Saunders Comprehensive Review for the NCLEX-RN® Examination, 5th Edition By Linda Anne Silvestri -Test Bank

Saunders Comprehensive Review for the NCLEX-RN® Examination, 5th Edition By Linda Anne Silvestri -Test Bank

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Saunders Comprehensive Review for the NCLEX-RN Examination, 5th Edition By Linda Anne Silvestri -Test Bank

Silvestri: Saunders Comprehensive Review for the NCLEX-RN Examination, 5^th Edition

 

Adult Health

 

Test Bank

 

MULTIPLE CHOICE

 

1. The nurse reviews the health record of a client with melasma. The nurse would anticipate that this client will exhibit:

1.	Skin that is uniformly dark in color
2.	Very pale skin with little pigmentation
3.	Patches of skin that have loss of pigmentation
4.	Blotchy brown macules across the cheeks and forehead

 

ANS:   4

 

Rationale: Melasma is a condition caused by hormonal influences on melanin production and is noted by the appearance of blotchy brown macules across the cheeks and forehead. Skin that is uniformly dark in color describes vitiligo. Very pale skin with little pigmentation and patches of skin that have loss of pigmentation refer to normal variations in skin color.

 

Test-Taking Strategy: To answer this question correctly, you must be familiar with the various terms used when discussing skin structures and functions. Skin that is uniformly dark in color describes vitiligo. Very pale skin with little pigmentation and patches of skin that have loss of pigmentation refer to normal variations in skin color. Review the description of melasma if you had difficulty with this question.

 

PTS:    1

DIF:    Level of Cognitive Ability: Understanding

REF:    Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.

OBJ:    Client Needs: Physiological Integrity

TOP:    Content Area: Adult Health/Integumentary

MSC:   Integrated Process: Nursing ProcessAssessment

 

2. The client with cellulitis of the lower leg has had cultures done on the affected area. The nurse reviewing the results of the culture report interprets that which of the following organisms is not part of the normal flora of the skin?

1.	Escherichia coli
2.	Candida albicans
3.	Staphylococcus aureus
4.	Staphylococcus epidermidis

 

ANS:   1

 

Rationale: E. coli is normally found in the intestines and is a common source of infection of wounds and the urinary system. C. albicans, S. aureus, and S. epidermis are part of the normal flora of the skin.

 

Test-Taking Strategy: To answer this question correctly, you must be familiar with the normal microorganisms that inhabit the skin. Note that the question asks for the organism that is not part of normal flora. Remember that E. coli is normally found in the intestines. Review basic skin structures if you had difficulty with this question.

 

PTS:    1

DIF:    Level of Cognitive Ability: Understanding

REF:    Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.

OBJ:    Client Needs: Physiological Integrity

TOP:    Content Area: Adult Health/Integumentary

MSC:   Integrated Process: Nursing ProcessAssessment

 

3. The client complains of chronic pruritus. Which of the following diagnoses would the nurse expect to support this clients complaint?

1.	Anemia
2.	Renal failure
3.	Hypothyroidism
4.	Diabetes mellitus

 

ANS:   2

 

Rationale: Clients with renal failure often have pruritus, or itchy skin. This is because of impaired clearance of waste products by the kidneys. The client who is markedly anemic is likely to have pale skin. Hypothyroidism may lead to complaints of dry skin. Clients with diabetes mellitus are at risk for skin infections and skin breakdown.

 

Test-Taking Strategy: Focus on the subject, chronic pruritus. Remember that clients with renal failure often experience this problem. If this question was difficult, review the common causes of pruritus.

 

PTS:    1

DIF:    Level of Cognitive Ability: Understanding

REF:    Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.

OBJ:    Client Needs: Physiological Integrity

TOP:    Content Area: Adult Health/Integumentary

MSC:   Integrated Process: Nursing ProcessAssessment

 

4. A client being seen in an ambulatory clinic for an unrelated complaint has a butterfly rash noted across the nose. The nurse interprets that this finding is consistent with early manifestations of which of the following disorders?

1.	Hyperthyroidism
2.	Pernicious anemia
3.	Cardiopulmonary disorders
4.	Systemic lupus erythematosus (SLE)

 

ANS:   4

 

Rationale: An early sign of SLE is the appearance of a butterfly rash across the nose. Hyperthyroidism often leads to moist skin and increased perspiration. Pernicious anemia is exhibited by pale skin. Severe cardiopulmonary disorders may lead to clubbing of the fingers.

 

Test-Taking Strategy: To answer this question accurately, you must be familiar with the impact of systemic conditions on the skin. Remember that SLE causes a characteristic butterfly rash. If this question was difficult, review the disorders identified in the options and the associated skin conditions that occur in each disorder.

 

PTS:    1

DIF:    Level of Cognitive Ability: Understanding

REF:    Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.

OBJ:    Client Needs: Physiological Integrity

TOP:    Content Area: Adult Health/Integumentary

MSC:   Integrated Process: Nursing ProcessAssessment

 

5. The nurse notes that the older adult client has a number of bright, ruby-colored, round lesions scattered on the trunk and thighs. The nurse correctly interprets the finding as alterations in blood vessels of the skin and defines them as:

1.	Purpura
2.	Venous star
3.	Cherry angioma
4.	Spider angioma

 

ANS:   3

 

Rationale: A cherry angioma occurs with increasing age and has no clinical significance. It is noted by the appearance of small, bright, ruby-colored round lesions on the trunk and/or extremities. Purpura results from hemorrhage into the skin. A venous star results from increased pressure in veins, usually in the lower legs, and has an irregularly shaped bluish center with radiating branches. Spider angiomas have a bright red center, with legs that radiate outward. These are commonly seen in those with liver disease or vitamin B deficiency, although they can occur occasionally without underlying pathology.

 

Test-Taking Strategy: To answer this question accurately, you must be familiar with the various alterations in vascularity that can occur in the skin. Note the relationship of the words ruby in the question and cherry in the correct option. If you had difficulty with this question, review the various skin alterations identified in each of the options.

 

PTS:    1

DIF:    Level of Cognitive Ability: Understanding

REF:    Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.

OBJ:    Client Needs: Physiological Integrity

TOP:    Content Area: Adult Health/Integumentary

MSC:   Integrated Process: Nursing ProcessAssessment

 

6. The client has been diagnosed with paronychia. The nurse understands that this is a disorder of the:

1.	Nails
2.	Hair follicles
3.	Pilosebaceous glands
4.	Epithelial layer of skin

 

ANS:   1

 

Rationale: Paronychia is a fungal infection that is most often caused by Candida albicans. This results in inflammation of the nail fold, with separation of the fold from the nail plate. The area is generally tender to touch, with purulent drainage. Disorders of the hair follicles include folliculitis, furuncles, and carbuncles. Disorders of the pilosebaceous glands include acne vulgaris and seborrheic dermatitis. There are a variety of disorders involving the epithelial skin.

 

Test-Taking Strategy: To answer this question accurately, you must be familiar with a variety of skin disorders and their causes. Remember that paronychia is a nail disorder. If this question was difficult, review the characteristics of paronychia.

 

PTS:    1

DIF:    Level of Cognitive Ability: Understanding

REF:    Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.

OBJ:    Client Needs: Physiological Integrity

TOP:    Content Area: Adult Health/Integumentary

MSC:   Integrated Process: Nursing ProcessAssessment

 

7. The client is diagnosed with a full-thickness burn. The nurse understands that which of the following structural areas of the skin is involved?

1.	Epidermis only
2.	Epidermis and deeper dermis
3.	Epidermis and upper layer of dermis
4.	Epidermis, entire dermis, and epithelial portion of subcutaneous fat

 

ANS:   4

 

Rationale: A full-thickness burn involves the epidermis, entire dermis, and epithelial portion of subcutaneous fat layer. Epidermis only describes a superficial burn. Epidermis and deeper dermis describes a partial-thickness burn, and epidermis, entire dermis, and epithelial portion of subcutaneous fat describes a deep partial-thickness burn.

 

Test-Taking Strategy: To answer this question accurately, you must be familiar with the classification of burn depth and the associated skin structures affected. Noting the words full-thickness will direct you to epidermis, entire dermis, and epithelial portion of subcutaneous fat. If this question was difficult, review the types of burn injuries.

 

PTS:    1

DIF:    Level of Cognitive Ability: Understanding

REF:    Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.

OBJ:    Client Needs: Physiological Integrity

TOP:    Content Area: Adult Health/Integumentary

MSC:   Integrated Process: Nursing ProcessAssessment

 

8. A client who suffered carbon monoxide poisoning from working on an automobile in a closed garage has a carbon monoxide level of 15%. The nurse would anticipate observing which sign or symptom?

1.	Coma
2.	Flushing
3.	Dizziness
4.	Tachycardia

 

ANS:   2

 

Rationale: The signs and symptoms worsen as the carbon monoxide level rises in the bloodstream. Impaired visual acuity occurs at 5% to 10%, whereas flushing and headache are seen at 11% to 20%. Nausea and impaired dexterity appear at levels of 21% to 30%, and a 31% to 40% level is accompanied by vomiting, dizziness, and syncope. Levels of 41% to 50% cause tachypnea and tachycardia, and those higher than 50% result in coma and death.

 

Test-Taking Strategy: Knowledge of the various manifestations of carbon monoxide poisoning is needed to answer this question. Remember that flushing is noted at levels of 11% to 20%. If you had difficulty with this question, review the manifestations associated with carbon monoxide poisoning.

 

PTS:    1

DIF:    Level of Cognitive Ability: Analyzing

REF:    Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.

OBJ:    Client Needs: Physiological Integrity

TOP:    Content Area: Adult Health/Integumentary

MSC:   Integrated Process: Nursing ProcessAssessment

 

9. A client is admitted to the hospital with cellulitis of the lower leg. The nurse would anticipate which of the following therapies to be prescribed?

1.	Intermittent heat lamp treatments
2.	Alternating hot and cold compresses
3.	Warm compresses to the affected area
4.	Cold compresses to the affected area

 

ANS:   3

 

Rationale: Warm compresses may be used to decrease the discomfort, erythema, and edema that accompany cellulitis. Definitive treatment includes antibiotic therapy after appropriate cultures have been done. Other supportive measures are also used to manage such symptoms as fatigue, fever, chills, headache, or myalgia. Heat lamps are not used because of the risk of burns, and moist heat is most useful in treating this disorder.

 

Test-Taking Strategy: Use knowledge of the disease process and concepts related to heat and cold therapy to answer this question. Eliminate alternating hot and cold compresses and cold compresses to the affected area first, because cold therapy would cause vasoconstriction rather than vasodilation. Choose correctly between intermittent heat lamp treatments and warm compresses to the affected area, knowing that moist heat decreases the discomfort, erythema, and edema that accompanies cellulitis. If you had difficulty with this question, review the treatment associated with cellulitis.

 

PTS:    1

DIF:    Level of Cognitive Ability: Analyzing

REF:    Monahan, F., Sands, J., Marek, J., Neighbors, M., & Green, C. (2007). Phipps medical-surgical nursing: health and illness perspectives (8th ed.). St. Louis: Mosby.

OBJ:    Client Needs: Physiological Integrity

TOP:    Content Area: Adult Health/Integumentary

MSC:   Integrated Process: Nursing ProcessPlanning

 

10. The nurse has instructed the client in the correct technique for breast self-examination (BSE). For a portion of the examination, the client will lie down. If the client were to examine the right breast, the nurse would tell the client to place a pillow:

1.	Under the left scapula
2.	Under the left shoulder
3.	Under the right shoulder
4.	Under the small of the back

 

ANS:   3

 

Rationale: The nurse would instruct the client to lie down and place a towel or pillow under the shoulder on the side of the breast to be examined. If the right breast is to be examined, the pillow would be placed under the right shoulder, and vice versa. Therefore under the left scapula, under the left shoulder, and under the small of the back are incorrect.

 

Test-Taking Strategy: Use the process of elimination, and visualize this procedure. This will direct you to under the right shoulder. If you are unfamiliar with the procedure for performing BSE, review this important self-examination.

 

PTS:    1

DIF:    Level of Cognitive Ability: Applying

REF:    Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.

OBJ:    Client Needs: Health Promotion and Maintenance

TOP:    Content Area: Adult Health/Oncology

MSC:   Integrated Process: Teaching and Learning

 

11. The nurse would identify that which of the following foods should be increased in the diet to help decrease the risk of cancer development?

1.	Bacon
2.	Broccoli
3.	Bologna
4.	Broiled beef

 

ANS:   2

 

Rationale: Broccoli is a cruciferous vegetable, which is helpful in reducing the risk of cancer. Other cruciferous vegetables are cauliflower, Brussels sprouts, and cabbage. Red meat (bacon) and meats with nitrites (bologna and broiled beef) can increase the risk of developing cancer.

 

Test-Taking Strategy: Remember that options that are comparable or alike are not likely to be correct. With this in mind, note that each incorrect option lists a meat, whereas the correct choice is a cruciferous vegetable. Review dietary risk factors for cancer if you had difficulty with this question.

 

PTS:    1

DIF:    Level of Cognitive Ability: Applying

REF:    Nix, S. (2009). Williams basic nutrition and diet therapy (13th ed.). St. Louis: Mosby.

OBJ:    Client Needs: Health Promotion and Maintenance

TOP:    Content Area: Adult Health/Oncology

MSC:   Integrated Process: Nursing ProcessImplementation

 

12. The nurse would include which of the following in a list of the most helpful foods for the vegan client wishing to increase foods high in vitamin A?

1.	Peas
2.	Carrots
3.	Potatoes
4.	Green beans

 

ANS:   2

 

Rationale: Foods that are high in vitamin A include carrots, green leafy vegetables, and yellow vegetables. The other vegetables are high in vitamins but do not necessarily have the highest amount of vitamin A.

 

Test-Taking Strategy: Note the strategic words most helpful. To answer this question accurately, you must be aware of the type of foods that are naturally high in vitamin A. Remember that carrots are high in vitamin A. If you had difficulty with this question, review foods that are in this vitamin group.

 

PTS:    1

DIF:    Level of Cognitive Ability: Applying

REF:    Peckenpaugh, N. (2010). Nutrition essentials and diet therapy (11th ed.). St. Louis: Saunders.

OBJ:    Client Needs: Health Promotion and Maintenance

TOP:    Content Area: Adult Health/Oncology

MSC:   Integrated Process: Nursing ProcessImplementation

 

13. According to the American Cancer Society, fecal occult blood testing should be done annually after the age of _____ years.

1.	30
2.	40
3.	50
4.	60

 

ANS:   3

 

Rationale: Fecal occult blood testing for colorectal cancer should be done annually for both men and women after the age of 50 years. The other options are incorrect.

 

Test-Taking Strategy: To answer this question correctly, you must be familiar with the recommendations for cancer screening published by the American Cancer Society. This would allow you to eliminate each of the incorrect options easily. Review these cancer prevention guidelines.

 

PTS:    1

DIF:    Level of Cognitive Ability: Applying

REF:    Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.

OBJ:    Client Needs: Health Promotion and Maintenance

TOP:    Content Area: Adult Health/Oncology

MSC:   Integrated Process: Nursing ProcessImplementation

 

14. A 27-year-old female client is undergoing evaluation of lumps in her breasts. In determining whether the client could have fibrocystic breast disorder, the nurse should ask the client whether the breast lumps seem to become more prominent or troublesome at which of the following times?

1.	After menses
2.	Before menses
3.	During menses
4.	At any time, regardless of the menstrual cycle

 

ANS:   2

 

Rationale: The nurse assesses the client with fibrocystic breast disorder for worsening of symptoms (breast lumps, painful breasts, and possible nipple discharge) before the onset of menses. This is associated with cyclical hormone changes. Therefore after menses, during menses, and at any time, regardless of the menstrual cycle are incorrect.

 

Test-Taking Strategy: Note the strategic words more prominent or troublesome. This implies that there is a predictable variation in symptoms. Use knowledge of the effects of hormonal variations to select the correct option. Review fibrocystic breast disorder if you had difficulty with this question.

 

PTS:    1

DIF:    Level of Cognitive Ability: Applying

REF:    Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.

OBJ:    Client Needs: Physiological Integrity

TOP:    Content Area: Adult Health/Oncology

MSC:   Integrated Process: Nursing ProcessAssessment

 

15. The nurse is assigned to the care of a client scheduled for surgery for a right colon tumor. Which of the following is the most characteristic manifestation of cancer at this site?

1.	Frequent diarrhea
2.	Crampy gas pains
3.	Flat, ribbon-like stools
4.	Dull abdominal pain exacerbated by walking

 

ANS:   4

 

Rationale: Characteristic symptoms of right colon tumors include vague, dull, abdominal pain exacerbated by walking, and dark red- or mahogany-colored blood mixed in the stool. The symptoms described in the other options are associated with left colon tumors.

 

Test-Taking Strategy: Knowledge regarding the signs of right and left colon tumors is required to answer this question. Note, however, that crampy gas pains and dull abdominal pain exacerbated by walking describe different patterns of pain. This may suggest to you that one of the two is correct. If you are not familiar with the differences between right and left colon tumors, review this content.

 

PTS:    1

DIF:    Level of Cognitive Ability: Understanding

REF:    Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.

OBJ:    Client Needs: Physiological Integrity

TOP:    Content Area: Adult Health/Oncology

MSC:   Integrated Process: Nursing ProcessAssessment

 

16. A client has undergone abdominal perineal resection for a bowel tumor. The nurse interprets that the clients colostomy is beginning to function if which of the following signs is noted?

1.	Absent bowel sounds
2.	The passage of flatus
3.	Blood drainage from the colostomy
4.	The clients ability to tolerate food

 

ANS:   2

 

Rationale: Following abdominal perineal resection, a colostomy should begin to function within 72 hours after surgery, although it may take up to 5 days. The nurse should monitor for a return of peristalsis by listening for bowel sounds and checking for the passage of flatus. Absent bowel sounds indicate that peristalsis has not returned. The client would remain NPO until bowel sounds return and the colostomy is functioning. Bloody drainage is not expected from a colostomy.

 

Test-Taking Strategy: Note the strategic words beginning to function. These strategic words should assist in eliminating absent bowel sounds. Knowledge of general postoperative measures will assist in eliminating the clients ability to tolerate food. Focus on the subject of the question to make your final selection. Review postoperative care of a client following abdominal perineal resection if you had difficulty with this question.

 

PTS:    1

DIF:    Level of Cognitive Ability: Analyzing

REF:    Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.

OBJ:    Client Needs: Physiological Integrity

TOP:    Content Area: Adult Health/Oncology

MSC:   Integrated Process: Nursing ProcessAssessment

 

17. A nurse assessing a postoperative ureterostomy client will interpret that the stoma has normal characteristics if the stoma is:

1.	Dry
2.	Pale
3.	Dark-colored
4.	Red and moist

 

ANS:   4

 

Rationale: Following ureterostomy, the stoma should be red and moist. A dry stoma may indicate fluid volume deficit. A pale stoma may indicate an inadequate vascular supply. Any darkness or duskiness of the stoma may mean loss of vascular supply and must be corrected immediately to prevent necrosis.

 

Test-Taking Strategy: Knowledge of normal stoma characteristics is needed to answer this question. Remember that a red and moist stoma is an expected finding. If you had difficulty with this question, review expected and unexpected findings following ureterostomy.

 

PTS:    1

DIF:    Level of Cognitive Ability: Analyzing

REF:    Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.

OBJ:    Client Needs: Physiological Integrity

TOP:    Content Area: Adult Health/Renal

MSC:   Integrated Process: Nursing ProcessAssessment

 

18. The nurse monitoring the oncological client for early signs of vena cava syndrome would include assessment for which of the following?

1.	Cyanosis
2.	Arm edema
3.	Periorbital edema
4.	Mental status changes

 

ANS:   3

 

Rationale: Vena cava syndrome occurs when the superior vena cava is compressed or obstructed by tumor growth. Early signs and symptoms generally occur in the morning and include edema of the face, especially around the eyes, and client complaints of tightness of a shirt or blouse collar. As the compression worsens, the client experiences edema of the hands and arms. Mental status changes and cyanosis are late signs.

 

Test-Taking Strategy: To answer this question accurately, you must be familiar with vena cava syndrome and its manifestations. Note the strategic word early in the question. This will assist in directing you to the correct option. If you are unfamiliar with vena cava syndrome, review the signs of this oncological emergency.

 

PTS:    1

DIF:    Level of Cognitive Ability: Analyzing

REF:    Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.

OBJ:    Client Needs: Physiological Integrity

TOP:    Content Area: Adult Health/Oncology

MSC:   Integrated Process: Nursing ProcessAssessment

 

19. The nurse understands that which of the following hormones is directly responsible for maintaining the free or unbound portion of serum calcium within normal limits?

1.	Thyroid hormone
2.	Parathyroid hormone
3.	Follicle-stimulating hormone
4.	Adrenocorticotropic hormone

 

ANS:   2

 

Rationale: Parathyroid hormone is responsible for maintaining serum calcium and phosphorous levels within normal range. Thyroid hormone is responsible for maintaining a normal metabolic rate in the body. Follicle-stimulating hormone and adrenocorticotropic hormone are produced by the anterior pituitary gland. They are responsible for growth and maturation of the ovarian follicle and stimulation of the adrenal glands, respectively.

 

Test-Taking Strategy: Basic knowledge of physiology associated with the parathyroid gland is needed to answer this question. This gland is responsible for maintaining the important balance of calcium and phosphorus in the body. Review the function of the parathyroid gland if you had difficulty with this question.

 

PTS:    1

DIF:    Level of Cognitive Ability: Understanding

REF:    Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.

OBJ:    Client Needs: Physiological Integrity

TOP:    Content Area: Adult Health/Endocrine

MSC:   Integrated Process: Nursing ProcessAssessment

 

20. The client with an endocrine disorder complains of weight loss and diarrhea, and says that he can feel his heart beating in his chest. The nurse interprets that which of the following glands is most likely responsible for these symptoms?

1.	Thyroid
2.	Pituitary
3.	Parathyroid
4.	Adrenal cortex

 

ANS:   1

 

Rationale: The thyroid gland is responsible for a number of metabolic functions in the body, including metabolism of nutrients (such as fats and carbohydrates). Increased metabolic function places a demand on the cardiovascular system for a higher cardiac output. Thus, a client with increased activity of the thyroid gland exhibits weight loss from higher metabolic rate and increased pulse rate.

 

Test-Taking Strategy: Use knowledge of the function of the thyroid gland to answer this question. Remember that the thyroid gland is responsible for metabolic function. This will assist in directing you to thyroid. If you had difficulty answering this question, review the function of the thyroid gland.

 

PTS:    1

DIF:    Level of Cognitive Ability: Understanding

REF:    Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.

OBJ:    Client Needs: Physiological Integrity

TOP:    Content Area: Adult Health/Endocrine

MSC:   Integrated Process: Nursing ProcessAssessment

 

21. The client is experiencing an episode of hypoglycemia. The nurse understands that the physiological mechanism that should take place to combat this decrease in the blood glucose level is:

1.	Decreased cortisol release
2.	Increased insulin secretion
3.	Decreased epinephrine release
4.	Increased glucagon secretion

 

ANS:   4

 

Rationale: Glucagon is secreted from the alpha cells in the pancreas in response to declining blood glucose levels. At the same time, hypoglycemia triggers increased cortisol release, increased epinephrine release, and decreased secretion of insulin. Decreased cortisol release, increased insulin secretion, and decreased epinephrine release are not physiological mechanisms that take place to combat the decrease in the blood glucose level.

 

Test-Taking Strategy: To answer this question accurately, you must be familiar with how each of the hormones listed is affected by blood glucose levels. Thinking about the pathophysiology of hypoglycemia will direct you to increased glucagon secretion. If this question was difficult, review this physiological mechanism.

 

PTS:    1

DIF:    Level of Cognitive Ability: Understanding

REF:    Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.

OBJ:    Client Needs: Physiological Integrity

TOP:    Content Area: Adult Health/Endocrine

MSC:   Integrated Process: Nursing ProcessAssessment

 

22. The client with diabetes experiences breakdown of fats for conversion to glucose. The nurse determines that this response is occurring if the client has elevated levels of which of the following substances?

1.	Glucose
2.	Ketones
3.	Glucagon
4.	Lactic dehydrogenase

 

ANS:   2

 

Rationale: Ketones are a byproduct of fat metabolism. When this process occurs to the extreme, it is termed ketoacidosis. Glucose, glucagon, and lactic dehydrogenase are incorrect.

 

Test-Taking Strategy: Knowledge of the pathophysiology of glucose metabolism is needed to answer this question. Remember that ketones are a byproduct of fat metabolism. If this question was difficult, review the physiological process of fat breakdown.

 

PTS:    1

DIF:    Level of Cognitive Ability: Understanding

REF:    Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.

OBJ:    Client Needs: Physiological Integrity

TOP:    Content Area: Adult Health/Endocrine

MSC:   Integrated Process: Nursing ProcessAssessment

 

23. The client with diabetes mellitus is being tested to determine long-term diabetic control. Which of the following results would the nurse expect to see if the clients long-term control is within acceptable limits?

1.	Glycosylated hemoglobin of 6%
2.	Fasting blood glucose level of 150 mg/dL
3.	Presence of ketones in the urine
4.	Presence of albumin in the urine

 

ANS:   1

 

Rationale: This measurement of glycosylated hemoglobin (Hb A_1c) detects glucose binding on the red blood cell (RBC) membrane and is expressed as a percentage. It measures glucose for the life of the RBC, which is 120 days. The fasting blood glucose level should be lower than 130 mg/dL. The urine should be free of both ketones and urine.

 

Test-Taking Strategy: Specific knowledge of the effects of an increased blood glucose level in the body is necessary to answer this question. Noting the words long-term will direct you to glycosylated hemoglobin of 6%. Review the alterations in normal physiology that occur with diabetes mellitus if you had difficulty with this question.

 

PTS:    1

DIF:    Level of Cognitive Ability: Analyzing

REF:    Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.

OBJ:    Client Needs: Physiological Integrity

TOP:    Content Area: Adult Health/Endocrine

MSC:   Integrated Process: Nursing ProcessAssessment

 

24. The nurse is caring for a client with a dysfunctional thyroid gland and is concerned that the client will exhibit signs of thyroid storm. Which of the following is an early indicator of this complication?

1.	Hyperreflexia
2.	Constipation
3.	Bradycardia
4.	Low-grade temperature

 

ANS:   1

 

Rationale: Clinical manifestations of thyroid storm include a fever as high as 106 F, hyperreflexia, abdominal pain, diarrhea, dehydration rapidly progressing to coma, severe tachycardia, extreme vasodilation, hypotension, atrial fibrillation, and cardiovascular collapse.

 

Test-Taking Strategy: To answer this question correctly, you must be familiar with the clinical manifestations of thyroid storm. This condition is a rare but potentially fatal hypermetabolic state. Remembering the description of thyroid storm will direct you to the correct option. If you are unfamiliar with thyroid storm, review this content.

 

PTS:    1

DIF:    Level of Cognitive Ability: Analyzing

REF:    Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.

OBJ:    Client Needs: Physiological Integrity

TOP:    Content Area: Adult Health/Endocrine

MSC:   Integrated Process: Nursing ProcessAssessment

 

25. The client is undergoing an oral glucose tolerance test. The nurse interprets that the clients results are not compatible with diabetes mellitus if the glucose level is lower than which of the following cutoff values after 120 minutes (2 hours)?

1.	80 mg/dL
2.	110 mg/dL
3.	140 mg/dL
4.	160 mg/dL

 

ANS:   3

 

Rationale: The normal reference values for oral glucose tolerance tests are lower than 140 mg/dL at 120 minutes; lower than 200 mg/dL at 30, 60, and 90 minutes; and lower than 115 mg/dL in the fasting state. The other values are not part of the reference ranges.

 

Test-Taking Strategy: To answer this question correctly, you must be familiar with the normal values for this screening test for diabetes. Think about the physiology associated with diabetes mellitus and the procedure for this test to answer correctly. Noting the words not compatible with diabetes mellitus will assist in answering correctly. Review this test if you had difficulty with this question.

 

PTS:    1

DIF:    Level of Cognitive Ability: Understanding

REF:    Pagana, K., & Pagana, T. (2009). Mosbys diagnostic and laboratory test reference (9th ed.). St. Louis: Mosby.OBJ:                Client Needs: Physiological Integrity

TOP:    Content Area: Adult Health/Endocrine

MSC:   Integrated Process: Nursing ProcessAssessment

 

26. A client who visits the physicians office for a routine physical reports new onset of intolerance to cold. Knowing that this is a frequent complaint associated with hypothyroidism, the nurse continues to assess for which of the following?

1.	Weight loss and thinning skin
2.	Complaints of weakness and lethargy
3.	Increased heart rate and respiratory rate
4.	Diaphoresis and increased hair growth

 

ANS:   2

 

Rationale: Weakness and lethargy are common complaints associated with hypothyroidism. Other common symptoms include weight gain, bradycardia, decreased respiratory rate, dry skin, and hair loss.

 

Test-Taking Strategy: Focus on the clients diagnosis. Recalling the pathophysiology associated with hypothyroidism will direct you to complaints of weakness and lethargy. Review this disorder if you had difficulty with this question.

 

PTS:    1

DIF:    Level of Cognitive Ability: Analyzing

REF:    Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.

OBJ:    Client Needs: Physiological Integrity

TOP:    Content Area: Adult Health/Endocrine

MSC:   Integrated Process: Nursing ProcessAssessment

 

27. The nurse is caring for a client diagnosed with suspected acute pancreatitis. When reviewing the clients laboratory results, the nurse determines that which of these findings will support the diagnosis?

1.	Elevated serum lipase level
2.	Elevated serum bilirubin level
3.	Decreased serum trypsin level
4.	Decreased serum amylase level

 

ANS:   1

 

Rationale: The serum lipase level is elevated in the presence of pancreatic cell injury. Serum trypsin and amylase levels are also elevated in pancreatic injury. Although bilirubin can be elevated in the client with pancreatitis, it is secondary to the hepatobiliary obstructive process.

 

Test-Taking Strategy: Focusing on the clients diagnosis and its pathophysiology will direct you to elevated serum lipase level. If this question was difficult, review tests for diagnosing acute pancreatitis.

 

PTS:    1

DIF:    Level of Cognitive Ability: Understanding

REF:    Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.

OBJ:    Client Needs: Physiological Integrity

TOP:    Content Area: Adult Health/Gastrointestinal

MSC:   Integrated Process: Nursing ProcessAssessment

 

28. A nurse is caring for a client postoperatively following creation of a colostomy. Which of the following nursing diagnoses should the nurse include in the plan of care?

1.	Sexual dysfunction
2.	Disturbed body image
3.	Fear
4.	Imbalanced nutrition: more than body requirements

 

ANS:   2

 

Rationale: Disturbed body image relates to loss of bowel control, the presence of a stoma, the release of fecal material onto the abdomen, the passage of flatus, odor, and the need for an appliance (external pouch). There are no data in the question to support sexual dysfunction and fear. A risk for imbalanced nutrition: less than body requirements is the more likely nursing diagnosis.

 

Test-Taking Strategy: Use the process of elimination. Use the data presented in the question to assist in selecting the correct option. There are no data in the question to support sexual dysfunction and fear. Reading imbalanced nutrition: less than body requirements carefully will assist in eliminating this option. Review care to the client following a colostomy creation if you had difficulty with this question.

 

PTS:    1

DIF:    Level of Cognitive Ability: Analyzing

REF:    Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.

OBJ:    Client Needs: Psychosocial Integrity

TOP:    Content Area: Adult Health/Gastrointestinal

MSC:   Integrated Process: Nursing ProcessPlanning

 

29. The client is experiencing blockage of the common bile duct. Which of the following food selections made by the client indicates the need to plan for further diet teaching?

1.	Rice
2.	Whole milk
3.	Broiled fish
4.	Baked chicken

 

ANS:   2

 

Rationale: Bile acids or bile salts are produced by the liver to emulsify or break down fats. Blockage of the common bile duct impedes the flow of bile from the gallbladder to the duodenum, thus preventing breakdown of fatty intake. Knowledge of this should direct you to whole milk. Dairy products, such as whole milk, ice cream, butter, and cheese, are high in cholesterol and fat and should be avoided.

 

Test-Taking Strategy: Note the strategic words need to plan for further diet teaching. These words indicate a negative event query and ask you to select an option that is an incorrect food item. Knowledge of carbohydrate and protein contents of various foods will also assist you with eliminating options rice, broiled fish, and baked chicken. If you had difficulty with this question, review the physiology of digestion.

 

PTS:    1

DIF:    Level of Cognitive Ability: Evaluating

REF:    Black, J., & Hawks, J. (2009). Medical-surgical nursing: clinical management for positive outcomes (8th ed.). St. Louis: Saunders.

OBJ:    Client Needs: Physiological Integrity

TOP:    Content Area: Adult Health/Gastrointestinal

MSC:   Integrated Process: Teaching and Learning

 

30. The nurse is reviewing laboratory test results for the client with liver disease and notes that the clients albumin level is low. Which of the following nursing actions is focused on the consequence of low albumin levels?

1.	Evaluating for asterixis
2.	Inspecting for petechiae
3.	Palpating for peripheral edema
4.	Evaluating for decreased level of consciousness

 

ANS:   3

 

Rationale: Albumin is responsible for maintaining the osmolality of the blood. When there is a low albumin level, there is decreased osmotic pressure, which in turn can lead to peripheral edema. Evaluating for asterixis, inspecting for petechiae, and evaluating for decreased level of consciousness are incorrect and are not associated with a low albumin level.

 

Test-Taking Strategy: To answer this question accurately, you must be familiar with the function of various substances produced by the liver. Evaluating for asterixis and evaluating for decreased level of consciousness can be eliminated because neuromuscular disturbances (such as asterixis and altered levels of consciousness) are the consequence of reabsorbed toxic substances. Eliminate inspecting for petechiae because petechiae are the result of hematological dysfunction secondary to liver disease. If needed, review the physiology of the liver and the function of albumin.

 

PTS:    1

DIF:    Level of Cognitive Ability: Applying

REF:    Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.

OBJ:    Client Needs: Physiological Integrity

TOP:    Content Area: Adult Health/Gastrointestinal

MSC:   Integrated Process: Nursing ProcessImplementation

 

31. Discharge teaching for a client recovering from an attack of chronic pancreatitis should include which of the following instructions?

1.	Alcohol should be consumed in moderation.
2.	Avoid caffeine, because it may aggravate symptoms.
3.	Diet should be high in carbohydrates, fats, and proteins.
4.	Frothy fatty stools indicate that enzyme replacement is working.

 

ANS:   2

 

Rationale: Knowing that caffeinated beverages, such as coffee, tea, and soda, will worsen symptoms, such as pain, will direct you to select Avoid caffeine, because it may aggravate symptoms. Alcohol can precipitate an attack of chronic pancreatitis and needs to be avoided. The recommended diet is moderate carbohydrates, low fat, and high protein. Frothy fatty stools indicate that the replacement enzyme dose needs to be increased.

 

Test-Taking Strategy: Alcohol should be consumed in moderation can be immediately eliminated because alcohol can precipitate another attack and needs to be avoided. Diet should be high in carbohydrates, fats, and proteins can be eliminated because the recommended diet is moderate carbohydrates, low fat, and high protein. Finally, frothy fatty stools indicate that the enzyme dose needs to be increased, so frothy fatty stools indicate that enzyme replacement is working can be eliminated. Review home care instructions for the client with chronic pancreatitis if you had difficulty answering this question.

 

PTS:    1

DIF:    Level of Cognitive Ability: Applying

REF:    Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.

OBJ:    Client Needs: Physiological Integrity

TOP:    Content Area: Adult Health/Gastrointestinal

MSC:   Integrated Process: Teaching and Learning

 

32. A client returns to the nursing unit after undergoing an esophagogastroduodenoscopy (EGD). Which of the following reflects appropriate intervention by the nurse?

1.	Allow the client unassisted bathroom privileges.
2.	Keep the client lying flat in bed in the supine position.
3.	Withhold oral fluids until the clients gag reflex has returned.
4.	Tell the client to report a sore throat immediately, because it is a serious complication.

 

ANS:   3

 

Rationale: In preparation for the passage of the endoscope, an anesthetic is sprayed to inactivate the gag reflex and thus facilitate passage of the tube. It may take 1 to 2 hours for the anesthetic spray to wear off and for the gag reflex to return. Allow the client unassisted bathroom privileges, keep the client lying flat in bed in the supine position, and tell the client to report a sore throat immediately, because it is a serious complication are incorrect.

 

Test-Taking Strategy: Apply knowledge of endoscopic procedures of the upper gastrointestinal tract to assist you with selecting the correct option. Because the client will receive conscious sedation for the procedure and anesthetic spray to the throat, postprocedure safety precautions must be maintained. This includes assistance to the bathroom and head of the bed elevation to prevent aspiration of oral secretions. A sore throat is common postprocedure and may persist for a few days but is not a cause for alarm. Review these postprocedural instructions if you had difficulty with this question.

 

PTS:    1

DIF:    Level of Cognitive Ability: Applying

REF:    Pagana, K., & Pagana, T. (2009). Mosbys diagnostic and laboratory test reference (9th ed.). St. Louis: Mosby.

OBJ:    Client Needs: Safe and Effective Care Environment

TOP:    Content Area: Adult Health/Gastrointestinal

MSC:   Integrated Process: Nursing ProcessImplementation

 

33. The nurse is assisting the physician during a colonoscopy procedure. The nurse helps the client to assume which of the following positions for the procedure?

1.	Left Sims
2.	Lithotomy
3.	Knee chest
4.	Right Sims

 

ANS:   1

 

Rationale: The client is placed in the left Sims position for the procedure. This position uses the clients anatomy to the best advantage for introducing the colonoscope. The left Sims position would also be used for giving the client an enema while lying down. Therefore lithotomy, knee chest, and right Sims are incorrect.

 

Test-Taking Strategy: Using concepts related to gastrointestinal (GI) anatomy to answer this question will help you eliminate right Sims. When answering such factual questions as these, remember the guiding principles and attempt to visualize the procedure to help you select the correct option. Knowledge and visualization of lithotomy and knee chest positions will help you eliminate these options. Review this procedure if you had difficulty with this question.

 

PTS:    1

DIF:    Level of Cognitive Ability: Applying

REF:    Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis: Saunders.

OBJ:    Client Needs: Physiological Integrity

TOP:    Content Area: Adult Health/Gastrointestinal

MSC:   Integrated Process: Nursing ProcessImplementation

 

34. The client is scheduled for oral cholecystography. For the evening meal prior to the test, the nurse provides a list of foods from which di

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