Medical Surgical Nursing Single Volume Assessment and Management of Clinical Problems 7th Edition by Sharon L. Lewis – Test Bank

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Lewis: Medical-Surgical Nursing, 7^th Edition

 

Test Bank

 

Chapter 5: Patient and Family Teaching

 

MULTIPLE CHOICE

 

1. A patient has just been diagnosed with breast cancer following a needle biopsy of a breast lump. The nurse plans teaching for the patient to meet the goal of

a.	preventing the recurrence of the tumor.
b.	learning skills to live with the disease.
c.	selecting and using treatment options.
d.	minimizing adverse effects of treatment.

 

Correct Answer: C

Rationale: Adults learn best when given information that can be used immediately. The first action the patient will need to take after a cancer diagnosis is to choose a treatment option. The other goals may be appropriate as treatment progresses.

 

Cognitive Level: Application                       Text Reference: pp. 54, 59

Nursing Process: Planning

NCLEX: Health Promotion and Maintenance

 

 

2. After the nurse implements diet instruction with a patient with heart disease, the patient can explain the information but fails to make the recommended dietary changes. The nurse’s evaluation is that

a.	learning did not occur because the patient’s behavior did not change.
b.	choosing not to follow the diet is the behavior that resulted from learning.
c.	the nursing responsibility for helping the patient make dietary changes has been fulfilled.
d.	the teaching methods were ineffective in helping the patient learn the dietary information.

 

Correct Answer: B

Rationale: Although the patient behavior has not changed, the patient’s ability to explain the information indicates that learning has occurred and the patient is choosing at this time to continue with the previous diet. The patient may be in the contemplation or preparation state in the transtheoretical model. The nurse should reinforce the need for change and continue to provide information and assistance with planning for change.

 

Cognitive Level: Application                       Text Reference: p. 55

Nursing Process: Evaluation

NCLEX: Health Promotion and Maintenance

 

 

 

3. The nurse applies principles of adult education when teaching a new diabetic about the disease by

a.	explaining that making lifestyle changes and taking medications correctly will help the patient start to feel better right away.
b.	informing the patient that a home health nurse will be scheduled to visit and evaluate how well the patient is managing the disease.
c.	telling the patient that learning about diabetes will be an opportunity for a completely new life experience.
d.	advising the patient that this information is needed to manage the disease and maintain long-term health.

 

Correct Answer: A

Rationale: Principles of adult education indicate that adults learn best when the information can be used immediately. The answer option beginning, “informing the patient that a home health nurse will be scheduled to visit” indicates a lack of respect for the patient’s independence. The answer option beginning, “telling the patient that learning about diabetes will be an opportunity” is less appropriate because adults prefer to base new learning on past experience. And the final answer option (advising the patient that this is information is needed to manage the disease and maintain long-term health) focuses on long-term benefits, which are less appealing to the adult learner.

 

Cognitive Level: Application                       Text Reference: pp. 54, 59

Nursing Process: Implementation

NCLEX: Health Promotion and Maintenance

 

 

4. A patient admitted to the hospital with hyperglycemia and diagnosed with diabetes mellitus is scheduled for discharge the second day after admission. In view of the patient’s limited hospitalization, the nurse should plan to

a.	include detailed information about diet and medication use in patient teaching.
b.	use every interaction to teach the patient about the details of glucose control.
c.	focus on teaching the family instead of the patient about diabetic management.
d.	teach the patient about how to monitor glucose and self-administer insulin.

 

Correct Answer: D

Rationale: When time is limited, the nurse should set realistic goals with the patient that will meet immediate needs. The patient and family will need further teaching about the role of diet, exercise, medications, etc., in controlling glucose, but these topics can be addressed through planning for appropriate referrals.

 

Cognitive Level: Application                       Text Reference: p. 56

Nursing Process: Planning

NCLEX: Health Promotion and Maintenance

 

 

5. When using the Transtheoretical Model of Health Behavior Change during patient teaching, the nurse identifies that the patient who states, “I told my wife that I was going to start exercising, and I think I will join a fitness club,” is in the stage of

a.	contemplation.
b.	preparation.
c.	maintenance.
d.	termination.

 

Correct Answer: B

Rationale: The patient’s statement indicating that the plan for change is being shared with someone else indicates that the preparation stage has been achieved. Contemplation of a change would be indicated by a statement like “I know I should exercise.” Maintenance of a change occurs when the patient practices the behavior regularly. Termination would be indicated when the change is a permanent part of the lifestyle.

 

Cognitive Level: Comprehension                 Text Reference: p. 55

Nursing Process: Assessment

NCLEX: Health Promotion and Maintenance

 

 

6. A 73-year-old Latino patient is seen at the health clinic and diagnosed with protein malnutrition. When developing a plan to teach the patient about meeting dietary needs, the first action by the nurse should be to

a.	encourage the patient to use milk and meat as primary protein intake sources.
b.	focus on the use of combinations of beans and rice to improve daily protein intake.
c.	ask the patient to record the intake of all foods and beverages for a 3-day period.
d.	stress the need to increase protein intake through the use of liquid supplements.

 

Correct Answer: C

Rationale: Assessment is the first step in assisting a patient with health changes. The other answers may be appropriate for the patient, but the nurse will not be able to determine this until the assessment of the patient is complete.

 

Cognitive Level: Application                       Text Reference: p. 57

Nursing Process: Assessment

NCLEX: Health Promotion and Maintenance

 

 

7. While admitting a patient to the medical unit, the nurse learns that the patient does not read well. This information will guide the nurse in determining

a.	which instructional strategies should be used in teaching.
b.	the degree of the patient’s motivation to learn.
c.	what information the patient will be able to understand.
d.	that the family must be included in the teaching process.

 

Correct Answer: A

Rationale: The information that the patient is illiterate indicates that the nurse should avoid the use of written materials in teaching and choose other strategies. The patient does not indicate a lack of motivation or an inability to understand new information. The patient’s lack of reading ability does not necessarily imply that the family must be included in the teaching process.

 

Cognitive Level: Comprehension                 Text Reference: p. 58

Nursing Process: Planning

NCLEX: Health Promotion and Maintenance

 

 

8. A postoperative patient says it hurts too much to deep breathe and cough every 2 hours and refuses to carry out the activity. The best initial action by the nurse is to

a.	explain how coughing and deep breathing will decrease the risk of complications.
b.	respect the patient’s wishes and assist the patient to turn side-to-side more frequently.
c.	enlist the help of the health care provider in reinforcing the need to cough and deep breathe.
d.	document the patient’s refusal to cough and deep breathe in the patient’s chart.

 

Correct Answer: A

Rationale: Teaching the patient about the reason for the deep breathing and coughing will be likely to improve compliance and decrease the risk for complications. Turning side-to-side will not be as effective in preventing postoperative complications. The health care provider may need to help reinforce the need for coughing and deep breathing, but this should not be the initial action by the nurse. Documentation is important but is not an adequate response to the situation.

 

Cognitive Level: Application                       Text Reference: p. 55

Nursing Process: Implementation

NCLEX: Health Promotion and Maintenance

 

 

9. When assessing the learning needs for a patient who has coronary heart disease, the nurse finds that the patient has recently made dietary changes to decrease fat intake and has stopped smoking. The best initial response by the nurse at this time is,

a.	“You have already accomplished some changes that are important in heart health.”
b.	“Although those are important, it is essential that you make other changes, too.”
c.	“Which additional changes in your lifestyle would you like to implement at this time?”
d.	“Are you having any difficulty in maintaining the changes you have already made?”

 

Correct Answer: A

Rationale: Adult learners are more motivated when their accomplishments are recognized. The other responses are also appropriate but are not the best initial response.

 

Cognitive Level: Application                       Text Reference: pp. 55, 63

Nursing Process: Implementation

NCLEX: Health Promotion and Maintenance

 

 

10. To assess a patient’s readiness to learn before planning teaching activities, the most appropriate question for the nurse to ask is,

a.	“What kind of work and leisure activities do you do?”
b.	“What information do you think you need right now?”
c.	“Do you have any religious beliefs that are inconsistent with the treatment?”
d.	“Can you describe the types of activities that help you learn new information?”

 

Correct Answer: B

Rationale: Motivation and readiness to learn depend on what the patient values. The other questions are also important but do not address what information interests the patient most at present.

 

Cognitive Level: Application                       Text Reference: pp. 54, 59

Nursing Process: Assessment

NCLEX: Health Promotion and Maintenance

 

 

11. The nurse identifies a nursing diagnosis of ineffective health maintenance related to low motivation based on the finding that the diabetic patient

a.	does not perform capillary blood glucose tests as directed.
b.	occasionally forgets to take the daily prescribed medication.
c.	says that dietary intake does not seem to impact fatigue level.
d.	cannot identify signs or symptoms of high and low blood glucose.

 

Correct Answer: C

Rationale: The patient’s motivation to follow a diabetic diet will be decreased if the patient feels that dietary changes do not impact symptoms. The other responses do not indicate that the ineffective health maintenance is caused by lack of motivation.

 

Cognitive Level: Application                       Text Reference: pp. 54, 60

Nursing Process: Diagnosis

NCLEX: Health Promotion and Maintenance

 

 

12. The nurse is teaching a patient with peripheral vascular disease about foot care. A correctly written learning objective is,

a.	“The nurse will instruct the patient on appropriate foot care before discharge.”
b.	“The patient will list three ways to protect the feet from injury by discharge.”
c.	“The nurse will demonstrate for the patient the proper technique for trimming toenails.”
d.	“The patient will understand the rationale for proper foot care after instruction.”

 

Correct Answer: B

Rationale: This objective contains all four elements of a specific learning objective. The objective stating, “The patient will understand the rationale for proper foot care after instruction” will be impossible to measure. The remaining two answer options describe actions that the nurse will take, not behaviors that indicate patient learning has occurred.

 

Cognitive Level: Application                       Text Reference: p. 60

Nursing Process: Planning

NCLEX: Health Promotion and Maintenance

 

 

13. When the nurse is planning teaching for a patient who needs to improve skills in being more assertive, the most effective teaching strategy will be

a.	lecture-discussion.
b.	role playing.
c.	peer teaching.
d.	printed materials.

 

Correct Answer: B

Rationale: Role-playing allows the patient to practice assertive behavior and receive feedback about how the behavior is perceived. Lecture-discussion, peer-teaching, and printed materials are more useful for other forms of teaching.

 

Cognitive Level: Comprehension                 Text Reference: pp. 58, 62

Nursing Process: Planning

NCLEX: Health Promotion and Maintenance

 

 

14. A newly diagnosed diabetic patient who will need instruction about diet, exercise, and insulin use tells the nurse, “I think that the most important thing I need to control my blood sugar is how to give my own insulin.” During implementation of the teaching plan, the nurse will initially focus on

a.	demonstrating how to draw up and administer the prescribed insulin.
b.	teaching the patient that changes in diet can help decrease insulin use.
c.	describing how exercise can be used to decrease the need for insulin.
d.	giving the patient written material with information about how insulin works.

 

Correct Answer: A

Rationale: Adult education is most effective when focused on information that the patient thinks is needed right now. All the indicated information will need to be included when planning teaching for this patient, but the teaching will be most effective if the nurse starts with the patient’s priority.

 

Cognitive Level: Application                       Text Reference: pp. 54, 59

Nursing Process: Implementation

NCLEX: Health Promotion and Maintenance

 

 

15. To evaluate how effective teaching has been for the following teaching objective, “The patient will select a 2000-mg sodium diet from the hospital menu daily for 3 days with 90% accuracy,” the nurse will

a.	ask the patient to identify which foods on the daily menu are highest in sodium.
b.	total the sodium content of the foods the patient has eaten for the last 3 days.
c.	note the food selected on three daily menus and determine whether the daily sodium content is within 1800 to 2200 mg.
d.	compare the patient’s sodium intake over the next 3 days with the sodium intake before the teaching was implemented.

 

Correct Answer: C

Rationale: The statement of the teaching objective is most clearly addressed with this answer. The other answers also address the patient’s sodium intake but do not directly address the objective as written.

 

Cognitive Level: Application                       Text Reference: pp. 60, 63-64

Nursing Process: Evaluation

NCLEX: Health Promotion and Maintenance

 

 

16. The nurse is preparing written handouts to be used as part of the standardized teaching plan for patients who have been recently diagnosed with diabetes. Which statement best reflects the appropriate reading level?

a.	Polyphagia, polydipsia, and polyuria are common symptoms of diabetes mellitus.
b.	Some diabetics control blood glucose with oral medications or nutritional interventions.
c.	The use of the right foods can help in keeping blood sugar at a near-normal level.
d.	Diabetes mellitus is characterized by chronic hyperglycemia and the associated symptoms.

 

Correct Answer: C

Rationale: The readability of this statement will be most appropriate for the widest variety of patients. The other responses have words with three or more syllables, use many medical terms, and/or are too long.

 

Cognitive Level: Application                       Text Reference: p. 62

Nursing Process: Planning

NCLEX: Health Promotion and Maintenance

 

 

17. The nurse in the hospital has implemented a teaching plan to assist a patient with rheumatoid arthritis in accomplishing daily activities independently. To evaluate the patient’s long-term response to the teaching, the best action by the nurse will be to

a.	check the patient’s ability to bathe without any assistance the next day.
b.	make a referral to the home health nursing department for home visits.
c.	arrange a physical therapy visit before the patient is discharged from the hospital.
d.	have the patient demonstrate the taught skills again at the end of the teaching session.

 

Correct Answer: B

Rationale: The patient’s long-term response may need to be assessed after discharge; a home health referral will allow this to occur. The other actions will allow evaluation of the patient’s short-term response to teaching.

 

Cognitive Level: Application                       Text Reference: p. 64

Nursing Process: Planning

NCLEX: Health Promotion and Maintenance

 

 

 

 

Lewis: Medical-Surgical Nursing, 7^th Edition

 

Test Bank

 

Chapter 31: Nursing Management: Hematologic Problems

 

MULTIPLE CHOICE

 

1. A patient with a history of iron-deficiency anemia who has not taken iron supplements for several years is experiencing increased fatigue and occasional palpitations. The nurse would expect the patient’s laboratory findings to include

a.	hematocrit (Hct) 38%.
b.	red blood cell count (RBC) 4,500,000/ml.
c.	hemoglobin (Hb) 8.6 g/dl (86 g/L).
d.	normal RBC indices.

 

Correct Answer: C

Rationale: The patient’s clinical manifestations indicate moderate anemia, which is consistent with a Hb of 6 to 10 g/dl. The other values are all within the range of low-normal to normal.

 

Cognitive Level: Comprehension                 Text Reference: pp. 686, 690

Nursing Process: Assessment                       NCLEX: Physiological Integrity

 

 

2. When discussing appropriate food choices with a patient who has iron-deficiency anemia and follows a low-cholesterol diet, the nurse will encourage the patient to increase the dietary intake of

a.	eggs and muscle meats.
b.	nuts and cornmeal.
c.	milk and milk products.
d.	legumes and dried fruits.

 

Correct Answer: D

Rationale: Legumes and dried fruits are high in iron and low in fat and cholesterol. Eggs and muscle meats are high in iron but also high in fat and cholesterol. Nuts and milk products will improve amino acid intake but are not high in iron. Cornmeal would be an appropriate choice for a vitamin B₆ deficiency.

 

Cognitive Level: Application                       Text Reference: p. 689

Nursing Process: Implementation                NCLEX: Physiological Integrity

 

 

3. A patient has a folic acid deficiency related to chronic alcohol abuse. The nurse would expect a complete blood cell count (CBC) to reveal

a.	macrocytic, normochromic red cells.
b.	normocytic, normochromic red cells.

 

c.	microcytic, hypochromic red cells.
d.	microcytic, normochromic red cells.

 

Correct Answer: A

Rationale: With folic acid deficiency, the cells are larger than normal, but the iron levels are normal or elevated, leading to findings of a macrocytic, normochromic anemia. Microcytic anemia, hypochromic anemia is more typical of iron deficiency. Normocytic, normochromic RBC indicate that the patient does not have anemia or may occur in patients with anemia-related chronic disease.

 

Cognitive Level: Comprehension                 Text Reference: pp. 686, 690

Nursing Process: Assessment                       NCLEX: Physiological Integrity

 

 

4. 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 will need to have cobalamin (B12) injections regularly for the rest of my life.”
b.	“I will stop having a glass of wine with dinner.”
c.	“The numbness in my feet will go away once my hemoglobin level returns to normal.”
d.	“My diet should include more red meat or liver.”

 

Correct Answer: A

Rationale: Pernicious anemia prevents the absorption of vitamin B₁₂, and the patient requires injections or intranasal administration of cobalamin. Alcohol use does not cause cobalamin deficiency. Neurologic symptoms may not resolve with treatment. Eating more foods rich in B₁₂ is not helpful because the lack of intrinsic factor prevents absorption of the vitamin.

 

Cognitive Level: Application                       Text Reference: p. 692

Nursing Process: Evaluation                         NCLEX: Physiological Integrity

 

 

5. A patient with chronic lymphocytic leukemia is hospitalized for treatment of severe hemolytic anemia. An appropriate nursing intervention for the patient is to

a.	provide a diet high in vitamin K.
b.	isolate the patient from visitors.
c.	plan care to alternate periods of rest and activity.
d.	encourage increased intake of fluid and fiber in the diet.

 

Correct Answer: C

Rationale: Nursing care for patients with anemia should alternate periods of rest and activity to maintain patient mobility without causing undue fatigue. High vitamin K diets might be used for a patient with a bleeding disorder. There is no indication that the patient is neutropenic, so isolation is not needed. Increased intake of fluid and fiber will not improve the anemia.

 

Cognitive Level: Application                       Text Reference: p. 688

Nursing Process: Implementation                NCLEX: Physiological Integrity

 

 

6. After teaching the patient about taking oral iron preparations for a moderate iron-deficiency anemia, the nurse determines that additional instruction is needed when the patient says,

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 will increase my fluid and fiber intake while I am taking the iron tablets.”
d.	“I should take the iron with orange juice about an hour before eating.”

 

Correct Answer: A

Rationale: 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.

 

Cognitive Level: Application                       Text Reference: p. 690

Nursing Process: Evaluation                         NCLEX: Physiological Integrity

 

 

7. A patient is admitted to the hospital with idiopathic aplastic anemia. An appropriate collaborative problem for the nurse to identify for the patient is

a.	potential complication: hemorrhage.
b.	potential complication: neurogenic shock.
c.	potential complication: pulmonary edema.
d.	potential complication: seizures.

 

Correct Answer: A

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

 

Cognitive Level: Application                       Text Reference: p. 694

Nursing Process: Diagnosis                          NCLEX: Physiological Integrity

 

 

8. A patient with sickle cell anemia 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.

 

Correct Answer: B

Rationale: 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.

 

Cognitive Level: Application                       Text Reference: pp. 696, 698

Nursing Process: Implementation                NCLEX: Physiological Integrity

 

 

9. A patient who is having a sickle cell crisis asks the nurse why the sickling causes such pain. The nurse explains that the pain of sickling is caused by

a.	spasms of the blood cells as they change shape.
b.	deposition of sickled red cells in the bone marrow.
c.	tissue hypoxia caused by small blood vessel occlusion.
d.	infectious processes in organs affected by the sickling.

 

Correct Answer: C

Rationale: The pain associated with a sickle cell crisis is caused by ischemia as the sickled cells occlude small blood vessels and capillaries. Blood vessels do not change shape during the crisis. Sickled red cells are not deposited in the bone marrow. Infection may precipitate sickling but is not the cause of the pain.

 

Cognitive Level: Application                       Text Reference: pp. 696-697

Nursing Process: Implementation                NCLEX: Physiological Integrity

 

 

10. When planning discharge teaching for the patient who was admitted with a sickle cell crisis, which information will the nurse include?

a.	Drink only one or two caffeinated beverages daily.
b.	Take a daily multivitamin with iron.
c.	Limit fluids to 2 to 3 quarts a day.
d.	Avoid exposure to crowds as much as possible.

 

Correct Answer: D

Rationale: 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.

 

Cognitive Level: Application                       Text Reference: p. 697

Nursing Process: Planning                            NCLEX: Physiological Integrity

 

 

11. Which of these assessment data obtained by the nurse when caring for a patient with thrombocytopenia should be immediately communicated to the health care provider?

a.	Platelet count is 52,000/ml.
b.	There are bullae on the oral mucosa.
c.	The patient is difficult to arouse.
d.	There are large bruises on the back.

 

Correct Answer: C

Rationale: 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 they are not urgent.

 

Cognitive Level: Application                       Text Reference: pp. 703, 705, 707

Nursing Process: Assessment                       NCLEX: Physiological Integrity

 

 

12. During the admission assessment of a patient who has an Hb of 7.6 g/dl (76 g/L), the nurse notes jaundice of the sclera. The nurse will plan to check the laboratory results for

a.	the stool occult blood test.
b.	the bilirubin level.
c.	the gastric analysis testing.
d.	the Schilling test.

 

Correct Answer: B

Rationale: Jaundice is caused by the elevation of bilirubin level associated with RBC hemolysis. The presence of jaundice suggests a hemolytic anemia, rather than gastrointestinal bleeding or cobalamin deficiency, as the cause of the anemia.

 

Cognitive Level: Application                       Text Reference: p. 686

Nursing Process: Assessment                       NCLEX: Physiological Integrity

 

 

13. The health care provider orders transfusion with packed RBCs for a patient who is hospitalized with severe anemia. The most important action by the nurse to prevent a transfusion reaction when administering the blood is to

a.	verify the patient identification according to hospital policy.
b.	administer the blood as soon as it arrives on the nursing unit.
c.	initiate the blood transfusion at a rate of no more than 2 ml/min.
d.	stay with the patient during the first 15 minutes of the transfusion.

 

Correct Answer: A

Rationale: Improper identification is responsible 90% of hemolytic transfusion reactions. The nurse should also administer the blood within 30 minutes of its arrival on the unit, transfuse the blood at 2 ml/min during the first 15 minutes, and stay with the patient during the first 15 minutes; however, these measures will not prevent a transfusion reaction if the person is receiving the wrong blood.

 

Cognitive Level: Comprehension                 Text Reference: p. 731

Nursing Process: Implementation

NCLEX: Safe and Effective Care Environment

 

 

14. A patient receiving a whole-blood transfusion develops chills and fever, headache, and anxiety 30 minutes after the transfusion is started. After stopping the transfusion, the nurse will plan to

a.	send a urine specimen to the laboratory.
b.	administer acetaminophen (Tylenol).
c.	give diphenhydramine (Benadryl).
d.	draw blood for a new cross-match.

 

Correct Answer: B

Rationale: 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.

 

Cognitive Level: Application                       Text Reference: p. 733

Nursing Process: Planning                            NCLEX: Physiological Integrity

 

 

15. Fifteen minutes after a transfusion of packed red cells is started, a patient develops tachycardia and tachypnea and complains of back pain and feeling warm. The nurse first action should be to

a.	disconnect the transfusion and infuse normal saline.
b.	obtain a urine specimen to send to the laboratory.
c.	administer oxygen therapy at a high flow rate.
d.	notify the health care provider about the transfusion reaction.

 

Correct Answer: A

Rationale: The first action should be to disconnect the transfusion and infuse normal saline to keep the line open and maintain the patient’s BP. The other actions are also needed but are not the highest priority.

 

Cognitive Level: Application                       Text Reference: pp. 732-733

Nursing Process: Implementation                NCLEX: Physiological Integrity

 

 

16. A patient who has been receiving a heparin infusion and warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia and thrombosis syndrome (HITTS). The nurse will anticipate a health care provider order to

a.	use saline for flushing IV lines.
b.	give low-molecular-weight (LMW) heparin.
c.	discontinue the warfarin.
d.	administer platelet transfusions.

 

Correct Answer: A

Rationale: All heparin is discontinued when the HITTS is diagnosed. The patient should be instructed to never receive heparin or LMW heparin. Warfarin will be continued because it does not induce thrombocytopenia. The platelet count does not drop low enough in HITTS for a platelet transfusion, and a transfusion will increase the risk for thrombosis

 

Cognitive Level: Application                       Text Reference: p. 704

Nursing Process: Planning                            NCLEX: Physiological Integrity

 

 

17. During treatment of the patient with an acute exacerbation of polycythemia vera, a critical action by the nurse is to

a.	check oxygen saturation q4hr.
b.	monitor fluid intake and output.
c.	place the patient on bed rest.
d.	administer iron supplements.

 

Correct Answer: B

Rationale: Monitoring hydration status is important during an acute exacerbation because the patient is at risk for fluid overload or underhydration. Problems with tissue oxygenation in polycythemia vera are due to increased blood viscosity and poor perfusion, not to poor oxygen saturation. (Oxygen is useful in secondary polycythemia.) The patient should be encouraged to ambulate to prevent DVT. Iron is contraindicated for polycythemia vera.

 

Cognitive Level: Application                       Text Reference: p. 701

Nursing Process: Planning                            NCLEX: Physiological Integrity

 

 

18. A patient admitted to the hospital in preparation for a splenectomy for treatment of immune thrombocytopenia purpura (ITP) asks the nurse about the benefits of the splenectomy. The nurse explains that the expected effect of the splenectomy is

a.	reduced destruction of platelets by macrophages.
b.	promotion of platelet sequesterization and release by the liver.
c.	increased production of platelets by the bone marrow.
d.	increased RBC production to compensate for blood loss.

 

Correct Answer: A

Rationale: Because sequesterization of platelets and platelet destruction by macrophages occurs in the spleen, splenectomy will increase the platelet count. Splenectomy does not promote sequesterization or release of platelets by the liver, increase platelet production, or increase RBC production.

 

Cognitive Level: Application                       Text Reference: p. 703

Nursing Process: Implementation                NCLEX: Physiological Integrity

 

 

19. 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 a history of sickle cell anemia who has had nausea and diarrhea for 24 hours
b.	The patient who has chemotherapy-induced neutropenia and has a temperature of 100.8° F
c.	The patient with thrombocytopenia who has oozing after having a tooth extracted
d.	The patient with hemophilia A who has ankle swelling after twisting the ankle

 

Correct Answer: B

Rationale: 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 so urgently as the neutropenic patient.

 

Cognitive Level: Analysis                             Text Reference: p. 714

Nursing Process: Assessment

NCLEX: Safe and Effective Care Environment

 

 

20. The nurse is caring for a patient 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.	Petechiae are present on the chest and back.
b.	Blood pressure (BP) is 94/56 mm Hg.
c.	Platelet count is 42,000/ml.
d.	Blood is oozing from the venipuncture site.

 

Correct Answer: C

Rationale: Platelet transfusions are not usually indicated until the platelet count is below 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.

 

Cognitive Level: Application                       Text Reference: p. 704

Nursing Process: Assessment                       NCLEX: Physiological Integrity

 

 

21. Which nursing intervention will be included in the care plan for a patient with ITP?

a.	Use rinses rather than a toothbrush for oral care.
b.	Restrict activity to passive and active range of motion.
c.	Place patient in a private room.
d.	Avoid intramuscular (IM) and subcutaneous injections.

 

Correct Answer: D

Rationale: 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.

 

Cognitive Level: Application                       Text Reference: pp. 705-706

Nursing Process: Planning

NCLEX: Safe and Effective Care Environment

 

 

22. The nurse suspects the development of heparin-induced thrombocytopenia and thrombosis syndrome (HITTS) when a patient receiving heparin

a.	develops a pancytopenia.
b.	has a platelet count of 200,000/ml.
c.	develops a spiking temperature and chills.
d.	has decreasing activated partial thromboplastin times.

 

Correct Answer: D

Rationale: Platelet aggregation in HITTS causes neutralization of heparin so that the activated partial thromboplastin times will be shorter and more heparin will be needed to maintain therapeutic levels. Decreases in WBCs and RBCs are not seen with HITTS. A platelet count of 200,000/ml is normal. A spiking temperature and chills indicate infection or sepsis, not HITTS.

 

Cognitive Level: Application                       Text Reference: p. 704

Nursing Process: Assessment                       NCLEX: Physiological Integrity

 

 

23. 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.	perform passive range of motion (ROM) to the knee.
d.	assist the patient with light weight-bearing.

 

Correct Answer: A

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

 

Cognitive Level: Application                       Text Reference: p. 709

Nursing Process: Implementation                NCLEX: Physiological Integrity

 

 

24. A patient with von Willebrand’s disease is admitted to the hospital for minor knee surgery. The nurse will review the coagulation survey to check the

a.	bleeding time.
b.	platelet count.
c.	prothrombin time.
d.	thrombin time.

 

Correct Answer: A

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

 

Cognitive Level: Application                       Text Reference: p. 709

Nursing Process: Implementation                NCLEX: Physiological Integrity

 

 

25. The nurse caring for a patient with hemophilia teaches the patient to seek immediate medical attention upon experiencing

a.	sore throat.
b.	skin abrasions.
c.	bleeding gums.
d.	dark tarry stools.

 

Correct Answer: D

Rationale: Melena is a sign of gastrointestinal bleeding and requires further assessment. A sore throat does not indicate bleeding, although neck swelling requires rapid medical care. The patient can apply pressure to abrasions or gum bleeding rather than immediately seeking medical attention.

 

Cognitive Level: Application                       Text Reference: pp. 708, 710

Nursing Process: Implementation

NCLEX: Health Promotion and Maintenance

 

 

26. A patient’s family member asks the nurse what caused the patient to develop disseminated intravascular coagulation (DIC). The nurse tells the family member that DIC

a.	is caused by an abnormal activation of clotting.
b.	occurs when the immune system attacks platelets.
c.	is a complication of cancer chemotherapy.
d.	is caused when hemolytic processes destroy erythrocytes.

 

Correct Answer: A

Rationale: DIC is an abnormal response of the clotting cascade stimulated by a variety of disease or disorders. ITP is caused by platelet destruction by the immune system. Various cancers are associated with DIC, but cancer chemotherapy is not a cause. Destruction of RBCs does not occur in DIC.

 

Cognitive Level: Application                       Text Reference: p. 710

Nursing Process: Assessment                       NCLEX: Physiological Integrity

 

 

27. During treatment of the patient who has sepsis-induced DIC with moderate bleeding, the nurse will expect that the initial collaborative care will focus on

a.	administration of heparin to reduce intravascular clotting.
b.	treatment of the infectious process with IV antibiotics.
c.	infusion of whole blood to replace clotting factors and RBCs.
d.	supportive management of symptoms until the DIC is resolved.

 

Correct Answer: B

Rationale: Treatment of the acute sepsis is essential to resolving the DIC and will be the major focus of collaborative care. Heparin administration is controversial in DIC, although it may be used if the DIC does not resolve and clotting factors continue to decrease. Selected blood components may be infused, but whole blood is not used. Supportive care will be given, but treatment of the sepsis is essential.

 

Cognitive Level: Application                       Text Reference: p. 712

Nursing Process: Planning                            NCLEX: Physiological Integrity

 

 

28. A patient with myelodysplastic syndrome (MDS) is receiving chemotherapy. Which of these laboratory values will be of most concern to the nurse?

a.	RBC 4,800,000/ml
b.	Monocytes 560/ml
c.	Neutrophils 2600/ml
d.	WBC 2800/lL

 

Correct Answer: D

Rationale: The low WBC level indicates a risk for infection; the nurse should notify the health care provider and expect an order to check the differential. The other values are normal and do not require any immediate action by the nurse except ongoing monitoring.

 

Cognitive Level: Application                       Text Reference: p. 717

Nursing Process: Assessment                       NCLEX: Physiological Integrity

 

 

29. The most appropriate nursing intervention to include in the care plan for a patient with neutropenia is to

a.	omit fresh fruits or vegetables from the diet.
b.	check the temperature q4hr.
c.	avoid any IM or subcutaneous injections.
d.	assess all wounds for redness and drainage.

 

Correct Answer: B

Rationale: The earliest sign of infection in a neutropenic patient is an elevation in temperature. Fruits and vegetables that are peeled are acceptable. Injections may be required for administration of medications such as filgrastim (Neupogen). Redness and drainage may not occur even with severe wound infections because these symptoms of infections are dependent on neutrophils.

 

Cognitive Level: Application                       Text Reference: pp. 714-716

Nursing Process: Assessment                       NCLEX: Physiological Integrity

 

 

30. A patient receiving chemotherapy for acute lymphocytic leukemia has pancytopenia, and filgrastim (Neupogen) is prescribed. The nurse teaches the patient that the reason for the use of the medication is

a.	to help promote remission of the acute leukemia.
b.	to improve the number and function of neutrophils.
c.	replacement of abnormal stem cells in the bone marrow with normal cells.
d.	prevention of hemorrhage complications in patients with thrombocytopenia.

 

Correct Answer: B

Rationale: Filgrastim increases the neutrophil count and function in neutropenic patients. It does not cause remission of the leukemia or cause changes in the bone marrow stem cells. Thrombocytopenic patients may receive oprelvekin (Neumega) to increase platelet count and decrease bleeding risk.

 

Cognitive Level: Application                       Text Reference: p. 715

Nursing Process: Planning                            NCLEX: Physiological Integrity

 

 

31. A 64-year-old patient with newly diagnosed acute myelogenous leukemia (AML) who is undergoing induction therapy with chemotherapeutic agents tells the nurse, “I feel so sick that I don’t know if the treatment is worth completing.” The nurse’s best response to the patient is

a.	“I know you feel really ill right now, but after this therapy your disease will go into a remission and you will feel normal again.”
b.	“Induction therapy is very aggressive and causes the most side effects, so when this phase is completed you won’t feel so ill.”
c.	“Your type of leukemia has an 80% survival rate if aggressive therapy is started, so the effects of treatment will be worth it to you.”
d.	“The chemotherapy is difficult, but it is necessary to put the disease into remission and give you time to make choices about your life.”

 

Correct Answer: D

Rationale: AML is very aggressive, and survival after diagnosis is short without treatment. Induction therapy is followed by more chemotherapy, so the nurse should not tell the patient that he or she will feel normal or not so ill. The survival with AML is not 80%.

 

Cognitive Level: Application                       Text Reference: p. 720

Nursing Process: Implementation                NCLEX: Psychosocial Integrity

 

 

32. Which of these 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.	Teaching the patient the purpose of neutropenic precautions
b.	Assessing the patient for signs and symptoms of infection
c.	Developing a discharge teaching plan for the patient and family
d.	Administer the ordered subcutaneous filgrastim (Neupogen) injection

 

Correct Answer: D

Rationale: 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.

 

Cognitive Level: Application                       Text Reference: pp. 714-716

Nursing Process: Implementation

NCLEX: Safe and Effective Care Environment

 

 

33. A patient with newly diagnosed leukemia is receiving chemotherapy. Which intervention will the nurse include in the plan of care?

a.	Avoid the intake of fresh fruits and vegetables.
b.	Administer oral prophylactic antibiotics.
c.	Teach visitors hand washing techniques.
d.	Place the patient in a laminar airflow room.

 

Correct Answer: C

Rationale: Infection-control measures such as handwashing are necessary for the patient receiving chemotherapy. Restrictions of fresh fruits and vegetables, prophylactic antibiotics, and laminar airflow rooms are used for patients who are neutropenic, but not for all patients receiving chemotherapy.

 

Cognitive Level: Application                       Text Reference: p. 716

Nursing Process: Planning

NCLEX: Safe and Effective Care Environment

 

 

34. A 45-year-old patient with chronic myelogenous leukemia (CML) is considering the possibility of treatment with a hematopoietic stem cell transplant (HSCT) from an HLA-matched sibling. 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.	ask the patient whether there are any questions or concerns about HSCT.
c.	explain that a cure is not possible with any other treatment except HSCT.
d.	discuss the need for adequate insurance to cover post-HSCT care.

 

Correct Answer: B

Rationale: Offering the patient an opportunity to ask questions or discuss concerns about HSCT will encourage the patient to voice concerns about this treatment and will also allow the nurse to assess whether the patient needs more information about the procedure. Treatment of CML 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.

 

Cognitive Level: Application                       Text Reference: pp. 721-722

Nursing Process: Implementation                NCLEX: Psychosocial Integrity

 

 

35. During care of the patient with multiple myeloma, an important nursing intervention is

a.	limiting weight-bearing and ambulation.
b.	maintaining a fluid intake of 3 to 4 L/day.
c.	assessing lymph nodes for enlargement.
d.	administration of calcium supplements.

 

Correct Answer: B

Rationale: A high fluid intake and urine output helps to 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.

 

Cognitive Level: Application                       Text Reference: pp. 728-729

Nursing Process: Planning                            NCLEX: Physiological Integrity

 

 

36. A patient with non-Hodgkin’s lymphoma develops a platelet count of 10,000/ml during chemotherapy. An appropriate nursing intervention for the patient, based on this finding, is to

a.	encourage fluids to 3000 ml/day.
b.	provide oral hygiene q2hr.
c.	check the temperature q4hr.
d.	check all stools for occult blood.

 

Correct Answer: D

Rationale: 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.

 

Cognitive Level: Application                       Text Reference: p. 706

Nursing Process: Planning                            NCLEX: Physiological Integrity

 

 

37. A 26-year-old patient with stage II Hodgkin’s lymphoma asks the nurse, “How long do I have to live?” The nurse’s best response to the patient is

a.	“Since no one can predict how long someone will live, try to focus on the present.”
b.	“It will depend on how your disease responds to radiation, but most patients do well.”
c.	“With ongoing maintenance chemotherapy, the 10-year survival rate is very good.”
d.	“Most patients with your stage of Hodgkin’s disease are treated successfully.”

 

Correct Answer: D

Rationale: The survival rate is almost 90% in patients with the early stages of Hodgkin’s lymphoma. The response beginning, “Since no one can predict” is nontherapeutic because the patient is likely to feel that the nurse is avoiding the question. Chemotherapy, rather than radiation, is the major treatment for Hodgkin’s lymphoma. Maintenance chemotherapy is not used for Hodgkin’s lymphoma.

 

Cognitive Level: Application                       Text Reference: p. 724

Nursing Process: Implementation                NCLEX: Psychosocial Integrity

 

 

38. A 22-year-old patient with acute myelogenous leukemia develops neutropenia after receiving outpatient chemotherapy. Which action by the nurse in the outpatient clinic is most appropriate?

a.	Plan to admit the patient to the hospital for treatment of the neutropenia.
b.	Schedule the patient to come into the hospital daily for filgrastim (Neupogen) injections.
c.	Teach the patient or family how to administer filgrastim (Neupogen) injections at home.
d.	Obtain a high-efficiency particulate-air (HEPA) filter for the patient to use at home.

 

Correct Answer: C

Rationale: The patient or family may be taught to self-administer filgrastim injections. 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.

 

Cognitive Level: Application                       Text Reference: p. 715

Nursing Process: Implementation

NCLEX: Safe and Effective Care Environment

 

 

MULTIPLE RESPONSE

 

1. A patient recently diagnosed with Hodgkin’s lymphoma undergoes extensive testing for staging of the disease and decisions regarding treatment. The nurse will plan to teach the patient about (Select all that apply.)

a.	angiography.
b.	lymph node biopsy.
c.	radiographic studies.
d.	peripheral blood analysis.
e.	bone marrow examination.
f.	laparotomy and splenectomy.

 

Correct Answer: B, C, D, E

Rationale: Lymph node biopsy, radiographic studies, blood analysis, and bone marrow biopsy are used in staging Hodgkin’s lymphoma and choosing treatment. Angiography, laparotomy, and splenectomy are not part of the diagnostic process.

 

Cognitive Level: Comprehension                 Text Reference: p. 724

Nursing Process: Implementation                NCLEX: Physiological Integrity

 

 

 

Lewis: Medical-Surgical Nursing, 7^th Edition

 

Test Bank

 

Chapter 56: Nursing Assessment: Nervous System

 

MULTIPLE CHOICE

 

1. A patient with a deep, large laceration of the left forearm, which has damaged nerve fibers as well as other tissue, asks the nurse to explain what the effect of the nerve damage will be. The nurse should respond that

a.	nerve cells do not regenerate, and the loss of sensation and movement will be permanent.
b.	normal motor and sensory function will return once the peripheral nerve cells regenerate.
c.	weak sensation and movement will come back because peripheral nerve cells are capable of partial regeneration.
d.	some sensory and motor function may return because peripheral nerve fibers can regenerate if cell bodies have not been damaged.

 

Correct Answer: D

Rationale: In the peripheral nerve system (PNS), regeneration of injured nerve fibers is possible if the cell body is intact. The final result depends on the connections the axon sprouts make with end-organs and other nerves. Nerves of the central nervous system (CNS) do not regenerate, but peripheral nerves have some regenerative abilities. Return of normal or weak function is possible, but the nurse should not imply that either is guaranteed.

 

Cognitive Level: Comprehension                 Text Reference: p. 1442

Nursing Process: Implementation                NCLEX: Physiological Integrity

 

 

2. When interviewing an acutely confused patient with a head injury, which of these questions will provide the most useful information?

a.	“Have you ever been hospitalized for a neurologic problem?”
b.	“Do you have any pain at the present time?”
c.	“What have you had to eat in the last 24 hours?”
d.	“Can you describe you usual pattern for coping with injury?”

 

Correct Answer: B

Rationale: The acutely confused patient will be able to state whether there is pain currently. The patient may not be able to provide accurate information about history of hospitalization, 24-hour dietary recall, or usual coping patterns.

 

Cognitive Level: Application                       Text Reference: p. 1455

Nursing Process: Assessment                       NCLEX: Physiological Integrity

 

 

 

3. When the nurse administers gabapentin (Neurontin), a drug that increases the level of gamma-aminobutyric acid (GABA) in the synapse, the effect the nurse would expect is

a.	widespread increases in nervous system activity.
b.	suppression of nervous system activity.
c.	increased patient alertness and arousal.
d.	excitation of the affected postsynaptic neurons.

 

Correct Answer: B

Rationale: GABA is a neurotransmitter that has inhibitory activity on action-potential generation and decreases nervous system activity. Because it has an inhibitory effect, the nurse will not expect increases in nervous system activity, increased alertness or arousal, or excitation of affected neurons.

 

Cognitive Level: Application                       Text Reference: p. 1444

Nursing Process: Evaluation                         NCLEX: Physiological Integrity

 

 

4. In a patient who has a corticospinal tract lesion, the nurse should assess for

a.	extremity movement and strength.
b.	cranial nerve function.
c.	peripheral sensitivity to pain.
d.	level of consciousness (LOC).

 

Correct Answer: A

Rationale: The corticospinal tract carries impulses from the cortex to the peripheral nerves that control voluntary muscle movement. Cranial nerve function is affected by damage to the corticobulbar tract. Peripheral pain impulses are carried to the higher levels of the CNS by the spinothalamic tracts. LOC is not affected by the ascending or descending tracts.

 

Cognitive Level: Application                       Text Reference: pp. 1444-1445

Nursing Process: Assessment                       NCLEX: Physiological Integrity

 

 

5. A patient has a lesion that affects lower motor neurons. During assessment of the patient’s lower extremities, the nurse expects to find

a.	spasticity.
b.	flaccidity.
c.	hyperactive reflexes.
d.	loss of sensation.

 

Correct Answer: B

Rationale: Because the cell bodies of lower motor neurons are located in the spinal cord, damage to the neuron will decrease motor activity of the affected muscles. Spasticity and hyperactive reflexes are caused by upper motor neuron damage. Sensation is not impacted by motor neuron lesions.

 

Cognitive Level: Application                       Text Reference: p. 1445

Nursing Process: Assessment                       NCLEX: Physiological Integrity

 

 

6. When performing a focused assessment on a patient with a lesion of the left posterior temporal lobe, the nurse will assess for

a.	reasoning and problem-solving abilities.
b.	sensation on the left side of the body.
c.	understanding of written and oral language.
d.	voluntary movement on the right side.

 

Correct Answer: C

Rationale: The posterior temporal lobe integrates the visual and auditory input for language comprehension. Reasoning and problem solving are functions of the anterior frontal lobe. Sensation on the left side of the body is located in the right postcentral gyrus. Voluntary movement on the right side is controlled in the left precentral gyrus.

 

Cognitive Level: Application                       Text Reference: pp. 1445, 1447

Nursing Process: Assessment                       NCLEX: Physiological Integrity

 

 

7. Propranolol (Inderal), an adrenergic blocking agent that inhibits sympathetic nervous system activity, is prescribed for a patient. The nurse monitors the patient for

a.	dry mouth.
b.	constipation.
c.	slowed pulse.
d.	urinary retention.

 

Correct Answer: C

Rationale: Inhibition of the fight or flight response leads to decreased heart rate. Dry mouth, constipation, and urinary retention are associated with PNS blockade.

 

Cognitive Level: Application                       Text Reference: p. 1451

Nursing Process: Evaluation                         NCLEX: Physiological Integrity

 

 

8. When obtaining a health history from a patient with a neurologic problem, which question by the nurse will elicit the most useful response from the patient?

a.	“Do you ever have any nausea or dizziness?”
b.	“Does the pain radiate from your back into your legs?”
c.	“Do you have any sensations of pins and needles in your feet?”
d.	“Can you describe the sensations you are having in your chest?”

 

Correct Answer: D

Rationale: The most useful and valid information is obtained through the use of open-ended questions that allow the patient to describe symptoms. The other questions encourage the use of “yes” or “no” responses and may cause the patient to omit useful additional data.

 

Cognitive Level: Application                       Text Reference: p. 1453

Nursing Process: Assessment                       NCLEX: Physiological Integrity

 

 

9. When admitting a patient with acute confusion to the hospital, the nurse will interview the patient about health problems and health history primarily to

a.	determine the patient’s motivation for self-care.
b.	include the patient in health care decisions.
c.	use the information given by the patient to guide care.
d.	assess the patient’s baseline cognitive abilities.

 

Correct Answer: D

Rationale: Appropriateness of the patient’s response and the patient’s use of language will help the nurse to assess the baseline cognitive abilities of the patient. A confused patient may not be able to participate in self-care or make informed health care decisions. The health history given by a confused patient should not be used to guide decisions about care unless it can be verified by another source.

 

Cognitive Level: Application                       Text Reference: p. 1455

Nursing Process: Assessment                       NCLEX: Physiological Integrity

 

 

10. When a 71-year-old patient who is being admitted to the hospital for minor surgery tells the nurse, “I haven’t slept through the night for several years now,” the nurse will plan to

a.	ask for an order for a mild nighttime sedative.
b.	teach the patient about electroencephalographic (EEG) testing.
c.	discuss sleep-pattern changes in older people.
d.	assess function of the cranial nerves.

 

Correct Answer: C

Rationale: Normal changes in the reticular activating system and autonomic nervous system lead to more spontaneous awakening and less sleep time in older adults. For these normal changes, there is no indication for sedative use, EEG testing, or cranial nerve testing.

 

Cognitive Level: Application                       Text Reference: p. 1454

Nursing Process: Planning

NCLEX: Health Promotion and Maintenance

 

 

11. To assess the functioning of the optic nerve (CN II), the nurse should

a.	apply a cotton wisp strand to the cornea.
b.	have the patient read a magazine.
c.	shine a bright light into the patient’s pupil.
d.	check for equal opening of the eyelids.

 

Correct Answer: B

Rationale: The optic nerve is responsible for visual fields and visual acuity. Trigeminal and facial nerve functions are tested by assessing the corneal reflex. Assessment of pupil response to light and ptosis are used to check function of the oculomotor nerve.

 

Cognitive Level: Comprehension                 Text Reference: pp. 1456-1457

Nursing Process: Assessment                       NCLEX: Physiological Integrity

 

 

12. Neurologic testing of the patient by the nurse indicates impaired functioning of the left glossopharyngeal nerve (CN IX) and the vagus nerve (CN X). Based on these findings, the nurse plans to

a.	insert an oral airway.
b.	withhold oral fluid or foods.
c.	provide highly seasoned foods.
d.	apply artificial tears every hour.

 

Correct Answer: B

Rationale: The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex; a patient with impaired function of these nerves is at risk for aspiration. An oral airway may be needed when a patient is unconscious and unable to maintain the airway, but it will not decrease aspiration risk. Taste and eye blink are controlled by the facial nerve.

 

Cognitive Level: Application                       Text Reference: p. 1458

Nursing Process: Planning                            NCLEX: Physiological Integrity

 

 

13. The following orders are received for a patient who is unconscious after a head injury caused by an automobile accident. Which one should the nurse question?

a.	Perform neurologic checks every 15 minutes.
b.	Prepare the patient for lumbar puncture.
c.	Obtain x-rays of the skull and spine.
d.	Do computed tomography (CT) scan with and without contrast.

 

Correct Answer: B

Rationale: After a head injury, the patient may be experiencing intracranial bleeding and increased intracranial pressure, which could lead to herniation of the brain with lumbar puncture. The other orders are appropriate.

 

Cognitive Level: Application                       Text Reference: p. 1461

Nursing Process: Implementation                NCLEX: Physiological Integrity

 

 

14. The charge nurse is observing a new staff nurse who is assessing a patient with a possible spinal cord lesion for sensation. Which action indicates a need for further teaching about neurologic assessment?

a.	The new nurse tests for light touch before testing for pain.
b.	The new nurse has the patient close the eyes during testing.
c.	The new nurse tells the patient, “You may feel a pinprick now.”
d.	The new nurse uses an irregular pattern to test for intact touch.

 

Correct Answer: C

Rationale: When performing a sensory assessment, the nurse should not provide verbal clues. The other actions by the new nurse are appropriate.

 

Cognitive Level: Application                       Text Reference: p. 1458

Nursing Process: Evaluation                         NCLEX: Physiological Integrity

 

 

15. A patient is scheduled for a lumbar puncture. The nurse will plan to

a.	administer a sedative medication 30 minutes before the procedure.
b.	transfer the patient to radiology just before the procedure.
c.	place the patient on NPO status for 4 hours before the procedure.
d.	help the patient lie on the side in the fetal position for the procedure.

 

Correct Answer: D

Rationale: For a lumbar puncture, the patient lies in the lateral recumbent position, with the knees drawn to the chest and the head flexed to the chest to separate the vertebrae. The procedure does not usually require a sedative, is done in the patient room, and has no risk for aspiration.

 

Cognitive Level: Application                       Text Reference: pp. 1461-1462

Nursing Process: Planning                            NCLEX: Physiological Integrity

 

 

16. When reviewing the results of a patient’s cerebrospinal fluid analysis, the nurse will notify the health care provider about

a.	pH of 7.35.
b.	white blood cell count (WBC) of 4/ml (0.004/L).
c.	protein 30 mg/dl (0.30 g/L).
d.	glucose 30 mg/dl (1.7 mmol/L).

 

Correct Answer: D

Rationale: The glucose level is low. The pH, WBCs, and protein values are normal.

 

Cognitive Level: Comprehension                 Text Reference: p. 1464

Nursing Process: Implementation                NCLEX: Physiological Integrity

 

 

17. A patient is scheduled for a myelogram to confirm the presence of a herniated intervertebral disk. Which information obtained when admitting the patient is most important for the nurse to communicate to the health care provider before the procedure?

a.	The patient has an allergy to shellfish.
b.	The patient has back pain when lying flat for long periods.
c.	The patient had 4 ounces of apple juice 4 hours earlier.
d.	The patient is anxious about the test.

 

Correct Answer: A

Rationale: Iodine containing contrast medium is injected into the subarachnoid space during a myelogram. The health care provider may need to modify the post-myelogram orders to prevent back pain, but this can be done after the procedure. Clear liquids are usually considered safe up to 4 hours before a diagnostic or surgical procedure. The patient’s anxiety should be addressed, but this is not as important as the iodine allergy.

 

Cognitive Level: Application                       Text Reference: p. 1462

Nursing Process: Implementation                NCLEX: Physiological Integrity

 

 

18. During the neurologic assessment, the patient cooperates with the nurse’s directions to grip with the hands and to move the feet but does not respond to the nurse’s questions. The nurse will suspect

a.	a temporal lobe lesion.
b.	injury to the cerebellum.
c.	a brainstem lesion.
d.	damage to the frontal lobe.

 

Correct Answer: D

Rationale: Expressive speech is controlled by Broca’s area in the frontal lobe. The temporal lobe contains Wernicke’s area, which is responsible for receptive speech. The cerebellum and brainstem do not affect higher cognitive functions such as speech.

 

Cognitive Level: Application                       Text Reference: p. 1445

Nursing Process: Assessment                       NCLEX: Physiological Integrity

 

 

19. A patient with a brainstem infarction is admitted to the nursing unit. The priority nursing assessment for the patient is

a.	level of consciousness.
b.	pupil reaction to light.
c.	respiratory rate and rhythm.
d.	reflex reaction time.

 

Correct Answer: C

Rationale: Vital centers that control respiration are located in the medulla, and these are the priority assessments because changes in respiratory function may be life threatening. The other information will also be collected by the nurse, but it is not as urgent.

 

Cognitive Level: Application                       Text Reference: p. 1447

Nursing Process: Assessment                       NCLEX: Physiological Integrity

 

 

20. When developing a plan of care for a patient with dysfunction of the cerebellum, the nurse will include interventions to

a.	improve short-term memory.
b.	stabilize mood.
c.	prevent falls.
d.	enhance the ability to swallow.

 

Correct Answer: C

Rationale: Because functions of the cerebellum include coordination and balance, the patient with dysfunction is at risk for falls. The cerebellum does not impact on memory, mood, or swallowing ability.

 

Cognitive Level: Application                       Text Reference: pp. 1447, 1458

Nursing Process: Planning                            NCLEX: Physiological Integrity

 

 

21. The nurse notes in the patient’s medical history that the patient has a positive Romberg test. Which nursing diagnosis is appropriate?

a.	Risk for falls related to dizziness or weakness
b.	Disturbed tactile sensory perception related to spinal cord damage
c.	Ineffective thermoregulation related to decreased vasomotor response
d.	Acute pain related to hyperreflexia and spasm

 

Correct Answer: A

Rationale: A positive Romberg test indicates that the patient has difficulty maintaining balance with the eyes closed. The Romberg does not test for tactile perception, thermoregulation, or hyperreflexia.

 

Cognitive Level: Application                       Text Reference: pp. 1458-1459

Nursing Process: Diagnosis                          NCLEX: Physiological Integrity