Test Bank For Adult Health Nursing 7th Edition By Cooper Gosnell

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Test Bank For Adult Health Nursing 7th Edition By Cooper Gosnell

Description

WITH ANSWERS

 

Adult Health Nursing 7th Edition By Cooper Gosnell

 

Chapter 1: Introduction to Anatomy and Physiology

 

MULTIPLE CHOICE

 

  1. The anatomic term ____ means toward the midline.
a. anterior
b. posterior
c. medial
d. cranial

 

 

ANS:  C

The term medial indicates an anatomic direction toward the midline.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 1            OBJ:   2

TOP:   Anatomic terminology                    KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What are the smallest living components in our body?
a. Cells
b. Organs
c. Electrons
d. Osmosis

 

 

ANS:  A

Cells are considered to be the smallest living units of structure and function in our body.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 4            OBJ:   6

TOP:   Structural levels of organization     KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity

 

  1. What is the largest organelle, responsible for cell reproduction and control of other organelles?
a. Nucleus
b. Ribosome
c. Mitochondrion
d. Golgi apparatus

 

 

ANS:  A

The nucleus is the largest organelle within the cell.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 5            OBJ:   8

TOP:   Parts of the cell                               KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. When the patient complains of pain in the bladder, the patient will indicate discomfort in which body cavity?
a. Pelvic
b. Mediastinum
c. Dorsal
d. Abdominal

 

 

ANS:  A

A subdivision called the pelvic cavity contains the lower portion of the large intestine (lower sigmoid colon, rectum), urinary bladder, and internal structures of the reproductive system.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 3, Figure 1-4

OBJ:   5                    TOP:   Body cavity   KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The four phases of cell division all occur in:
a. diffusion.
b. mitosis.
c. osmosis.
d. filtration.

 

 

ANS:  B

During mitosis, the cell goes through four phases: prophase, metaphase, anaphase, and telophase.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 7            OBJ:   9

TOP:   Cell division   KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity

 

  1. Telophase is which phase of cell reproduction during mitosis?
a. First phase
b. Latent phase
c. Final phase
d. Spindle phase

 

 

ANS:  C

During mitosis, the cell goes through four phases: prophase, metaphase, anaphase, and telophase.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 7            OBJ:   9

TOP:   Cell division   KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is aware that which muscle group is both striated and involuntary?
a. Skeletal
b. Glial
c. Cardiac
d. Visceral

 

 

ANS:  C

The cardiac muscle is both striated and involuntary.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 9-10, Figure 1-12

OBJ:   11                  TOP:   Tissues           KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. What is a group of several different kinds of tissues arranged so that together they can perform a more complex function than any tissue alone?
a. Organ
b. System
c. Cell
d. Endoplasmic reticulum

 

 

ANS:  A

When several kinds of tissues are united to perform a more complex function than any tissue alone, they are called organs.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 11          OBJ:   7

TOP:   Organs           KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity

 

  1. What traits describe visceral muscles?
a. Smooth and voluntary
b. Smooth and involuntary
c. Striated and voluntary
d. Striated and involuntary

 

 

ANS:  B

Visceral (smooth) muscles will not function at will; thus, they act involuntarily.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 9, Figure 1-12

OBJ:   7                    TOP:   Tissues           KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. How are the thoracic and abdominal cavities separated?
a. By the pleura
b. By the diaphragm
c. By the sagittal plane
d. By the peritoneum

 

 

ANS:  B

The diaphragm (a muscle directly beneath the lungs) separates the ventral cavity into the thoracic (chest) and abdominal cavities.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 10, Figure 1-3

OBJ:   3                    TOP:   Ventral cavity

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. What is the broad section of biology dealing with the description of human structure?
a. Hematology
b. Anatomy
c. Kinesiology
d. Physiology

 

 

ANS:  B

Anatomy is the study, classification, and description of the structure and organs of the body.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 1            OBJ:   1

TOP:   Terminology                                   KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity

 

  1. ____ explains the processes and functions of many structures of the body and how they interact with one another.
a. Anatomy
b. Mitosis
c. Filtration
d. Physiology

 

 

ANS:  D

Physiology explains the processes and functions of the various structures and how they interrelate with one another.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 1            OBJ:   1

TOP:   Terminology                                   KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity

 

  1. The anatomic structure that is not in the thoracic cavity is/are the _____.
a. Heart
b. Lungs
c. Blood vessels
d. Transverse colon

 

 

ANS:  D

The transverse colon is located in the abdominal cavity.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 2, Figure 1-3

OBJ:   5                    TOP:   Thoracic cavity

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. When several organs and parts are grouped together for certain functions, they form:
a. tissues.
b. systems.
c. cells.
d. membranes.

 

 

ANS:  B

A system is an organization of varying numbers and kinds of organs arranged so that together they can perform complex functions for the body.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 4            OBJ:   7

TOP:   Systems          KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What are the distinct surface proteins of the plasma membrane essential in determining?
a. Tissue typing
b. Blood count
c. Effectiveness of a drug
d. Sexual maturity

 

 

ANS:  A

The plasma membrane has distinct surface proteins as coming from one individual.  This is the basis for the procedure of tissue typing to determine compatibility before an organ transplant.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 5            OBJ:   12

TOP:   Cells               KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. In anatomic terminology, posterior means toward the:
a. tail.
b. head.
c. back.
d. trunk.

 

 

ANS:  C

The posterior is toward the back.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 1            OBJ:   2

TOP:   Anatomic terminology                    KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What does the transverse body plane divide?
a. The front and back (coronal) of the body
b. The body lengthwise (two equal halves)
c. The superior and inferior portions of the body
d. The body into axial and appendicular

 

 

ANS:  C

The transverse plane cuts the body horizontally into the sagittal and the frontal planes, dividing the body into caudal and cranial portions.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 2, Figure 1-2

OBJ:   3                    TOP:   Body planes   KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. Caudal is defined as toward the ____.
a. head
b. feet
c. tail
d. chest

 

 

ANS:  C

Caudal is a directional word that indicates toward the tail, the distal portion of the spine.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 1            OBJ:   3

TOP:   Anatomic terminology                    KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What is the term for movement of water from an area of lower solute concentration to an area of higher solute concentration?
a. Absorption
b. Filtration
c. Diffusion
d. Osmosis

 

 

ANS:  D

Osmosis is the passage of water from less concentrated solution to more concentrated solution.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 8, Table 1-4

OBJ:   10                  TOP:   Transport processes

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. What is the type of tissue composed of cells that contract in response to a message from the brain or spinal cord?
a. Epithelial
b. Connective
c. Membrane
d. Muscle

 

 

ANS:  D

Muscle tissue is composed of cells that contract in response to a message from the brain or spinal cord.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 9            OBJ:   7

TOP:   Tissues           KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What is the type of tissue associated with the storage of fat?
a. Areolar tissue
b. Adipose tissue
c. Osseous tissue
d. Muscle tissue

 

 

ANS:  B

Adipose tissue is associated with the important function of storing fat.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 9-10, Table 1-5

OBJ:   11                  TOP:   Tissues           KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What are the thin sheets of tissue that lubricate and line the body surfaces that open to the outside environment?
a. Mucous membranes
b. Serous membranes
c. Cytoplasm
d. Involuntary visceral muscles

 

 

ANS:  A

Mucous membranes secrete mucus. They line the body surfaces that open to the outside environment.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 11          OBJ:   7

TOP:   Tissues           KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What is the process by which a cell digests a foreign material by surrounding it?
a. Pinocytosis
b. Phagocytosis
c. Absorption
d. Diffusion

 

 

ANS:  B

Phagocytosis is the process that permits a cell to engulf or surround any foreign material and digest it.

 

DIF:    Cognitive Level: Knowledge          REF:   Pages 7-8, Table 1-3

OBJ:   10                  TOP:   Active transport processes

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. Active transport in the movement of ions and other water-soluble particles across cell membranes requires that the body uses its::
a. rapid filtration.
b. charged diffusion.
c. a chemical pump.
d. osmosis.

 

 

ANS:  C

Active transport of ions and other water-soluble particles of the cell membrane require a chemical pump, such as insulin, to move glucose into the cell.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 8, Table 1-4

OBJ:   10                  TOP:   Active transport processes

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. What is the term for the passage of water containing dissolved materials through a membrane as the result of a greater mechanical force on one side?
a. Metabolism
b. Mitosis
c. Filtration
d. Osmosis

 

 

ANS:  C

Filtration is the movement of water and particles through a membrane by a force from either pressure or gravity.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 8, Table 1-4

OBJ:   10                  TOP:   Passive transport processes

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is aware that when a patient complains of pain in the epigastric region, the source of the pain is most likely to be a disorder involving the:
a. gallbladder.
b. transverse colon.
c. stomach.
d. appendix.

 

 

ANS:  C

The epigastric region of the abdomen is comprised of parts of the right and left lobes of the liver and a large portion of the stomach.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 3, Figure 1-4

OBJ:   5                    TOP:   Epigastric region

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. What are tissues that cover the outside of the body and some internal structures?
a. Connective
b. Epithelial
c. Nerve
d. Muscle

 

 

ANS:  B

Epithelial tissue covers the outside of the body and some of the internal structures.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 9            OBJ:   7

TOP:   Tissues           KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. When the nurse assesses an arm in proximal to distal order, the assessment is performed from:
a. the shoulder to the fingers.
b. front to back.
c. fingers to the center of the body.
d. center of the body to the fingers.

 

 

ANS:  A

Proximal is nearest the origin of the structure. Distal is farthest from the origin of the structure.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 2            OBJ:   3

TOP:   Anatomic terminology                    KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What is the function of epithelial membranes?
a. Secretes mucus, lines ends of bones, and lines bursae
b. Lines ends of bones, secretes synovial fluid, and lines internal surfaces of organs
c. Covers the wall of lower digestive tract, secretes mucus, and lines lungs, peritoneum, and pericardium
d. Lines lungs, peritoneum, and pericardium, and secretes synovial fluid

 

 

ANS:  C

The epithelial membrane secretes mucus, lines the lungs, peritoneum, and pericardium, and covers the wall of the lower digestive tract. The synovial membrane secretes synovial fluid to prevent friction between joints and the ends of bones, and lines the bursae found between moving body parts.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 11          OBJ:   7

TOP:   Tissues           KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse explains that pinocytosis is a process by which cells:
a. divide.
b. take in extracellular fluid.
c. use a chemical pump.
d. convert mitochondria.

 

 

ANS:  B

Pinocytosis is a process by which the cell wall makes an indentation allowing extracellular fluid to fill in, then encloses it into the cell.

 

DIF:    Cognitive Level: Comprehension   REF:   Pages 7-8, Table 1-3

OBJ:   10                  TOP:   Pinocytosis    KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

MULTIPLE RESPONSE

 

  1. Which are among the 11 body systems? (Select all that apply.)
a. Lymphatic
b. Cellular
c. Digestive
d. Reproductive
e. Accessory
f. Spinal cord

 

 

ANS:  A, C, D

There are 11 body systems: integumentary, respiratory, skeletal, digestive, muscular, nervous, endocrine, urinary, reproductive, cardiovascular, and lymphatic.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 12, Table 1-6

OBJ:   7                    TOP:   Body systems

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. Which of the following are characteristics of visceral muscles? (Select all that apply.)
a. Involuntary
b. Smooth
c. Striated
d. Independent from the spinal cord
e. Voluntary
f. Present in the blood vessels

 

 

ANS:  A, B, F

Smooth muscles are smooth, involuntary, and respond to messages from the spinal cord.

 

DIF:    Cognitive Level: Application          REF:   Page 9            OBJ:   7

TOP:   Voluntary muscle                           KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. Which of the following are passive transport mechanisms that move material across the cell membranes? (Select all that apply.)
a. Diffusion
b. Evaporation
c. Filtration
d. Osmosis
e. Mitosis
f. Anaphase

 

 

ANS:  A, C, D

The passive transport systems are diffusion, filtration, and osmosis.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 8, Table 1-4

OBJ:   10                  TOP:   Passive transport system

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. The nurse clarifies that the dorsal cavity is composed of the (select all that apply) :
a. Descending colon
b. Kidneys
c. Gallbladder
d. Brain
e. Pancreas
f. Spinal cavities

 

 

ANS:  D, F

The dorsal cavity is composed of the brain and the spinal cavities. The spinal cavities hold the cord and the meninges.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 3            OBJ:   5

TOP:   Dorsal cavity                                  KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

COMPLETION

 

  1. The nurse clarifies that the three functions of epithelial tissue are _____________,___________, and __________.

 

ANS:

protection, absorption, secretion

absorption, secretion, protection

absorption, protection, secretion

secretion, absorption, protection

secretion, protection, absorption

protection, secretion, absorption

 

The function of epithelial tissue is protection by covering the body and preventing invasion; absorption by absorbing material; and secretion by secreting mucus to line and moisten the body surfaces.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 9            OBJ:   7

TOP:   Epithelial tissue function                KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse explains that ___________are small saclike structures inside the cell that digest compounds that have invaded the cell.

 

ANS:

lysosomes

 

Lysosomes are small saclike structures inside the cell that digest compounds that have invaded the cell.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 6            OBJ:   8

TOP:   Lysosomes     KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The body plane that divides the body into the ventral and dorsal section is the_________ plane.

 

ANS:

coronal

 

The coronal plane divides the body into ventral and dorsal (front and back) sections.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 2            OBJ:   3

TOP:   Coronal plane                                           KEY:              Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

OTHER

 

  1. List in order of increasing complexity the structural levels of organization of the body. (Separate letters by a comma and space as follows: A, B, C, D)
  2. Body as a whole
  3. Cellular
  4. Organs
  5. Tissue
  6. Chemical
  7. System

 

ANS:

E, B, D, C, F, A

 

The structural levels of organization progress from the least complex (chemical) through cells, tissues, organs, systems to the most complex (the body as a whole).

 

DIF:    Cognitive Level: Comprehension   REF:   Page 4            OBJ:   6

TOP:   Structural levels of organization     KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Place the body structures in cranial-caudal priority. (Separate letters by a comma and space as follows: A, B, C, D)

 

  1. Ribs
  2. Neck
  3. Clavicle
  4. Mandible
  5. Radius
  6. Occiput

 

ANS:

F, D, B, C, A, E

 

The top-to-bottom priority is occiput, mandible, neck, clavicle, ribs, and radius.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 2, Figure 1-3

OBJ:   4                    TOP:   Anatomic positions

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. Using a poster, the nurse demonstrates the protection of the nucleus. Arrange the layers starting with the most superficial. (Separate letters by a comma and space as follows: A, B, C, D)

 

  1. Endoplasmic reticulum
  2. Nuclear membrane
  3. Nucleus
  4. Plasma membrane
  5. Cytoplasm

 

ANS:

D, E, A, B, C

 

The most superficial covering of the nucleus is the plasma membrane, under which is the cytoplasm containing the endoplasmic reticulum, nuclear membrane, and nucleus.

 

DIF:    Cognitive Level: Application          REF:   Page 5            OBJ:   8

TOP:   Protective covering of nucleus       KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

Chapter 3: Care of the Patient with an Integumentary Disorder

 

MULTIPLE CHOICE

 

  1. What should the nurse do when administering a therapeutic bath to a patient who has severe pruritus?
a. Use Burows solution to help promote healing
b. Rub the skin briskly to decrease pruritus
c. Limit bathing to 3 times a week
d. Ensure that bath area is at least 85 degrees and dehumidified

 

 

ANS:  A

Pruritus is responsible for most of the discomfort. Wet dressings and using Burows solution help promote the healing process. A cool environment with increased humidity decreases the pruritus. Give daily baths with an application to cleanse the skin.

 

DIF:    Cognitive Level: Application          REF:   Page 80          OBJ:   14

TOP:   Pruritus          KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. A frail, older adult home health patient who had chickenpox as a child has been exposed to varicella (chickenpox) several days ago. What should the nurse do?
a. Assess frequently for herpes zoster
b. Be aware of the patients immunity to chickenpox
c. Encourage the patient to have a pneumonia vaccine
d. Arrange for the patient to receive gamma globulin

 

 

ANS:  A

Herpes zoster is caused by the same virus that causes chickenpox (Herpes varicella). The greatest risk occurs to patients who have a lowered resistance to infection, such as those on chemotherapy, aging, or receiving large doses of prednisone, in whom the disease could be fatal because of the patients compromised immune system.

 

DIF:    Cognitive Level: Application          REF:   Page 72          OBJ:   5

TOP:   Shingles         KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. A patient has herpes zoster (shingles) and is being treated with acyclovir (Zovirax). What should the nurse do when administering this drug?
a. Apply lightly, being careful not to completely cover the lesion
b. After application, wrap in warm wet dressings
c. Use gloves
d. Rub medication into lesions

 

 

ANS:  C

The topical application requires that the nurse uses gloves, completely covers the lesion gently, then leaves it open to the air.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 70, Table 3-3

OBJ:   5                    TOP:   Anti-infective

KEY:  Nursing Process Step: Planning       MSC:  NCLEX: Physiological Integrity

 

  1. A child has been sent to the school nurse with pruritus and honey-colored crusts on the lower lip and chin. The nurse believes these lesions most likely are:
a. chickenpox.
b. impetigo.
c. shingles.
d. herpes simplex type I.

 

 

ANS:  B

Impetigo is seen at all ages, but is particularly common in children. The crust is honey-colored and easily removed and is associated with pruritus. The disease is highly contagious and spreads by contact.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 76          OBJ:   6

TOP:   Infection        KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. A school nurse assesses a child who has an erythematous circular patch of vesicles on her scalp with alopecia and complains of pain and pruritus. Why would the nurse use a Woods lamp?
a. To dry out the lesions
b. To reduce the pruritus
c. To kill the fungus
d. To cause fluorescence of the infected hairs

 

 

ANS:  D

Tinea capitis is commonly known as ringworm of the scalp. Microsporum audouinii is the major fungal pathogen. The use of the diagnostic Woods lamp causes the infected hairs to turn a brilliant blue green.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 79, Figure 3-7

OBJ:   6                    TOP:   Infection        KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. A patient, age 46, reports to his physicians office with urticaria with elevated lesions that are white in the center with a pale red border on hands and arms. He says, It itches like crazy. Which type of lesion would the nurse include in her documentation?
a. Macules
b. Plaques
c. Wheals
d. Vesicles

 

 

ANS:  C

Urticaria is the term applied to the presence of wheals or hives in an allergic reaction commonly caused by drugs, food, insect bites, inhalants, emotional stress, or exposure to heat or cold. The lesions are elevated with a white center and a pale red border.

 

DIF:    Cognitive Level: Analysis               REF:   Page 82, Table 3-1

OBJ:   6                    TOP:   Urticaria         KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The home health nurse assessing skin lesions uses the PQRST mnemonic as a guide. What does the S in this guide indicate?
a. Severity of the symptoms
b. Site of the lesions
c. Symptomatology of the lesions
d. Surface area of the lesions

 

 

ANS:  A

The mnemonic PQRST stands for Provocative factors (causes), Quantity, Region of the body, Severity of the symptoms, Time (length of time the disorder has been present).

 

DIF:    Cognitive Level: Knowledge          REF:   Page 66          OBJ:   4

TOP:   Skin Assessment                             KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. What would the nurse stress to the 17-year-old girl who has been prescribed Accutane for her acne?
a. Avoid alcoholic beverages
b. Drink at least 1000 mL of fluid daily
c. Use dependable birth control to avoid pregnancy
d. Avoid exposure to the sun

 

 

ANS:  C

Accutane has a destructive effect on fetal development. Dependable birth control is important to avoid a pregnancy.

 

DIF:    Cognitive Level: Application          REF:   Page 70, Table 3-3

OBJ:   6                    TOP:   Effects of Accutane

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. A 30-year-old African American had surgery 6 months ago and the incision site is now raised, indurated, and shiny. This is most likely which type of tissue growth?
a. Angioma
b. Keloid
c. Melanoma
d. Nevus

 

 

ANS:  B

Keloids, which originate in scars, are hard and shiny and are seen more often in African Americans than in whites.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 60, Table 3-1

OBJ:   9                    TOP:   Keloid            KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Physiological Integrity

 

  1. A patient, age 37, sustained partial- and full-thickness burns to 26% of the body surface area. When would the greatest fluid loss resulting from the burns occur?
a. Within 12 hours after burn trauma
b. 24 to 36 hours after burn trauma
c. 24 to 48 hours after burn trauma
d. 48 to 72 hours after burn trauma

 

 

ANS:  A

In a burn injury, usually the greatest fluid loss occurs within the first 12 hours.

 

DIF:    Cognitive Level: Analysis               REF:   Page 97          OBJ:   12

TOP:   Burns: fluid loss                             KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. Most of the deaths from burn trauma in the emergent phase that require a referral to a burn center result from:
a. infection.
b. arrhythmias with cardiac arrest.
c. hypovolemic shock and renal failure.
d. adrenal failure.

 

 

ANS:  C

Hypovolemic shock is frequently lethal in the emergent period of a severe burn because of the transfer of fluids into the interstitial tissue from the circulating volume.

 

DIF:    Cognitive Level: Analysis               REF:   Page 100        OBJ:   10

TOP:   Burns: infection                              KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse takes into consideration that carbon monoxide intoxication secondary to smoke inhalation is often fatal because carbon monoxide:
a. binds with hemoglobin in place of oxygen.
b. interferes with oxygen intake.
c. is a respiratory depressant.
d. is a toxic agent.

 

 

ANS:  A

Carbon monoxide poisoning is likely if the patient has been in an enclosed area. Carbon monoxide displaces oxygen by binding with hemoglobin.

 

DIF:    Cognitive Level: Analysis               REF:   Page 99          OBJ:   12

TOP:   CO2 intoxication                            KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. A nurse arrives at an accident scene where the victim has just received an electrical burn. What is the nurses primary concern?
a. The extent and depth of the burn
b. The sites of entry and exit
c. The likelihood of cardiac arrest
d. Control of bleeding

 

 

ANS:  C

Most electrical burns result in cardiac arrest, and the patient will require CPR or acute cardiac monitoring.

 

DIF:    Cognitive Level: Application          REF:   Page 99          OBJ:   10

TOP:   Burns             KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. A patient, age 27, sustained thermal burns to 18% of her body surface area. After the first 72 hours, the nurse will have to observe for the most common cause of burn-related deaths, which is:
a. shock.
b. respiratory arrest.
c. hemorrhage.
d. infection.

 

 

ANS:  D

Infection is the most common complication and cause of death after the first 72 hours.

 

DIF:    Cognitive Level: Analysis               REF:   Page 100        OBJ:   14

TOP:   Burns             KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. Two weeks after a severe burn of over 20% of the body, the patient vomits bright red blood. Which condition is most likely?
a. Curling ulcer
b. Paralytic ileus
c. Hypoglycemia perforation of the stomach by the NG tube
d. Gastritis

 

 

ANS:  A

Curling ulcer is a duodenal ulcer that develops 8 to 14 days after severe burns on the surface of the body. The first sign is usually vomiting of bright red blood.

 

DIF:    Cognitive Level: Analysis               REF:   Page 100        OBJ:   12

TOP:   Curling ulcer                                   KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. When providing the open method of treatment for a patient who is 52 years old with burns to the lower extremities, what would a nurse include in the nursing plan?
a. Change the dressing using good medical asepsis
b. Provide an analgesic immediately after the dressing change
c. Perform circulation checks every 2 to 4 hours
d. Keep the room temperature at 85 F (29.4 C) to prevent chilling

 

 

ANS:  D

Chilling may be controlled by keeping the room temperature at 85 F (29.4 C). Strict surgical protocol is observed and analgesia should be given before the treatment. Frequent circulation checks are not a high priority with the open method.

 

DIF:    Cognitive Level: Application          REF:   Page 101        OBJ:   12

TOP:   Burn treatment                                KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse has staged a pressure ulcer that has a shallow crater with a dry pink wound bed as a:
a. stage I
b. stage II
c. stage III
d. stage IV

 

 

ANS:  B

Stage II pressure ulcers have a shallow crater with a dry pink wound bed without slough.

 

DIF:    Cognitive Level: Analysis               REF:   Page 67          OBJ:   4

TOP:   Pressure ulcers                                KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What would the nurse dressing a necrotic pressure ulcer with a minimal exudate most likely use?
a. Hydrocolloid dressing
b. Alginate dressing
c. Hydrofiber dressing
d. Transparent film

 

 

ANS:  A

Hydrocolloid dressings are useful in necrotic wounds with little exudate. Alginate and hydrofiber dressings are used for wounds with copious exudate. Transparent film is not absorbent.

 

DIF:    Cognitive Level: Application          REF:   Page 68, Table 3-2

OBJ:   14                  TOP:   Eczema          KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is caring for a 26-year-old male patient who was burned 72 hours ago. He has partial-thickness burns to 24% of his body surface area. He begins to excrete large amounts of urine. What should the nurse do?
a. Increase the IV rate and monitor for burn shock
b.

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