient during the crisis, it is important for the nurse to
a. limit the patient’s intake of oral and IV fluids.
b. evaluate the effectiveness of opioid analgesics.
c. encourage the patient to ambulate as much as tolerated.
d. teach the patient about high-protein, high-calorie foods.

 

 

ANS:  B

Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control. Fluid intake should be increased to reduce blood viscosity and improve perfusion. Rest is usually ordered to decrease metabolic requirements. Patients are instructed about the need for dietary folic acid, but high-protein, high-calorie diets are not emphasized.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. Which statement by a patient with sickle cell anemia indicates good understanding of the nurse’s teaching about prevention of sickle cell crisis?
a. “Home oxygen therapy is frequently used to decrease sickling.”
b. “There are no effective medications that can help prevent sickling.”
c. “Routine continuous dosage narcotics are prescribed to prevent a crisis.”
d. “Risk for a crisis can be lowered by having an annual influenza vaccination.”

 

 

ANS:  D

Since infection is the most common cause of a sickle cell crisis, influenza, Haemophilus influenzae, pneumococcal pneumonia, and hepatitis immunizations should be administered. Although continuous dose opioids and oxygen may be administered during a crisis, patients do not receive these therapies to prevent crisis. Hydroxyurea (Hydrea) is used for many patients to decrease the number of sickle cell crises.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Evaluation

MSC:  NCLEX: Physiological Integrity

 

  1. When planning discharge teaching for the patient who was admitted with a sickle cell crisis, which instruction will the nurse include?
a. Limit fluids to 2 to 3 quarts a day.
b. Take a daily multivitamin with iron.
c. Avoid exposure to crowds as much as possible.
d. Drink only one or two caffeinated beverages daily.

 

 

ANS:  C

Exposure to crowds increases the patient’s risk for infection, the most common cause of sickle cell crisis. There is no restriction on caffeine use. Iron supplementation is generally not recommended. A high-fluid intake is recommended.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. During the admission assessment of a patient with hemolytic anemia, the nurse notes jaundice of the sclerae. The nurse will plan to check the laboratory results for
a. the Schilling test.
b. the bilirubin level.
c. the stool occult blood test.
d. the gastric analysis testing.

 

 

ANS:  B

Jaundice is caused by the elevation of bilirubin level associated with red blood cell (RBC) hemolysis. The other tests would not be helpful in monitoring or treating a hemolytic anemia.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. A patient who has been receiving a heparin infusion and warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT). Which action will the nurse include in the plan of care?
a. Use low-molecular-weight heparin (LMWH) only.
b. Flush all intermittent IV lines using normal saline.
c. Administer the warfarin (Coumadin) at the scheduled time.
d. Teach the patient about the purpose of platelet transfusions.

 

 

ANS:  B

All heparin is discontinued when the HIT is diagnosed. The patient should be instructed to never receive heparin or LMWH. Warfarin is usually not given until the platelet count has returned to 150,000/µl. The platelet count does not drop low enough in HIT for a platelet transfusion, and platelet transfusions increase the risk for thrombosis.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. During treatment of the patient with an acute exacerbation of polycythemia vera, a critical action by the nurse is to
a. place the patient on bed rest.
b. administer iron supplements.
c. avoid use of aspirin products.
d. monitor fluid intake and output.

 

 

ANS:  D

Monitoring hydration status is important during an acute exacerbation because the patient is at risk for fluid overload or underhydration. Aspirin therapy is used to decrease risk for thrombosis. The patient should be encouraged to ambulate to prevent deep vein thrombosis (DVT). Iron is contraindicated in patients with polycythemia vera.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. Which nursing intervention will be included in the care plan for a patient with immune thrombocytopenic purpura (ITP)?
a. Assign the patient to a private room.
b. Avoid intramuscular (IM) injections.
c. Use rinses rather than a toothbrush for oral care.
d. Restrict activity to passive and active range of motion.

 

 

ANS:  B

IM or subcutaneous injections should be avoided because of the risk for bleeding. A soft toothbrush can be used for oral care. There is no need to restrict activity or place the patient in a private room.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Planning

MSC:  NCLEX: Safe and Effective Care Environment

 

  1. Which laboratory information will the nurse monitor to detect heparin-induced thrombocytopenia (HIT) in a patient who is receiving a continuous heparin infusion?
a. Prothrombin time
b. Erythrocyte count
c. Fibrinogen degradation products
d. Activated partial thromboplastin time

 

 

ANS:  D

Platelet aggregation in HIT causes neutralization of heparin, so that the activated partial thromboplastin time will be shorter and more heparin will be needed to maintain therapeutic levels. The other data will not be affected by HIT.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. A patient with type A hemophilia has been admitted to the hospital with severe pain and swelling in the right knee. During the initial care of the patient, the nurse should
a. immobilize the knee.
b. apply heat to the joint.
c. assist the patient with light weight bearing.
d. perform passive range of motion to the knee.

 

 

ANS:  A

The initial action should be total rest of the knee to minimize bleeding. Ice packs are used to decrease bleeding. Range of motion (ROM) and weight-bearing exercise are contraindicated initially, but after the bleeding stops, ROM and physical therapy are started.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. A patient with von Willebrand disease is admitted to the hospital for minor knee surgery. The nurse will review the coagulation survey to check the
a. platelet count.
b. bleeding time.
c. thrombin time.
d. prothrombin time.

 

 

ANS:  B

The bleeding time is affected by von Willebrand disease. Platelet count, prothrombin time, and thrombin time are normal in von Willebrand disease.

 

DIF:    Cognitive Level: Comprehension     TOP:   Nursing Process: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. A routine complete blood count indicates that a patient may have myelodysplastic syndrome. At this time, the nurse will plan to teach the patient about
a. packed red blood cells (PRBCs) transfusion.
b. bone marrow biopsy.
c. filgrastim (Neupogen) administration.
d. erythropoietin (Epogen) administration.

 

 

ANS:  B

Bone marrow biopsy is needed to make the diagnosis and determine the specific type of myelodysplastic syndrome. The other treatments may be necessary if there is progression of the myelodysplastic syndrome, but the initial action for this asymptomatic patient will be a bone marrow biopsy.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. Which action will be included in the care plan for a hospitalized patient who is neutropenic?
a. Avoid any IM or subcutaneous injections.
b. Check the oral temperature every 4 hours.
c. Omit all fruits or vegetables from the diet.
d. Place a “No Visitors” sign on the patient door.

 

 

ANS:  B

The earliest sign of infection in a neutropenic patient is an elevation in temperature. Although unpeeled fresh fruits and vegetables should be avoided, fruits and vegetables that are peeled or cooked are acceptable. Injections may be required for administration of medications such as filgrastim (Neupogen). The number of visitors may be limited and visitors with communicable diseases should be avoided, but a “no visitors” policy is not needed.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. Which laboratory test will the nurse use to determine whether the prescribed filgrastim (Neupogen) is effective in the treatment of a patient who is receiving chemotherapy for acute lymphocytic leukemia?
a. Platelet count
b. Reticulocyte count
c. Total lymphocyte count
d. Absolute neutrophil count

 

 

ANS:  D

Filgrastim increases the neutrophil count and function in neutropenic patients. Although total lymphocyte, platelet, and reticulocyte counts also are important to monitor in this patient, the absolute neutrophil count is used to evaluate the effects of filgrastim.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Evaluation

MSC:  NCLEX: Physiological Integrity

 

  1. A 64-year-old with acute myelogenous leukemia (AML) who has induction therapy prescribed asks the nurse whether the planned chemotherapy will be worth undergoing. Which response by the nurse is appropriate?
a. “If you do not want to have chemotherapy, there are other options for treatment such as stem cell transplantation.”
b. “The decision about chemotherapy is one that you and the doctor need to make rather than asking what I would do.”
c. “You don’t need to make a decision about treatment right now since leukemias in adults tend to progress quite slowly.”
d. “The side effects of the chemotherapy are difficult, but AML frequently does go into remission with chemotherapy.”

 

 

ANS:  D

This response uses therapeutic communication by addressing the patient’s question and giving accurate information. The other responses either give inaccurate information or fail to address the patient’s question, which will discourage the patient from asking the nurse for information.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. A patient who has a history of a transfusion-related acute lung injury (TRALI) is to receive a transfusion of packed red blood cells (PRBCs). Which action will the nurse take to decrease the risk for TRALI for this patient?
a. Infuse the PRBCs slowly over 4 hours.
b. Transfuse only leukocyte-reduced PRBCs.
c. Administer the scheduled oral diuretic before the transfusion.
d. Give the PRN dose of antihistamine before starting the transfusion.

 

 

ANS:  B

TRALI is caused by a reaction between the donor and the patient leukocytes that causes pulmonary inflammation and capillary leaking. The other actions may help prevent respiratory problems caused by circulatory overload or by allergic reactions, but they will not prevent TRALI.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. A 45-year-old patient with acute myelogenous leukemia (AML) is considering the possibility of treatment with a hematopoietic stem cell transplant (HSCT). To assist the patient with treatment decisions, the best approach for the nurse to use is to
a. emphasize the positive outcomes of a bone marrow transplant.
b. discuss the need for adequate insurance to cover post-HSCT care.
c. ask the patient whether there are any questions or concerns about HSCT.
d. explain that a cure is not possible with any other treatment except HSCT.

 

 

ANS:  C

Offering the patient an opportunity to ask questions or discuss concerns about HSCT will encourage the patient to voice concerns about this treatment and also will allow the nurse to assess whether the patient needs more information about the procedure. Treatment of AML using chemotherapy is another option for the patient. It is not appropriate for the nurse to ask the patient to consider insurance needs in making this decision.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. Which nursing action will be included in the plan of care for a patient admitted with multiple myeloma?
a. Monitor fluid intake and output.
b. Administer calcium supplements.
c. Assess lymph nodes for enlargement.
d. Limit weight-bearing and ambulation.

 

 

ANS:  A

A high fluid intake and urine output helps prevent the complications of kidney stones caused by hypercalcemia and renal failure caused by deposition of Bence-Jones protein in the renal tubules. Weight bearing and ambulation are encouraged to help bone retain calcium. Lymph nodes are not enlarged with multiple myeloma. Calcium supplements will further increase the patient’s calcium level and are not used.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. A patient with non-Hodgkin’s lymphoma develops a platelet count of 18,000/µl during chemotherapy. An appropriate nursing intervention for the patient based on this finding is to
a. provide oral hygiene every 2 hours.
b. check all stools for occult blood.
c. check the temperature every 4 hours.
d. encourage fluids to 3000 mL/day.

 

 

ANS:  B

Because the patient is at risk for spontaneous bleeding, the nurse should check stools for occult blood. A low platelet count does not require an increased fluid intake. Oral hygiene is important, but it is not necessary to provide oral care every 2 hours. The low platelet count does not increase risk for infection, so frequent temperature monitoring is not indicated.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. A 22-year-old with acute myelogenous leukemia who is receiving outpatient chemotherapy develops an absolute neutrophil count of 900/µl. Which action by the nurse in the outpatient clinic is most appropriate?
a. Discuss the need for hospital admission to treat the neutropenia.
b. Plan to discontinue the chemotherapy until the neutropenia resolves.
c. Teach the patient how to administer filgrastim (Neupogen) injections at home.
d. Obtain a high-efficiency particulate air (HEPA) filter for the patient for home use.

 

 

ANS:  C

The patient may be taught to self-administer filgrastim injections. Although chemotherapy may be stopped with severe neutropenia (neutrophil count less than 500/µl), administration of filgrastim usually allows the chemotherapy to continue. Patients with neutropenia are at higher risk for infection when exposed to other patients in the hospital. HEPA filters are expensive and are used in the hospital, where the number of pathogens is much higher than in the patient’s home environment.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. Which of the following assessment data obtained by the nurse when caring for a patient with thrombocytopenia should be immediately communicated to the health care provider?
a. The platelet count is 52,000/µl.
b. The patient is difficult to arouse.
c. There are large bruises on the back.
d. There are purpura on the oral mucosa.

 

 

ANS:  B

Difficulty in arousing the patient may indicate a cerebral hemorrhage, which is life threatening and requires immediate action. The other information should be documented and reported, but would not be unusual in a patient with thrombocytopenia.

 

DIF:    Cognitive Level: Application           OBJ:   Special Questions: Prioritization

TOP:   Nursing Process: Assessment           MSC:  NCLEX: Physiological Integrity

 

  1. Which nursing action should the nurse delegate to nursing assistive personnel (NAP) when administering a transfusion of packed red blood cells (PRBCs) to a patient with blood loss?
a. Verify the patient identification (ID) according to hospital policy.
b. Obtain the temperature, blood pressure, and pulse before the transfusion.
c. Double-check the product numbers on the PRBCs with the patient ID band.
d. Monitor the patient for shortness of breath or chest pain during the transfusion.

 

 

ANS:  B

NAP education includes measurement of vital signs. The NAP would report the vital signs to the RN. The other actions require more education and a larger scope of practice and should be done by licensed nursing staff members.

 

DIF:    Cognitive Level: Application           OBJ:   Special Questions: Delegation

TOP:   Nursing Process: Implementation     MSC:  NCLEX: Safe and Effective Care Environment

 

  1. A patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 30 minutes after the transfusion is started. After stopping the transfusion, what is the first action that the nurse should take?
a. Draw blood for a new crossmatch.
b. Send a urine specimen to the laboratory.
c. Give the PRN diphenhydramine (Benadryl).
d. Administer the PRN acetaminophen (Tylenol).

 

 

ANS:  D

The patient’s clinical manifestations are consistent with a febrile, nonhemolytic transfusion reaction. The transfusion should be stopped and antipyretics administered for the fever as ordered. A urine specimen is needed if an acute hemolytic reaction is suspected. Diphenhydramine (Benadryl) is used for allergic reactions. This type of reaction does not indicate incorrect crossmatching.

 

DIF:    Cognitive Level: Application           OBJ:   Special Questions: Prioritization

TOP:   Nursing Process: Implementation     MSC:  NCLEX: Physiological Integrity

 

  1. Fifteen minutes after a transfusion of packed red blood cells is started, a patient complains of back pain and dyspnea. The pulse rate is 124. The nurse’s first action should be to
a. administer oxygen therapy at a high flow rate.
b. obtain a urine specimen to send to the laboratory.
c. notify the health care provider about the symptoms.
d. disconnect the transfusion and infuse normal saline.

 

 

ANS:  D

The patient’s symptoms indicate a possible acute hemolytic reaction caused by the transfusion. The first action should be to disconnect the transfusion and infuse normal saline. The other actions also are needed but are not the highest priority.

 

DIF:    Cognitive Level: Application           OBJ:   Special Questions: Prioritization

TOP:   Nursing Process: Implementation     MSC:  NCLEX: Physiological Integrity

 

  1. Which newly admitted patient should the nurse assign as a roommate for a patient who has aplastic anemia?
a. A patient with severe heart failure
b. A patient who has viral pneumonia
c. A patient who has right leg cellulitis
d. A patient with multiple abdominal drains

 

 

ANS:  A

Patients with aplastic anemia are at risk for infection because of the low white blood cell production associated with this type of anemia, so the nurse should avoid assigning a roommate with any possible infectious process.

 

DIF:    Cognitive Level: Application           OBJ:   Special Questions: Multiple Patients

TOP:   Nursing Process: Implementation     MSC:  NCLEX: Safe and Effective Care Environment

 

  1. All of the following patients are waiting to be admitted by the emergency department nurse. Which one requires the most rapid assessment and care by the nurse?
a. The patient with hemochromatosis who is complaining of abdominal pain
b. The patient with thrombocytopenia who has oozing after having a tooth extracted
c. The patient with chemotherapy-induced neutropenia who has a temperature of 100.8° F
d. The patient with a history of sickle cell anemia who has had nausea and diarrhea for 24 hours

 

 

ANS:  C

A neutropenic patient with a fever is assumed to have an infection and is at risk for rapidly developing sepsis. Rapid assessment, cultures, and initiation of antibiotic therapy are needed. The other patients also require rapid assessment and care but not as urgently as the neutropenic patient.

 

DIF:    Cognitive Level: Analysis                OBJ:   Special Questions: Multiple Patients

TOP:   Nursing Process: Assessment           MSC:  NCLEX: Safe and Effective Care Environment

 

  1. The nurse is caring for a patient with immune thrombocytopenic purpura (ITP) who has an order for a platelet transfusion. Which patient information indicates that the nurse should consult with the health care provider before administering platelets?
a. The platelet count is 42,000/mL.
b. Blood pressure (BP) is 94/56 mm Hg.
c. Blood is oozing from the venipuncture site.
d. Petechiae are present on the chest and back.

 

 

ANS:  A

Platelet transfusions are not usually indicated until the platelet count is below 10,000 to 20,000/ml unless the patient is actively bleeding, so the nurse should clarify the order with the health care provider before giving the transfusion. The other data all indicate that bleeding caused by ITP may be occurring and indicate that the platelet transfusion is appropriate.

 

DIF:    Cognitive Level: Application           OBJ:   Special Questions: Prioritization

TOP:   Nursing Process: Assessment           MSC:  NCLEX: Physiological Integrity

 

  1. A patient with hemophilia calls the nurse in the hemophilia clinic to discuss all of these problems. Which problem is most important to communicate to the physician?
a. Skin abrasions
b. Bleeding gums
c. Multiple bruises
d. Dark tarry stools

 

 

ANS:  D

Melena is a sign of gastrointestinal bleeding and requires collaborative actions such as checking hemoglobin and hematocrit and administration of coagulation factors. The other problems indicate a need for patient teaching about how to avoid injury, but are not indicators of possible serious blood loss.

 

DIF:    Cognitive Level: Application           OBJ:   Special Questions: Prioritization

TOP:   Nursing Process: Assessment           MSC:  NCLEX: Physiological Integrity

 

  1. A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which action is most important for the nurse to take?
a. Notify the patient’s physician.
b. Avoid unnecessary venipunctures.
c. Apply sterile dressings to the sites.
d. Give prescribed proton-pump inhibitors.

 

 

ANS:  A

The patient’s new onset of bleeding and diagnosis of sepsis suggest that disseminated intravascular coagulation (DIC) may have developed, which will require collaborative actions such as diagnostic testing, blood product administration, and heparin administration. The other actions also are appropriate, but the most important action should be to notify the physician so that DIC treatment can be initiated rapidly.

 

DIF:    Cognitive Level: Application           OBJ:   Special Questions: Prioritization

TOP:   Nursing Process: Implementation     MSC:  NCLEX: Physiological Integrity

 

  1. A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature 102° F (38.9° C), and severe back pain. Which of these physician orders will the nurse implement first?
a. Administer morphine sulfate 4 mg IV.
b. Infuse normal saline 500 mL over 30 minutes.
c. Draw blood for complete blood count and coagulation studies.
d. Give acetaminophen (Tylenol) 650 mg for temperature 102° F or higher.

 

 

ANS:  B

The patient’s blood pressure indicates hypovolemia caused by blood loss and should be addressed immediately to improve perfusion to vital organs. The other actions also are appropriate and should be rapidly implemented, but improving perfusion is the priority for this patient.

 

DIF:    Cognitive Level: Application           OBJ:   Special Questions: Prioritization

TOP:   Nursing Process: Implementation     MSC:  NCLEX: Physiological Integrity

 

  1. Which of the following nursing actions included in the care plan for a patient with neutropenia is appropriate for the RN to delegate to an LPN/LVN who is assisting with patient care?
a. Assessing the patient for signs and symptoms of infection
b. Teaching the patient the purpose of neutropenic precautions
c. Developing a discharge teaching plan for the patient and family
d. Administering the ordered subcutaneous filgrastim (Neupogen) injection

 

 

ANS:  D

Administration of medications is included in LPN/LVN education and scope of practice. Patient education, assessment, and developing the plan of care require RN level education and scope of practice.

 

DIF:    Cognitive Level: Application           OBJ:   Special Questions: Delegation

TOP:   Nursing Process: Implementation     MSC:  NCLEX: Safe and Effective Care Environment

 

  1. All of these patients call the outpatient clinic and ask to make an appointment as soon as possible. Which patient should the nurse schedule to be seen first?
a. 19-year-old with no previous health problems who has a nontender lump in the axilla
b. 46-year-old with sickle cell anemia who says “that my eyes always look sort of yellow”
c. 21-year-old with hemophilia who wants to learn how to self-administer factor VII replacement
d. 50-year-old with early-stage chronic lymphocytic leukemia who has complaints of chronic fatigue

 

 

ANS:  A

The patient’s age and presence of a nontender axillary lump suggest possible lymphoma, which needs rapid diagnosis and treatment. The other patients have questions about treatment or symptoms that are consistent with their diagnosis but do not need to be seen urgently.

 

DIF:    Cognitive Level: Analysis                OBJ:   Special Questions: Multiple Patients

TOP:   Nursing Process: Implementation     MSC:  NCLEX: Safe and Effective Care Environment

 

  1. After receiving change-of-shift report for the following four patients with neutropenia, which patient should the nurse assess first?
a. 66-year-old who has white pharyngeal lesions
b. 35-year-old who has a fever of 100.8° F (38.2° C)
c. 56-year-old who has frequent explosive diarrhea
d. 23-year old who is complaining of severe fatigue

 

 

ANS:  B

Any fever in a neutropenic patient indicates infection and can quickly lead to sepsis and septic shock. Rapid assessment and (if prescribed) initiation of antibiotic therapy within 1 hour are needed. The other patients also need to be assessed but do not exhibit symptoms of potentially life-threatening problems.

 

DIF:    Cognitive Level: Application           OBJ:   Special Questions: Multiple Patients

TOP:   Nursing Process: Assessment           MSC:  NCLEX: Safe and Effective Care Environment

 

 

 

Chapter 53: Nursing Management: Sexually Transmitted Diseases

Test Bank

 

MULTIPLE CHOICE

 

  1. A man who has a profuse, purulent urethral discharge with painful urination is seen at the sexually transmitted disease (STD) clinic. Which information will be most important for the nurse to obtain?
a. Contraceptive use
b. Sexual orientation
c. Immunization history
d. Recent sexual contacts

 

 

ANS:  D

Information about sexual contacts is needed to help establish whether the patient has been exposed to an STD and because sexual contacts also will need treatment. The other information also may be gathered, but is not as important in determining the plan of care for the patient’s current symptoms.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. A 21-year-old woman is being seen in the family medicine clinic for an annual physical exam. The nurse will plan to teach the patient about
a. testing for chlamydia infection.
b. immunization for herpes simplex.
c. the relationship between the herpes virus and cervical cancer.
d. the risk of infertility associated with the human papillomavirus (HPV).

 

 

ANS:  A

Testing for chlamydia is recommended for all sexually active females under age 25 by the Centers for Disease Control and Prevention. HPV infection does not cause infertility. There is no vaccine available for herpes simplex, and herpes simplex infection does not cause cervical cancer.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Planning

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. A patient with gonorrhea is treated with a single IM dose of ceftriaxone (Rocephin) and is given a prescription for doxycycline (Vibramycin) 100 mg bid for 7 days. The nurse explains to the patient that this combination of antibiotics is prescribed to
a. prevent reinfection during treatment.
b. treat any coexisting chlamydial infection.
c. eradicate resistant strains of N. gonorrhoeae.
d. prevent the development of resistant organisms.

 

 

ANS:  B

Because there is a high incidence of co-infection with gonorrhea and chlamydia, patients are usually treated for both. The other explanations about the purpose of the antibiotic combination are not accurate.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. A patient who has labs drawn for an insurance screening has a positive Venereal Disease Research Laboratory (VDRL) test. Which action should the nurse take next?
a. Ask the patient about past treatment for syphilis.
b. Discuss the need for blood and spinal fluid cultures.
c. Obtain a specimen for fluorescent treponemal antibody absorption (FAT-ABS) testing.
d. Assess for the presence of chancres, flulike symptoms, or a bilateral rash on the trunk.

 

 

ANS:  A

Once antibody testing is positive for syphilis, the antibodies remain present for an indefinite period of time even after successful treatment, so the nurse should inquire about previous treatment before doing other assessments or testing. Culture, FAT-ABS testing, and assessment for symptoms may be appropriate, based on whether the patient has been previously treated for syphilis.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. A male patient who has been diagnosed with gonococcal urethritis tells the nurse about recent sexual contact with a woman but says she did not appear to have any disease. In responding to the patient, the nurse explains that
a. women do not develop gonorrhea infections but can serve as carriers to spread the disease to males.
b. women develop subclinical cases of gonorrhea that do not cause tissue damage or clinical manifestations.
c. many women are not aware they have gonorrhea because they often do not have symptoms of infection.
d. when gonorrhea infections occur in women, the disease affects only the ovaries and not the genital organs.

 

 

ANS:  C

Many women with gonorrhea are asymptomatic or have minor symptoms that are overlooked. The disease may affect both the genitals and the other reproductive organs and cause complications such as pelvic inflammatory disease (PID). Women who can transmit the disease have active infections.

 

DIF:    Cognitive Level: Comprehension     TOP:   Nursing Process: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. A patient with positive Venereal Disease Research Laboratory (VDRL) and fluorescent treponemal antibody absorption (FAT-ABS) tests has a rash on the palms and the soles of the feet and moist papules in the anal and vulvar area. Which action will the nurse include in the plan of care?
a. Assess for arterial aneurysms.
b. Place the patient in a private room.
c. Wear gloves when touching the patient.
d. Apply antibiotic ointments to the perineum.

 

 

ANS:  C

Exudate from any lesions with syphilis is highly contagious. Systemic antibiotics, rather than local treatment of lesions, are used to treat syphilis. The patient does not require a private room because the disease is spread through contact with the lesions. This patient has clinical manifestations of secondary syphilis and does not need to be monitored for manifestations of tertiary syphilis.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Planning

MSC:  NCLEX: Safe and Effective Care Environment

 

  1. After the nurse teaches the patient who has primary genital herpes about management of the disease, which statement by the patient indicates that the teaching has been effective?
a. “I will use the acyclovir ointment on the area to relieve the pain.”
b. “I will use condoms for intercourse until the medication is all gone.”
c. “I will take the acyclovir (Zovirax) every 8 hours for the next week.”
d. “I will need to take all of the medication to be sure the infection is cured.”

 

 

ANS:  C

The treatment regimen for primary genital herpes infections includes acyclovir 400 mg 3 times daily for 7 to 10 days. The patient is taught to abstain from intercourse until the lesions are gone. (Condoms should be used even when the patient is asymptomatic.) Acyclovir ointment is not effective in treating lesions or reducing pain. Herpes infection is chronic and recurrent.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Evaluation

MSC:  NCLEX: Physiological Integrity

 

  1. When counseling a woman who is having difficulty conceiving, the nurse will be most concerned about a history of infection with
a. N. gonorrhoeae.
b. Treponema pallidum.
c. condyloma acuminatum.
d. herpes simplex virus type 2.

 

 

ANS:  A

Complications of gonorrhea include scarring of the fallopian tubes, which can lead to tubal pregnancies and infertility. Syphilis, genital warts, and genital herpes do not lead to problems with conceiving, although transmission to the fetus (syphilis) or newborn (genital warts or genital herpes) is a concern.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. A woman who is 6 weeks’ pregnant is diagnosed with primary syphilis. The nurse will plan to teach the patient about
a. the likelihood of a stillbirth.
b. the need for cesarean section.
c. intramuscular injection of penicillin.
d. use of antibiotic eye drops for the newborn.

 

 

ANS:  C

A single injection of penicillin is recommended to treat primary syphilis, and this will treat the mother and prevent transmission of the disease to the fetus. Instillation of erythromycin into the eyes of the newborn is used to prevent gonorrheal eye infections. C-section is used to prevent the transmission of herpes to the newborn. Although stillbirth can occur if the fetus is infected with syphilis, treatment before the tenth week of gestation will eliminate in utero transmission to the fetus.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. A 23-year-old patient has genital warts around her external genitalia and perianal area. She tells the nurse that she has not had treatment until now because “the warts are so disgusting.” Which nursing diagnosis is most appropriate?
a. Disturbed body image related to feelings about the genital warts
b. Ineffective coping related to denial of increased risk for infection
c. Risk for infection related to lack of knowledge about transmission
d. Anxiety related to impact of condition on interpersonal relationships

 

 

ANS:  A

The patient’s statement that her lesions are disgusting suggests that disturbed body image is the major concern. There is no evidence to indicate ineffective coping or lack of knowledge about mode of transmission. The patient may be experiencing anxiety, but there is nothing in the data indicating that the genital warts are impacting interpersonal relationships.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Diagnosis

MSC:  NCLEX: Psychosocial Integrity

 

  1. When a patient returns to the clinic for follow-up after treatment for gonococcal urethritis, a purulent urethral discharge is still present. When trying to determine the reason for the recurrent infection, which question is most appropriate for the nurse to ask the patient?
a. “Did you take the prescribed antibiotic for a week?”
b. “Did you drink at least 2 quarts of fluids every day?”
c. “Were your sexual partners treated with antibiotics?”
d. “Do you wash your hands after using the bathroom?”

 

 

ANS:  C

A common reason for recurrence of symptoms is reinfection because infected partners have not been simultaneously treated. Because gonorrhea is treated with one dose of antibiotic, antibiotic therapy for a week is not needed. An adequate fluid intake is important, but a low fluid intake is not a likely cause for failed treatment. Poor hygiene may cause complications such as ocular trachoma but will not cause a failure of treatment.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. A patient is treated for chlamydia that was detected during a routine pelvic examination. The nurse knows that teaching regarding the management of the condition has been effective when the patient says,
a. “Go ahead and give me the antibiotic injection so I will be cured.”
b. “My boyfriend will need to take antibiotics at the same time I do.”
c. “I will use condoms during sex until I finish taking all the antibiotics.”
d. “Since I do not plan on having any children, treatment is not as important.”

 

 

ANS:  B

Sex partners should be treated simultaneously to prevent reinfection. Chlamydia is treated with oral antibiotics. Abstinence from sexual intercourse is recommended for 7 days after treatment, and condoms should be recommended during all sexual contacts to prevent infection. Chronic pelvic pain, as well as infertility, can result from untreated chlamydia.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Evaluation

MSC:  NCLEX: Physiological Integrity

 

  1. A woman in the sexually transmitted disease (STD) clinic tells the nurse that she is concerned she may have been exposed to gonorrhea by her partner. To determine whether the patient has gonorrhea, the nurse will plan to
a. interview the patient about symptoms of gonorrhea.
b. take a sample of cervical discharge for Gram staining.
c. draw a blood specimen or rapid plasma reagin (RPR) testing.
d. obtain vaginal secretions for a nucleic acid amplification test (NAAT).

 

 

ANS:  D

NAAT has a high sensitivity (similar to a culture) for gonorrhea. Because women have few symptoms of gonorrhea, asking the patient about symptoms is not helpful in making a diagnosis. Smears and Gram staining are not useful because the female genitourinary tract has many normal flora that resemble N. gonorrhoeae. RPR testing is used to detect syphilis.

 

DIF:    Cognitive Level: Application           TOP:   Nursing Process: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. A woman who is diagnosed with chlamydia tells the nurse that she is very angry because her husband is her only sexual partner. Which response should the nurse make first?
a. “You may need professional counseling to help resolve your anger.”
b. “It is understandable that you are angry with your husband right now.”
c. “Your feelings are justified and you should share them with your husband.”
d. “It is important that both you and your husband be treated for the infection.”

 

 

ANS:  B

This response expresses the nurse’s acceptance of the patient’s feelings and encourages further discussion and problem solving. The patient may need professional counseling, but more assessment of the patient is needed before making this judgment. The nurse also should assess further before suggesting that the patient share her feelings with the husband because problems such as abuse might be present in the relationship. Although it is important that both partners be treated, the patient’s current anger suggests that this is not the appropriate time to bring this up.

 

DIF:    Cognitive Level: Application           OBJ:   Special Questions: Prioritization

TOP:   Nursing Process: Implementation     MSC:  NCLEX: Psychosocial Integrity

 

  1. Which of these patients will the nurse plan on teaching about the Gardasil vaccine?
a. A 50-year-old woman who has multiple sexual partners
b. A 23-year-old woman who is pregnant for the first time
c. An 18-year-old female who has never been sexually active
d. A 28-year-old woman who is in a monogamous relationship

 

 

ANS:  C

Gardasil is recommended for females ages 9 through 26, preferably those who have never been sexually active. It is not recommended for men, women during pregnancy, or for older women.

 

DIF:    Cognitive Level: Application           OBJ:   Special Questions: Multiple Patients

TOP:   Nursing Process: Planning               MSC:  NCLEX: Health Promotion and Maintenance

 

MULTIPLE RESPONSE

 

  1. A 47-year-old patient with a long history of IV drug use is seen at a community clinic, where the patient reports difficulty walking because “I don’t know where my feet are.” Diagnostic screening reveals positive Venereal Disease Research Laboratory (VDRL) and fluorescent treponemal antibody absorption (FAT-ABS) tests. Based on the patient history, the nurse will assess which of the following (select all that apply)?
a. Heart sounds
b. Genitalia for lesions
c. Joints for swelling and inflammation
d. Mental state for judgment and orientation
e. Skin and mucous membranes for gummas

 

 

ANS:  A, D, E

The patient’s clinical manifestations and laboratory tests are consistent with tertiary syphilis; valvular insufficiency, gummas, and changes in mentation are other clinical manifestations of this stage.

 

DIF:    Cognitive Level: Analysis                OBJ:   Special Questions: Alternate Item Format

TOP:   Nursing Process: Assessment           MSC:  NCLEX: Physiological Integrity

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