Clinical Guidelines in Primary Care: A Reference and Review Book 1st Edition Test Bank

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Clinical Guidelines in Primary CareTestbank/Study GuideChapter 1 Cardiovascular DisordersMULTIPLECHOICE1.The nurse is aware that the muscle layer of the heart, which is responsible for the heartscontraction, is the:a.endocardium.b.pericardium.c.mediastinum.d.myocardium.ANS: DThe myocardium is the specialized muscle layer that allows the heart to contract.2.The nurse clarifies that the master pacemaker of the heart is the:a.left ventricle.b.atrioventricular (AV) node.c.sinoatrial (SA) node.d.bundle of His.ANS: CThe SA node is the master pacemaker of the heart.3.The nurse is aware that the symptoms of an impending myocardial infarction (MI) differ inwomen because acute chest pain isnot present. Women are frequently misdiagnosed as having:a.hepatitis A.b.indigestion.c.urinary infection.d.menopausal complications.

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ANS: BIndigestion, gallbladder attack, anxiety attack, and depression are frequent misdiagnoses forwomen having an MI.4.The nurse identifies the LUBB sound of the LUBB/DUBB of the cardiac cycle as the sound ofthe:a.AV valves closing.b.closure of the semilunar valves.c.contraction of the papillary muscles.d.contraction of theventricles.ANS: AThe LUBB is the first sound of a low pitch heard when the AV valves close.5.A patient is admitted from the emergency department. The emergency department physiciannotes the patient has a diagnosis of heart failure with a New York Heart Association (NYHA)classification of IV. This indicates the patients condition as:a.moderate heart failure.b.severe heart failure.c.congestive heart failure.d.negligible heart failure.ANS: BClass IV: Severe; patient unable to perform anyphysical activity without discomfort. Angina orsymptoms of cardiac inefficiency may develop at rest.6.The nurse assesses that the home health patient has no signs or symptoms of heart failure, butdoes have a history of rheumatic fever and has been recently diagnosed with diabetes mellitus.The nurse is aware that using the American College of Cardiology and the American HeartAssociation (ACC/AHA) staging, this patient would be a:a.stage A.b.stage B.c.stage C.d.stage D.ANS: ATheACC/AHA staging describes stage A as a person without symptoms of heart failure, butwith primary conditions associated with the development of the disease.

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7.The nurse caring for a patient recovering from a myocardial infarct who is on remote telemetryrecognizes the need for added instruction when the patient says:a.I can ambulate in the hallway with this gadget on.b.I always take off the telemetry device when I shower.c.My EKG is being watched by one of the nurses in CCU on the home unit.d.Iam able to sleep just fine with this device on.ANS: BRemote telemetry allows the patient to be on a separate unit, but be monitored in a centrallocation. The patients can be ambulatory and can sleep with the monitor on. Theyshouldnotremove the monitor to shower.8.The nurse assesses pitting edema that can be depressed approximatelyinch and refills in 15seconds. The nurse would document this assessment as:a.+1 edema.b.+2 edema.c.+3 edema.d.+4 edema.ANS: BA +2 edema can bedocumented if the skin can be depressedinch and respond within 15seconds.9.What do dark or cold spots on a thallium scan indicate?a.Tissue with adequate blood supplyb.Dilated vesselsc.Areas of neoplastic growthd.Tissue that hasinadequate perfusionANS: DThallium scans show adequate perfused areas by the collection of thallium. Dark spots or coldspots indicate tissues that have inadequate perfusion.10.The nurse recognizes the echocardiogram report that shows an ejection factor of 42% as anindication of:a.normal heart action.b.mild heart failure.c.moderate heart failure.

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d.severe heart failure.ANS: CAn ejection factor (cardiac output) of 42% indicates moderate heart failure.11.The nurse takes intoconsideration that age-related changes can affect the peripheralcirculation because of:a.sclerosed blood vessels.b.hypotension.c.inactivity.d.poor nutrition.ANS: AAging causes sclerotic changes in the blood vessels that lead todecreased elasticity andnarrowing of the vessel lumen.12.The nurse assessing a cardiac monitor notes that the cardiac complexes each have a P wavefollowed by a QRS and a T. The rate is 120. The nurse recognizes this arrhythmia as:a.sinus bradycardia.b.atrial fibrillation.c.sinus tachycardia.d.ventricular tachycardia.ANS: CSinus tachycardia has a P wave followed by the QRS and the T. All the components of thecomplex are present and in the correct order, but the rate is over 100 beats aminute.13.After an influenza-like illness, the patient complains of chills and small petechiae in hismouth and his legs. A heart murmur is detectable. These are characteristic signs of:a.congestive heart failure.b.heart block.c.aorticstenosis.d.infective endocarditis.ANS: DCollection of subjective data includes noting patient complaints of influenza-like symptoms withrecurrent fever, undue fatigue, chest pain, and chills. Objective data may reveal the significant

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signs of petechiae in the conjunctiva and mouth. Both subjective data and objective data areindicative of infective endocarditis.14.The nurse notes a run of three ventricular contractions (PVC) that are not preceded by a Pwave. This particular arrhythmia can progressinto:a.atrial fibrillation and possible emboli.b.sinus tachycardia and syncope.c.ventricular tachycardia and death.d.sinus bradycardia and fatigue.ANS: CPVCs are capable of progressing into ventricular tachycardia and death.15.The nursereminds the patient who is on Coumadin for the treatment of atrial fibrillation thatthe ideal is to maintain the international normalized ratio (INR) at between:a.1 and 2.b.2 and 3.c.3 and 4.d.4 and 5.ANS: BThe desired INR for themonitoring of anticoagulant therapy is between 2 and 3.16.What should a person with unstable angina avoid?a.Walking outsideb.Eating red meatc.Swimming in warm poold.Shoveling snowANS: DThe person with angina should avoid exposure tocold, heavy exercise, eating heavy meals, andemotional stress.17.The elderly patient with angina pectoris says she is unsure how she should take nitroglycerinwhen she has an attack. The nurses most helpful response would be:a.Continue to take nitroglycerin sublingually at 5-minute intervals until the pain is relieved.b.If the pain is not relieved after three doses of nitroglycerin at 5-minute intervals, call yourphysician and come to the hospital.

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c.When nitroglycerin is not relieving thepain, lie down and rest.d.Use oxygen at home to relieve pain when nitroglycerin is not successful.ANS: BAdminister prescribed nitroglycerin. Repeat every 5 minutes, three times. If pain is unrelieved,notify the physician. Nitroglycerin administeredsublingually usually relieves angina symptomsbut does not relieve the pain from an MI. Administering nitroglycerin more than three times willprobably not relieve the pain.18.The patient has been hospitalized for hypertensive episodes three times in thelast months.While preparing the discharge teaching plan, the nurse assesses that he does not comply with hismedication regimen. The nurses immediate course of action would be to:a.reteach him about his medications.b.have a serious talk with himand his family about compliance.c.arrange for home visits after discharge.d.collect more information to identify his reasons for noncompliance.ANS: DNursing interventions include measures to prevent disease progression and complications.Reteaching about medication will not identify the cause of noncompliance.19.What is the major cause of cardiac valve disease?a.Rheumatic feverb.Long history of malnutritionc.Drug abused.ObesityANS: ARheumatic fever, a streptococcalinfection, is the major cause of cardiac valve disease.20.The patient has a total cholesterol of 190 with a high-density lipid (HDL) of 110 and a low-density lipid (LDL) of 80. The nurses reaction is one of:a.satisfaction. This is good cholesterol control.b.determination. This is evidence that more instruction is necessary.c.inquiry. This needs to clarified as to the cause of noncompliance with the drug protocol.d.regret. This shows very poor cholesterol control.ANS: A

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Totalcholesterol of less than 200 is desirable. The higher the number of HDLs the better. A highnumber of LDLs puts the patient at risk for heart disease.21.A patient, age 72, was admitted to the medical unit with a diagnosis of angina pectoris.Characteristic signs and symptoms of angina pectoris include:a.substernal pain that radiates down the left arm.b.epigastric pain that radiates to the jaw.c.indigestion, nausea, and eructation.d.fatigue, shortness of breath, and dyspnea.ANS: AThe painoften radiates down the left inner arm to the little finger and also upward to theshoulder and jaw.22.A patient admitted to the emergency room with a possible myocardial infarction (MI) hasreports back from the laboratory. Which laboratory report is specific for myocardial damage?a.CK-MBb.Elevated white countc.Elevated sedimentation rated.Low level of sodiumANS: AThe CK-MB is elevated when there is infarcted myocardial muscle. The elevated white count,low sodium, and ESR arenonspecific.23.The patient, age 26, is hospitalized with cardiomyopathy. While obtaining a nursing historyfrom her, the nurse recognizes that the increased incidence of cardiomyopathy in youngadults who have minimal risk factors for cardiovascular disease is related to which factor(s)?a.Cocaine useb.Viral infectionsc.Vitamin B1deficienciesd.PregnancyANS: ACardiomyopathy caused by cocaine abuse is seen more frequently than ever before. Cocaine alsocauses high circulating levels of catecholamines, which may further damage myocardial cells,leading to ischemic or dilated cardiomyopathy. The cardiomyopathy produced is difficult totreat. Interventions deal mainly with the HF that ensues.

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24.The patient has become very dyspneic, respirations are 32, and the pulse is 100. The patient iscoughing up frothy red sputum. What should be the initial nursing intervention?a.Lay the patient flat to reduce hypotension and the symptoms of cardiogenic shock.b.Place patient in side-lying position to reduce the symptoms of atrial fibrillation.c.Place patient upright with legs in dependent position to reduce thesymptoms of pulmonaryedema.d.Lay the patient flat and elevate the feet to increase venous return in cardiogenic shock.ANS: CSigns and symptoms of pulmonary edema are restlessness; vague uneasiness; agitation;disorientation; diaphoresis; severe dyspnea; tachypnea; tachycardia; pallor or cyanosis; coughproducing large quantities of blood-tinged, frothy sputum; audible wheezing and crackles; andcold extremities. The legs in a dependent position will decrease venous return and ease thepulmonary edema.25.The nurse caring for a patient recovering from a myocardial infarction (MI) teaches whichmethod to avoid the Valsalva maneuver during a bowel movement?a.Mouth breathingb.Pursing the lips and whistlingc.Taking a deep breath and holding itd.Breathing rapidly through the noseANS: AMouth breathing will lessen the severity of straining and will decrease the effect of the Valsalvamaneuver on intrathoracic pressure.26.The nurse reminds the patient that the National Heart, Lung, and Blood Institute recommendsa lipid study every _________ years.a.2b.3c.4d.5ANS: DThe National Heart, Lung, and Blood Institute recommend a lipid study every 5 years for allAmericans, but especially for the older adult.27.During a healthinterview by the home health nurse, which patient complaint suggests left-sided heart failure?

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a.I have to sleep in my recliner and I have this hacking cough.b.I have no appetite and I have lost 3 lb in the last week.c.I have to urinate every 2hours, even during the night.d.I go barefoot most of the time because my feet are so hot.ANS: ALeft ventricular failure; the first is signs and symptoms of decreased cardiac output. The secondis pulmonary congestion. Signs and symptoms of this condition include dyspnea, orthopnea,pulmonary crackles, hemoptysis, and cough.28.The home health nurse caring for a patient with infective endocarditis overhears the patientmaking a dental appointment for an extraction next month. Which question is most important forthe nurse to ask?a.Do you have a toothache?b.Have you contacted your physician about your dental appointment?c.Is your dentist board certified?d.Do you think you should wait that long for your tooth extraction?ANS: BPatients with endocarditis are put on a protocol of prophylactic antibiotics for any invasiveprocedure. The dentist and physician should be contacted before the extraction.29.The home health nurse warns the patient who is taking warfarin (Coumadin) for anticoagulanttherapy for thrombophlebitis to stop taking the herbal remedy of ginkgo because ginkgo can:a.cause severe episodes of diarrhea.b.cause a severe skin eruption if taken with Coumadin.c.increase the action of the Coumadin.d.causethe Coumadin to be less effective.ANS: CHerbal remedies such as ginkgo, garlic, angelica, and red clover can increase (potentiate) theaction of the Coumadin.30.What is the difference between primary and secondary hypertension?a.Secondary hypertension is caused by another disorder like renal disease.b.Secondary hypertension is related to hereditary factors.c.Secondary hypertension cannot be treated effectively.d.Secondary hypertension is no real threat to health.

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ANS: ASecondaryhypertension is a consistently elevated blood pressure that is caused by anotherdisorder, such as renal disease, diabetes, or Cushing syndrome.31.The nurse is treating a patient who has had a pacemaker inserted for the correction of atrialfibrillation.Which diagnostic test is no longer available to the patient because of the implanteddevice?a.MRIb.CT scanc.Thallium scand.PETANS: ABecause of the large magnets in the MRI cabinet, the pacemaker may be reset to a fixed modeandinterfere with the functioning of the pacemaker.32.Which assessment would lead the nurse to examine the leg closely for evidence of a stasisulcer?a.Cool dry lower limbb.Edematous, red scaly skin on medial surface of the legc.Lack of hair andshiny appearance of the lower legd.Lack of a pedal pulseANS: BSuggestion of a stasis ulcer in the making is an edematous, dry scaly area on the medial surfaceof the lower leg that has a darker pigmentation (rubor). Cool hairless limbs with absent orweakpedal pulses are indicative of arterial insufficiency.33.What is the patient goal of the walking exercise program designed for the rehabilitation of apost-MI patient?a.Walk 2 miles in less than 60 minutes after 12 weeks.b.Jogmile in lessthan 30 minutes after 12 weeks.c.Fast walk 1 mile in less than 20 minutes after 12 weeks.d.Walk 1 mile in 15 minutes without dyspnea after 12 weeks.ANS: AThe goal of the 12-week walking program is that the patient can walk 2 miles in less than 60minutes.

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34.The postsurgical patient has a painful and swollen right calf that appears to be larger than thecalf of the left leg. What is the nurse assessing for when she flexes the patients right leg anddorsiflexes the foot?a.Pain, which would be a positive Homans signb.Muscular spasm, which would be a sign of hypocalcemiac.Rigidity, which would be a sign of ankylosisd.Crepitus, which would be a sign of a joint disorderANS: AA positive Homanssign for deep vein thrombosis (DVT) is a report of pain when the affected legis flexed and the foot is dorsiflexed.35.How should the nurse advise a patient with an international normalized ratio (INR) of 5.8?a.Make arrangements to go to the emergencyroom immediatelyb.Increase fluid intake to 2000 mL/dayc.Stop taking the anticoagulant and notify health care providerd.Add more leafy green vegetables to patient dietANS: CThe INR that is desired should be maintained between 2 and 3. Areading of 5.8 puts the patientat risk for hemorrhage. The patient should stop taking the anticoagulant and contact thephysician for further instruction.36.The nurse making a teaching plan for a patient with Buerger disease (thromboangiitisobliterans)will focus on the need for:a.reduction of alcohol intake.b.avoiding cold remedies.c.cessation of smoking.d.weight reduction.ANS: CThe hazards of cigarette smoking and its relationship to Buerger disease are the primary focus ofpatient teaching. None of the palliative treatments are effective if the patient does not stopsmoking. Nowhere are the cause and effect of smoking so dramatically seen as with Buergerdisease.37.Which statement would lead the nurse to offer more instruction about taking warfarin(Coumadin)?a.I eat a banana every morning with breakfast.

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b.I try to eat more green leafy vegetables, especiallybroccoli, spinach, and kale.c.I try to eat a well-balanced, low-fat diet.d.I dont drink alcohol or caffeine.ANS: BAvoid marked changes in eating habits, such as dramatically increasing foods high in vitamin K(e.g., broccoli, spinach, kale,greens). Limit alcohol intake to small amounts.38.The nurse caring for a 92-year-old patient with pneumonia who is receiving IV carefullymonitors the flow rate of the IV infusion because rapid infusion can cause:a.hypotension.b.thrombophlebitis.c.pulmonary emboli.d.heart failure.ANS: DHeart failure can result from rapid infusion of intravenous fluids in older adults.39.The nurse making the schedule for the daily dose of furosemide (Lasix) would schedule theadministration for which of the following times?a.Late in the afternoonb.At bedtimec.With any meald.In the morningANS: DDiuretics should be scheduled for morning administration to avoid causing the patient nocturia.

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Chapter 2 Dermatologic DisordersMULTIPLECHOICE1.What should the nurse do when administering a therapeutic bath to a patient who has severepruritus?a.Use Burows solution to help promote healingb.Rub the skin briskly to decrease pruritusc.Limit bathing to 3 times a weekd.Ensure that bath area is at least 85 degrees and dehumidifiedANS: APruritus is responsible for most of the discomfort. Wet dressings and using Burows solution helppromote the healing process. A cool environment with increased humidity decreases the pruritus.Give daily baths with an application to cleanse the skin.2.A frail, older adult home health patient who had chickenpox as a child has been exposed tovaricella (chickenpox) several days ago. What should the nurse do?a.Assess frequently for herpes zosterb.Be aware of the patients immunity to chickenpoxc.Encourage the patient to have a pneumonia vaccined.Arrange for the patient to receive gamma globulinANS: AHerpes zoster is caused by the same virus that causes chickenpox (Herpes varicella). The greatestrisk occurs to patients who have a lowered resistance to infection, such as those onchemotherapy, aging, or receiving large doses of prednisone, in whom the disease could be fatalbecause of the patients compromised immune system.3.A patient has herpes zoster (shingles) and is being treated with acyclovir (Zovirax). Whatshould the nurse do when administering this drug?a.Apply lightly, being careful not to completely cover the lesionb.After application, wrap in warm wet dressingsc.Use glovesd.Rub medication into lesionsANS: CThetopical application requires that the nurse uses gloves, completely covers the lesion gently,then leaves it open to the air.

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4.A child has been sent to the school nurse with pruritus and honey-colored crusts on the lowerlip and chin. The nurse believes these lesions most likely are:a.chickenpox.b.impetigo.c.shingles.d.herpes simplex type I.ANS: BImpetigo is seen at all ages, but is particularly common in children. The crust is honey-coloredand easily removed and is associated withpruritus. The disease is highly contagious and spreadsby contact.5.A school nurse assesses a child who has an erythematous circular patch of vesicles on her scalpwith alopecia and complains of pain and pruritus. Why would the nurse use a Woods lamp?a.To dry out the lesionsb.To reduce the pruritusc.To kill the fungusd.To cause fluorescence of the infected hairsANS: DTinea capitis is commonly known as ringworm of the scalp.Microsporumaudouiniiis the majorfungal pathogen. The use ofthe diagnostic Woods lamp causes the infected hairs to turn abrilliant blue green.6.A patient, age 46, reports to his physicians office with urticaria with elevated lesions that arewhite in the center with a pale red border on hands and arms. He says, It itches like crazy. Whichtype of lesion would the nurse include in her documentation?a.Maculesb.Plaquesc.Whealsd.VesiclesANS: CUrticariais the term applied to the presence of wheals or hives in an allergic reaction commonlycaused by drugs, food, insect bites, inhalants, emotional stress, or exposure to heat or cold. Thelesions are elevated with a white center and a pale red border.

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7.The home health nurse assessing skin lesions uses the PQRST mnemonic as a guide. Whatdoes the S in this guide indicate?a.Severity of the symptomsb.Site of the lesionsc.Symptomatology of the lesionsd.Surface area of the lesionsANS: AThemnemonic PQRST stands for Provocative factors (causes), Quantity, Region of the body,Severity of the symptoms, Time (length of time the disorder has been present).8.What would the nurse stress to the 17-year-old girl who has been prescribed Accutane forheracne?a.Avoid alcoholic beveragesb.Drink at least 1000 mL of fluid dailyc.Use dependable birth control to avoid pregnancyd.Avoid exposure to the sunANS: CAccutane has a destructive effect on fetal development. Dependable birthcontrol is important toavoid a pregnancy.9.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.Angiomab.Keloidc.Melanomad.NevusANS: BKeloids, which originate in scars, are hard and shiny and are seen more often in AfricanAmericans than in whites.10.A patient, age 37, sustained partial-and full-thickness burns to 26% of the body surface area.When would thegreatest fluid loss resulting from the burns occur?a.Within 12 hours after burn traumab.24 to 36 hours after burn trauma

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c.24 to 48 hours after burn traumad.48 to 72 hours after burn traumaANS: AIn a burn injury, usually the greatestfluid loss occurs within the first 12 hours.11.Most of the deaths from burn trauma in the emergent phase that require a referral to a burncenter result from:a.infection.b.arrhythmias with cardiac arrest.c.hypovolemic shock and renalfailure.d.adrenal failure.ANS: CHypovolemic shock is frequently lethal in the emergent period of a severe burn because of thetransfer of fluids into the interstitial tissue from the circulating volume.12.The nurse takes into consideration that carbon monoxide intoxication secondary to smokeinhalation 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: ACarbonmonoxide poisoning is likely if the patient has been in an enclosed area. Carbonmonoxide displaces oxygen by binding with hemoglobin.13.A nurse arrives at an accident scene where the victim has just received an electrical burn.What is the nurses primaryconcern?a.The extent and depth of the burnb.The sites of entry and exitc.The likelihood of cardiac arrestd.Control of bleedingANS: CMost electrical burns result in cardiac arrest, and the patient will require CPR or acute cardiacmonitoring.

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14.A patient, age 27, sustained thermal burns to 18% of her body surface area. After the first 72hours, the nurse will have to observe for the most common cause of burn-related deaths, whichis:a.shock.b.respiratory arrest.c.hemorrhage.d.infection.ANS: DInfection is the most common complication and cause of death after the first 72 hours.15.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 ulcerb.Paralytic ileusc.Hypoglycemia perforation of the stomach by the NG tubed.GastritisANS: ACurling ulcer is a duodenal ulcer that develops 8 to 14 days after severe burns on the surface ofthe body. The first sign is usuallyvomiting of bright red blood.16.When providing the open method of treatment for a patient who is 52 years old with burns tothe lower extremities, what would a nurse include in the nursing plan?a.Change the dressing using good medical asepsisb.Provide an analgesic immediately after the dressing changec.Perform circulation checks every 2 to 4 hoursd.Keep the room temperature at 85 F (29.4 C) to prevent chillingANS: DChilling may be controlled by keeping the room temperature at 85 F (29.4C). Strict surgicalprotocol is observed and analgesia should be given before the treatment. Frequent circulationchecks are not a high priority with the open method.17.The nurse has staged a pressure ulcer that has a shallow crater with a dry pink woundbed asa:a.stage Ib.stage II

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c.stage IIId.stage IVANS: BStage II pressure ulcers have a shallow crater with a dry pink wound bed without slough.18.What would the nurse dressing a necrotic pressure ulcer with a minimal exudate mostlikelyuse?a.Hydrocolloid dressingb.Alginate dressingc.Hydrofiber dressingd.Transparent filmANS: AHydrocolloid dressings are useful in necrotic wounds with little exudate. Alginate and hydrofiberdressings are used for wounds with copious exudate. Transparent film is not absorbent.19.The nurse is caring for a 26-year-old male patient who was burned 72hours ago. He haspartial-thickness burns to 24% of his body surface area. He begins to excrete large amounts ofurine. What should the nurse do?a.Increase the IV rate and monitor for burn shockb.Monitor for signs of seizure activity.c.Assess for signs of fluid overloadd.Raise the foot of the bed and apply blanketsANS: CAs the blood volume increases, the cardiac output increases to increase renal perfusion. Theresult includes diuresis. However, a great risk for the patient includes fluid overload because ofthe rapid movement of fluid back into the intravascular space.20.A patient with severe eczema is starting a coal tar derivative treatment. What should the nurseinclude in the teaching plan for the patient relative to this treatment?a.Drink at least 1000 mL of fluid dailyb.Avoid exposure to sunlight for 72 hours after usec.Bathe with an astringent soapd.Reduce intake of high calcium foodsANS: B

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Persons using coal tar derivatives should avoid exposure tosunlight for 72 hours after use. Theproduct stains clothes and bathroom fixtures.21.What should the nurse examine in assessing a patient for tinea corporis?a.Soles of the feetb.Scalpc.Armpitsd.AbdomenANS: DTinea corporisis known as ringworm of the body. It occurs on parts of the body with little or nohair.22.What is the initial intervention for relief of the pruritus of dermatitis venenata?a.Apply baking soda to lesionsb.Wash area with copious amounts ofwaterc.Apply cool compresses continuouslyd.Expose area to airANS: BIn dermatitis venenata (poison oak or ivy), the patient should wash the affected part immediatelyafter contact with the offending allergen.23.The nurse debriding a burn wound explains that the purpose of debridement is to:a.increase the effectiveness of the skin graft.b.prevent infection and promote healing.c.promote suppuration of the wound.d.promote movement in the affected area.ANS: BDebridement is theremoval of damaged tissue and cellular debris from a wound or burn toprevent infection and to promote healing.24.A patient has been admitted to the hospital with burns to the upper chest. The nurse notessinged nasal hairs. The nurse needs to assess thispatient frequently for which condition?a.Decreased activityb.Bradycardiac.Respiratory complications

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d.HypertensionANS: CSigns and symptoms of inhalation injury include singed nasal hairs. Breathing difficulties maytake several hours tooccur.25.Which may indicate a malignant melanoma in a nevus on a patients arm?a.Even coloring of the moleb.Decrease in size of the molec.Irregular border of the moled.Symmetry of the moleANS: CAny change in color, size, or texture andany bleeding or pruritus of a nevus deservesinvestigation. A malignant melanoma is a cancerous neoplasm in which pigment cells ormelanocytes invade the epidermis, dermis, and sometimes the subcutaneous tissue.26.A nurse can assess cyanosis in a dark-skinned patient by noting the color of the:a.conjunctiva.b.sclera.c.lips and mucous membranes.d.soles of the feet.ANS: CAssessment of color is more easily made in areas where the epidermis is thin, such as the lipsand mucousmembranes.27.A patient developed a severe contact dermatitis of the hands, arms, and lower legs afterspending an afternoon picking strawberries. The patient states that the itching is severe andcannot keep from scratching. Which instruction would be most helpful in managing the pruritus?a.Use cool, wet dressings and baths to promote vasoconstriction.b.Trim the fingernails short to prevent skin damage from scratching.c.Expose the areas to the sun to promote drying and healing of thelesions.d.Wear cotton gloves and cover all other affected areas with clothing to prevent environmentalirritation.ANS: A

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Wet dressings and using Burows solution help promote the healing process. Cold compressesmay be applied to decrease circulation to the area (vasoconstriction). Short nails prevent skindamage, but not pruritus.28.What is the best instruction by the nurse regarding reducing the risk factors for melanoma?a.Avoid exposure to the sun and use protective measures when exposure occurs.b.Have all nevi removed.c.Watch for changes in moles, especially on the back.d.Use a sun lamp for tanning.ANS: AEncourage the patient to protect skin from the sun by wearing protective clothing, including a hatwith 4-inch brim, applyingsunscreen all over the body, and avoiding the midday sun from 10 amto 4 pm. Sun lamps are just as damaging as the sun.29.Which patient instruction should the nurse include in the teaching plan relative to themanagement of systemic lupus erythematosus?a.Maintain a balance between rest and activityb.Increase activity to promote mobilityc.Increase exposure to the sun to increase vitamin D absorptiond.Increase sodium consumptionANS: ABalanced rest, activity, and diet will supportmedication management. Limited sunlight exposureis recommended to prevent photosensitivity. SLE often has kidney involvement, which wouldrequire reduction of sodium.30.Which patient statement indicates that more teaching is needed regarding antibiotic therapyfor the treatment of cellulitis?a.My skin is cleared up. I dont think I need the medication anymore.b.Cellulitis can come back at any time.c.If I had washed that scratch with soap and water, I probably would not have gottencellulitis.d.Cellulitis is contagious.ANS: AThe entire amount of antibiotic medication should be completed even if the symptoms haveabated to ensure the eradication of the infectious agent.31.What should a patient be assessed for upon the diagnosisof genital herpes?

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a.Hepatitis Bb.Syphilisc.Human immunodeficiency virus (HIV).d.CirrhosisANS: CPersons with genital herpes should be assessed for HIV because the therapy for herpes issuppressive; persons with HIV are notcandidates for suppressant therapy.32.The school nurse recognizes the signs of scabies when a child presents with:a.small fluid filled blisters that sting when scratched.b.dry scaly patches in body creases that itch.c.wavy threadlike lines onthe body and pruritus.d.cluster of papular lesions with pruritus.ANS: CScabies is manifested by brown threadlike lines on the body, especially the hands, anus, andbody folds. Pruritus is severe.33.Melanocytes give rise to the pigment melanin, which is responsible for skin color. Where canthe melanocytes be found?a.Dermisb.Superficial fasciac.Epidermisd.Loose connective tissueANS: CA layer in the epidermis contains highly specialized cells called melanocytes.MULTIPLERESPONSE34.Which of the following are major functions of the skin? (Select all that apply.)a.Excretion of wastesb.Protectionc.Vitamin C synthesisd.Temperature regulation

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e.Prevention of dehydrationANS: A, B, D, EFunctions of the skin includeprotection from the environment (pathogenic organisms, foreignsubstances, natural barrier against infection), temperature regulation, prevention of dehydration,excretion of waste products, and vitamin D synthesis.35.During primary surveyassessment of a burn patient, the nurse checks for which of thefollowing as early signs of carbon monoxide poisoning? (Select all that apply.)a.Dizzinessb.Urticariac.Vomitingd.Headachee.Vertigof.Unsteady gaitANS: C, D, FEarlysigns of carbon monoxide poisoning include headache, nausea, vomiting, and unsteadygait.Chapter 3Ear, Nose & Throat Disorders

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MULTIPLECHOICE1.A client is not able to successfully pass the whisper test. Which of the following would beindicated for this client?1.Head CT scan2.Audiometry3.MRI of the brain4.ElectroencephalogramANS: 2Failure to pass the whisper test would indicate the need for formal audiometry testing. The clientwould not need a head CT or MRI at thistime. An electroencephalogram is not necessary.2.A client is prescribed a medication that is ototoxic. The nurse realizes that this medication maycause:1.permanent or temporary vision loss.2.permanent or temporary hearing loss.3.nausea andvomiting.4.central nervous system (CNS) depression.ANS: 2Although many drugs cause nausea and vomiting and central nervous system (CNS) depression,ototoxic drugs cause hearing loss and the risks must be considered prior to suggesting these typesofmedications.3.The nurse is trying to communicate with a hearing-impaired client. The best way to do this isto:1.write down all of the message.

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2.shout in the impaired ear.3.speak slowly and clearly while facing the client.4.talk in aregular voice in the good ear.ANS: 3When trying to communicate with the hearing-impaired client, the nurse should speak slowly andclearly while facing the client to give her the opportunity to see and hear the words being spoken.The nurse should not write down all of the messages. Shouting in the impaired ear will notimprove the clients hearing. Talking in a regular voice into the good ear will not improvehearing.4.A client is diagnosed with a conductive hearing loss. The nurse realizes type of hearing lossisnotassociated with:1.cerumen.2.brain damage.3.otitis media.4.otosclerosis.ANS: 2Conductive hearing loss results in a blockage of sound waves in the external or middle portionsof the ear. Wax (cerumen) buildup and infections are a large part of conductive hearing loss.Otosclerosis is associated with conductive hearing loss. Brain damage is not a cause ofconductive hearing loss.5.A client is complaining of dizziness, unilateral ringing in the ear, feeling of pressure or fullnessin the ear, and unilateral hearing loss. The nurse would suspect the client is experiencing:1.Mnires disease.2.osteosclerosis.3.otitis media.

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4.mastoiditis.ANS: 1All of the clients complaints are signs and symptoms of Mnires disease. Although hearingdisorders may have similar signs and symptoms, they do not include all of them.6.A client complains of a slight itching, slight pain, and a scratching sound in the ear. The nursesuspects that an insect may have entered the ear. Which of the following shouldnotbe done?1.Add water to flush out the insect.2.Add mineral oil to killthe insect.3.Add lidocaine to kill the insect.4.Call an otologist for a referral.ANS: 1Avoid placing water in the ear canal, which will only make the insect swell, thereby making itmore difficult to remove. An otologist should be called for the removal. The audiologist mayprescribe mineral oil or lidocaine to be applied to the ear canal.7.The hearing of an unresponsive client needs to be assessed. Which of the following will beused to assess the hearing of this client?1.Audiometer2.Brainstem auditory evoked responses (BAER) test3.Rinne test4.Weber testANS: 2The BAER test calculates the ability to hear in a client who is unresponsive. The BAERmeasures the sound impulse needed to evoke a brain response, which will indicate the clientsability to hear. The other tests need the cooperation of the client and cannot be done at this time.

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8.The nurse is planning to assess a client diagnosed with conductive hearing loss. Whenperforming the Weber test, the nurse would expect which of the following findings?1.The sound will be louder in the affected ear.2.The sound will be louder in the good ear.3.Air conduction is shorter than bone conduction.4.No sounds will be heard.ANS: 1During a Weber test, which tests bone conduction, a client with a conductive hearing loss hearslouder sounds on the affected side. Hearing louder sounds on the unaffected side is sensorineuralloss. The Rinne test compares bone with air conduction. The client will hear sounds louder in theaffected ear.9.The nurse is performing postoperative teaching with a client recovering from a stapedectomy.Which of the following instructions would the nurse want to include in the teaching?1.It is okay toresume exercise the next day.2.It is okay to resume work the same day.3.It is okay to shower and shampoo the next day.4.It is okay to blow the nose gently one side at a time.ANS: 4Care must be taken not to disturb the ossicles from their position, so exercise and work shouldnot be resumed until healing is complete. It is also important to keep the ear dry. The clientshould be taught to blow the nose gently on one side at a time so as not to increase the pressurein the ear.10.After a mastoidectomy, the most important complication for the nurse to assess for is:1.vomiting.

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2.headache.3.fever.4.stiff neck.ANS: 3All are complications that can occur following this type of surgery. Fever is of extra importancebecause of itspossible link to infection. The mastoid bone is in direct contact with the brain, andtherefore any infection can travel to the brain.11.When instructing a client on cleaning the ear, the nurse should instruct the client to clean:1.only the outer ear.2.all the way to the middle ear.3.all parts of the ear outer, middle, and inner ear.4.just the tympanic membrane.ANS: 1Only the outer portion of the ear should be cleaned. Inserting different objects into the ear canalmay result in injury and damage.12.Which of the following would prohibit an elderly client from wanting to obtain and use ahearing aid?1.Fears sounds will be too loud2.Thinks not necessary for a temporary problem3.Fears the cost4.PreferssilenceANS: 3

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Some of the problems encountered by clients obtaining hearing aids include appearance, cost,education, unrealistic expectations, and difficulty with the care and maintenance of the hearingaids. The other choices are not problems encountered by clients obtaining hearing aids.13.Which of the following should the nurse instruct a client who is being fitted for a hearing aid?1.Keep the appliance turned on at all times.2.Store the hearing aid in a warm, moist place.3.Batteries lastfor at least 1 month.4.Clean ear molds at least once a week.ANS: 4The nurse should instruct the client to turn off the appliance when not in use; store in a cool, dryplace; change the batteries at least once per week; and clean ear molds atleast once per week.MULTIPLERESPONSE14.The nurse is instructing a client diagnosed with otitis media on management during the acutephase. Which of the following should the nurse include in the teaching? (Select all that apply.)1.Take theantibiotics as ordered.2.Take over-the-counter analgesics for mild pain as recommended.3.It is okay to go swimming.4.It is okay to go on vacation and trips that require flying.5.If excruciating pain develops, seek medical care.6.Limitfluids.ANS: 1, 2, 5Clients must complete the medication as ordered to kill the infection. Mild analgesics for painare often needed. If excruciating ear pain develops, the client should seek medical care to ruleout perforation of the eardrum. It is important to keep the ear dry, so the client should not swim

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at this time. Flying is not recommended at this time. Limiting fluids is not necessary with otitismedia.15.When caring for a client with total hearing loss, the nurse is instructing the client about themany options that are available to function in a hearing world. Which of the following should thenurse include? (Select all that apply.)1.Flashing lights for alarms2.TV with closed captions3.Talking computer4.Lip reading and signlanguage5.Cell phones with headsets6.Loud ringers on telephonesANS: 1, 2, 4Patients who have no hearing have access to various mechanisms to alert them to various sounds.Flashing lights for alarms to phones and doorbells, TV with closedcaptions for the hearingimpaired, and classes in lip reading and sign language are some options. Talking computers andcell phones with headsets are advancements for the hearing, not for the hearing impaired. Loudringers on telephones would also be helpful to the client with some hearing and not a totalhearing loss.16.A client is diagnosed with a congenital hearing loss. Which causes does the nurse realize arereasons for this type of hearing loss? (Select all that apply.)1.Genetics2.Natal infections3.Physical deformities4.Noise levels

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