Medical Surgical Nursing Critical Thinking in Client Care Single Volume 4th Edition By Priscilla T LeMone -Test Bank
Medical Surgical Nursing Critical Thinking in Client Care Single Volume 4th Edition By Priscilla T LeMone -Test Bank
- MC A client asks the nurse, Whats the difference between having good health and being well? Which of the following could the nurse say in response?
- Wellness is a passive state of freedom from illness.
B.* Wellness maximizes individual potential.
- Good health maximizes individual potential.
- There isnt a difference.
- MC A client tells the nurse, Everyone in my family holds extra weight around their hips and legs. The nurse realizes this client is describing which of the following health risk factors?
- Cultural background
- Developmental level
C.* Genetic makeup
- Cognitive ability
- MC An African-American client comes into the clinic for a routine check-up. The nurse realizes this client is most prone to developing which of the following health conditions?
- Diabetes mellitus
- MC The nurse is caring for a male client with heart disease. Which of the following would be considered the health promotion behavior with the greatest impact for this client?
- Perform breast selfexaminations.
- Perform foot self-examinations daily.
C.* Cease smoking.
- Have a tetanus booster every ten years.
- MC The client asks the nurse for information about healthy living. Which of the following topics should the nurse review with this client? (Select all that apply.)
- Incorporate mild exercise into a daily routine.
B.* Cease smoking.
C.* Eat three balanced meals per day.
- Avoid red wine.
E.* Sleep seven to eight hours per day.
- MC A client is admitted with an alteration in pancreatic functioning. The nurse realizes this client is experiencing which of the following causes of disease?
- MC A client with an acute illness asks, How long will I be sick? I need to get back to work. The nurse realizes this clients statement will:
- Cause the client to have a relapse.
- Have no impact on the recovery phase.
- Adversely affect the recovery phase.
D.* Most likely cause the client to adhere to the treatment plan.
- MC A client with a chronic illness says, I must be getting better because I dont have any of the symptoms I used to have. The nurse realizes this client is demonstrating:
- MC The nurse is planning a primary prevention program for a group of clients. Which of the following topics could be included in this program?
- The need for annual tuberculosis tests
B.* Seat belt safety
- The goals of cardiac rehabilitation
- The purpose of diabetes mellitus detection screenings
- MC A 22-year-old client says, I have no reason to keep going. I have no job, no home, and no family. The nurse realizes this client is at risk for:
- Nothing. This is normal young adult behavior.
- Onset of disease.
- Unsafe sexual practices.
- MC A female client says, I seem to be gaining weight ever since I turned 40. Which statement by the nurse is most therapeutic?
A.* The metabolic rate change that occurs with age and less physical activity could be the cause.
- There isnt anything you can do about it.
- You arent as young as you used to be.
- You must be overeating.
- MC A 47-year-old female client says, I worry about my parents everyday and my job is overwhelming. The nurse realizes this client is most at risk for:
- A divorce.
B.* Psychosocial stress.
- Committing suicide.
- Developing cancer.
- MC The middle-aged adult client says, I want to spend more time volunteering at the local food bank. The nurse identifies this statement as being:
- A potential weight management problem for the client.
- Of no significance.
- A desire to be around food.
D.* An achievement of a significant developmental task.
- MC A middle-aged adult is asking questions about avoiding the onset of heart disease. Which of the following would be an appropriate intervention for this client?
- Tell the client that heart disease is not a concern at their age.
- Sign them up to learn CPR.
C.* Suggest that the client attend a one-day seminar about ways to prevent or reduce heart disease.
- Ask the client the reasons for concern.
- MC A 79-year-old male comes into the clinic for prescription renewals. The nurse realizes this client would be categorized as being:
- MC A middle-old client says, I wish I didnt have high blood pressure and this arthritis is killing me. The most therapeutic response by the nurse would be:
- Be glad you dont have cancer.
- I dont expect to see your age myself.
C.* These illnesses are an unfortunate occurrence associated with aging.
- I would think you would be happy just to be alive.
- MC An old-old client tells the nurse, I hate all of those throw rugs my daughter has on the floor. Which of the following is the most significant risk factor for this client?
- Urinary tract infection
- MC A middle-old client is not recovering as anticipated from an acute respiratory infection. Which statement by the nurse can provide the most useful assessment information?
- Are you sleeping at least seven hours per night?
- Are you drinking enough fluids?
C.* Have you been able to purchase the antibiotics the doctor prescribed?
- Are you eating at least five servings of fruits and vegetables per day?
- MC An elderly client says, I cant ask my daughter to do too much for me during the day because she has to go to work. The nurse realizes this client is describing which of the following family features?
- Performing family tasks
- Adapting to change
D.* Maintaining boundaries
- MC A family unit that consists of two middle-aged adults has no children who live at home. Which of the following developmental tasks is important for this family to accomplish?
A.* Reestablish their relationship.
- Close the family home.
- Promote joint decision making with adults and children.
- Balance freedom with independence.
- MC The parent of two preschool children voices concerns to the nurse about feeling stressed lately and being worried about the limited amount of time to devote to the marriage. Based upon knowledge of the stages of family development, what are the primary tasks for the family during this time?
- Accept mortality of older friends and family members.
- Adjust to increased financial responsibilities.
- Reestablish the marital relationship after expansion of the family.
D.* Encourage the educational achievement of the children in the family.
- MC A client is being transferred from the operating room to the recovery room. The nurse in the recovery room will be providing which phase of nursing care?
- MC A client is signing a surgical consent. Afterwards, the nurse also signs the form. What is the meaning of the nursing signature?
A.* It means the client was alert and aware of what was being signed.
- It means there is a likelihood of a successful outcome.
- It means the surgeon was too busy to wait for the client to sign the form.
- It means the client understood the procedure as described by the nurse.
- MC An elderly client is being prepared for orthopedic surgery. The nurse realizes this client is at risk for which of the following?
- Increased hypotensive effects of anesthesia
- Wound dehiscence
C.* Decreased tolerance of general anesthesia
- Prolonged effects of anesthesia because of herbal supplements
- MC An elderly client is completing preoperative diagnostic testing. The nurse notes that the clients carbon dioxide level is elevated. Which of the following nursing interventions would be indicated for this client?
- Monitor intake and output.
B.* Monitor respiratory status and arterial blood gases.
- Monitor serum sodium level.
- Monitor serum potassium level.
- MC An elderly postoperative client is given an antiemetic for nausea. Which of the following signs would indicate this client is experiencing a possible reaction to the medication?
A.* Involuntary muscle movements
- Dry mouth
- Breakthrough vomiting
- MC A clients endotracheal tube is being removed after the surgical procedure. The intra-operative nurse realizes this client is in which phase of the general anesthesia process?
- MC A client has received conscious sedation for a surgical procedure. The nurse realizes this client will most likely:
- Not respond to any stimuli.
B.* Respond to physical and verbal stimuli.
- Need blood product replacements.
- Need an endotracheal tube inserted.
- MC A client is prescribed patient-controlled analgesia for postoperative pain. Which of the following should the nurse instruct the client about this analgesia?
- Use this analgesia every hour on the hour.
- Use this analgesia only when the pain is extremely severe.
- Avoid the use of this because of the risk of addiction.
D.* Use this analgesia regularly.
- MC A client is in the recovery room. Which of the following members of the healthcare team should the nurse contact regarding the clients level of pain control?
A.* The anesthesiologist
- The circulating nurse
- The surgeon
- The scrub nurse
- MC A recovery room nurse is consulting with a circulating nurse about a client who is having a surgical procedure. These nurses are most likely in which zone of the surgical department?
- MC A client is being positioned for a hip replacement procedure. In which of the following positions will this client most likely be placed?
A.* Lateral chest
- Dorsal recumbent
- MC A postoperative client tells the nurse, A book I read said that I should not eat after surgery for at least a week. Which of the following statements would be an appropriate nursing response?
- Thats true.
- You dont need any food to heal anyway.
- Ill be giving you intravenous feedings anyway.
D.* Thats not true. You could get an infection in your stomach.
- MC A client is being scheduled for surgery. Which of the following should be included in the preoperative teaching provided by the nurse?
- Cost of the procedure
- The credentials of the anesthesiologist
C.* Planned length of stay at the hospital
- Information concerning the surgical procedure which will be performed by the surgeon
- MC A client has just arrived in the recovery room. How often should the nurse assess the client?
- Every two hours.
- Every 15 minutes for 30 minutes and then every one hour afterwards.
C.* Every 15 minutes for the first hour.
- Every hour.
- MC A client is demonstrating signs of postoperative hemorrhage. Which of the following would be an appropriate nursing intervention at this time?
- Slow the intravenous fluid administration rate.
B.* Apply sterile pads and a snug pressure dressing to the area.
- Support the clients physiologic mechanism for dissolving clots.
- Raise the head of the clients bed.
- MC The nurse is assisting a postoperative client in using an incentive spirometer. Which of the following postoperative complications is this nurse attempting to avoid with this client?
- Deep vein thrombosis
- Pulmonary embolism
- MC A client is in his fifth postoperative day and has sanguineous drainage with a thick, reddish appearance. The nurse realizes this clients wound is in which stage of healing?
- Stage III
B.* Stage II
- Stage I
- Stage IV
- MC A client who is recovering from abdominal surgery has a penrose drain. Which of the following should the nurse include in the care of this client?
- Remove the drain four hours postoperatively.
- Clean the wound with normal saline every two hours.
C.* Make sure there is a safety pin on the end of the drain.
- Empty the drain every 30 minutes.
- MC During the assessment of a postoperative clients bowel sounds, the nurse auscultates high-pitched sounds over all four abdominal quadrants. The nurse realizes this finding could indicate:
- The onset of flatus.
- The onset of stool.
C.* Paralytic ileus.
- Normal bowel function.
- MC A client is scheduled for removal of a cataract. The nurse realizes this clients procedure is classified as being:
- Minor diagnostic.
- Major elective.
- Major constructive.
D.* Minor elective.
- MC A client who is being admitted for surgery asks the nurse why information is being collected about the clients use of herbal and natural supplements. Which of the following statements is an appropriate nursing response?
A.* Herbal supplements may interact with anesthesia agents.
- Herbal remedies may cause pain relievers to be ineffective.
- The physician is in charge of medications.
- There is no need to take these preparations.
- MC A client is complaining of discomfort after a surgical procedure. The client voices fear of addition with taking analgesics as prescribed. What information should be provided to the client regarding these concerns? (Select all that apply.)
- Clients should be screened for addiction potential prior to being given narcotics.
B.* Pain tolerance and the need for opioid analgesics is individualized.
C.* Psychological tolerance is not commonly experienced by clients who take narcotic analgesics during the postoperative experience.
D.* Addiction to opioid analgesics is rare when used for short-term postoperative pain management.
- MC The client who is preparing for surgery asks the nurse to keep their glasses and hearing aid in-place until they are under anesthesia. Which of the following statements by the nurse demonstrates accurate, therapeutic communication?
- The policies in the surgery unit will not allow it.
- You cannot keep those in.
- Certainly, you can keep them for that time.
D.* I will contact the surgery department to discuss you requests.