Study Guide for Med-Surg. Donald S.

Laird

Chapter 41:

1.Which statement best describes the etiology of obesity?

c. Obesity is the result of complex interactions between genetic and environmental factors.

Rationale: The environment and psychosocial factors highly influence significate genetic and

biologic susceptibility factors plays an important part in causing obesity.

2.The obesity classification that is most often associated with cardiovascular health problems is

d. android fat distribution.

Rationale: Individuals with fat distribution primarily in the abdominal area also known as apple-

shaped are at greater risk for obesity-related diseases such as heart disease. Individuals whose fat

is distributed around the abdomen and chest area are classified as having android fat distribution

also known as android obesity.

3.Health risks associated with obesity include (select all that apply)

a. colorectal cancer.

c. polycystic ovary syndrome.

d. nonalcoholic steatohepatitis.

Rationale: The majority of obesity-related co-morbidities, such as central obesity is identified as

one of the independent predictors of an increased risk for cancer Waist circumference primarily

correlates with cancers of the colon, liver, endometrial, breast and pancreas. This suggests there

is a pathogenetic link between visceral adiposity and carcinogenesis. Adults with a BMI greater
than 22 kg/m 2 are at a higher risk for cancer. Obesity related NAFLD is a cause of chronic liver

disease and the most severe form Non-alcoholic steatohepatitis (NASH) can progress to cirrhosis

and hepatocellular carcinoma.

4.The best nutritional therapy plan for a person who is obese is

d. foods from the basic food groups.

Rationale: Restricting a person’s food intake is essential for any weight loss or maintenance

program. The basic food groups should always be included in any weight loss program in order

for the body to receive essential nutrition.

5.This bariatric surgical procedure involves creating a stoma and gastric pouch that is reversible,

and no malabsorption occurs. What surgical procedure is this?

d. Adjustable gastric banding

Rationale: This laparoscopic procedure consists of the placement of an adjustable band made of

silicone around the upper portion of a person’s stomach leaving a small pouch. The pouch can

only hold around one ounce of food. The band can be adjusted, in order to modify weight loss or

reduce any unwanted side effects, by placing or removing saline from the band through a small

line that is placed under the skin and ran to the band. The procedure can be reversed or modified

if need be.

6.A severely obese patient has undergone Roux-en-Y gastric bypass surgery. In planning

postoperative care, the nurse anticipates that the patient

d. may have only liquids orally, and in very limited amounts, during the early postoperative

period.
Rationale: In the early postop period the patient is given 30 milliliters of sugar free clear liquids

and water every two hours while awake.

7.Which of the following criteria must be met for a diagnosis of metabolic syndrome (select all

that apply)?

a. Hypertension

b. Elevated triglycerides

c. Elevated plasma glucose

d. Increased waist circumference

Rationale: The diagnostic variables for metabolic syndrome increased blood pressure greater

than or equal to 135/85, fasting blood glucose greater than or equal 5.6mmol/L, waist

circumference greater than or equal 102cm in men and 88cm in women, triglycerides greater

than or equal 1.7mmol/L, and HDL cholesterol less than 1.03mmolL in men and 1.29mmol in

women.

Chapter 42:

1.M.J. calls to tell the nurse that her 85-year-old mother has been nauseated all day and has

vomited twice. Before the nurse hangs up and calls the health care provider, she should instruct

M.J. to

b. gives her mother sips of water and elevate the head of her bed to prevent aspiration.

Rationale: Older adults which have a higher chance of suffering from chronic diseases such as

heart failure or renal disease, this increases the chance for fluid and electrolyte imbalances which

can be life threatening, can go into chronic fluid overload by receiving too much fluid to fast.
The elderly with a decreased level of consciousness have an increased chance for aspiration from

vomiting. Elderly patients who take antiemetic medication have a higher risk for side effects

such as confusion. If this occurs the dosage should be adjusted and the patient reevaluated to see

if the confusion is eliminated.

2.The nurse explains to the patient with Vincent's infection that treatment will include

d. topical application of antibiotics.

Rationale: Vincent's infection is form of gingivitis that is very painful and is caused by the

symbiotic microorganisms. Topical applications of antibiotics are used to treat the infection.

Patients are also encouraged to rinse with hydrogen peroxide and a saline solution. Avoiding

alcohol and tobacco products are encouraged along with getting adequate rest. Most patients are

able to tolerate a soft, nutritious diet.

3.The nurse teaching young adults about behaviors that put them at risk for oral cancer includes

c. avoiding use of smokeless tobacco.

Rationale: Oral cancers can occur on the lips, tongue, and oral cavity. Predisposing risks factors

are: using alcohol and tobacco products, such as pipes, cigars chewing tobacco, and snuff,

chronic oral irritants such as broken or jagged teeth, improper fitting dentures, mechanical or

chemical, and the human papillomavirus. Over exposure from the sun or tanning beds especially

with a ruddy and fair completion. Irritation to the lips from pipe stems and recurring fever

blisters (Herpes blisters), syphilis of the lips, and immune compromised patients.

4.The nurse explains to the patient with gastroesophageal reflux disease (GERD) that this

disorder
d. often involves relaxation of the lower esophageal sphincter, allowing stomach contents to back

up into the esophagus.

Rationale: Gastroesophageal reflux disease also known as GERD occurs when the gastric content

from the stomach seems into the esophagus through a sphincter that separates the stomach and

the esophagus which is also called the lower esophageal sphincter (LES). This happens when the

LES becomes weak and relaxes inappropriately. This often occurs in patients suffer with a hiatal

hernia

5.A patient who has undergone an esophagectomy for esophageal cancer develops increasing

pain, fever, and dyspnea when a full liquid diet is started postoperatively. The nurse recognizes

that these symptoms are most indicative of

c. leakage of fluid or foods into the mediastinum.

Rationale: An assessment of increased temperature, pain and dyspnea after esophageal surgery

are indicative of a leakage of food or fluid into the mediastinum from the feeding tube.

6.The pernicious anemia that may accompany gastritis is due to

C. a lack of intrinsic factor normally produced by acid-secreting cells of the gastric mucosa.

Rationale: Parietal cells and the source of intrinsic factor are loss as a result of atrophy in many

cases of gastritis. Intrinsic factor which is found in the terminal ileum is necessary for absorbing

cobalamin also found in the terminal ileum which leads to the deficiency of cobalamin. This

depletion of the body's storage causes a state of deficiency. Red blood cells require cobalamin to

grow and mature and its deficiency leads to neurologic complications and pernicious anemia.

7.The nurse is teaching the patient and family that peptic ulcers are
d. promoted by a combination of factors that may result in erosion of the gastric mucosa,

including certain drugs and alcohol.

Rationale: High acid levels are necessary for the development of peptic ulcers, but peptic ulcers

don’t always form in the presence of high amounts of hydrochloric acid (HCl). When

hydrochloric acid seem back in the gastric mucosa cells are destroyed and the mucosa becomes

inflamed. This causes the release of histamines, which leads to vasodilation and increases the

capillary permeability. This results in increased secretion of hydrochloric acid and pepsin. The

mucosal barrier is also damaged by over the counter and doctor prescribed medications,

infections of the body and certain types of lifestyles. Some of these medications such as aspirin

and NSAIDs, which inhibit prostaglandin synthesis, cause the increase of gastric acid secretion,

which reduces the mucosal barrier integrity. Anticoagulation drugs, corticosteroids, and SSRI’s

can increase patients chances of developing ulcers. Excessive consumption of alcohol increases

acid secretion which can result in acute lesions of the mucosa. Simple things such as coffee

increases the secretion of gastric acid. Immunocompromised patients who are infected with

herpes and cytomegalovirus (CMV) can develop gastric ulcers. Bacteria such as helicobacter

pylori can enters your digestive tract through accessible portals and damage gastric tissue and

form peptic ulcers by altering gastric secretions. Your diet, environment and genetics can affect

the way the bacteria affects the gastric mucosa. Once these ulcers have formed the healing

process can be slowed by smoking and psychologic issues such as stress and depression.

8.An optimal teaching plan for an outpatient with stomach cancer receiving radiation therapy

should include information about

d. wound and skin care, nutrition, drugs, and community resources.

Rationale: Patients diagnosed with stomach cancer are treated with radiation therapy. It can be

used as the sole treatment, or as an adjuvant to chemotherapy or surgery, or as a palliative

treatment for stomach cancer. The role of the nurse is to provide the patient with detailed

instructions about the treatment, reassurance, and ensure the patient completes the total number

of assigned treatments. It is necessary to assess the patient's knowledge about radiation therapy.

It is very important to teach the patient the uses of antiemetic drugs for nausea and pain

medications. Proper nutrition and fluid intake is necessary during the treatments and for fighting

cancer. It is important to teach the patient about good skin care due to the damage radiation can

cause to the skin.

9.The teaching plan for the patient being discharged after an acute episode of upper GI bleeding

includes information concerning the importance of (select all that apply)

b. avoiding taking aspirin and drugs containing aspirin.

c. only taking drugs prescribed by the health care provider.

Rationale: Before discharging your patient instructions should be provided to the patient and

caregiver about the importance of avoiding any future episodes of a GI bleed. These GI bleeds

can be caused by liver, repertory and ulcer disease along with abuse of drugs and alcohol. It is

important for the patient and caregiver to understand the consequences for noncompliance with

drug therapy. Aspirin and NSAIDs must be avoided unless prescribed by the doctor. The patient

must avoid smoking and the use of alcohol to prevent irritation and decrease tissue repair.
10.Several patients are seen at an urgent care center with symptoms of nausea, vomiting, and

diarrhea that began 2 hours ago while attending a large family reunion potluck dinner. You

question the patients specifically about foods they ingested containing

b. meat and milk.

Rationale: Within 30 minutes up to 7 hours’ patients who are infected with toxins from

staphylococcus aureus start showing signs and symptoms including diarrhea, nausea, and

vomiting. These toxins can enter the skin and repertory tracts of people who handle contaminated

Meats, milk, salad dressings, and bakery products containing cream fillings.

Chapter 43:

1.The appropriate collaborative therapy for the patient with acute diarrhea caused by a viral

infection is to

a. increase fluid intake.

Rationale: Viral acute diarrhea usually will resolve itself without treatment. Preventing the

transmission of the diarrhea, dehydration, and resolving the diarrhea are a priority. Other types of

diarrhea can be treated with antidiarrheal medication, but viral infectious types are

contraindicated. These medications can increase the exposure time to the infectious organism.

Antibiotics have little effect on acute viral type illnesses. Hand washing before and after patient

contact and body fluid contact is one of the best practices to prevent the spread of virus related

diarrhea. Immediately flush any vomit or bowel movements and wash any contaminated clothing

immediately using hot water and detergent.

2.When a 35-year-old female patient is admitted to the emergency department with acute

abdominal pain, which possible diagnosis should you consider that may be the cause of her pain

(select all that apply)?

a. Gastroenteritis

b. Ectopic pregnancy

c. Gastrointestinal bleeding

d. Irritable bowel syndrome

e. Inflammatory bowel disease

Rationale: Gastroenteritis happens when the intestinal lining becomes inflamed. Gastrointestinal

bleeding is bleeding of the GI tract caused by some type of irritation. Ectopic pregnancy happens

when a fertilized egg does not move from the fallopian tubes to the uterus after being fertilized

by the male’s sperm. Irritable bowel syndrome (IBS) is a group of symptoms usually happening

at the same time which cause abdominal pain and bloating, along with diarrhea and constipation

happening together or separate. Inflammatory bowel disease (IBD) causes your entire your

digestive tract to become inflamed. Each of the conditions can cause acute abdominal pain.

3.Assessment findings suggestive of peritonitis include

a. rebound abdominal pain.

Rationale: Patients who have peritonitis have a very hard abdomen with severe abdominal pain

that worsens with sudden movement. By placing both hands on the patient’s abdomen and

pressing in gently with the fingers and releasing the hands suddenly will cause the patient to feel

severe pain which is known as rebound tenderness.

4.In planning care for the patient with Crohn's disease, the nurse recognizes that a major

difference between ulcerative colitis and Crohn's disease is that Crohn's disease

c. often recurs after surgery, whereas ulcerative colitis is curable with a colectomy.

Rationale: Crohn's disease and ulcerative colitis is different in that Crohn’s disease affects many

layers of the GI Tract and ulcerative colitis will affect the colon lining only. Ulcerative colitis can

cause rectal bleeding and megacolon, but does not affect nutritional malabsorption. By surgically

removing the rectum and colon this disorder can be cured. With Crohn's disease the ileum is

usually involved and nutritional malabsorption can be affected, Crohn’s disease will usually

reoccur at the same site after being treated surgically.

5.The nurse performs a detailed assessment of the abdomen of a patient with a possible bowel

obstruction, knowing that manifestations of an obstruction in the large intestine are (select all

that apply)

a. persistent abdominal pain.

b. marked abdominal distention.

Rationale: Symptoms of an obstruction of the lower intestinal are significantly distended

abdomen and persistent pain. There is a gradual onset of an obstruction of the large intestine with

symptoms of absolute constipation, Diarrhea and vomiting is rare with this type of obstruction.

6.A patient with stage I colorectal cancer is scheduled for surgery. Patient teaching for this

patient would include an explanation that

c. follow-up colonoscopies will be needed to ensure that the cancer does not recur.
Rationale: With a diagnosis of stage 1 colorectal cancer it is not recommended for chemotherapy

as a treatment, the tumor is usually surgically removed. If a colostomy was placed, it is reversed.

Follow-up colonoscopy is recommended because Since colorectal cancer can reoccur it is

recommended for the patient to have follow up colon ostomies.

7.The nurse explains to the patient undergoing ostomy surgery that the procedure that maintains

the most normal functioning of the bowel is

a. a sigmoid colostomy.

Rationale: Sigmoid colostomies produce a firmer stool than other colostomies. There are limited

irritating digestive enzymes in the stool. Bowel movements from these types of colostomies can

happen at usual expected times as a reflex. This occurs after a sufficient amount of stool collects

in the colon above the colostomy. Patients are not required to wear a collection bag only is they

feel more comfortable with one. Due to the distal location of the ostomy intestinal contents

closely resemble feces from a normal intact rectum.

8.In contrast to diverticulitis, the patient with diverticulosis

b. often has no symptoms.

Rationale: Diverticulosis is when small outpouchings form in the colon usually in the sigmoid

colon. Patients usually have little to no symptoms. Diverticulitis happens when the diverticulum

of the colon becomes inflamed or infected with signs and symptoms of inflammation, abdominal

cramping, pain and tenderness, chills, and fever. Severe cases can lead to a bowel obstruction or

perforation.
9.A nursing intervention that is most appropriate to decrease postoperative edema and pain after

an inguinal herniorrhaphy is

d. applying a scrotal support with ice bag.

Rationale: Complications from an inguinal hernia repair surgery include scrotal pain and

inflammation. Supporting the scrotum by applying an ice pack may reduce pain and edema.

10.The nurse determines that the goals of dietary teaching have been met when the patient with

celiac disease selects from the menu

a. scrambled eggs and sausage.

Rationale: Patients who are diagnosed with Celiac disease must avoid dietary gluten for the rest

of their life. Products such as rye, barley, oaks, and wheat contain gluten and must be avoided.

Certain medications, food, preservatives, stabilizers, and additives also contain gluten.

11.What should a patient be taught after a hemorrhoidectomy?

d. Use prescribed pain medication before a bowel movement.

Rationale: Bowel movements are painful after a hemorrhoidectomy, patients will try and delay

their first bowel movement as long as possible. Giving pain medication before defecating can

help reduce the pain and discomfort. It is important for the patient not to become constipated and

they must avoid straining. High-fiber diets can help reduce or prevent constipation. Colace (a

stool softener) is normally given the first couple days after surgery to help prevent or relieve

constipation. Oil-retention enemas are used for patients who have not had a bowel movement

within the first 2 to 3 days after surgery.

Chapter 44:

1.A patient with hepatitis A is in the acute phase. The nurse plans care for the patient based on

the knowledge that

a. pruritus is a common problem with jaundice in this phase.

Rationale: When jaundice is in its acute phase it can be anicteric or icteric. The diffusion of

bilirubin into the tissue causes jaundice. Pruritus sometimes accompanies jaundice. Bile salts

accumulate beneath the skin and cause pruritus.

2.A patient with acute hepatitis B is being discharged in 2 days. In the discharge teaching plan,

the nurse should include instructions to

b. uses a condom during sexual intercourse.

Rationale: The transmission of Hepatitis B virus is transmitted through mucous membranes with

exposure to infected body fluids, blood, and blood products. The infected body fluids can be

saliva, semen, and vaginal secretions. This disease is sexually transmitted by unprotected sexual

intercourse with a person who is infected with hepatitis B. Patients should be taught how to use

condoms in order to prevent the transmission of hepatitis B.

3.A patient has been told that she has elevated liver enzymes caused by nonalcoholic fatty liver

disease (NAFLD). The nursing teaching plan should include

b. recommending a heart-healthy diet.

Rationale: Nonalcoholic fatty liver disease (NAFLD) has no definitive treatment and can

progress to cirrhosis of the liver. Reducing the risk factors is therapeutic for the patient. Risk

factors include eliminating harmful medications, reducing body weight, and treating diabetes.
Weight reduction can help decrease liver enzymes and improve insulin sensitivity. The American

Heart Association’s heart healthy diet is appropriate.

4.The patient with advanced cirrhosis asks why his abdomen is so swollen. The nurse's response

is based on the knowledge that

b. portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space.

Rationale: Patients who suffer from cirrhosis have a condition called ascites which is when

serous fluid accumulates in the abdominal cavity or peritoneal. Portal hypertension causes

proteins to shift from blood vessels into the lymph space through larger pores of the sinusoids.

When the lymphatic system is unable to carry off the Excess proteins and water which the

lymphatic system can’t carry off, leak through liver capsule into the peritoneal cavity. Additional

fluid is pulled into the peritoneal cavity by the proteins of osmotic pressure. Hypoalbuminemia,

which occurs due to decreased colloidal oncotic pressure, is the next mechanism of the formation

of ascites this occurs when the liver is unable to synthesize albumin. Hyperaldosteronism, a third

mechanism, happens when aldosterone can’t metabolize due to hepatocyte damage. Sodium

reabsorption by the renal tubules is increased due to increased levels of aldosterone. Sodium

retention and increased levels of antidiuretic hormones cause additional water retention is caused

by retention of sodium and increased levels of antidiuretic hormones.

5.In planning care for a patient with metastatic liver cancer, the nurse should include

interventions that

a. focus primarily on symptomatic and comfort measures.

Rationale: Palliative measure and comfort are the nurse’s priority for patients with liver cancer

due to the poor prognosis. Death can occur within 4 to 7 months due to the rapid growth of the
cancer. This rapid growth of the cancer causes massive loss of blood from GI bleeds and hepatic

encephalopathy.

6.Nursing management of the patient with acute pancreatitis includes (select all that apply)

a. checking for signs of hypocalcemia.

e. monitoring for infection, particularly respiratory tract infection.

Rationale: In cases of acute pancreatitis you should monitor for signs and symptoms of

hypocalcemia. Monitor for signs of tetany which are muscle twitching, jerking, and irritability.

An early indicator of hypocalcemia is tingling and numbness around the lips and fingers. Also

asses for signs of Chvostek's and Trousseau's. Monitor for signs of infection and fever in cases of

acute pancreatitis. Patients with acute phase of pancreatitis often develop respiratory infections

due to increased retroperitoneal fluid that causes the diaphragm to raise, which leads to shallow,

guarded abdominal breaths.

7.A patient with pancreatic cancer is admitted to the hospital for evaluation of possible treatment

options. The patient asks the nurse to explain the Whipple procedure that the surgeon has

described. The explanation includes the information that a Whipple procedure involves

c. removal of part of the pancreas, part of the stomach, the duodenum, and the gallbladder, with

joining of the pancreatic duct, the common bile duct, and the stomach into the jejunum.

Rationale: Whipple procedure also known as a radical pancreaticoduodenectomy, is the name of

the surgery for treating pancreatic cancer. The stomach along with the pancreatic and common

bile duct are anastomosed to the jejunum.

8.The nursing management of the patient with cholecystitis associated with cholelithiasis is

based on the knowledge that

d. laparoscopic cholecystectomy is the treatment of choice in most patients who are

symptomatic.

Rationale: Cholecystitis, inflammation of the gallbladder, is inflamed due to the cystic duct being

obstructed by gallstones also known as cholelithiasis. Symptomatic cholelithiasis is treated by

performing a laparoscopic cholecystectomy.

9.Teaching in relation to home management after a laparoscopic cholecystectomy should include

b. reporting any bile-colored drainage or pus from any incision.

Rationale: Patients discharge instructions about the care needed after a laparoscopic

cholecystectomy should be taught to patient and caregiver. Instruct the patient and caregiver on

removing the bandages from the surgical site the day after surgery and having the patient shower.

The surgeon should be notified if these signs and symptoms occur: if the incision site has any

swelling, redness, bile-colored drainage or pus; and fever, chills, nausea or vomiting, or severe

abdominal pain. Instruct the patient on resuming normal activities gradually. With no severe

complications the patient may return to work or school 1 week after surgery. A low-fat diet is

usually tolerated better the first several weeks after surgery and then a regular diet may resume.

Chapter 56:

1.In a patient with a disease that affects the myelin sheath of nerves, such as multiple sclerosis,

the glial cells affected are the

d. oligodendrocytes.
Rationale: In the CNS the nerve fibers myelin sheath is produced by specialized cells called

Oligodendrocytes.

2.Drugs or diseases that impair the function of the extrapyramidal system may cause loss of

d. automatic movements associated with skeletal muscle activity.

Impulses from the extrapyramidal system are carried by descending motor tracts called

automotive, which includes all motor systems (except the pyramidal system) that is concerned

with voluntary movement. It includes descending pathways originating in the cerebellum,

ganglia, and brainstem. The motor output exits the spinal cord by way of the ventral roots of the

spinal nerves.

3.An obstruction of the anterior cerebral arteries will affect functions of

c. judgment, insight, and reasoning.

Rationale: The medial and anterior portions of the frontal lobes are fed by the anterior cerebral

artery. Judgment and reasoning are higher order processing that is controlled by the frontal lobes

anterior portion.

4.Paralysis of lateral gaze indicates a lesion of cranial nerve

d.VI.

Rationale: Cranial nerves III, IV, and VI are the nerves responsible for eye movement. The lateral

rectus eye muscle is innervated by cranial nerve VI innervates the lateral rectus eye muscle, and

it’s the primary muscle responsible for the eye’s lateral movement.
5.A result of stimulation of the parasympathetic nervous system is (select all that apply)

a. constriction of the bronchi.

b. dilation of skin blood vessels.

c. increased secretion of insulin.

e. relaxation of the urinary sphincters.

Rationale: When the parasympathetic nervous system becomes stimulated it can cause the

constriction of the bronchi, dilation of blood vessels to the skin, urinary sphincter relaxation, and

increased secretion of insulin. Sympathetic nervous system stimulation results in increased blood

glucose levels.

6.Assessment of muscle strength of older adults cannot be compared with that of younger adults

because

d. aging leads to a decrease in muscle bulk and strength.

Rationale: Aging bring changes such as decreases in muscle strength and agility which leads to

decreased muscle bulk.

7.Data regarding mobility, strength, coordination, and activity tolerance are important for the

nurse to obtain because

a. many neurologic diseases affect one or more of these areas.

Rationale: A change in the patient's coordination, strength, and mobility can be the result of a

neurologic disorder. The patient's usual activity and exercise patterns can be altered by these

problems.
8.During neurologic testing, the patient is able to perceive pain elicited by pinprick. Based on

this finding, the nurse may omit testing for

c. temperature perception.

Rationale: Pain sensation and temperature sensation are both carried by the same ascending

pathways so if pain sensation is intact then temperature sensation will also so temperature

sensation can be eliminated.

9.A patient's eyes jerk while the patient looks to the left. You will record this finding as

a. nystagmus.

Rationale: Fine, rapid jerking movements of the patient’s eyes is a sign of nystagmus.

10.The nurse is caring for a patient with peripheral neuropathy who is going to have EMG

studies tomorrow morning. The nurse should

b. instructs the patient that there is no risk of electric shock.

Rationale: Assessing electrical activity associated with nerves and skeletal muscles can be done

with an Electromyography (EMG). The EMG records activity by the insertion of needle

electrodes which will detect muscle and peripheral nerve disease. The patient is informed by the

nurse that they will experience some pain and discomfort from the insertion of the needles. The

patient is at no risk for electrical shock during this procedure.

Chapter 57:

1.Vasogenic cerebral edema increases intracranial pressure by

b. altering the endothelial lining of cerebral capillaries.

Rationale: The vasogenic cerebral edema is caused by changes in the endothelial lining of

cerebral capillaries and mainly occurs in the white matter.

2.A patient with intracranial pressure monitoring has a pressure of 12 mm Hg. The nurse

understands that this pressure reflects

d. a normal balance between brain tissue, blood, and cerebrospinal fluid.

Rationale: Intracranial pressure (ICP) ranging from 5 to 15 mm Hg is within a normal range. A

sustained pressure that is above the upper limit is considered abnormal.

3.A nurse plans care for the patient with increased intracranial pressure with the knowledge that

the best way to position the patient is to

b. elevates the head of the bed to 30 degrees.

Rationale: In order to enhances respiratory exchange and decrease cerebral edema the nurse

should maintain the head of the bed at 30 degrees. To avoid venous obstruction and elevation in

ICP the nurse should position the patient to prevent extreme neck flexion. This also reduces

sagittal sinus pressure, promotes drainage from the head through the jugular veins and valve less

venous system, and decreases the vascular congestion that can produce cerebral edema.

4.The nurse is alerted to a possible acute subdural hematoma in the patient who

c. develops decreased level of consciousness and a headache within 48 hours of a head injury.

Rationale: Within 24 to 48 hours of an injury an acute subdural hematoma can occur. The signs

and symptoms include headache and decreasing level of consciousness which are similar to those

associated with brain tissue compression in elevated ICP.

5. During admission of a patient with a severe head injury to the emergency department, the

nurse places the highest priority on assessment for

a. patency of airway.

Rationale: Ensuring the patient has a patent airway in an emergency management of a patient

with a severe head injury is the nurse’s initial priority.

6.A patient is suspected of having a brain tumor. The signs and symptoms include memory

deficits, visual disturbances, weakness of right upper and lower extremities, and personality

changes. The nurse recognizes that the tumor is most likely located in the

a. frontal lobe.

Rationale: Signs and symptoms of a unilateral frontal lobe tumor may result in the following:

seizures, memory deficit, unilateral hemiplegia, personality and judgment changes, along with

visual disturbances. A bilateral frontal lobe tumor may present with symptoms closely associated

with an ataxic gait and unilateral frontal lobe tumor.

7.Nursing management of a patient with a brain tumor includes (select all that apply)

c. assisting and supporting the family in understanding any changes in behavior.

e. planning for seizure precautions and teaching the patient and the caregiver about antiseizure

drugs.

Rationale: Clinical manifestations of brain tumors include headaches, seizures (common in

gliomas and brain metastases), nausea and vomiting from increased ICP. Cognitive changes

include mood or personality changes along with problems with memory. Visual spatial

dysfunction, aphasia, sensory loss and muscle weakness are manifestations of a brain tumor.
8.The nurse on the clinical unit is assigned to four patients. Which patient should she assess first?

c. Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0-to-10

scale

Rationale: Patients with meningitis must be closely observed for manifestations of increased ICP,

it is believed this occurs from increased cerebrospinal fluid (CSF) volume and swelling around

the dura. Changes occurring suddenly in the level of consciousness or changes that occur in

behavior including a sudden severe headache may indicate an acute elevation of ICP.

9.A nursing measure that is indicated to reduce the potential for seizures and increased

intracranial pressure in the patient with bacterial meningitis is

b. controlling fever with prescribed drugs and cooling techniques.

Rationale: The frequency of seizures and increased cerebral edema is increased by fever and it

must be a priority management. Extremely high temperature’s over prolonged periods can result

in neurologic damage. Measures for lowering temperature include administering aspirin or

acetaminophen; placing a cooling blanket on the patient and a tepid sponge baths with water.

Chapter 58:

1.Of the following patients, the nurse recognizes that the one with the highest risk for a stroke is

a(n)

d. 65-year-old African American man with hypertension.

Rationale: Risk factors for stroke patients that cannot be modified are age (65 years and older),

male gender, ethnicity or race (African Americans has the highest incidence following closely

behind is Hispanics, Native Americans/Alaska Natives, and Asian Americans; and whites are the
next highest), and history of stroke within the family unit or personal history of a transient

ischemic attack or stroke. Risk factors for a stroke that can be modified are hypertension (most

important), heart disease (especially atrial fibrillation), excessive alcohol consumption and

smoking (causes hypertension), lack of exercise, metabolic syndrome, abdominal obesity, and

sleep apnea, diets that are high in saturated fat and low in vegetables and fruit, and abuse of

drugs such as cocaine. Additional risk factors for stroke patients include being diagnosed with

diabetes mellitus, increased levels of serum cholesterol, birth control pills which can cause high

levels of progestin and estrogen, hyperhomocystinemia, history of migraine headaches, sickle

cell disease, and inflammatory conditions.

2.The factor related to cerebral blood flow that most often determines the extent of cerebral

damage from a stroke is the

C. degree of collateral circulation.

Rationale: The severity of a stroke will depend on the rapid onset, size of the lesion, and

presence of collateral circulation.

3.Information provided by the patient that would help differentiate a hemorrhagic stroke from a

thrombotic stroke includes

d. sudden onset of severe headache.

Rationale: Symptoms of a hemorrhagic stroke are usually sudden onset of symptoms, that

include neurologic deficits, nausea and vomiting, headache, hypertension, and a decreased level

of consciousness. Symptoms of an ischemic stroke can progress in the first 72 hours as infarction

and cerebral edema increase.

4.A patient with right-sided hemiplegia and aphasia resulting from a stroke most likely has

involvement of the

c. left middle cerebral artery.

Rationale: The expected clinical manifestations of a stroke with middle cerebral artery

involvement include sensory deficient. motor deficit, aphasia, and hemianopsia on the dominant

side and include sensory deficit, motor deficit, neglect, and hemianopsia on the nondominant

side.

5.The nurse explains to the patient with a stroke who is scheduled for angiography that this test is

used to determine the

c. patency of the cerebral blood vessels.

Rationale: Visualization of the cerebral blood vessels are provided by an angiography and it

helps estimate perfusion and detect filling defects in cerebral arteries.

6.A patient experiencing TIAs is scheduled for a carotid endarterectomy. The nurse explains that

this procedure is done to

C. prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow.

Rationale: To improve blood flow in the carotid artery the atheromatous lesion is removed by

performing a carotid endarterectomy.

7.For a patient who is suspected of having a stroke, one of the most important pieces of

information that the nurse can obtain is

b. time at which stroke symptoms first appeared.

Rationale: The most import information to assess for during the initial evaluation is the time of

onset of the first signs and symptoms of the stroke. Recombinant tissue plasminogen activator

(tPA) must be administered within 3 to 4.5 hours of the onset of clinical signs of an ischemic

stroke; With onset of acute ischemic stroke tPA will reestablish blood flow through a blocked

artery and lesson the death of brain cells.

8.Bladder training in a male patient who has urinary incontinence after a stroke includes

c. assisting the patient to stand to void.

Rationale: The primary urinary problem with patients in the acute stage of a stroke is poor

bladder control and incontinence. The use of an indwelling catheter should be avoided and

normal bladder function should be promoted. A bladder retraining program must consist of an

adequate intake of fluid, consuming the greatest amount of fluids between 7:00 am and 7:00 pm;

consistent scheduled intervals of toileting every 2 hours using a bedpan, commode, or bathroom;

and noting signs of restlessness, which could be a sign for the need to empty the bladder. The use

of an intermittent catheter may be needed to empty the bladder to prevent urinary retention this

should not be used for urinary incontinence. After a stroke, the rehab phase nursing interventions

should focus on urinary continence which should include palpating the bladder for distention;

offering the bedpan, urinal, commode, or toilet every 2 hours while patient is awake and alert and

during the night every 3 to 4 hours; the use of a direct command will help the patient focus on

the need to urinate; assisting with dressing and mobility; encouraging the patient to schedule

fluid intake between 7:00 am and 7:00 pm; and have the patient use the position they normally

use for urinating (i.e., standing for men and sitting for women).
9.Common psychosocial reactions of the stroke patient to the stroke include (select all that

apply)

a. depression.

d. sleep disturbances.

e. denial of severity of stroke.

Rationale: Many losses may be experienced by patients with a stroke including sensory,

intellectual, communicative, functional, role behavior, vocational, social, and emotional losses.

Some patients experience long-term depression, symptom manifestation of fatigue, sleep

disturbances, weight loss, anxiety, and poor appetite. The patient can experience anger and

frustration from the increased time and energy it can take to perform previously simple task. The

first year following a stroke it is common for patients to become frustrated and depressed.

Strokes are normally sudden, extremely stressful event for the patient, caregiver, significant

other, and family. Due to the change in the roles and responsibilities of the family members they

can suffer financially, socially, and emotionally. The variation of reactions varies considerably

but may involve depression, sorrow, anger, fear, apprehension, and denial of the severity of

stroke.

Chapter 59:

1. A 50-year-old man complains of recurring headaches. He describes these as sharp, stabbing,

and located around his left eye. He also reports that his left eye seems to swell and get teary

when these headaches occur. Based on this history, you suspect that he has

a. cluster headaches.
Rationale: Patients experiencing cluster headaches have repeated headaches which occur from

weeks to months and follows with periods of remission. The patient experiences sharp and

stabbing pain can last for minutes to 3 hours. Cluster headaches often occur up to eight times a

day every other day. The clusters normally occur with regularity. They normally happen about

the same time each day and ranging around the same seasons each year. Typically, a cluster lasts

2 weeks to 3 months, then they go into remission from months to years. The pain usually is

located around the eye and radiates to the temple, cheek, forehead nose, and gums. In most cases

patients can experience facial flushing or pallor, nasal congestion, swelling around the eye,

lacrimation (tearing), and constriction of the pupil. While the headache is occurring the patient

experiences restlessness, agitation, and inability to relax or sit still.

2.A 65-year-old woman was just diagnosed with Parkinson's disease. The priority nursing

intervention is

c. promoting physical exercise and a well-balanced diet.

Rationale: For patients with Parkinson's disease the major nursing intervention is promoting a

well-balanced diet and physical exercise.

3.The nurse finds that an 87-year-old woman with Alzheimer's disease is continually rubbing,

flexing, and kicking out her legs throughout the day. The night shift reports that this same

behavior escalates at night, preventing her from obtaining her required sleep. The next step the

nurse should take is to

d. assesses the patient more closely, suspecting a disorder such as restless legs syndrome.

Rationale: The sensory symptoms caused by restless legs syndrome (RLS) ranges from

infrequent, minor discomfort (paresthesia, tingling, numbness, and feeling sensations of "pins
and needles") to severe pain. The discomfort occurs when the patient is sitting and is usually the

evening time and night. The pain at night can disrupt sleep and is lessened or relieved by

performing physical activity in the day including walking, kicking, stretching, or rocking. More

severe cases the patients only sleep a few hours at night resulting in fatigue during the day and

disruption of their daily routines. The motor abnormalities associated with issue consist of

stereotyped, periodic, involuntary movements and voluntary restlessness. During sleep is when

involuntary movements normally occur. RLS symptoms become aggravated by fatigue.

4.Social effects of a chronic neurologic disease include (select all that apply)

a. divorce.

b. job loss.

c. depression.

d. role changes.

e. loss of self-esteem.

Rationale: Social problems in relations to Chronic neurologic disease may include social

problems such as changes in relationships and roles including role changes, divorce, and job loss.

Chronic neurologic disease may include psychologic problems such as loss of self-esteem and

depression also may have social effects.

5.The nurse is reinforcing teaching with a newly diagnosed patient with amyotrophic lateral

sclerosis. Which statement would be appropriate to include in the teaching?

d. “This is a progressing disease that eventually results in permanent paralysis, though you will

not lose any cognitive function.”

Rationale: ALS causes destruction of motor neurons located in the brainstem and spinal cord this

leads to gradual paralysis. The patient maintains cognitive function throughout the entire process.

Amyotrophic lateral sclerosis (ALS) has no cure and collaborative care is palliative based on

symptom relief. Life expectance is 3-6 years after diagnosis.

Chapter 60:

1.Dementia is defined as a

d. syndrome characterized by cognitive dysfunction and loss of memory.

Rationale: Patients diagnosed with dementia show symptom of dysfunction in or loss of memory,

orientation, attention, language, reasoning, and judgment. Patients may manifest hallucinations,

delusions, along with agitation associated with personality changes and behavioral problems.

2.Vascular dementia is associated with

c. cognitive changes secondary to cerebral ischemia.

Rationale: During vascular dementia the patient loses cognitive function as a result of ischemic,

ischemic-hypoxic, or hemorrhagic brain lesions caused by cardiovascular disease. The blood

supply that supplies the brain is decreased by narrowing and blocking of arteries in this type of

dementia.

3.The clinical diagnosis of dementia is based on

d. patient history and cognitive assessment.

Rationale: In order to properly diagnosis dementia you need to determine the cause. To rule out

other potential medical conditions a thorough physical exam must be performed. A Mini-Mental

State Examination is a cognitive test that’s focuses on evaluating the patents degree of alertness,
memory, visual-spatial skills, and ability to calculate language. Diagnosing dementia related to

vascular causes is in relations to the presence of cognitive loss, the presence of vascular brain

lesions demonstrated by neuroimaging techniques, and excluding other causes of dementia.

Magnetic resonance imaging (MRI) and structural neuroimaging with computed tomography

(CT) are used to evaluate the patients with dementia. To determine the presence of depression a

psychologic evaluation is performed.

4.Which statement(s) accurately describe(s) mild cognitive impairment (select all that apply)?

b. Caused by variety of factors and may progress to AD

Rationale: Patients who are diagnosed with mild cognitive impairment (MCI) can revert to

normal cognitive function or do not and develop Alzheimer's disease (AD). Patients diagnosed

with MCI are at high risk for AD. There are no FDA approved drugs for the treatment of MCI.

Moat patients diagnosed with MCI are aware of a significant change in memory.

5.The early stage of AD is characterized by

b. memory problems and mild confusion.

Rationale: Initial manifestations of AD are normally related to changes in a person’s cognitive

functioning such as subtle deterioration in memory, mild disorientation, or trouble with numbers

and words.

6.A major goal of treatment for the patient with AD is to

a. maintains patient safety.

Rationale: The goals set to manage patients with AD are that the patient with AD will (1)

maintain functional ability for as long as possible, (2) maintain a safe environment with minimal
injuries, (3) have personal care needs met, and (4) maintaining dignity. While planning and

providing nursing care emphasis should be placed on patient safety.

7.Creutzfeldt-Jakob disease is characterized by

b. memory impairment, muscle jerks, and blindness.

Rationale: A prion protein is the cause of Creutzfeldt-Jakob disease (CJD) which is a fatal brain

disorder. Early symptoms of the disease present as behavioral changes and memory impairment.

This disease progresses rapidly, with mental deterioration, involuntary movements such as

muscle jerks, limb weakness, blindness, and eventually coma

8.Which patient is most at risk for developing delirium?

d. A 78-year-old man admitted to the medical unit with complications related to heart failure

Rationale: Precipitating risk factors for patients diagnosed with delirium are male gender, 65

years or older in age, and severe acute illness such as heart failure. The 78-year-old man has the

most risk factors for delirium

Chapter 61:

1.During assessment of the patient with trigeminal neuralgia, the nurse should (select all that

apply)

a. inspects all aspects of the mouth and teeth.

d. test for temperature and sensation perception on the face.

e. asks the patient to describe factors that initiate an episode.

Rationale: Due to fear of triggering facial pain oral hygiene is frequently neglected Since the

sensory branches of the nerves are affected by trigeminal neuralgia clenching the facial muscles

will not be useful. Lightly touching and palpating could trigger pain and should be avoided.

Assessment of the attacks characteristics, frequency, triggering factors, and pain management

techniques will help in planning patient care.

2.During routine assessment of a patient with Guillain-Barre syndrome, the nurse finds the

patient is short of breath. The patient's respiratory distress is caused by

d. paralysis ascending to the nerves that stimulate the thoracic area.

Rationale: When assessing a patient with Guillain-Barre syndrome, Vigilant monitoring of the

patient's respiratory status in necessary due to the acute risk of repertory failure. Ascending,

symmetric paralysis characterizes Guillain-Barre syndrome due to its affect on cranial nerves and

the peripheral nervous system. Respiratory failure is the most serious complication of this

syndrome, which occurs as the paralysis progresses to the nerves that innervate the thoracic area.

3.A patient is admitted to the ICU with a C7 spinal cord injury and diagnosed with Brown-

Séquard syndrome. On physical examination, the nurse would most likely find

d. ipsilateral motor loss and contralateral sensory loss below C7.

Rationale: Damage to one half of the spinal cord results in Brown-Séquard syndrome. This

syndrome is characterized by a loss of position and vibratory sense, and motor function, as well

as vasomotor paralysis on the same side (ipsilateral) as the lesion. The contralateral side has loss

of pain and temperature sensation below the level of the lesion.

4.A patient is admitted to the hospital with a C4 spinal cord injury after a motorcycle collision.

The patient's BP is 84/50 mm Hg, his pulse is 38 beats/minute, and he remains orally intubated.

The nurse determines that this pathophysiologic response is caused by

d. loss of sympathetic nervous system innervation resulting in peripheral vasodilation.

Rationale: Neurogenic shock is caused by the loss of vasomotor tone caused by injury, and it is

characterized by bradycardia and hypotension. Peripheral vasodilation, venous pooling, and a

decreased cardiac output causes the loss of sympathetic nervous system innervation which is

usually are associated with a cervical or high thoracic injury (T6 or higher).

5.Goals of rehabilitation for the patient with an injury at the C6 level include (select all that

apply)

b. feed self with hand devices.

c. assist with transfer activities.

d. drive adapted van from wheelchair.

e. pushes a wheelchair on a flat surface.

Rationale: For a patient with C6 spinal cord injury rehabilitation goals include ability to perform

some self-care and assist with transfer and; push wheelchair on smooth, flat surface; feed self

with hand devices; drive adapted van from wheelchair; able to use computer independently with

adaptive equipment; and needing attendant care only for 6 hours per day.

6.A patient with a C7 spinal cord injury undergoing rehabilitation tells the nurse he must have the

flu because he has a bad headache and nausea. The nurse's first priority is to

C. take the patient's blood pressure.

Rationale: Patients with an injury at the T6 level or higher who complains of a headache, the BP

should be assessed immediately this will determine if autonomic dysreflexia’s causing the

symptoms, including hypertension. After the BP is obtained it is appropriate to notify the

patients’ health care provider. After autonomic dysreflexia’s ruled out for causing the nausea

antiemetic’s can be administrated. The nurse may assess for a fecal impaction after checking the

patients BP then apply lidocaine jelly in order to prevent further increases in the BP this will

determine whether autonomic dysreflexia is causing the symptoms, including the hypertension. It

is appropriate after the BP is obtained to notify the patient's health care provider. Administrating

antiemetic’s is indicated after ruling out autonomic dysreflexia as the cause of the nausea. The

nurse assesses the patient for a fecal impaction, but this should be done after checking the BP

and to prevent further increases in the BP lidocaine jelly should be used.

7.For a 65-year-old woman who has lived with a T1 spinal cord injury for 20 years, which health

teaching instructions should the nurse emphasize?

a. A mammogram is needed every year.

Rationale: It is important for the Older patient with a spinal cord injury to have health promotion

and screening. Monthly breast examinations and yearly mammograms should be performed by

older women with spinal cord injuries.

8.The most common early symptom of a spinal cord tumor is

b. back pain that worsens with activity.

Rationale: Back pain is the most common symptom that occurs early in a spinal cord tumor

outside the cord, with radicular pain simulating intercostal neuralgia, herpes zoster infection or
angina. The location of the pain depends on the level of compression. The pain worsens with

activity, lying down, straining, and coughing.

Chapter 21:

1.In a patient who has a hemorrhage in the posterior cavity of the eye, the nurse knows that blood

is accumulating

b. between the lens and the retina.

Rationale: In the eye located in between the anterior surface of the lens and the posterior surface

of the iris lies the posterior chamber. The posterior cavity located in a large space behind the lens

and in the front of the retina.

2.Increased intraocular pressure may occur as a result of

d. increased production of aqueous humor by the ciliary process.

Rationale: Intraocular pressure can be elevated above the normal 10 to 21 mm Hg by excess

aqueous humor production and decreased outflow. This is a condition known as glaucoma.

3.Question patients using eye drops to treat their glaucoma about

c. a history of heart or lung disease.

Rationale: Assess and review the patient’s medication list for adrenergic blockers, β-adrenergic

blockers used for the treatment of glaucoma can potentiate adrenergic drugs. Many medications

used to treat colds contain a form of epinephrine (i.e., pseudoephedrine) which can cause dilation

in the pupils, and ocular dryness can be caused by antihistamines or decongestants.

4.Always assess the patient with an ophthalmic problem for

a. visual acuity.

Rationale: For medical and legal reasons you must always assess the patient’s visual acuity and

record the results.

5.During an assessment of hearing, the nurse would expect to find normal finding of

c. midline tone heard equally in both ears.

Rationale: During a physical assessment of the auditory system normal findings include

symmetry of the ears in location and shape; nontenderness and no lesions of tragus and auricles;

clear canal; pearl-gray color of tympanic membrane with light reflex and landmarks intact;

patient having the ability to hear low whisper at a distance of 30 cm; better Rinne test with the

results for air conduction greater than for bone conduction (AC > BC); and no lateralization

according to the Weber test results.

6.Age-related changes in the auditory system commonly include (select all that apply)

a. drier cerumen.

c. auditory nerve degeneration.

d. atrophy of the tympanic membrane.

Rationale: Atrophic changes of tympanic membrane, increased production of drier cerumen and

neuron degeneration in auditory nerve and central pathways are common age-related changes in

the auditory system.

7.Before injecting fluorescein for angiography, it is important for the nurse to (select all that

apply)

a. obtains an emesis basin.

d. inform patient that skin may turn yellow.

Rationale: Signs and symptoms of fluorescein dye are nausea or vomiting, and possible transient

yellow-orange discoloration of urine and skin. Tissue toxicity caused by extravasation of the dye.

The nurse should be familiar with emergency equipment and procedures for systemic allergic

reactions to the dye.

Chapter 22:

1.Presbyopia occurs in older individuals because

b. the lens becomes inflexible.

Rationale: The loss of accommodation in relation with age is known as presbyopia. With aging

the lens becomes firmer, less elastic, and larger.

2.The most important intervention for the patient with epidemic keratoconjunctivitis is

c. regular instillation of artificial tears to the affected eye.

Rationale: One of the most serious ocular adenoviral disease today is Epidemic

keratoconjunctivitis (EKC). The main way EKC is spread is by direct contact, including sexual

activity. The nurse should teach The patient and caregiver should be instructed on the importance

of good hygienic to avoid spreading the disease.

3.Inflammation and infection of the eye

a. is caused by irritants and microorganisms.

Rationale: Microorganisms and external irritants are the cause of inflammation and infection of

the eye. The nurse will teach the patient appropriate interventions related to the specified

disorder. Administration of antibiotics and applying warm and moist compresses are common

interventions.

4.Which patient behaviors would the nurse promote for healthy eyes and ears (select all that

apply)?

a. Wearing protective sunglasses when bicycling

d. Patient notifying the health care provider of tinnitus while on antibiotics

Rationale: To help prevent the development of cataracts and age-related macular degeneration it

is suggested to wear sunglasses while in the sun. To reduce the chances of an eye injury it is

recommended to wear protective eyewear during sports activities. Drugs such as diuretics,

antibiotics, salicylates, and antineoplastic are commonly associated with ototoxicity.

5.What should be included in the postoperative teaching of the patient who has undergone

cataract surgery (select all that apply)?

a. Eye discomfort is often relieved with mild analgesics.

d. Notify surgeon if an increase in redness or drainage occurs.

Rationale: Postop cataract surgery, the nurse should instruct the patient and caregiver on the

following topics before patient discharge: topical antibiotics and corticosteroids including other

anti-inflammatory agents, mild analgesia if necessary, eye shield if needed (to be worn overnight
and removed at first postoperative visit), and restrictions of certain activities that will increase

the intraocular pressure, including lifting, bending or stooping, and coughing by the surgeon.

Patient should immediately report intense pain (which may indicate hemorrhage), increased

intraocular pressure, infection, increased redness, increased purulent drainage, and the

occurrence of any decrease in visual acuity to the doctor.

6.What should be included in the nursing plan for a patient who needs to administer antibiotic

eardrops?

c. Be careful to avoid touching the tip of the dropper bottle to the ear.

Rationale: Hand washing before and after administration of otic (eardrops) drops in

recommended. The tip of the dropper should not touch the ear during administration in order to

prevent contaminating the entire bottle of drops. To prevent vertigo, caused by administering

cold ear drops, ensure they are at room temperature before administration and do not heat drops

to prevent burning the tympanum. Position the ear to ensure drops can run into the canal. To

allow drops to become instilled in ear canal maintain this position for 2 minutes after

administering drops. Drops can be administered by placing them on a cotton wick and placing it

in the canal without pushing the cotton too far into the ear. Carefully handle and discard material

saturated with drainage.

7.What is important for the nurse to include in the postoperative care of the patient following

tympanoplasty?

d. Instruct patient to refrain from forceful nose blowing.

Rationale: Disruption of surgical repair during healing and facial nerve paralysis can be caused

by a sudden change in ear pressure and postop infection.

8.The patient who has a conductive hearing loss

a. hears better in a noisy environment.

Rationale: Due conductive hearing loss when patient hears his or her own voice (which is

conducted by bone) it sounds loud to them so they will usually talk softly. Noisy and loud

environments are usually places the patient can hear better in. Identifying and treating the

causing factor is the first step to resolving the hearing issue. If the hearing issue can’t not be

corrected and hearing loss is greater than 40 to 50dB using a hearing aid may help.

9.Instruct the patient who is newly fitted with bilateral hearing aids to (select all that apply)

b. cleans the ear molds weekly or as needed.

d. disconnects or remove the batteries when not in use.

e. initially restrict usage to quiet listening in the home.

Rationale: Restrict hearing aid use in the beginning to quiet situations at home. When the patient

adjusts to increased sounds and background noises they can progress the use to situations when

several people are talking simultaneously. Next, they can expand their use to outdoors and

grocery stores or malls. When the hearing aid is not in use disconnect or remove. The average

life of the battery is one week. Weekly cleaning is sufficient unless needed more often.

10.Which strategies would best assist the nurse in communicating with a patient who has a

hearing loss (select all that apply)?

b. Speak normally and slowly.

e. Write out names or difficult words.

Rationale: When speaking with patients with a hearing loss avoid shouting, speak normal and

slow, and directly in the patient’s better ear. Avoid using exaggerated facial expressions. Avoid

over enunciating your words. It is most helpful to utilize simple sentences, input different words

that mean the same, and if necessary rephrase your sentences. You can write down difficult word

and names.

11.Patients with permanent visual impairment

d. may experience the same grieving process that is associated with other losses.

Rationale: Patients who experience visual function loss or loss of the entire eye, will go through

a grieving process the same as when they lose a significant possession or person. Assisting the

patient through their grieving process is very helpful. The nurse should monitor the patient for

issues such as depression during the grieving process.

Chapter 23:

1.The primary function of the skin is

b. protection.

Rationale: The skins primary job is to protect the underlying tissues and organs of the body. The

skin serves as a surface barrier to protect the internal part of the body from the external

environment.

2.Age-related changes in the hair and nails include (select all that apply)

b. scaly scalp.

d. thicker, brittle nails.

e. longitudinal nail ridging.

Rationale: As we age our bodies production of oil is decreased and our hair become dry and

coarse which causes the scalp to become scaly. Thick and brittle nails are caused by a decrease in

the peripheral blood supply. Aging also causes longitudinal ridging in the persons nails.

3.When assessing the nutritional-metabolic pattern in relation to the skin, the nurse questions the

patient regarding

c. recent changes in wound healing.

Rationale: In the nurse’s assessment for nutritional-metabolic patterns, the nurse asks the patient

a set of questions: Have there been any recent changes in the way wounds or sores are healing?

“Please verify if any changes have occurred in your mucous membranes, nails, or hair, did you

notice any type of changes? Have you experience any recent weight loss or dietary changes?

Please list any recent supplemental vitamins and minerals you have added to your diet?”

4.During the physical examination of a patient's skin, the nurse would

c. pinches up a fold of skin to assess for turgor.

Rationale: Turgor is the elasticity of the skin. The nurse can assess turgor by gently pinching an

area of skin on the back part of the hand or under the person’s clavicle. If the person’s skin turgor

is good it should move easily as it is lifted and should return to its original position immediately

when released.

5.The nurse assessed the patient's skin lesions as firm, edematous, irregularly shaped with a

variable diameter. They would be called

a. wheals.
Rationale: A skin lesion that is firm, edematous, with an irregularly shaped area which has

variable diameter is a wheal. Examples of a wheal are insect bites and urticaria.

6.To assess the skin for temperature and moisture, the most appropriate technique for the nurse to

use is

a. palpation.

Rationale: When assessing for temperature and moisture of the patients skin it is best for the

nurse to use the back of their hands to palpate the patient’s skin.

7.Individuals with dark skin are more likely to develop

a. keloids.

Rationale: Keloids are overgrowths of collagenous tissue at sites of a skin injury. Individuals

who have dark skin are predisposed to certain skin and hair conditions, such as keloids.

8.On inspection of a patient's dark skin, the nurse notes a blue-gray birthmark on the forehead

and eye area. This assessment finding is called

d. Nevus of Ota.

Rationale: Nevus of Ota is A flat, gray to blue pigmentation on a person’s forehead and eye area

of the face and possibly involve the sclera is known as a nevus of ota. Nevus of ota may be found

in dark skin individuals.

9.Diagnostic testing is recommended for skin lesions when

b. a more definitive diagnosis is needed.

Rationale: One of the most common diagnostic tests used to evaluation skin lesions is a biopsy. It

is indicated in all suspected malignancy conditions and when a specific questionable diagnosis.

Chapter 24:

1.Which safe sun practices would the nurse include in the teaching care plan for a patient who

has photosensitivity (select all that apply)?

a. Wear protective clothing.

b. Apply sunscreen liberally and often.

d. Avoid exposure to the sun, especially during midday.

Rationale: Sun safety guidelines for patients include avoidance of the sun, especially during the

midday hours, using a broad spectrum sun screen such as a sun protective factor [SPF] 15, SPF

30 if a patient has a history of being sensitive to the sun or having or had skin cancer and

protective clothing. Sunscreens should be applied 20 to 30 minutes before the patient goes

outdoors in the sun and should be reapplied every 2 hours and after swimming or sweating.

Tanning booths and sun lamps should be avoided by all patients.

2.In teaching a patient who is using topical corticosteroids to treat acute dermatitis, the nurse

should tell the patient that (select all that apply)

b. short-term use of topical corticosteroids usually does not cause systemic side effects.

d. abruptly discontinuing the use of topical corticosteroids may cause a reappearance of the

dermatitis.

Rationale: Often there are undesirable systemic side effects from the use of systemic

corticosteroids. Short-term therapy of the topical corticosteroids has fewer systemic effects.
Rebound dermatitis is common when therapy is stopped Abruptly stopping the use of topical

corticosteroids can cause rebound dermatitis and to reduce this effect taper off the use of the

topical corticosteroids.

3.A patient with acne vulgaris tells the nurse that she has quit her job as a receptionist because

she believes her facial appearance is unattractive to customers. The nursing diagnosis that best

describes this patient response is

d. social isolation related to decreased activities secondary to fear of rejection.

Rationale: Adults can develop acne and some cases can persist into adulthood, with acne flare

ups occurring during female menses and with using androgen-dominant birth control pills. Due

to visible lesions the patients may withdraw themselves from social contact with the public.

4.In teaching a patient with malignant melanoma about this disorder, the nurse recognizes that

the patient's prognosis is most dependent on

a. the thickness of the lesion.

Rationale: Tumor thickness at the time of diagnosis is the most important factor in prognosis.

Two methods are used to determine thickness. The depth of the tumor in millimeters is

determined by the Breslow measurement, and the depth of invasion of the tumor is determined

by the Clark level. The deeper the melanoma into the body the higher the number will be.

5.The nurse determines that a patient with a diagnosis of which disorder is most at risk for

spreading the disease?

b. Impetigo on the face

Rationale: Impetigo a highly contagious bacterial infection is caused by either group A β-

hemolytic streptococci or staphylococci. To prevent the spread of this infection good skin

hygiene and infection control practices must be implemented. Candidiasis and Tinea pedis and

are fungal infections and psoriasis is a noncontagious autoimmune chronic dermatitis.

6.A mother and her two children have been diagnosed with pediculosis corporis at a health care

center. An appropriate measure in treating this condition is

a. applying pyrethrins to the body.

Rationale: Y-benzene hexachloride and pyrethrins and used to treat pediculosis corporis also

known as body lice.

7.A common site for the lesions associated with atopic dermatitis is the

c. antecubital space.

Rationale: Antecubital and popliteal spaces are the most common location for atopic dermatitis

in adults.

8.During the assessment of a patient, you note an area of red, sharply defined plaques covered

with silvery scales that are mildly itchy on the patient's knees and elbows. You recognize this

finding as

b. psoriasis.

Rationale: Clinical manifestations Patients with psoriasis manifest signs and symptoms which

include sharply demarcated, silvery scaling plaques on reddish skin, commonly on the patients

palms, fingernails, soles, scalp, elbows, and knees with itching, burning, and pain that is
localized or general with continuous or intermittent pattern and with symptoms that vary in

intensity from mild to severe.

9.Dermatologic manifestation(s) of Addison's disease can include (select all that apply)

b. loss of body hair.

d. generalized hyperpigmentation.

Rationale: Patients with Addison’s disease manifest dermatologic signs and symptoms which

include the loss of body hair, especially in the axillary area and generalized hyperpigmentation

that is accentuated in the folds of the skin.

10.Important patient teaching after a chemical peel includes

a. avoidance of sun exposure.

Rationale: Patient’s should be instructed to use sunscreen and avoid sun exposure for at least 6

months to prevent hyperpigmentation after a chemical peel.

Chapter 25:

1.Knowing the most common causes of household fires, which prevention strategy would the

nurse focus on when teaching about fire safety?

c. Encourage regular home fire exit drills.

Rationale: Regular home fire exit drills should be encouraged to reduce the risk for injury and

death in household fires. Hot water heater temperatures should be set less than 120° F (40° C) if

set at 140° F (60° C) or higher they are a burn hazard in the home. Installation of hard-wired

smoke and carbon monoxide detectors that do not require batteries replacement can prevent
inhalation injuries. You may also use battery operated detectors if no hard wired ones are

installed. When older adults are cooking supervision is necessary only if the person has cognitive

alterations.

2.The injury that is least likely to result in a full-thickness burn is

a. sunburn.

Rationale: Sun burns are not likely to cause full-thickness burns they may be caused by contact

with scalding liquids, fire flames, chemicals, electrical current or tar.

3.When assessing a patient with a partial-thickness burn, the nurse would expect to find (select

all that apply)

a. blisters.

d. intact nerve endings.

e. red, shiny, wet appearance.

Rationale: Patients with partial-thickness (deep) burns which can include fluid-filled vesicles

(blisters) that are shiny, red or wet (if vesicles have ruptured). Exposure of nerve endings may

cause the patient severe pain and may have mild to moderate edema.

4.A patient is admitted to the burn center with burns of his head and neck, chest, and back after

an explosion in his garage. On assessment, the nurse auscultates wheezes throughout the lung

fields. On reassessment, the wheezes are gone and the breath sounds are greatly diminished.

Which action is the most appropriate for the nurse to take next?

d. Anticipate the need for endotracheal intubation and notify the physician.
Rationale: Inhalation injury results in exposure of When the respiratory tract is exposed to

intense heat or flames and inhaling noxious chemicals, such as smoke, or carbon monoxide the

patient suffers inhalation injuries. The need for intubation and mechanical ventilation should be

anticipated due to the fact this patient is demonstrating signs of severe respiratory distress.

5.Fluid and electrolyte shifts that occur during the early emergent phase of a burn injury include

c. sequestering of sodium and water in interstitial fluid.

Rationale: Sodium rapidly shifts to the patient’s interstitial spaces and will remain there until the

edema formation ceases.

6.To maintain a positive nitrogen balance in a major burn, the patient must

a. eats a high-protein, low-fat, high-carbohydrate diet.

Rationale: In order to meet the increased caloric needs patients should be encouraged to eat high-

protein and high-carbohydrate foods. Protein breakdown and increased gluconeogenesis can

occur and is characterized by massive catabolism. Inadequate protein and calories can lead to

malnutrition and delays in healing.

7.A patient has 25% TBSA burned from a car fire. His wounds have been debrided and covered

with a silver-impregnated dressing. The nurse's priority intervention for wound care would be to

b. observes the wound for signs of infection during dressing changes.

Rationale: Burn wounds should be assessed for signs of infection during dressing changes

because the most serious threat to cause further tissue injury and possible sepsis is infection.
8.Pain management for the burn patient is most effective when (select all that apply)

a. a pain rating tool is used to monitor the patient's level of pain.

c. the patient is informed about and has some control over the management of the pain.

d. a multimodal approach is used (e.g., sustained-release and short-acting opioids, NSAIDs,

adjuvant analgesics).

Rationale: To assess, monitor, and evaluate the pain management plan The nurse will use a pain

rating tool. In order for the chosen strategies to be successful the patient is given control over his

pain management. Burn patients have a selected variety of medications that will offer better pain

relief from the burns. The pain can be continuous and related to treatment over varying periods

of time. Complete elimination of pain is not realistic and should not be promised to the patient.

Nonpharmacologic pain management is not realistic during any phase of burn care and should

not be suggested. This type of pain management is individualized and adjuvant.

9.A therapeutic measure used to prevent hypertrophic scarring during the rehabilitation phase of

burn recovery is

a. applying pressure garments.

Rationale: To reduce hypertrophic scarring and help keep a scar flat pressure should be applied.

With custom-fitted pressure garments gentle pressure can be maintained on the healed burn.

10.A patient is recovering from second- and third-degree burns over 30% of his body and is now

ready for discharge. The first action the nurse should take when meeting with the patient would

be to

c. reviews the patient's current health care status and readiness for discharge to home.
Rationale: It is physically and emotionally exhausting and time consuming for the patient when

recovering from burn injuries to 30% of the patient’s total body surface area. The health care

team may think that a patient is ready for discharge, but the patient maybe clueless that discharge

is being contemplated in the near future. Patients often fear the idea of going home and how they

will manage. The patient would benefit from the nurse’s careful review of the progress they have

made and their readiness to be discharged; the nurse should outline the plans for support and

follow-up after discharge.

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