Test Bank for Current Medical Diagnosis and Treatment 2023 (Ie), 62nd Edition (Chapters 27)

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TEST BANK FOR CURRENT MEDICAL DIAGNOSISANDTREATMENT(2022/2023)Chapter 1. Disease Prevention & Health Promotion1. Which of the following behaviors indicates the highest potential for spreadinginfectionsamong clients? The nurse:1)disinfectsdirtyhandswithantibacterialsoap.2)allowsalcohol-basedrubtodryfor10seconds.3)washes handsonlyafterleavingeachroom.4)usescoldwaterformedicalasepsis.2. What is themostfrequent cause of the spread of infection among institutionalizedpatients?1)Airbornemicrobesfromotherpatients2)Contactwithcontaminatedequipment3)Handsofhealthcareworkers4)Exposurefromfamilymembers3. Which of the following nursing activities is of highest priority for maintainingmedicalasepsis?1)Washing hands2)Donning gloves3)Applying sterile drapes4)Wearing a gown4. A patient infected with a virus but who does not have any outward sign of thedisease isconsidered a:1)pathogen.2)fomite.3)vector.4)carrier.5. A patient is admitted to the hospital with tuberculosis. Which precautions must thenurseinstitute when caring for this patient?1)Droplet transmission2)Airborne transmission3)Direct contact4)Indirect contact

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6.Apatientbecomesinfectedwithoralcandidiasis(thrush)whilereceivingintravenous antibiotics to treat a systemic infection. Which type of infection has the patientdeveloped?1)Endogenous nosocomial2)Exogenous nosocomial3)Latent4)Primary7. A patient admitted to the hospital with pneumonia has been receiving antibiotics for2 days. His condition has stabilized, and his temperature has returned to normal. Whichstage ofinfection is the patient most likely experiencing?1)Incubation2)Prodromal3)Decline4)Convalescence8. The nurse assists a surgeon with central venous catheter insertion. Whichaction isnecessary to help maintain sterile technique?1)Closing the patients door to limit room traffic while preparing the sterile field2)Using clean procedure gloves to handle sterile equipment3)Placing the nonsterile syringes containing flush solution on the sterile field4)Remaining 6 inches away from the sterile field during the procedure9. A patient develops localized heat and erythema over an area on the lower leg.Thesefindings are indicative of which secondary defense against infection?1)Phagocytosis2)Complement cascade3)Inflammation4)Immunity10. The patient suddenly develops hives, shortness of breath, and wheezing afterreceivingan antibiotic. Which antibody is primarily responsible for this patients response?1)IgA2)IgE3)IgG4)IgM11. What type of immunity is provided by intravenous (IV)administration ofimmunoglobulin G?1)Cell-mediated2)Passive3)Humoral4)Active

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12. A patient asks the nurse why there is no vaccine available for the common cold.Whichresponse by the nurse is correct?1)The virus mutates too rapidly to develop a vaccine.2)Vaccines are developed only for very serious illnesses.3)Researchers are focusing efforts on an HIV vaccine.4)1The virus for the common cold has not been identified.. A patient who has a temperature of 101F (38.3C) most likely requires:1)acetaminophen (Tylenol).2)increased fluids.3)bedrest.4)tepid bath.14. Why is a lotion without petroleum preferred over a petroleum-based product asaskinprotectant? It:1)Prevents microorganisms from adhering to the skin.2)Facilitates the absorption of latex proteins through the skin.3)Decreases the risk of latex allergies.4)Prevents the skin from drying and chaffing.15. For which range of time must a nurse wash her hands before working in theoperatingroom?1)1 to 2 minutes2)2 to 4 minutes3)2 to 6 minutes4)6 to 10 minutes16. How should the nurse dispose of the breakfast tray of a patient who requiresairborneisolation?1)Place the tray in a specially marked trash can inside the patients room.2)Place the tray in a special isolation bag held by a second healthcare workeratthepatients door.3)Return the tray with a note to dietary services so it can be cleaned and reused forthenextmeal.4)1Carry the tray to an isolation trash receptacle located in the dirty utilityroomanddispose of it there.. How much liquid soap should the nurse use for effective hand washing? At least:1)2 mL2)3 mL3)6 mL4)7 mL

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18. To assure effectiveness, when should the nurse stop rubbing antiseptic handsolutionover all surfaces of the hands?1)When fingers feel sticky2)After 5 to 10 seconds3)When leaving the clients room4)Once fingers and hands feel dry19. A patient is admitted to the hospital for chemotherapy and has a low whiteblood cellcount. Which precaution should the staff take with this patient?1)Contact2)Protective3)Droplet4)Airborne20. While donning sterile gloves, the nurse notices the edges of the glove package areslightly yellow. The yellow area is over 1 inch away from the gloves and only appearsto beonthe outside of the glove package. What is the best action for the nurse to take at thispoint?1)Continue using the gloves inside the package because the package is intact.2)Remove gloves from sterile field and use a new pair of sterile gloves.3)Throw all supplies away that were to be used and begin again.4)Use the gloves and make sure the yellow edges of the package do not touch the client.21. The nurse is removing personal protective equipment (PPE). Which itemshould beremoved first?1)Gown2)Gloves3)Face shield4)Hair covering22. A nurse is splashed in the face by body fluid during a procedure. Prioritize thenursesactions, listing the most important one first.A.Contact employee healthB.Complete an incident reportC.Wash the exposed areaD.Report to another nurse that she is leaving the immediate area.1)1, 2, 3, 42)2, 3, 4, 13)3, 4, 1, 24)4, 1, 2, 3Multiple ResponseIdentify one or more choices that best complete the statement or answer the question.1. In which situation would using standard precautions be adequate? Select all that apply.

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1)While interviewing a client with a productive cough2)While helping a client to perform his own hygiene care3)While aiding a client to ambulate after surgery4)While inserting a peripheral intravenous catheter2. Which of the following protect(s) the body against infection? Select all that apply.1)Eating a healthy well-balanced diet2)Being an older adult or an infant3)Leisure activities three times a week4)Exercising for 30 minutes 5 days a week3. The nurse is teaching a group of newly hired nursing assistive personnel (NAP)aboutproper hand washing. The nurse will know that the teaching was effective if the NAPdemonstrate what? Select all that apply. The NAP:1)uses a paper towel to turn off the faucet.2)holds fingertips above the wrists while rinsing off the soap.3)removes all rings and watch before washing hands.4)cleans underneath each fingernail.4. Alcohol-based solutions for hand hygiene can be used to combat whichtypes oforganisms? Select all that apply.1)Virus2)Bacterial spores3)Yeast4)Mold5. A patient with tuberculosis is scheduled for computed tomography (CT). Howshould thenurse proceed? Select all that apply.1)Question the order because the patient must remain in isolation.2)Place an N-95 respirator mask on the patient and transport him to the test.3)Place a surgical mask on the patient and transport him to CT lab.4)Notify the computed tomography department about precautions prior to transport.True/FalseIndicate whether the statement is true or false.1. Bacteria are necessary for human health and well-being.Chapter 1. DiseasepreventionAnswer SectionMULTIPLE CHOICE1.ANS: 3Patients acquire infection by contact with other patients, family members, and healthcareequipment. Butmostinfection among patients is spread through the hands of healthcareworkers.Hand washing interrupts the transmission and should be done before and after allcontact with

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patients, regardless of the diagnosis. When the hands are soiled, healthcare staff shoulduseantibacterial soap with warm water to remove dirt and debris from the skin surface. Whennovisible dirt is present, an alcohol-based rub should be applied and allowed to dry for 10to 15seconds.2.ANS: 3Patients are exposed to microbes by contact (direct contact, airborne, or otherwise) with otherpatients, family members, and contaminated healthcare equipment. Some of these arepathogenic(cause illness) and some are nonpathogenic (do not cause illness). But mostmicrobes causing infection among patients are spread by direct contact on the hands ofhealthcare workers.3.ANS: 1Scrupulous hand washing is themostimportant part of medical asepsis. Donning gloves,applying sterile drapes before procedures, and wearing a protective gown may beneeded toensure asepsis, but they are not themostimportant aspect becausemicrobescausing most healthcare-related infections are transmitted by lack of or ineffectivehand washing.4.ANS: 4Some people might harbor a pathogenic organism, such as the human immunodeficiencyvirus within their body, and yet do not acquire the disease/infection. These individuals,called carriers, have no outward sign of active disease, yet they can pass the infection toothers. A pathogen is anorganism capable of causing disease. A fomite is a contaminatedobject that transfers a pathogen,such as pens, stethoscopes, and contaminated needles. Avector is an organism that carries a pathogen to a susceptible host through a portal for entryinto the body. An example of a vector is a mosquito or tick that bites or stings.5.ANS: 2The organisms responsible for measles and tuberculosis, as well as many fungal infections,arespread through airborne transmission.Neisseria meningitidis,the organism that causesmeningitis, is spread through droplet transmission. Pathogens that cause diarrhea, such asClostridium difficile,are spread by direct contact. The common cold can be spread byindirectcontact or droplet transmission.6.ANS: 1Thrush in this patient is an example of an endogenous, nosocomial infection. This type ofinfection arises from suppression of the patients normal flora as a result of some form oftreatment, such as antibiotics. Normal flora usually keep yeast from growing in the mouth. Inexogenous nosocomial infection, the pathogen arises from the healthcare environment. Alatentinfection causes no symptoms for long periods. An example of a latent infection ishuman immunodeficiency virus infection. A primary infection is the first infection that occursin a patient.7.ANS: 3The stage of decline occurs when the patients immune defenses, along with any medicaltherapies (in this case antibiotics), are successfully reducing the number of pathogenicmicrobes.As a result, the signs and symptoms of infection begin to fade. Incubation is the stagebetween the invasion by the organism and the onset of symptoms. During the incubation stage,the patientdoes not know he is infected and is capable of infecting others.The prodromal stageis characterized by the first appearance of vague symptoms.Convalescence is characterized by tissue repair and a return to heal as the organisms

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disappear.

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8.ANS: 1

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To maintain sterile technique, the nurse should close the patients door and limit the numberofpersonsenteringandexitingtheroombecauseaircurrentscancarrydustandmicroorganisms. Sterile gloves, not clean gloves, should be used to handle sterile equipment.Placing nonsterile syringes on the sterile field contaminates the field. One foot, not 6 inches,is required between people and the sterile field to prevent contamination.9.ANS: 3The classic signs of inflammation, a secondary defense against infection, are erythema(redness)and localized heat. The secondary defenses phagocytosis (process by which whiteblood cells engulf and destroy pathogens) and the complement cascade (process by whichblood proteins trigger the release of chemicals that attack the cell membranes of pathogens)do not produce visible findings. Immunity is a tertiary defense that protects thebody fromfuture infection.10.ANS: 2The patient is most likely experiencing an allergic response to the antibiotic. IgE is the antibodyprimarily responsible for this allergic response. The antibodies IgA, IgG, and IgMare notinvolved in the allergic response. IgA antibodies protect the body from in fighting viral andbacterial infections. IgG antibioties are the only type that cross the placenta in a pregnantwomento protect her unborn baby (fetus). IgM are the first antibodies made in response toinfection.11.ANS: 2Intravenous administration of immunoglobulin G provides the patient with passive immunity.Immunoglobulin G does not provide cell-mediated, humoral, or active immunity. Passiveimmunity occurs when antibodies are transferred by antibodies from animmune host, such asfrom a placenta to a fetus. Passive immunity is short-lived. Active immunity is longer lived andcomes from the host itself. Humoral immunity occurs by secreted antibodies binding toantigens.Cell-mediated immunity does not involve antibodies but rather fight infection frommacrophagesthat kills pathogens.12.ANS: 1More than 200 viruses are known to cause the common cold. These viruses mutate too rapidlytodevelop a vaccine. Although some researchers are focusing efforts on a vaccinefor HIVinfection, others continue to research the common cold.13.ANS: 2Fever, a common defense against infection, increases water loss; therefore, additionalfluid is needed to supplement this loss. Acetaminophen and a tepid bath are notnecessary for this low-grade fever because fever is beneficial in fighting infection.Adequate rest, not necessarily bedrest, is necessary with a fever.14.ANS: 3Nonpetroleum-based lotion is preferred because it prevents the absorption of latex proteinsthrough the skin, which can cause latex allergy. Both types of lotion prevent the skin fromdryingand becoming chafed. Neither prevents microorganisms from adhering tothe skin.15.ANS: 3In a surgical setting, hands should be washed for 2 to 6 minutes, depending on the type ofsoapused.

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16.ANS: 2Patients who require airborne isolation are served meals on disposable dishes and trays. Todispose of the tray, the nurse inside the room must wear protective garb and place the trayand its

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contents inside a special isolation bag that is held by a second healthcare worker at thepatients door. The items must be placed on the inside of the bag without touching the outsideof the bag.17.ANS: 2APIC guidelines dictate that 3 to 5 mL of liquid soap is necessary for effective hand washing.18.ANS: 4The nurse should rub the antiseptic hand solution over all surfaces of the hands until thesolutiondries, usually 10 to 15 seconds, to ensure effectiveness.19.ANS: 2Protective isolation is used to protect those patients who are unusually vulnerable toorganisms brought in by healthcare workers. Such patients include those with low whiteblood cell counts, with burns, and undergoing chemotherapy. Some hospital units, such asneonatal intensive care units and labor and delivery suites, also use forms of protectiveisolation.20.ANS: 2The gloves should be thrown away because the gloves are likely to be contaminated fromanoutside source. The supplies do not have to be thrown away because they havenot beencontaminated.21.ANS: 2The gloves are removed first because they are usually the most contaminated PPE andmust be removed to avoid contamination of clean areas of the other PPE during theirremoval. The gownis removed second, then the mask or face shield, and finally, the haircovering.22.ANS: 3If a nurse becomes exposed to body fluid, she should first wash the area, tell another nurse sheisleaving the area, contact the infection control or employee health nurse immediately,andcomplete an incident report. It is most important to remove the source of contamination(body fluid) as soon as possible after exposure to help prevent the nurses from becominginfected. Theother activities can wait until that is done.MULTIPLE RESPONSE1. ANS: 3, 4Standard precautions should be instituted with all clients whenever there is a possibility ofcoming in contact with blood, body fluids (except sweat), excretions, secretions, mucousmembranes, and breaks in the skin (e.g., while inserting a peripheral IV). When interviewing aclient, if the disease is not spread by air or droplets, there is no likelihood ofthe nursesencountering body fluids. If the disease is spread by air or droplets, then droplet or airborneprecautions would be needed in addition to standard precautions. If giving a complete bedbath or performing oral hygiene, the nurse would need to use standard precautions (gloves); ifmerelyassisting a client to perform those ADLs, it is not necessary. No exposure to body fluidsis likelywhen helping a client to ambulate after surgery.2. ANS: 1, 3, 4Nutrition, hygiene, rest, exercise, stress reduction, and immunization protect the bodyagainstinfection. Illness, injury, medical treatment, infancy or old age, frequent publiccontact, and various lifestyle factors can make the body more susceptible to infection. 3.ANS: 1, 3, 4Hand washing requires at least 15 seconds of washing, which includes lathering allsurfaces ofthe hands and fingers to be effective. The fingers should be held lower than

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the wrists.4. ANS: 1, 3, 4

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If there is potential for contact with bacterial spores, hands must be washed with soap andwater;alcohol-based solutions are ineffective against bacterial spores.5. ANS: 3, 4Transporting a patient who requires airborne precautions should be limited; however, whennecessary the patient should wear a surgical mask (an N-95 respirator mask is notrequired)thatcovers the mouth and nose to prevent the spread of infection. Moreover, thedepartment where the patient is being transported should be notified about the precautionsbefore transport.TRUE/FALSE1.ANS: TOrganisms that normally inhabit the body, called normal flora, are essential for human healthandwell-being. They keep pathogens in check. In the intestine, these flora function toaiddigestion and promote the release of vitamin K, vitamin B12, thiamine, and riboflavin.Chapter 1 Health Promotion (Part 2)1. A client informs the nurse that he has quit smoking because his father died fromlungcancer3monthsago.Basedonhismotivation,smokingcessationshouldberecognized as anexample of which of the following?1)Healthy living2)Health promotion3)Wellness behaviors4)Health protection2. A patient with morbid obesity was enrolled in a weight loss program last month andhasattended four weekly meetings. But now he believes he no longer needs to attendmeetings because he has learned what to do. He informs the nurse facilitator about hisdecision to quit theprogram. What should the nurse tell him?1)By now you have successfully completed the steps of the change process. Youshouldbeable to successfully lose the rest of the weight on your own.2)Although you have learned some healthy habits, you will need at least another 6weeksbefore you can quit the program and have success.3)You have done well in this program. However, it is important to continue in theprogram to learn how to maintain weight loss. Otherwise, you are likely to return toyour previouslifestyle.4)You have entered the determination stage and are ready to make positive changesthatyou can keep for the rest of your life. If you need additional help, you can comebackata later time.3. The school nurse at a local elementary school is performing physical fitnessassessmentson the third-grade children. When assessing students cardiorespiratoryfitness, the most appropriate test is to have the students:1)Step up and down on a 12-inch bench.2)Perform the sit-and-reach test.3)Run a mile without stopping, if they can.

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4)Performrange-of-motionexercises.

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4. In the Leavell and Clark model of health protection, the chief distinctionbetween thelevels of prevention is:1)The point in the disease process at which they occur.2)Placement on theWheelsofWellness.3)The level of activity required to achieve them.4)Placement in theModelofChange.5. The muscle strength of a woman weighing 132 pounds who is able to lift 72poundswould be recorded as which of the following?1)1.832)Moderate3)0.554)18.3%6. Which is one of the greatest concerns with heavy and chronic use of alcohol inteens andyoung adults?1)Liver damage2)Unintentional death3)Tobacco use4)Obesity7. A 55-year-old man suffered a myocardial infarction (heart attack) three monthsago. During his hospitalization, he had stents inserted in two locations in the coronaryarteries. He was also placed on a cholesterol-lowering agent and two antihypertensives.What type of care ishe receiving?1)Primary prevention2)Secondary prevention3)Tertiary prevention4)8Health promotionHealth screening activities are designed to:1)Detect disease at an early stage.2)Determine treatment options.3)Assess lifestyle habits.4)9Identify healthcare beliefs.Which individuals should receive annual lipid screening?1)All overweight children2)All adults 20 years and older3)Persons with total cholesterol greater than 150 mg/dL4)Persons with HDL less than 40 mg/dL

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10. A mother of three young children is newly diagnosed with breast cancer. She isintensely committed to fighting the cancer. She believes she can control her cancer to somedegree with a positive attitude and feelings of inner strength. Which of the followingtraits isshedemonstrating that is linked to health and healing?1)Invincibility2)Hardiness3)Baseline strength4)VulnerabilityMultiple ResponseIdentify one or more choices that best complete the statement or answer the question.1. The World Health Organizations definition ofhealthincludes which of thefollowing?Choose all that apply.1)Absence of disease2)Physical well-being3)Mental well-being4)Social well-being2. According to Penders health promotion model, which variables must be consideredwhenplanning a health promotion program for a client? Choose all that apply.1)Individual characteristics and experiences2)Levels of prevention3)Behavioral outcomes4)Behavior-specific cognitions and affect3. Goals forHealthy People 2020include which of the following? Choose all that apply.1)Eliminate health disparities among various groups.2)Decrease the cost of healthcare related to tobacco use.3)Increase the quality and years of healthy life.4)Decrease the number of inpatient days annually.4. The nurse is implementing a wellness program based on data gathered from a groupof low-income seniors living in a housing project. He is using theWheels of Wellnessas amodel forhis planned interventions. Which of the following interventions would beappropriate based on this model? Choose all that apply.1)Creating a weekly discussion group focused on contemporary news2)Facilitating a relationship between local pastors and residents of subsidized housing3)Coordinating a senior tutorial program for local children at the housing center4)Establishing an on-site healthcare clinic operating one day per week5. The nurse working in an ambulatory care program asks questions about theclients locusof control as a part of his assessment because of which of the following?Choose all that apply.1)People who feel in charge of their own health are the easiest to motivate towardchange.

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2)Peoplewhofeelpowerlessaboutpreventingillnessareleastlikelytoengageinhealthpromotionactivities.3)Peoplewhorespondtodirectionfromrespectedauthoritiesoftenpreferahealthpromotionprogramthatis supervisedbyahealthprovider.4)Peoplewhofeelinchargeoftheirownhealtharelessmotivated byhealthpromotionactivities.6. Health promotion programs assist a person to advance toward optimal health.Which ofthe following activities might such programs include? Choose all that apply.1)Disseminating information2)Changing lifestyle and behavior3)Prescribing medications to treat underlying disorders4)7Environmental control programsWhich of the following actions demonstrate how nurses promote health?1)Role modeling2)Educating patients and families3)Counseling4)Providing supportCompletionComplete each statement.1.A middle-aged woman performs breast self-examination monthly. Thisintervention isconsidered to beprevention.2.refers to nursing actions performed to help clients toachieve anoptimal state of health.3.What is the name of the nursing theorist who defines health as having three elements: ahigh level of overall physical, mental, and social functioning; a general adaptive- maintenancelevel ofdaily functioning; and the absence of illness (or the presence of effortsthat lead to itsabsence)?Chapter 1. Health Promotion (Part2)Answer SectionMULTIPLE CHOICE1.ANS: 4Although health promotion and health protection may involve the same activities, theirdifference lies in the motivation for action. Health protection is motivated by a desire toavoid illness. Health promotion is motivated by the desire to increase wellness. Smokingcessation mayalso be a wellness behavior and may be considered a step toward healthyliving; however, neitherof these addresses motivation for action.Comprehension2.ANS: 3Prochaska and Diclemente identified four stages of change: the contemplation stage, thedetermination stage, the action stage, and the maintenance stage. This patient demonstratesbehaviors typical of the action stage. If a participant exits a program beforethe end of themaintenance stage, relapse is likely to occur as the individual resumes his

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previous life style.

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3.ANS: 3Field tests for running are good for children and can be utilized when assessingcardiorespiratoryfitness. The step test is appropriate for adults. The 12-inch bench heightistoo high for young children. The sit-and-reach test as well as range-of-motion exerciseswouldbe appropriate when assessing flexibility.4.ANS: 1Leavell and Clark identified three levels of activities for health protection: primary,secondary,and tertiary. Interventions are classified according to the point in the diseaseprocess in which they occur.5.ANS: 3Muscle strength measures the amount of weight a muscle (or group of muscles) can moveatonetime. This is recorded as a ratio of weight pushed (or lifted) divided by body weight.Awoman weighing 132 pounds who is able to lift 72 pounds has a ratio of 72 divided by 132, or0.55.6.ANS: 2Heavy and chronic use of alcohol and use of illicit drugs increase the risk of disease and injuriesand intentional death (suicide and homicide). Although alcohol as a depressant slowsmetabolism, chronic alcohol use is more likely associated with poor nutrition, whichmay ormaynot lead to obesity. Chronic alcohol use causes damage to liver cells over time in the lateryears. Alcohol intake is often associated with tobacco and recreational drug use; however, therisk of unintentional injury, such as car accident, suicide, or violence, is more concerning thansmoking.7.ANS: 3Primary prevention activities are designed to prevent or slow the onset of disease. Activitiessuchas eating healthy foods, exercising, wearing sunscreen, obeying seat-belt laws, and gettingimmunizations are examples of primary level interventions. Secondary prevention activitiesdetect illness so it can be treated in the early stages. Tertiary prevention focuses on stoppingthe disease from progressing and returning the individual to the pre-illness phase. The patienthas an established disease and is receiving care to stopthe disease from progressing.8.ANS: 1Health screening activities are designed to detect disease at an early stage so thattreatment canbegin before there is an opportunity for disease to spread or becomedebilitating.9.ANS: 1The American Academy of Pediatrics take a targeted approach, recommending thatoverweight children receive cholesterol screening, regardless of family history or other riskfactors for cardiovascular disease. The American Heart Association recommends that all adultsage 20 yearsor older have a fasting lipid panel at least once every 5 years. If totalcholesterol is200 mg/dL orgreateror HDL is less than 40 mg/dLfrequent monitoring is required.10.ANS: 2Research has also demonstrated that in the face of difficult life events, some people develophardiness rather than vulnerability. Hardiness is a quality in which an individualexperienceshigh levels of stress yet does not fall ill. There are three general characteristics of the hardyperson: control (belief in the ability to control the experience), commitment (feeling deeplyinvolved in the activity producing stress), and challenge (the ability to view the change as achallenge to grow). These traits are

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associated with a strong resistance to negative feelings thatoccur under adversecircumstances.MULTIPLE RESPONSE1. ANS: 2, 3, 4

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The World Health Organization defines health as a state of complete physical, mental, andsocialwell-being, not merely the absence of disease of infirmity.2. ANS: 1, 3, 4Pender identified three variables that affect health promotion: individual characteristicsand experiences, behavior-specific cognitions and affect, and behavioral outcomes.Levels of prevention were identified by Leavell and Clark; threelevels relate to healthprotection. Thelevels differ based on their timing in the illness cycle.3. ANS: 1, 3The four overarching goals ofHealthy People 2020are to 1) increase the quality and years ofhealthy life, free of disease, injury, and premature death, 2) eliminate health disparities andimprove health for all groups of people, 3) create physical and social environments forpeopletolive a healthy life, and 4) promote healthy development for people in all stages oflife.4. ANS: 1, 2, 3, 4TheWheels of Wellnessmodel identifies the following dimensions of health: emotional,intellectual, physical, spiritual, social/family, and occupational. A weekly discussion groupstimulates intellectual health. A relationship between local pastors and those living insubsidizedhousing creates a climate for spiritual health. A tutorial program offered by seniorsto local children will facilitate occupational health. An on-site healthcare clinic addressesphysical health.5. ANS: 1, 2, 3Identifying a persons locus of control helps the nurse determine how to approach a clientabouthealth promotion. People who feel powerless about preventing illness are least likely toengagein health promotion activities. People who respond to direction from respectedauthorities oftenprefer a health promotion program that is supervised by a health provider.Clients who feel in charge of their own health are the easiest to motivatetoward positivechange.6. ANS: 1, 2, 4Health promotion programs may be categorized into four types: disseminating information;programs for changing lifestyle and behavior; environmental control programs; andwellnessappraisal and health risk assessment programs. Prescribing medications to treatunderlying disorders is an activity that fosters health focused at anindividual level rather thanat a groupprogram level.7. ANS: 1, 2, 3, 4Nurses promote health by acting as role models, counseling, providing health education,andproviding and facilitating support.1. ANS: secondarySecondary prevention activitiesdetect illness so that it can be treatedin the early stages.Healthactivities such as mammograms, testicular examinations, regular physicalexaminations, blood pressure and diabetes screenings, and tuberculosis skin tests areexamples of secondary interventions. Primary prevention activities are designed to preventor slow the onset of disease and promote health. Activities such as eating healthyfoods,exercising, wearing sunscreen, obeying seat-belt laws, and getting immunizations areexamples of primary level interventions. Tertiary prevention focuses on stopping the diseasefrom progressing and returning the individual to the pre-illness phase.

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Chapter 2. Common Symptoms

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1.The nurse is listening to the breath sounds of a patient with severe asthma. Air passingthroughnarrowed bronchioles would produce which of these adventitious sounds?a.Wheezesb.Bronchial soundsc.Bronchophonyd.Whispered pectoriloquyANS: AWheezes are caused by air squeezed or compressed through passageways narrowedalmost toclosure by collapsing, swelling, secretions, or tumors, such as with acuteasthma or chronic emphysema.2.A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells thenurse that he has had a runny nose for a week. When performing the physical assessment, thenurse notes that the child has nasal flaring and sternal and intercostal retractions. The nursesnextaction should be to:a.Assure the mother that these signs are normal symptoms of a cold.b.Recognize that these are serious signs, and contact the physician.c.Ask the mother if the infant has had trouble with feedings.d.Perform a complete cardiac assessment because these signs are probably indicative ofearlyheartfailure.ANS: BThe infant is an obligatory nose breather until the age of 3 months. Normally, no flaring ofthenostrils and no sternal or intercostal retraction occurs. Significant retractions of the sternumand intercostal muscles and nasal flaring indicate increased inspiratory effort, asinpneumonia, acuteairway obstruction, asthma, and atelectasis; therefore, immediate referralto the physician is warranted. These signs do not indicate heart failure, and an assessment ofthe infants feeding is not a priority at this time.3.A teenage patient comes to the emergency department with complaints of an inability tobreathe and a sharp pain in the left side of his chest. The assessment findings includecyanosis,tachypnea, tracheal deviation to the right, decreased tactile fremitus on the left,hyperresonanceon the left, and decreased breath sounds on the left. The nurse interpretsthat these assessment findings are consistent with:a.Bronchitis.b.Pneumothorax.c.Acute pneumonia.d.Asthmatic attack.ANS: BWith a pneumothorax, free air in the pleural space causes partial or complete lung collapse.Ifthepneumothorax is large, then tachypnea and cyanosis are evident. Unequal chest expansion,decreased or absent tactile fremitus, tracheal deviation to the unaffected side, decreased chest

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expansion, hyperresonant percussion tones, and decreased or absent breath sounds arefoundwiththe presence of pneumothorax.4.The nurse has just recorded a positive iliopsoas test on a patient who has abdominalpain. Thistest is used to confirm a(n):a.Inflamed liver.b.Perforated spleen.c.Perforated appendix.d.Enlarged gallbladder.ANS: CAn inflamed or perforated appendix irritates the iliopsoas muscle, producing pain in the RLQ.5.Which statement indicates that the nurse understands the pain experienced by an older adult?a.Older adults must learn to tolerate pain.b.Pain is a normal process of aging and is to be expected.c.Pain indicates a pathologic condition or an injury and is not a normal process of aging.d.Older individuals perceive pain to a lesser degree than do younger individuals.ANS: CPain indicates a pathologic condition or an injury and should never be considered somethingthatan older adult should expect or tolerate. Pain is not a normal process ofaging, and noevidence suggests that pain perception is reduced with aging.6.In assessing the tonsils of a 30 year old, the nurse notices that they are involuted,granular inappearance, and appear to have deep crypts. What is correct response tothese findings?a.Refer the patient to a throat specialist.b.No response is needed; this appearance is normal for the tonsils.c.Continue with the assessment, looking for any other abnormal findings.d.Obtain a throat culture on the patient for possible streptococcal (strep) infection.ANS: BThe tonsils are the same color as the surrounding mucous membrane, although they lookmoregranular and their surface shows deep crypts. Tonsillar tissue enlarges during childhooduntil puberty and then involutes.7.The nurse is obtaining a health history on a 3-month-old infant. During the interview,the mother states, I think she is getting her first tooth because she has started drooling alot. Thenurses best response would be:a.Youre right, drooling is usually a sign of the first tooth.b.It would be unusual for a 3 month old to be getting her first tooth.c.This could be the sign of a problem with the salivary glands.d.She is just starting to salivate and hasnt learned to swallow the saliva.

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ANS: DIn the infant, salivation starts at 3 months. The baby will drool for a few months beforelearning to swallow the saliva. This drooling does not herald the eruption of the first tooth,although manyparents think it does.8.The nurse is assessing an 80-year-old patient. Which of these findings would beexpected forthis patient?a.Hypertrophy of the gumsb.Increased production of salivac.Decreased ability to identify odorsd.Finer and less prominent nasal hairANS: CThe sense of smell may be reduced because of a decrease in the number of olfactory nervefibers.Nasal hairs grow coarser and stiffer with aging. The gums may recede with aging, nothypertrophy, and saliva production decreases.9.The nurse is palpating the sinus areas. If the findings are normal, then the patient shouldreportwhich sensation?a.No sensationb.Firm pressurec.Pain during palpationd.Pain sensation behind eyesANS: B The person should feel firm pressure but no pain. Sinus areas are tender topalpation inpersons with chronic allergies or an acute infection (sinusitis).10.A 60-year-old man has just been told that he has benign prostatic hypertrophy (BPH). Hehas a friend who just died from cancer of the prostate. He is concerned this will happen to him.Howshould the nurse respond?a.The swelling in your prostate is only temporary and will go away.b.We will treat you with chemotherapy so we can control the cancer.c.It would be very unusual for a man your age to have cancer of the prostate.d.The enlargement of your prostate is caused by hormonal changes, and not cancer.ANS: D The prostate gland commonly starts to enlarge during the middle adult years. BPHispresent in 1 in 10 men at the age of 40 years and increases with age. It is believed that thehypertrophy is caused by hormonal imbalance that leads to the proliferation of benignadenomas.The other responses are not appropriate.11.A patient reports excruciating headache pain on one side of his head, especially aroundhis eye, forehead, and cheek that has lasted approximately to 2 hours, occurringonce ortwice eachday. The nurse should suspect:a.Hypertension.

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b.Clusterheadaches.c.Tensionheadaches.d.Migraineheadaches.ANS: B Cluster headaches produce pain around the eye, temple, forehead, and cheek andareunilateral and always on the same side of the head. They are excruciating and occur onceor twice per day and last to 2 hours each.12.A patient says that she has recently noticed a lump in the front of her neck below herAdamsapple that seems to be getting bigger. During the assessment, the finding that leadsthenurse to suspect that this may not be a cancerous thyroid nodule is that the lump (nodule):a.Is tender.b.Is mobile and not hard.c.Disappears when the patient smiles.d.Is hard and fixed to the surrounding structures.ANS: BPainless, rapidly growing nodules may be cancerous, especially the appearance ofasingle nodule in a young person. However, cancerous nodules tend to be hard and fixedto surrounding structures, not mobile.Chapter 3. Preoperative Evaluation & Perioperative ManagementMULTIPLE CHOICE1.The nurse is identifying diagnoses appropriate for a client scheduled for a surgicalprocedure.Which of the following is a diagnosis commonly used for preoperative client?

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1.Anxiety2.Sleepdeprivation3.Excessfluidvolume4.DisturbedbodyimageANS: 1The preoperative experience may be one of the most tension-producing periods ofhospitalization. The nursing diagnosis anxiety is commonly used for preoperative clients.Theother diagnoses are not commonly used as preoperative diagnoses.2.The preoperative nurse cares for the client until the client progresses into theintraoperativephase of care which begins when the client:1.signsthesurgicalconsentform.2.arrivesatthesurgicalsuitedoors.3.istransferredtothepostanesthesiacareunit.4.acceptsthatsurgeryispending.ANS: 2The preoperative period ends and the intraoperative period begins when the patient andfamilyare at the door to the surgical suites. Intraoperative care does not begin when the client signsthesurgical consent form, is transferred to the postanesthesia care unit, or accepts thatsurgery is pending.3.The nurse is ensuring that a client is able to make knowledgeable decisionsregarding an upcoming surgery and can provide informed consent. What is theresponsibility of the nurseregarding informed consent?1.Explainthesurgicaloptions2.Explaintheoperativerisks

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3.Describethe operativeproceduretobedone4.WitnessapatientssignatureANS: 4The nurse may concurrently sign that he has witnessed a patients signature. It is thephysiciansresponsibility toexplain the other answer choices.PTS: 1 DIF: Apply REF: Decision Strategies and Informed Consent4.A client being prepared for surgery has a pulse oximeter placed on one digit of hishand. Thenurse is applying this device to monitor the clients:1.oxygenlevel.2.heartrate.3.bloodpressure.4.urineoutput.ANS: 1Pulse oximeters are used to precisely identify the clients peripheral tissue oxygenation.Pulseoximeters are not to measure heart rate, blood pressure, or urine output.PTS: 1 DIF: Analyze REF: Trends5.A client is scheduled for surgery in 2 weeks. Which of the following should the nurseinstructthe client regarding healthy lifestyle behaviors?1.Eatnutritiousmeals.2.Ifobese,cutcaloriesbeforethesurgery.3.Ifsedentary,exercisemorebeforethesurgery.4.Stopallprescribedmedications.

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ANS: 1The client should be encouraged to adopt healthy dietary, rest, and exercise habits beforethesurgery. A client who has not followed healthy lifestyle habits should not suddenly makethesechanges before a surgical procedure. The nurse should encourage the client to eatnutritious meals. A client who is obese should not be encouraged to cut calories before thesurgery. The client who is sedentary should not be encouraged to suddenly exercise beforethe surgery. The client should not be instructed to stop prescribed medications unless aphysician has prescribedthis action.PTS: 1 DIF: Apply REF: Time Frames and Tasks6.The nurse wants to reduce the stress level for a preoperative client. Which of thefollowingcommunication techniques can the nurse use to achieve this result?1.Allowtheclient tobealonebeforethesurgery.2.Observeandasktheclientifthereisanythingthatcanbedonetohelpreduceheranxiety.3.Refertotheclientbyherfirstname.4.Maketastefuljokesorcomments tohelptheclientlaugh.ANS: 2Strategies to reduce preoperative stress include observing and asking the client if there isanything that can be done to help reduce her anxiety. Leaving the client alone before thesurgerywill not help reduce stress. Referring to the client by her first name might beconsidered unprofessional and should not be done. Making jokes is also not a professionalbehavior and should not be done by the nurse.PTS: 1 DIF: Apply REF: Nurse/Patient Communication7.Which of the following can the nurse do to help an elderly client scheduled for asurgicalprocedure?1.Workataslowerpace.2.Speedupthepacesotheclienthastimetorest.3.Talktofamilymembersandleavetheclient alone.

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4.Sendthemtothesurgicalholdingareainadvance.ANS: 1When caring for elderly clients, pace is important. Nurses should slow the pace. The nurseshould not ignore the client. The nurse should also not send the client to the surgical holdingareain advance since this could prove to be uncomfortable for the elderly client.PTS:1DIF:ApplyREF:Age-Related Issues8.The nurse is concerned that a client scheduled for surgery will be at risk forhypothermia.Which of the following did the nurse assess in this client to determinetherisk?1.Clientisavegetarian.2.Clientexercises5daysaweekfor30minutes.3.Clienthasahistoryofcongestiveheart failure.4.Clintis48yearsold.ANS: 3Clients at risk for hypothermia include the very young, the very old, those with a history ofheartdisease, those with a bleeding tendency, having complex surgery, and having surgeryon alargebody area that will be exposed. Being a vegetarian or exercising does not predispose aclient to developing hypothermia during surgery.PTS:1DIF:AnalyzeREF:Environmental Safety9.The nurse is concerned that a client may have an undocumented allergy to latex whenwhich ofthe following is assessed?1.Recent episodeofappendicitis2.Recoveredfrombronchitis3monthsago3.Allergytospecificfoods4.Doesnotliketowearwoolclothing

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