Test Bank for Current Medical Diagnosis and Treatment 2023 (Ie), 62nd Edition (Chapters 27)
Test Bank for Current Medical Diagnosis and Treatment 2023 (Ie), 62nd Edition (Chapters 27) provides in-depth questions and solutions to reinforce key concepts. Start practicing today!
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TEST BANK FOR CURRENT MEDICAL DIAGNOSIS AND TREATMENT
(2022/2023)
Chapter 1. Disease Prevention & Health Promotion
1. Which of the following behaviors indicates the highest potential for spreading
infectionsamong clients? The nurse:
1) disinfects dirty hands with antibacterial soap.
2) allows alcohol-based rub to dry for 10 seconds.
3) washes hands only after leaving each room.
4) uses cold water for medical asepsis.
2. What is the most frequent cause of the spread of infection among institutionalizedpatients?
1) Airborne microbes from other patients
2) Contact with contaminated equipment
3) Hands of healthcare workers
4) Exposure from family members
3. Which of the following nursing activities is of highest priority for maintaining
medicalasepsis?
1) Washing hands
2) Donning gloves
3) Applying sterile drapes
4) Wearing a gown
4. A patient infected with a virus but who does not have any outward sign of the
disease isconsidered a:
1) pathogen.
2) fomite.
3) vector.
4) carrier.
5. A patient is admitted to the hospital with tuberculosis. Which precautions must the
nurseinstitute when caring for this patient?
1) Droplet transmission
2) Airborne transmission
3) Direct contact
4) Indirect contact
(2022/2023)
Chapter 1. Disease Prevention & Health Promotion
1. Which of the following behaviors indicates the highest potential for spreading
infectionsamong clients? The nurse:
1) disinfects dirty hands with antibacterial soap.
2) allows alcohol-based rub to dry for 10 seconds.
3) washes hands only after leaving each room.
4) uses cold water for medical asepsis.
2. What is the most frequent cause of the spread of infection among institutionalizedpatients?
1) Airborne microbes from other patients
2) Contact with contaminated equipment
3) Hands of healthcare workers
4) Exposure from family members
3. Which of the following nursing activities is of highest priority for maintaining
medicalasepsis?
1) Washing hands
2) Donning gloves
3) Applying sterile drapes
4) Wearing a gown
4. A patient infected with a virus but who does not have any outward sign of the
disease isconsidered a:
1) pathogen.
2) fomite.
3) vector.
4) carrier.
5. A patient is admitted to the hospital with tuberculosis. Which precautions must the
nurseinstitute when caring for this patient?
1) Droplet transmission
2) Airborne transmission
3) Direct contact
4) Indirect contact
TEST BANK FOR CURRENT MEDICAL DIAGNOSIS AND TREATMENT
(2022/2023)
Chapter 1. Disease Prevention & Health Promotion
1. Which of the following behaviors indicates the highest potential for spreading
infectionsamong clients? The nurse:
1) disinfects dirty hands with antibacterial soap.
2) allows alcohol-based rub to dry for 10 seconds.
3) washes hands only after leaving each room.
4) uses cold water for medical asepsis.
2. What is the most frequent cause of the spread of infection among institutionalizedpatients?
1) Airborne microbes from other patients
2) Contact with contaminated equipment
3) Hands of healthcare workers
4) Exposure from family members
3. Which of the following nursing activities is of highest priority for maintaining
medicalasepsis?
1) Washing hands
2) Donning gloves
3) Applying sterile drapes
4) Wearing a gown
4. A patient infected with a virus but who does not have any outward sign of the
disease isconsidered a:
1) pathogen.
2) fomite.
3) vector.
4) carrier.
5. A patient is admitted to the hospital with tuberculosis. Which precautions must the
nurseinstitute when caring for this patient?
1) Droplet transmission
2) Airborne transmission
3) Direct contact
4) Indirect contact
(2022/2023)
Chapter 1. Disease Prevention & Health Promotion
1. Which of the following behaviors indicates the highest potential for spreading
infectionsamong clients? The nurse:
1) disinfects dirty hands with antibacterial soap.
2) allows alcohol-based rub to dry for 10 seconds.
3) washes hands only after leaving each room.
4) uses cold water for medical asepsis.
2. What is the most frequent cause of the spread of infection among institutionalizedpatients?
1) Airborne microbes from other patients
2) Contact with contaminated equipment
3) Hands of healthcare workers
4) Exposure from family members
3. Which of the following nursing activities is of highest priority for maintaining
medicalasepsis?
1) Washing hands
2) Donning gloves
3) Applying sterile drapes
4) Wearing a gown
4. A patient infected with a virus but who does not have any outward sign of the
disease isconsidered a:
1) pathogen.
2) fomite.
3) vector.
4) carrier.
5. A patient is admitted to the hospital with tuberculosis. Which precautions must the
nurseinstitute when caring for this patient?
1) Droplet transmission
2) Airborne transmission
3) Direct contact
4) Indirect contact
6. A patient becomes infected with oral candidiasis (thrush) while receiving
intravenous antibiotics to treat a systemic infection. Which type of infection has the patient
developed?
1) Endogenous nosocomial
2) Exogenous nosocomial
3) Latent
4) Primary
7. A patient admitted to the hospital with pneumonia has been receiving antibiotics for
2 days. His condition has stabilized, and his temperature has returned to normal. Which
stage ofinfection is the patient most likely experiencing?
1) Incubation
2) Prodromal
3) Decline
4) Convalescence
8. The nurse assists a surgeon with central venous catheter insertion. Which
action isnecessary to help maintain sterile technique?
1) Closing the patients door to limit room traffic while preparing the sterile field
2) Using clean procedure gloves to handle sterile equipment
3) Placing the nonsterile syringes containing flush solution on the sterile field
4) Remaining 6 inches away from the sterile field during the procedure
9. A patient develops localized heat and erythema over an area on the lower leg.
Thesefindings are indicative of which secondary defense against infection?
1) Phagocytosis
2) Complement cascade
3) Inflammation
4) Immunity
10. The patient suddenly develops hives, shortness of breath, and wheezing after
receivingan antibiotic. Which antibody is primarily responsible for this patients response?
1) IgA
2) IgE
3) IgG
4) IgM
11. What type of immunity is provided by intravenous (IV)
administration ofimmunoglobulin G?
1) Cell-mediated
2) Passive
3) Humoral
4) Active
intravenous antibiotics to treat a systemic infection. Which type of infection has the patient
developed?
1) Endogenous nosocomial
2) Exogenous nosocomial
3) Latent
4) Primary
7. A patient admitted to the hospital with pneumonia has been receiving antibiotics for
2 days. His condition has stabilized, and his temperature has returned to normal. Which
stage ofinfection is the patient most likely experiencing?
1) Incubation
2) Prodromal
3) Decline
4) Convalescence
8. The nurse assists a surgeon with central venous catheter insertion. Which
action isnecessary to help maintain sterile technique?
1) Closing the patients door to limit room traffic while preparing the sterile field
2) Using clean procedure gloves to handle sterile equipment
3) Placing the nonsterile syringes containing flush solution on the sterile field
4) Remaining 6 inches away from the sterile field during the procedure
9. A patient develops localized heat and erythema over an area on the lower leg.
Thesefindings are indicative of which secondary defense against infection?
1) Phagocytosis
2) Complement cascade
3) Inflammation
4) Immunity
10. The patient suddenly develops hives, shortness of breath, and wheezing after
receivingan antibiotic. Which antibody is primarily responsible for this patients response?
1) IgA
2) IgE
3) IgG
4) IgM
11. What type of immunity is provided by intravenous (IV)
administration ofimmunoglobulin G?
1) Cell-mediated
2) Passive
3) Humoral
4) Active
6. A patient becomes infected with oral candidiasis (thrush) while receiving
intravenous antibiotics to treat a systemic infection. Which type of infection has the patient
developed?
1) Endogenous nosocomial
2) Exogenous nosocomial
3) Latent
4) Primary
7. A patient admitted to the hospital with pneumonia has been receiving antibiotics for
2 days. His condition has stabilized, and his temperature has returned to normal. Which
stage ofinfection is the patient most likely experiencing?
1) Incubation
2) Prodromal
3) Decline
4) Convalescence
8. The nurse assists a surgeon with central venous catheter insertion. Which
action isnecessary to help maintain sterile technique?
1) Closing the patients door to limit room traffic while preparing the sterile field
2) Using clean procedure gloves to handle sterile equipment
3) Placing the nonsterile syringes containing flush solution on the sterile field
4) Remaining 6 inches away from the sterile field during the procedure
9. A patient develops localized heat and erythema over an area on the lower leg.
Thesefindings are indicative of which secondary defense against infection?
1) Phagocytosis
2) Complement cascade
3) Inflammation
4) Immunity
10. The patient suddenly develops hives, shortness of breath, and wheezing after
receivingan antibiotic. Which antibody is primarily responsible for this patients response?
1) IgA
2) IgE
3) IgG
4) IgM
11. What type of immunity is provided by intravenous (IV)
administration ofimmunoglobulin G?
1) Cell-mediated
2) Passive
3) Humoral
4) Active
intravenous antibiotics to treat a systemic infection. Which type of infection has the patient
developed?
1) Endogenous nosocomial
2) Exogenous nosocomial
3) Latent
4) Primary
7. A patient admitted to the hospital with pneumonia has been receiving antibiotics for
2 days. His condition has stabilized, and his temperature has returned to normal. Which
stage ofinfection is the patient most likely experiencing?
1) Incubation
2) Prodromal
3) Decline
4) Convalescence
8. The nurse assists a surgeon with central venous catheter insertion. Which
action isnecessary to help maintain sterile technique?
1) Closing the patients door to limit room traffic while preparing the sterile field
2) Using clean procedure gloves to handle sterile equipment
3) Placing the nonsterile syringes containing flush solution on the sterile field
4) Remaining 6 inches away from the sterile field during the procedure
9. A patient develops localized heat and erythema over an area on the lower leg.
Thesefindings are indicative of which secondary defense against infection?
1) Phagocytosis
2) Complement cascade
3) Inflammation
4) Immunity
10. The patient suddenly develops hives, shortness of breath, and wheezing after
receivingan antibiotic. Which antibody is primarily responsible for this patients response?
1) IgA
2) IgE
3) IgG
4) IgM
11. What type of immunity is provided by intravenous (IV)
administration ofimmunoglobulin G?
1) Cell-mediated
2) Passive
3) Humoral
4) Active
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)
1
The 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 asa
skinprotectant? 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 the
operatingroom?
1) 1 to 2 minutes
2) 2 to 4 minutes
3) 2 to 6 minutes
4) 6 to 10 minutes
16. How should the nurse dispose of the breakfast tray of a patient who requires
airborneisolation?
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 workerat
thepatients door.
3)
Return the tray with a note to dietary services so it can be cleaned and reused forthenext
meal.
4)
1
Carry the tray to an isolation trash receptacle located in the dirty utilityroom
anddispose of it there.
. How much liquid soap should the nurse use for effective hand washing? At least:
1) 2 mL
2) 3 mL
3) 6 mL
4) 7 mL
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)
1
The 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 asa
skinprotectant? 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 the
operatingroom?
1) 1 to 2 minutes
2) 2 to 4 minutes
3) 2 to 6 minutes
4) 6 to 10 minutes
16. How should the nurse dispose of the breakfast tray of a patient who requires
airborneisolation?
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 workerat
thepatients door.
3)
Return the tray with a note to dietary services so it can be cleaned and reused forthenext
meal.
4)
1
Carry the tray to an isolation trash receptacle located in the dirty utilityroom
anddispose of it there.
. How much liquid soap should the nurse use for effective hand washing? At least:
1) 2 mL
2) 3 mL
3) 6 mL
4) 7 mL
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18. To assure effectiveness, when should the nurse stop rubbing antiseptic hand
solutionover all surfaces of the hands?
1) When fingers feel sticky
2) After 5 to 10 seconds
3) When leaving the clients room
4) Once fingers and hands feel dry
19. A patient is admitted to the hospital for chemotherapy and has a low white
blood cellcount. Which precaution should the staff take with this patient?
1) Contact
2) Protective
3) Droplet
4) Airborne
20. While donning sterile gloves, the nurse notices the edges of the glove package are
slightly yellow. The yellow area is over 1 inch away from the gloves and only appearsto be
onthe outside of the glove package. What is the best action for the nurse to take at this
point?
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 item
should beremoved first?
1) Gown
2) Gloves
3) Face shield
4) Hair covering
22. A nurse is splashed in the face by body fluid during a procedure. Prioritize the
nursesactions, listing the most important one first.
A. Contact employee health
B. Complete an incident report
C. Wash the exposed area
D. Report to another nurse that she is leaving the immediate area.
1) 1, 2, 3, 4
2) 2, 3, 4, 1
3) 3, 4, 1, 2
4) 4, 1, 2, 3
Multiple Response
Identify 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.
solutionover all surfaces of the hands?
1) When fingers feel sticky
2) After 5 to 10 seconds
3) When leaving the clients room
4) Once fingers and hands feel dry
19. A patient is admitted to the hospital for chemotherapy and has a low white
blood cellcount. Which precaution should the staff take with this patient?
1) Contact
2) Protective
3) Droplet
4) Airborne
20. While donning sterile gloves, the nurse notices the edges of the glove package are
slightly yellow. The yellow area is over 1 inch away from the gloves and only appearsto be
onthe outside of the glove package. What is the best action for the nurse to take at this
point?
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 item
should beremoved first?
1) Gown
2) Gloves
3) Face shield
4) Hair covering
22. A nurse is splashed in the face by body fluid during a procedure. Prioritize the
nursesactions, listing the most important one first.
A. Contact employee health
B. Complete an incident report
C. Wash the exposed area
D. Report to another nurse that she is leaving the immediate area.
1) 1, 2, 3, 4
2) 2, 3, 4, 1
3) 3, 4, 1, 2
4) 4, 1, 2, 3
Multiple Response
Identify 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 cough
2) While helping a client to perform his own hygiene care
3) While aiding a client to ambulate after surgery
4) While inserting a peripheral intravenous catheter
2. Which of the following protect(s) the body against infection? Select all that apply.
1) Eating a healthy well-balanced diet
2) Being an older adult or an infant
3) Leisure activities three times a week
4) Exercising for 30 minutes 5 days a week
3. 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 NAP
demonstrate 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 which
types oforganisms? Select all that apply.
1) Virus
2) Bacterial spores
3) Yeast
4) Mold
5. A patient with tuberculosis is scheduled for computed tomography (CT). How
should 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/False
Indicate whether the statement is true or false.
1. Bacteria are necessary for human health and well-being.
Chapter 1. Disease
preventionAnswer Section
MULTIPLE CHOICE
1. ANS: 3
Patients acquire infection by contact with other patients, family members, and healthcare
equipment. But most infection among patients is spread through the hands of healthcare
workers.Hand washing interrupts the transmission and should be done before and after all
contact with
2) While helping a client to perform his own hygiene care
3) While aiding a client to ambulate after surgery
4) While inserting a peripheral intravenous catheter
2. Which of the following protect(s) the body against infection? Select all that apply.
1) Eating a healthy well-balanced diet
2) Being an older adult or an infant
3) Leisure activities three times a week
4) Exercising for 30 minutes 5 days a week
3. 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 NAP
demonstrate 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 which
types oforganisms? Select all that apply.
1) Virus
2) Bacterial spores
3) Yeast
4) Mold
5. A patient with tuberculosis is scheduled for computed tomography (CT). How
should 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/False
Indicate whether the statement is true or false.
1. Bacteria are necessary for human health and well-being.
Chapter 1. Disease
preventionAnswer Section
MULTIPLE CHOICE
1. ANS: 3
Patients acquire infection by contact with other patients, family members, and healthcare
equipment. But most infection among patients is spread through the hands of healthcare
workers.Hand washing interrupts the transmission and should be done before and after all
contact with
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patients, regardless of the diagnosis. When the hands are soiled, healthcare staff shoulduse
antibacterial soap with warm water to remove dirt and debris from the skin surface. When
novisible dirt is present, an alcohol-based rub should be applied and allowed to dry for 10
to 15seconds.
2. ANS: 3
Patients are exposed to microbes by contact (direct contact, airborne, or otherwise) with other
patients, family members, and contaminated healthcare equipment. Some of these are
pathogenic(cause illness) and some are nonpathogenic (do not cause illness). But most
microbes causing infection among patients are spread by direct contact on the hands of
healthcare workers.
3. ANS: 1
Scrupulous hand washing is the most important part of medical asepsis. Donning gloves,
applying sterile drapes before procedures, and wearing a protective gown may be
needed toensure asepsis, but they are not the mostimportant aspect becausemicrobes
causing most healthcare-related infections are transmitted by lack of or ineffective
hand washing.
4. ANS: 4
Some people might harbor a pathogenic organism, such as the human immunodeficiency
virus 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 to
others. A pathogen is anorganism capable of causing disease. A fomite is a contaminated
object that transfers a pathogen,such as pens, stethoscopes, and contaminated needles. A
vector is an organism that carries a pathogen to a susceptible host through a portal for entry
into the body. An example of a vector is a mosquito or tick that bites or stings.
5. ANS: 2
The organisms responsible for measles and tuberculosis, as well as many fungal infections,
arespread through airborne transmission. Neisseria meningitidis, the organism that causes
meningitis, is spread through droplet transmission. Pathogens that cause diarrhea, such as
Clostridium difficile, are spread by direct contact. The common cold can be spread by
indirectcontact or droplet transmission.
6. ANS: 1
Thrush in this patient is an example of an endogenous, nosocomial infection. This type of
infection arises from suppression of the patients normal flora as a result of some form of
treatment, such as antibiotics. Normal flora usually keep yeast from growing in the mouth. In
exogenous nosocomial infection, the pathogen arises from the healthcare environment. A
latentinfection causes no symptoms for long periods. An example of a latent infection is
human immunodeficiency virus infection. A primary infection is the first infection that occurs
in a patient.
7. ANS: 3
The stage of decline occurs when the patients immune defenses, along with any medical
therapies (in this case antibiotics), are successfully reducing the number of pathogenic
microbes.As a result, the signs and symptoms of infection begin to fade. Incubation is the stage
between 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 stage
is characterized by the first appearance of vague symptoms.
Convalescence is characterized by tissue repair and a return to heal as the organisms
antibacterial soap with warm water to remove dirt and debris from the skin surface. When
novisible dirt is present, an alcohol-based rub should be applied and allowed to dry for 10
to 15seconds.
2. ANS: 3
Patients are exposed to microbes by contact (direct contact, airborne, or otherwise) with other
patients, family members, and contaminated healthcare equipment. Some of these are
pathogenic(cause illness) and some are nonpathogenic (do not cause illness). But most
microbes causing infection among patients are spread by direct contact on the hands of
healthcare workers.
3. ANS: 1
Scrupulous hand washing is the most important part of medical asepsis. Donning gloves,
applying sterile drapes before procedures, and wearing a protective gown may be
needed toensure asepsis, but they are not the mostimportant aspect becausemicrobes
causing most healthcare-related infections are transmitted by lack of or ineffective
hand washing.
4. ANS: 4
Some people might harbor a pathogenic organism, such as the human immunodeficiency
virus 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 to
others. A pathogen is anorganism capable of causing disease. A fomite is a contaminated
object that transfers a pathogen,such as pens, stethoscopes, and contaminated needles. A
vector is an organism that carries a pathogen to a susceptible host through a portal for entry
into the body. An example of a vector is a mosquito or tick that bites or stings.
5. ANS: 2
The organisms responsible for measles and tuberculosis, as well as many fungal infections,
arespread through airborne transmission. Neisseria meningitidis, the organism that causes
meningitis, is spread through droplet transmission. Pathogens that cause diarrhea, such as
Clostridium difficile, are spread by direct contact. The common cold can be spread by
indirectcontact or droplet transmission.
6. ANS: 1
Thrush in this patient is an example of an endogenous, nosocomial infection. This type of
infection arises from suppression of the patients normal flora as a result of some form of
treatment, such as antibiotics. Normal flora usually keep yeast from growing in the mouth. In
exogenous nosocomial infection, the pathogen arises from the healthcare environment. A
latentinfection causes no symptoms for long periods. An example of a latent infection is
human immunodeficiency virus infection. A primary infection is the first infection that occurs
in a patient.
7. ANS: 3
The stage of decline occurs when the patients immune defenses, along with any medical
therapies (in this case antibiotics), are successfully reducing the number of pathogenic
microbes.As a result, the signs and symptoms of infection begin to fade. Incubation is the stage
between 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 stage
is 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 number
ofpersons entering and exiting the room because air currents can carry dust and
microorganisms. 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: 3
The classic signs of inflammation, a secondary defense against infection, are erythema
(redness)and localized heat. The secondary defenses phagocytosis (process by which white
blood cells engulf and destroy pathogens) and the complement cascade (process by which
blood 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 from
future infection.
10. ANS: 2
The patient is most likely experiencing an allergic response to the antibiotic. IgE is the antibody
primarily responsible for this allergic response. The antibodies IgA, IgG, and IgMare not
involved in the allergic response. IgA antibodies protect the body from in fighting viral and
bacterial infections. IgG antibioties are the only type that cross the placenta in a pregnant
womento protect her unborn baby (fetus). IgM are the first antibodies made in response to
infection.
11. ANS: 2
Intravenous administration of immunoglobulin G provides the patient with passive immunity.
Immunoglobulin G does not provide cell-mediated, humoral, or active immunity. Passive
immunity occurs when antibodies are transferred by antibodies from animmune host, such as
from a placenta to a fetus. Passive immunity is short-lived. Active immunity is longer lived and
comes from the host itself. Humoral immunity occurs by secreted antibodies binding to
antigens.Cell-mediated immunity does not involve antibodies but rather fight infection from
macrophagesthat kills pathogens.
12. ANS: 1
More than 200 viruses are known to cause the common cold. These viruses mutate too rapidly
todevelop a vaccine. Although some researchers are focusing efforts on a vaccinefor HIV
infection, others continue to research the common cold.
13. ANS: 2
Fever, a common defense against infection, increases water loss; therefore, additional
fluid is needed to supplement this loss. Acetaminophen and a tepid bath are not
necessary for this low-grade fever because fever is beneficial in fighting infection.
Adequate rest, not necessarily bedrest, is necessary with a fever.
14. ANS: 3
Nonpetroleum-based lotion is preferred because it prevents the absorption of latex proteins
through the skin, which can cause latex allergy. Both types of lotion prevent the skin from
dryingand becoming chafed. Neither prevents microorganisms from adhering tothe skin.
15. ANS: 3
In a surgical setting, hands should be washed for 2 to 6 minutes, depending on the type of
soapused.
ofpersons entering and exiting the room because air currents can carry dust and
microorganisms. 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: 3
The classic signs of inflammation, a secondary defense against infection, are erythema
(redness)and localized heat. The secondary defenses phagocytosis (process by which white
blood cells engulf and destroy pathogens) and the complement cascade (process by which
blood 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 from
future infection.
10. ANS: 2
The patient is most likely experiencing an allergic response to the antibiotic. IgE is the antibody
primarily responsible for this allergic response. The antibodies IgA, IgG, and IgMare not
involved in the allergic response. IgA antibodies protect the body from in fighting viral and
bacterial infections. IgG antibioties are the only type that cross the placenta in a pregnant
womento protect her unborn baby (fetus). IgM are the first antibodies made in response to
infection.
11. ANS: 2
Intravenous administration of immunoglobulin G provides the patient with passive immunity.
Immunoglobulin G does not provide cell-mediated, humoral, or active immunity. Passive
immunity occurs when antibodies are transferred by antibodies from animmune host, such as
from a placenta to a fetus. Passive immunity is short-lived. Active immunity is longer lived and
comes from the host itself. Humoral immunity occurs by secreted antibodies binding to
antigens.Cell-mediated immunity does not involve antibodies but rather fight infection from
macrophagesthat kills pathogens.
12. ANS: 1
More than 200 viruses are known to cause the common cold. These viruses mutate too rapidly
todevelop a vaccine. Although some researchers are focusing efforts on a vaccinefor HIV
infection, others continue to research the common cold.
13. ANS: 2
Fever, a common defense against infection, increases water loss; therefore, additional
fluid is needed to supplement this loss. Acetaminophen and a tepid bath are not
necessary for this low-grade fever because fever is beneficial in fighting infection.
Adequate rest, not necessarily bedrest, is necessary with a fever.
14. ANS: 3
Nonpetroleum-based lotion is preferred because it prevents the absorption of latex proteins
through the skin, which can cause latex allergy. Both types of lotion prevent the skin from
dryingand becoming chafed. Neither prevents microorganisms from adhering tothe skin.
15. ANS: 3
In a surgical setting, hands should be washed for 2 to 6 minutes, depending on the type of
soapused.
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16. ANS: 2
Patients who require airborne isolation are served meals on disposable dishes and trays. To
dispose of the tray, the nurse inside the room must wear protective garb and place the tray
and its
Patients who require airborne isolation are served meals on disposable dishes and trays. To
dispose of the tray, the nurse inside the room must wear protective garb and place the tray
and its
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contents inside a special isolation bag that is held by a second healthcare worker at the
patients door. The items must be placed on the inside of the bag without touching the outside
of the bag.
17. ANS: 2
APIC guidelines dictate that 3 to 5 mL of liquid soap is necessary for effective hand washing.
18. ANS: 4
The nurse should rub the antiseptic hand solution over all surfaces of the hands until the
solutiondries, usually 10 to 15 seconds, to ensure effectiveness.
19. ANS: 2
Protective isolation is used to protect those patients who are unusually vulnerable to
organisms brought in by healthcare workers. Such patients include those with low white
blood cell counts, with burns, and undergoing chemotherapy. Some hospital units, such as
neonatal intensive care units and labor and delivery suites, also use forms of protective
isolation.
20. ANS: 2
The gloves should be thrown away because the gloves are likely to be contaminated from
anoutside source. The supplies do not have to be thrown away because they havenot been
contaminated.
21. ANS: 2
The gloves are removed first because they are usually the most contaminated PPE and
must be removed to avoid contamination of clean areas of the other PPE during their
removal. The gownis removed second, then the mask or face shield, and finally, the hair
covering.
22. ANS: 3
If a nurse becomes exposed to body fluid, she should first wash the area, tell another nurse she
isleaving the area, contact the infection control or employee health nurse immediately, and
complete 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 becoming
infected. Theother activities can wait until that is done.
MULTIPLE RESPONSE
1. ANS: 3, 4
Standard precautions should be instituted with all clients whenever there is a possibility of
coming in contact with blood, body fluids (except sweat), excretions, secretions, mucous
membranes, and breaks in the skin (e.g., while inserting a peripheral IV). When interviewing a
client, if the disease is not spread by air or droplets, there is no likelihood of the nurses
encountering body fluids. If the disease is spread by air or droplets, then droplet or airborne
precautions would be needed in addition to standard precautions. If giving a complete bed
bath or performing oral hygiene, the nurse would need to use standard precautions (gloves); if
merelyassisting a client to perform those ADLs, it is not necessary. No exposure to body fluids
is likelywhen helping a client to ambulate after surgery.
2. ANS: 1, 3, 4
Nutrition, hygiene, rest, exercise, stress reduction, and immunization protect the body
againstinfection. Illness, injury, medical treatment, infancy or old age, frequent public
contact, and various lifestyle factors can make the body more susceptible to infection. 3.
ANS: 1, 3, 4
Hand washing requires at least 15 seconds of washing, which includes lathering all
surfaces ofthe hands and fingers to be effective. The fingers should be held lower than
patients door. The items must be placed on the inside of the bag without touching the outside
of the bag.
17. ANS: 2
APIC guidelines dictate that 3 to 5 mL of liquid soap is necessary for effective hand washing.
18. ANS: 4
The nurse should rub the antiseptic hand solution over all surfaces of the hands until the
solutiondries, usually 10 to 15 seconds, to ensure effectiveness.
19. ANS: 2
Protective isolation is used to protect those patients who are unusually vulnerable to
organisms brought in by healthcare workers. Such patients include those with low white
blood cell counts, with burns, and undergoing chemotherapy. Some hospital units, such as
neonatal intensive care units and labor and delivery suites, also use forms of protective
isolation.
20. ANS: 2
The gloves should be thrown away because the gloves are likely to be contaminated from
anoutside source. The supplies do not have to be thrown away because they havenot been
contaminated.
21. ANS: 2
The gloves are removed first because they are usually the most contaminated PPE and
must be removed to avoid contamination of clean areas of the other PPE during their
removal. The gownis removed second, then the mask or face shield, and finally, the hair
covering.
22. ANS: 3
If a nurse becomes exposed to body fluid, she should first wash the area, tell another nurse she
isleaving the area, contact the infection control or employee health nurse immediately, and
complete 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 becoming
infected. Theother activities can wait until that is done.
MULTIPLE RESPONSE
1. ANS: 3, 4
Standard precautions should be instituted with all clients whenever there is a possibility of
coming in contact with blood, body fluids (except sweat), excretions, secretions, mucous
membranes, and breaks in the skin (e.g., while inserting a peripheral IV). When interviewing a
client, if the disease is not spread by air or droplets, there is no likelihood of the nurses
encountering body fluids. If the disease is spread by air or droplets, then droplet or airborne
precautions would be needed in addition to standard precautions. If giving a complete bed
bath or performing oral hygiene, the nurse would need to use standard precautions (gloves); if
merelyassisting a client to perform those ADLs, it is not necessary. No exposure to body fluids
is likelywhen helping a client to ambulate after surgery.
2. ANS: 1, 3, 4
Nutrition, hygiene, rest, exercise, stress reduction, and immunization protect the body
againstinfection. Illness, injury, medical treatment, infancy or old age, frequent public
contact, and various lifestyle factors can make the body more susceptible to infection. 3.
ANS: 1, 3, 4
Hand washing requires at least 15 seconds of washing, which includes lathering all
surfaces 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
4. ANS: 1, 3, 4
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If there is potential for contact with bacterial spores, hands must be washed with soap and
water;alcohol-based solutions are ineffective against bacterial spores.
5. ANS: 3, 4
Transporting a patient who requires airborne precautions should be limited; however, when
necessary 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, the
department where the patient is being transported should be notified about the precautions
before transport.
TRUE/FALSE
1. ANS: T
Organisms that normally inhabit the body, called normal flora, are essential for human health
andwell-being. They keep pathogens in check. In the intestine, these flora function toaid
digestion 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 from
lung cancer 3 months ago. Based on his motivation, smoking cessation should be
recognized as anexample of which of the following?
1) Healthy living
2) Health promotion
3) Wellness behaviors
4) Health protection
2. A patient with morbid obesity was enrolled in a weight loss program last month and
hasattended four weekly meetings. But now he believes he no longer needs to attend
meetings because he has learned what to do. He informs the nurse facilitator about his
decision to quit theprogram. What should the nurse tell him?
1)
By now you have successfully completed the steps of the change process. Youshould
beable 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 6
weeksbefore you can quit the program and have success.
3)
You have done well in this program. However, it is important to continue in the
program to learn how to maintain weight loss. Otherwise, you are likely to return to
your previouslifestyle.
4)
You have entered the determination stage and are ready to make positive changesthat
you can keep for the rest of your life. If you need additional help, you can comeback
ata later time.
3. The school nurse at a local elementary school is performing physical fitness
assessmentson the third-grade children. When assessing students cardiorespiratory
fitness, 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.
water;alcohol-based solutions are ineffective against bacterial spores.
5. ANS: 3, 4
Transporting a patient who requires airborne precautions should be limited; however, when
necessary 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, the
department where the patient is being transported should be notified about the precautions
before transport.
TRUE/FALSE
1. ANS: T
Organisms that normally inhabit the body, called normal flora, are essential for human health
andwell-being. They keep pathogens in check. In the intestine, these flora function toaid
digestion 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 from
lung cancer 3 months ago. Based on his motivation, smoking cessation should be
recognized as anexample of which of the following?
1) Healthy living
2) Health promotion
3) Wellness behaviors
4) Health protection
2. A patient with morbid obesity was enrolled in a weight loss program last month and
hasattended four weekly meetings. But now he believes he no longer needs to attend
meetings because he has learned what to do. He informs the nurse facilitator about his
decision to quit theprogram. What should the nurse tell him?
1)
By now you have successfully completed the steps of the change process. Youshould
beable 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 6
weeksbefore you can quit the program and have success.
3)
You have done well in this program. However, it is important to continue in the
program to learn how to maintain weight loss. Otherwise, you are likely to return to
your previouslifestyle.
4)
You have entered the determination stage and are ready to make positive changesthat
you can keep for the rest of your life. If you need additional help, you can comeback
ata later time.
3. The school nurse at a local elementary school is performing physical fitness
assessmentson the third-grade children. When assessing students cardiorespiratory
fitness, 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) Perform range-of-motion exercises.
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4. In the Leavell and Clark model of health protection, the chief distinction
between thelevels of prevention is:
1) The point in the disease process at which they occur.
2) Placement on the Wheels of Wellness.
3) The level of activity required to achieve them.
4) Placement in the Model of Change.
5. The muscle strength of a woman weighing 132 pounds who is able to lift 72
poundswould be recorded as which of the following?
1) 1.83
2) Moderate
3) 0.55
4) 18.3%
6. Which is one of the greatest concerns with heavy and chronic use of alcohol in
teens andyoung adults?
1) Liver damage
2) Unintentional death
3) Tobacco use
4) Obesity
7. A 55-year-old man suffered a myocardial infarction (heart attack) three months
ago. During his hospitalization, he had stents inserted in two locations in the coronary
arteries. He was also placed on a cholesterol-lowering agent and two antihypertensives.
What type of care ishe receiving?
1) Primary prevention
2) Secondary prevention
3) Tertiary prevention
4)
8
Health promotion
Health screening activities are designed to:
1) Detect disease at an early stage.
2) Determine treatment options.
3) Assess lifestyle habits.
4)
9
Identify healthcare beliefs.
Which individuals should receive annual lipid screening?
1) All overweight children
2) All adults 20 years and older
3) Persons with total cholesterol greater than 150 mg/dL
4) Persons with HDL less than 40 mg/dL
between thelevels of prevention is:
1) The point in the disease process at which they occur.
2) Placement on the Wheels of Wellness.
3) The level of activity required to achieve them.
4) Placement in the Model of Change.
5. The muscle strength of a woman weighing 132 pounds who is able to lift 72
poundswould be recorded as which of the following?
1) 1.83
2) Moderate
3) 0.55
4) 18.3%
6. Which is one of the greatest concerns with heavy and chronic use of alcohol in
teens andyoung adults?
1) Liver damage
2) Unintentional death
3) Tobacco use
4) Obesity
7. A 55-year-old man suffered a myocardial infarction (heart attack) three months
ago. During his hospitalization, he had stents inserted in two locations in the coronary
arteries. He was also placed on a cholesterol-lowering agent and two antihypertensives.
What type of care ishe receiving?
1) Primary prevention
2) Secondary prevention
3) Tertiary prevention
4)
8
Health promotion
Health screening activities are designed to:
1) Detect disease at an early stage.
2) Determine treatment options.
3) Assess lifestyle habits.
4)
9
Identify healthcare beliefs.
Which individuals should receive annual lipid screening?
1) All overweight children
2) All adults 20 years and older
3) Persons with total cholesterol greater than 150 mg/dL
4) 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 is
intensely committed to fighting the cancer. She believes she can control her cancer to some
degree with a positive attitude and feelings of inner strength. Which of the followingtraits is
shedemonstrating that is linked to health and healing?
1) Invincibility
2) Hardiness
3) Baseline strength
4) Vulnerability
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. The World Health Organizations definition of health includes which of the
following?Choose all that apply.
1) Absence of disease
2) Physical well-being
3) Mental well-being
4) Social well-being
2. According to Penders health promotion model, which variables must be considered
whenplanning a health promotion program for a client? Choose all that apply.
1) Individual characteristics and experiences
2) Levels of prevention
3) Behavioral outcomes
4) Behavior-specific cognitions and affect
3. Goals for Healthy People 2020 include 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 group
of low-income seniors living in a housing project. He is using the Wheels of Wellnessas a
model forhis planned interventions. Which of the following interventions would be
appropriate based on this model? Choose all that apply.
1) Creating a weekly discussion group focused on contemporary news
2) Facilitating a relationship between local pastors and residents of subsidized housing
3) Coordinating a senior tutorial program for local children at the housing center
4) Establishing an on-site healthcare clinic operating one day per week
5. The nurse working in an ambulatory care program asks questions about the
clients 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.
intensely committed to fighting the cancer. She believes she can control her cancer to some
degree with a positive attitude and feelings of inner strength. Which of the followingtraits is
shedemonstrating that is linked to health and healing?
1) Invincibility
2) Hardiness
3) Baseline strength
4) Vulnerability
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. The World Health Organizations definition of health includes which of the
following?Choose all that apply.
1) Absence of disease
2) Physical well-being
3) Mental well-being
4) Social well-being
2. According to Penders health promotion model, which variables must be considered
whenplanning a health promotion program for a client? Choose all that apply.
1) Individual characteristics and experiences
2) Levels of prevention
3) Behavioral outcomes
4) Behavior-specific cognitions and affect
3. Goals for Healthy People 2020 include 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 group
of low-income seniors living in a housing project. He is using the Wheels of Wellnessas a
model forhis planned interventions. Which of the following interventions would be
appropriate based on this model? Choose all that apply.
1) Creating a weekly discussion group focused on contemporary news
2) Facilitating a relationship between local pastors and residents of subsidized housing
3) Coordinating a senior tutorial program for local children at the housing center
4) Establishing an on-site healthcare clinic operating one day per week
5. The nurse working in an ambulatory care program asks questions about the
clients 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)
People who feel powerless about preventing illness are least likely to engage in
healthpromotion activities.
3)
People who respond to direction from respected authorities often prefer a
healthpromotion program that is supervised by a health provider.
4)
People who feel in charge of their own health are less motivated by health
promotionactivities.
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 information
2) Changing lifestyle and behavior
3) Prescribing medications to treat underlying disorders
4)
7
Environmental control programs
Which of the following actions demonstrate how nurses promote health?
1) Role modeling
2) Educating patients and families
3) Counseling
4) Providing support
Completion
Complete each statement.
1. A middle-aged woman performs breast self-examination monthly. This
intervention isconsidered to be prevention.
2. refers to nursing actions performed to help clients to
achieve anoptimal state of health.
3. What is the name of the nursing theorist who defines health as having three elements: a
high level of overall physical, mental, and social functioning; a general adaptive- maintenance
level ofdaily functioning; and the absence of illness (or the presence of effortsthat lead to its
absence)?
Chapter 1. Health Promotion (Part
2)Answer Section
MULTIPLE CHOICE
1. ANS: 4
Although health promotion and health protection may involve the same activities, their
difference lies in the motivation for action. Health protection is motivated by a desire to
avoid illness. Health promotion is motivated by the desire to increase wellness. Smoking
cessation mayalso be a wellness behavior and may be considered a step toward healthy
living; however, neitherof these addresses motivation for action.
Comprehension
2. ANS: 3
Prochaska and Diclemente identified four stages of change: the contemplation stage, the
determination stage, the action stage, and the maintenance stage. This patient demonstrates
behaviors typical of the action stage. If a participant exits a program beforethe end of the
maintenance stage, relapse is likely to occur as the individual resumes his
People who feel powerless about preventing illness are least likely to engage in
healthpromotion activities.
3)
People who respond to direction from respected authorities often prefer a
healthpromotion program that is supervised by a health provider.
4)
People who feel in charge of their own health are less motivated by health
promotionactivities.
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 information
2) Changing lifestyle and behavior
3) Prescribing medications to treat underlying disorders
4)
7
Environmental control programs
Which of the following actions demonstrate how nurses promote health?
1) Role modeling
2) Educating patients and families
3) Counseling
4) Providing support
Completion
Complete each statement.
1. A middle-aged woman performs breast self-examination monthly. This
intervention isconsidered to be prevention.
2. refers to nursing actions performed to help clients to
achieve anoptimal state of health.
3. What is the name of the nursing theorist who defines health as having three elements: a
high level of overall physical, mental, and social functioning; a general adaptive- maintenance
level ofdaily functioning; and the absence of illness (or the presence of effortsthat lead to its
absence)?
Chapter 1. Health Promotion (Part
2)Answer Section
MULTIPLE CHOICE
1. ANS: 4
Although health promotion and health protection may involve the same activities, their
difference lies in the motivation for action. Health protection is motivated by a desire to
avoid illness. Health promotion is motivated by the desire to increase wellness. Smoking
cessation mayalso be a wellness behavior and may be considered a step toward healthy
living; however, neitherof these addresses motivation for action.
Comprehension
2. ANS: 3
Prochaska and Diclemente identified four stages of change: the contemplation stage, the
determination stage, the action stage, and the maintenance stage. This patient demonstrates
behaviors typical of the action stage. If a participant exits a program beforethe end of the
maintenance stage, relapse is likely to occur as the individual resumes his
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previous life style.
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3. ANS: 3
Field tests for running are good for children and can be utilized when assessing
cardiorespiratoryfitness. The step test is appropriate for adults. The 12-inch bench height is
too high for young children. The sit-and-reach test as well as range-of-motion exerciseswould
be appropriate when assessing flexibility.
4. ANS: 1
Leavell and Clark identified three levels of activities for health protection: primary,
secondary,and tertiary. Interventions are classified according to the point in the disease
process in which they occur.
5. ANS: 3
Muscle strength measures the amount of weight a muscle (or group of muscles) can move at
onetime. This is recorded as a ratio of weight pushed (or lifted) divided by body weight. A
woman weighing 132 pounds who is able to lift 72 pounds has a ratio of 72 divided by 132, or
0.55.
6. ANS: 2
Heavy and chronic use of alcohol and use of illicit drugs increase the risk of disease and injuries
and intentional death (suicide and homicide). Although alcohol as a depressant slows
metabolism, chronic alcohol use is more likely associated with poor nutrition, whichmay or
maynot lead to obesity. Chronic alcohol use causes damage to liver cells over time in the later
years. Alcohol intake is often associated with tobacco and recreational drug use; however, the
risk of unintentional injury, such as car accident, suicide, or violence, is more concerning than
smoking.
7. ANS: 3
Primary prevention activities are designed to prevent or slow the onset of disease. Activities
suchas eating healthy foods, exercising, wearing sunscreen, obeying seat-belt laws, and getting
immunizations are examples of primary level interventions. Secondary prevention activities
detect illness so it can be treated in the early stages. Tertiary prevention focuses on stopping
the disease from progressing and returning the individual to the pre-illness phase. The patient
has an established disease and is receiving care to stopthe disease from progressing.
8. ANS: 1
Health screening activities are designed to detect disease at an early stage so that
treatment canbegin before there is an opportunity for disease to spread or become
debilitating.
9. ANS: 1
The American Academy of Pediatrics take a targeted approach, recommending that
overweight children receive cholesterol screening, regardless of family history or other risk
factors for cardiovascular disease. The American Heart Association recommends that all adults
age 20 yearsor older have a fasting lipid panel at least once every 5 years. If totalcholesterol is
200 mg/dL orgreateror HDL is less than 40 mg/dLfrequent monitoring is required.
10. ANS: 2
Research has also demonstrated that in the face of difficult life events, some people develop
hardiness rather than vulnerability. Hardiness is a quality in which an individualexperiences
high levels of stress yet does not fall ill. There are three general characteristics of the hardy
person: control (belief in the ability to control the experience), commitment (feeling deeply
involved in the activity producing stress), and challenge (the ability to view the change as a
challenge to grow). These traits are
Field tests for running are good for children and can be utilized when assessing
cardiorespiratoryfitness. The step test is appropriate for adults. The 12-inch bench height is
too high for young children. The sit-and-reach test as well as range-of-motion exerciseswould
be appropriate when assessing flexibility.
4. ANS: 1
Leavell and Clark identified three levels of activities for health protection: primary,
secondary,and tertiary. Interventions are classified according to the point in the disease
process in which they occur.
5. ANS: 3
Muscle strength measures the amount of weight a muscle (or group of muscles) can move at
onetime. This is recorded as a ratio of weight pushed (or lifted) divided by body weight. A
woman weighing 132 pounds who is able to lift 72 pounds has a ratio of 72 divided by 132, or
0.55.
6. ANS: 2
Heavy and chronic use of alcohol and use of illicit drugs increase the risk of disease and injuries
and intentional death (suicide and homicide). Although alcohol as a depressant slows
metabolism, chronic alcohol use is more likely associated with poor nutrition, whichmay or
maynot lead to obesity. Chronic alcohol use causes damage to liver cells over time in the later
years. Alcohol intake is often associated with tobacco and recreational drug use; however, the
risk of unintentional injury, such as car accident, suicide, or violence, is more concerning than
smoking.
7. ANS: 3
Primary prevention activities are designed to prevent or slow the onset of disease. Activities
suchas eating healthy foods, exercising, wearing sunscreen, obeying seat-belt laws, and getting
immunizations are examples of primary level interventions. Secondary prevention activities
detect illness so it can be treated in the early stages. Tertiary prevention focuses on stopping
the disease from progressing and returning the individual to the pre-illness phase. The patient
has an established disease and is receiving care to stopthe disease from progressing.
8. ANS: 1
Health screening activities are designed to detect disease at an early stage so that
treatment canbegin before there is an opportunity for disease to spread or become
debilitating.
9. ANS: 1
The American Academy of Pediatrics take a targeted approach, recommending that
overweight children receive cholesterol screening, regardless of family history or other risk
factors for cardiovascular disease. The American Heart Association recommends that all adults
age 20 yearsor older have a fasting lipid panel at least once every 5 years. If totalcholesterol is
200 mg/dL orgreateror HDL is less than 40 mg/dLfrequent monitoring is required.
10. ANS: 2
Research has also demonstrated that in the face of difficult life events, some people develop
hardiness rather than vulnerability. Hardiness is a quality in which an individualexperiences
high levels of stress yet does not fall ill. There are three general characteristics of the hardy
person: control (belief in the ability to control the experience), commitment (feeling deeply
involved in the activity producing stress), and challenge (the ability to view the change as a
challenge to grow). These traits are
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associated with a strong resistance to negative feelings thatoccur under adverse
circumstances.
MULTIPLE RESPONSE
1. ANS: 2, 3, 4
circumstances.
MULTIPLE RESPONSE
1. ANS: 2, 3, 4
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The World Health Organization defines health as a state of complete physical, mental, and
socialwell-being, not merely the absence of disease of infirmity.
2. ANS: 1, 3, 4
Pender identified three variables that affect health promotion: individual characteristics
and experiences, behavior-specific cognitions and affect, and behavioral outcomes.
Levels of prevention were identified by Leavell and Clark; threelevels relate to health
protection. Thelevels differ based on their timing in the illness cycle.
3. ANS: 1, 3
The four overarching goals of Healthy People 2020 are to 1) increase the quality and years of
healthy life, free of disease, injury, and premature death, 2) eliminate health disparities and
improve health for all groups of people, 3) create physical and social environments forpeople
tolive a healthy life, and 4) promote healthy development for people in all stages of life.
4. ANS: 1, 2, 3, 4
The Wheels of Wellness model identifies the following dimensions of health: emotional,
intellectual, physical, spiritual, social/family, and occupational. A weekly discussion group
stimulates intellectual health. A relationship between local pastors and those living in
subsidizedhousing creates a climate for spiritual health. A tutorial program offered by seniors
to local children will facilitate occupational health. An on-site healthcare clinic addresses
physical health.
5. ANS: 1, 2, 3
Identifying a persons locus of control helps the nurse determine how to approach a client
abouthealth promotion. People who feel powerless about preventing illness are least likely to
engagein health promotion activities. People who respond to direction from respected
authorities 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 motivate toward positive
change.
6. ANS: 1, 2, 4
Health promotion programs may be categorized into four types: disseminating information;
programs for changing lifestyle and behavior; environmental control programs; and
wellnessappraisal and health risk assessment programs. Prescribing medications to treat
underlying disorders is an activity that fosters health focused at anindividual level rather than
at a groupprogram level.
7. ANS: 1, 2, 3, 4
Nurses promote health by acting as role models, counseling, providing health education,
andproviding and facilitating support.
1. ANS: secondary
Secondary prevention activities detect illness so that it can be treated in the early stages.
Healthactivities such as mammograms, testicular examinations, regular physical
examinations, blood pressure and diabetes screenings, and tuberculosis skin tests are
examples of secondary interventions. Primary prevention activities are designed to prevent
or slow the onset of disease and promote health. Activities such as eating healthy foods,
exercising, wearing sunscreen, obeying seat-belt laws, and getting immunizations are
examples of primary level interventions. Tertiary prevention focuses on stopping the disease
from progressing and returning the individual to the pre-illness phase.
socialwell-being, not merely the absence of disease of infirmity.
2. ANS: 1, 3, 4
Pender identified three variables that affect health promotion: individual characteristics
and experiences, behavior-specific cognitions and affect, and behavioral outcomes.
Levels of prevention were identified by Leavell and Clark; threelevels relate to health
protection. Thelevels differ based on their timing in the illness cycle.
3. ANS: 1, 3
The four overarching goals of Healthy People 2020 are to 1) increase the quality and years of
healthy life, free of disease, injury, and premature death, 2) eliminate health disparities and
improve health for all groups of people, 3) create physical and social environments forpeople
tolive a healthy life, and 4) promote healthy development for people in all stages of life.
4. ANS: 1, 2, 3, 4
The Wheels of Wellness model identifies the following dimensions of health: emotional,
intellectual, physical, spiritual, social/family, and occupational. A weekly discussion group
stimulates intellectual health. A relationship between local pastors and those living in
subsidizedhousing creates a climate for spiritual health. A tutorial program offered by seniors
to local children will facilitate occupational health. An on-site healthcare clinic addresses
physical health.
5. ANS: 1, 2, 3
Identifying a persons locus of control helps the nurse determine how to approach a client
abouthealth promotion. People who feel powerless about preventing illness are least likely to
engagein health promotion activities. People who respond to direction from respected
authorities 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 motivate toward positive
change.
6. ANS: 1, 2, 4
Health promotion programs may be categorized into four types: disseminating information;
programs for changing lifestyle and behavior; environmental control programs; and
wellnessappraisal and health risk assessment programs. Prescribing medications to treat
underlying disorders is an activity that fosters health focused at anindividual level rather than
at a groupprogram level.
7. ANS: 1, 2, 3, 4
Nurses promote health by acting as role models, counseling, providing health education,
andproviding and facilitating support.
1. ANS: secondary
Secondary prevention activities detect illness so that it can be treated in the early stages.
Healthactivities such as mammograms, testicular examinations, regular physical
examinations, blood pressure and diabetes screenings, and tuberculosis skin tests are
examples of secondary interventions. Primary prevention activities are designed to prevent
or slow the onset of disease and promote health. Activities such as eating healthy foods,
exercising, wearing sunscreen, obeying seat-belt laws, and getting immunizations are
examples of primary level interventions. Tertiary prevention focuses on stopping the disease
from progressing and returning the individual to the pre-illness phase.
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Chapter 2. Common Symptoms
Loading page 23...
1. The nurse is listening to the breath sounds of a patient with severe asthma. Air passing
throughnarrowed bronchioles would produce which of these adventitious sounds?
a. Wheezes
b. Bronchial sounds
c. Bronchophony
d. Whispered pectoriloquy
ANS: A
Wheezes are caused by air squeezed or compressed through passageways narrowed
almost toclosure by collapsing, swelling, secretions, or tumors, such as with acute
asthma or chronic emphysema.
2. A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the
nurse that he has had a runny nose for a week. When performing the physical assessment, the
nurse notes that the child has nasal flaring and sternal and intercostal retractions. The nurses
nextaction 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 ofearly
heartfailure.
ANS: B
The infant is an obligatory nose breather until the age of 3 months. Normally, no flaring ofthe
nostrils and no sternal or intercostal retraction occurs. Significant retractions of the sternum
and intercostal muscles and nasal flaring indicate increased inspiratory effort, as in
pneumonia, acuteairway obstruction, asthma, and atelectasis; therefore, immediate referral
to the physician is warranted. These signs do not indicate heart failure, and an assessment of
the infants feeding is not a priority at this time.
3. A teenage patient comes to the emergency department with complaints of an inability to
breathe and a sharp pain in the left side of his chest. The assessment findings include
cyanosis,tachypnea, tracheal deviation to the right, decreased tactile fremitus on the left,
hyperresonanceon the left, and decreased breath sounds on the left. The nurse interprets
that these assessment findings are consistent with:
a. Bronchitis.
b. Pneumothorax.
c. Acute pneumonia.
d. Asthmatic attack.
ANS: B
With a pneumothorax, free air in the pleural space causes partial or complete lung collapse.If
thepneumothorax is large, then tachypnea and cyanosis are evident. Unequal chest expansion,
decreased or absent tactile fremitus, tracheal deviation to the unaffected side, decreased chest
throughnarrowed bronchioles would produce which of these adventitious sounds?
a. Wheezes
b. Bronchial sounds
c. Bronchophony
d. Whispered pectoriloquy
ANS: A
Wheezes are caused by air squeezed or compressed through passageways narrowed
almost toclosure by collapsing, swelling, secretions, or tumors, such as with acute
asthma or chronic emphysema.
2. A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the
nurse that he has had a runny nose for a week. When performing the physical assessment, the
nurse notes that the child has nasal flaring and sternal and intercostal retractions. The nurses
nextaction 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 ofearly
heartfailure.
ANS: B
The infant is an obligatory nose breather until the age of 3 months. Normally, no flaring ofthe
nostrils and no sternal or intercostal retraction occurs. Significant retractions of the sternum
and intercostal muscles and nasal flaring indicate increased inspiratory effort, as in
pneumonia, acuteairway obstruction, asthma, and atelectasis; therefore, immediate referral
to the physician is warranted. These signs do not indicate heart failure, and an assessment of
the infants feeding is not a priority at this time.
3. A teenage patient comes to the emergency department with complaints of an inability to
breathe and a sharp pain in the left side of his chest. The assessment findings include
cyanosis,tachypnea, tracheal deviation to the right, decreased tactile fremitus on the left,
hyperresonanceon the left, and decreased breath sounds on the left. The nurse interprets
that these assessment findings are consistent with:
a. Bronchitis.
b. Pneumothorax.
c. Acute pneumonia.
d. Asthmatic attack.
ANS: B
With a pneumothorax, free air in the pleural space causes partial or complete lung collapse.If
thepneumothorax is large, then tachypnea and cyanosis are evident. Unequal chest expansion,
decreased or absent tactile fremitus, tracheal deviation to the unaffected side, decreased chest
Loading page 24...
expansion, hyperresonant percussion tones, and decreased or absent breath sounds arefound
withthe presence of pneumothorax.
4. The nurse has just recorded a positive iliopsoas test on a patient who has abdominal
pain. Thistest is used to confirm a(n):
a. Inflamed liver.
b. Perforated spleen.
c. Perforated appendix.
d. Enlarged gallbladder.
ANS: C
An 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: C
Pain indicates a pathologic condition or an injury and should never be considered something
thatan older adult should expect or tolerate. Pain is not a normal process ofaging, and no
evidence 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 to
these 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: B
The tonsils are the same color as the surrounding mucous membrane, although they look
moregranular and their surface shows deep crypts. Tonsillar tissue enlarges during childhood
until 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 a
lot. 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.
withthe presence of pneumothorax.
4. The nurse has just recorded a positive iliopsoas test on a patient who has abdominal
pain. Thistest is used to confirm a(n):
a. Inflamed liver.
b. Perforated spleen.
c. Perforated appendix.
d. Enlarged gallbladder.
ANS: C
An 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: C
Pain indicates a pathologic condition or an injury and should never be considered something
thatan older adult should expect or tolerate. Pain is not a normal process ofaging, and no
evidence 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 to
these 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: B
The tonsils are the same color as the surrounding mucous membrane, although they look
moregranular and their surface shows deep crypts. Tonsillar tissue enlarges during childhood
until 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 a
lot. 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.
Loading page 25...
ANS: D
In the infant, salivation starts at 3 months. The baby will drool for a few months before
learning 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 be
expected forthis patient?
a. Hypertrophy of the gums
b. Increased production of saliva
c. Decreased ability to identify odors
d. Finer and less prominent nasal hair
ANS: C
The sense of smell may be reduced because of a decrease in the number of olfactory nerve
fibers.Nasal hairs grow coarser and stiffer with aging. The gums may recede with aging, not
hypertrophy, and saliva production decreases.
9. The nurse is palpating the sinus areas. If the findings are normal, then the patient should
reportwhich sensation?
a. No sensation
b. Firm pressure
c. Pain during palpation
d. Pain sensation behind eyes
ANS: B The person should feel firm pressure but no pain. Sinus areas are tender to
palpation 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). He
has 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. BPHis
present in 1 in 10 men at the age of 40 years and increases with age. It is believed that the
hypertrophy is caused by hormonal imbalance that leads to the proliferation of benign
adenomas.The other responses are not appropriate.
11. A patient reports excruciating headache pain on one side of his head, especially around
his eye, forehead, and cheek that has lasted approximately to 2 hours, occurringonce or
twice eachday. The nurse should suspect:
a. Hypertension.
In the infant, salivation starts at 3 months. The baby will drool for a few months before
learning 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 be
expected forthis patient?
a. Hypertrophy of the gums
b. Increased production of saliva
c. Decreased ability to identify odors
d. Finer and less prominent nasal hair
ANS: C
The sense of smell may be reduced because of a decrease in the number of olfactory nerve
fibers.Nasal hairs grow coarser and stiffer with aging. The gums may recede with aging, not
hypertrophy, and saliva production decreases.
9. The nurse is palpating the sinus areas. If the findings are normal, then the patient should
reportwhich sensation?
a. No sensation
b. Firm pressure
c. Pain during palpation
d. Pain sensation behind eyes
ANS: B The person should feel firm pressure but no pain. Sinus areas are tender to
palpation 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). He
has 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. BPHis
present in 1 in 10 men at the age of 40 years and increases with age. It is believed that the
hypertrophy is caused by hormonal imbalance that leads to the proliferation of benign
adenomas.The other responses are not appropriate.
11. A patient reports excruciating headache pain on one side of his head, especially around
his eye, forehead, and cheek that has lasted approximately to 2 hours, occurringonce or
twice eachday. The nurse should suspect:
a. Hypertension.
Loading page 26...
b. Cluster headaches.
c. Tension headaches.
d. Migraine headaches.
ANS: B Cluster headaches produce pain around the eye, temple, forehead, and cheek and
areunilateral and always on the same side of the head. They are excruciating and occur once
or 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 her
Adamsapple that seems to be getting bigger. During the assessment, the finding that leadsthe
nurse 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 of
asingle nodule in a young person. However, cancerous nodules tend to be hard and fixed
to surrounding structures, not mobile.
Chapter 3. Preoperative Evaluation & Perioperative Management
MULTIPLE CHOICE
1. The nurse is identifying diagnoses appropriate for a client scheduled for a surgical
procedure.Which of the following is a diagnosis commonly used for preoperative client?
c. Tension headaches.
d. Migraine headaches.
ANS: B Cluster headaches produce pain around the eye, temple, forehead, and cheek and
areunilateral and always on the same side of the head. They are excruciating and occur once
or 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 her
Adamsapple that seems to be getting bigger. During the assessment, the finding that leadsthe
nurse 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 of
asingle nodule in a young person. However, cancerous nodules tend to be hard and fixed
to surrounding structures, not mobile.
Chapter 3. Preoperative Evaluation & Perioperative Management
MULTIPLE CHOICE
1. The nurse is identifying diagnoses appropriate for a client scheduled for a surgical
procedure.Which of the following is a diagnosis commonly used for preoperative client?
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1. Anxiety
2. Sleep deprivation
3. Excess fluid volume
4. Disturbed body image
ANS: 1
The preoperative experience may be one of the most tension-producing periods of
hospitalization. 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 the
intraoperativephase of care which begins when the client:
1. signs the surgical consent form.
2. arrives at the surgical suite doors.
3. is transferred to the postanesthesia care unit.
4. accepts that surgery is pending.
ANS: 2
The preoperative period ends and the intraoperative period begins when the patient andfamily
are at the door to the surgical suites. Intraoperative care does not begin when the client signs
thesurgical consent form, is transferred to the postanesthesia care unit, or accepts that
surgery is pending.
3. The nurse is ensuring that a client is able to make knowledgeable decisions
regarding an upcoming surgery and can provide informed consent. What is the
responsibility of the nurseregarding informed consent?
1. Explain the surgical options
2. Explain the operative risks
2. Sleep deprivation
3. Excess fluid volume
4. Disturbed body image
ANS: 1
The preoperative experience may be one of the most tension-producing periods of
hospitalization. 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 the
intraoperativephase of care which begins when the client:
1. signs the surgical consent form.
2. arrives at the surgical suite doors.
3. is transferred to the postanesthesia care unit.
4. accepts that surgery is pending.
ANS: 2
The preoperative period ends and the intraoperative period begins when the patient andfamily
are at the door to the surgical suites. Intraoperative care does not begin when the client signs
thesurgical consent form, is transferred to the postanesthesia care unit, or accepts that
surgery is pending.
3. The nurse is ensuring that a client is able to make knowledgeable decisions
regarding an upcoming surgery and can provide informed consent. What is the
responsibility of the nurseregarding informed consent?
1. Explain the surgical options
2. Explain the operative risks
Loading page 28...
3. Describe the operative procedure to be done
4. Witness a patients signature
ANS: 4
The nurse may concurrently sign that he has witnessed a patients signature. It is thephysiciansresponsibility to
explain the other answer choices.
PTS: 1 DIF: Apply REF: Decision Strategies and Informed Consent
4.A client being prepared for surgery has a pulse oximeter placed on one digit of his
hand. Thenurse is applying this device to monitor the clients:
1. oxygen level.
2. heart rate.
3. blood pressure.
4. urine output.
ANS: 1
Pulse 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: Trends
5.A client is scheduled for surgery in 2 weeks. Which of the following should the nurse
instructthe client regarding healthy lifestyle behaviors?
1. Eat nutritious meals.
2. If obese, cut calories before the surgery.
3. If sedentary, exercise more before the surgery.
4. Stop all prescribed medications.
4. Witness a patients signature
ANS: 4
The nurse may concurrently sign that he has witnessed a patients signature. It is thephysiciansresponsibility to
explain the other answer choices.
PTS: 1 DIF: Apply REF: Decision Strategies and Informed Consent
4.A client being prepared for surgery has a pulse oximeter placed on one digit of his
hand. Thenurse is applying this device to monitor the clients:
1. oxygen level.
2. heart rate.
3. blood pressure.
4. urine output.
ANS: 1
Pulse 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: Trends
5.A client is scheduled for surgery in 2 weeks. Which of the following should the nurse
instructthe client regarding healthy lifestyle behaviors?
1. Eat nutritious meals.
2. If obese, cut calories before the surgery.
3. If sedentary, exercise more before the surgery.
4. Stop all prescribed medications.
Loading page 29...
ANS: 1
The client should be encouraged to adopt healthy dietary, rest, and exercise habits beforethe
surgery. A client who has not followed healthy lifestyle habits should not suddenly make
thesechanges before a surgical procedure. The nurse should encourage the client to eat
nutritious meals. A client who is obese should not be encouraged to cut calories before the
surgery. The client who is sedentary should not be encouraged to suddenly exercise before
the surgery. The client should not be instructed to stop prescribed medications unless a
physician has prescribedthis action.
PTS: 1 DIF: Apply REF: Time Frames and Tasks
6. The nurse wants to reduce the stress level for a preoperative client. Which of the
followingcommunication techniques can the nurse use to achieve this result?
1. Allow the client to be alone before the surgery.
2.
Observe and ask the client if there is anything that can be done to help
reduce heranxiety.
3. Refer to the client by her first name.
4. Make tasteful jokes or comments to help the client laugh.
ANS: 2
Strategies to reduce preoperative stress include observing and asking the client if there is
anything that can be done to help reduce her anxiety. Leaving the client alone before the
surgerywill not help reduce stress. Referring to the client by her first name might be
considered unprofessional and should not be done. Making jokes is also not a professional
behavior and should not be done by the nurse.
PTS: 1 DIF: Apply REF: Nurse/Patient Communication
7. Which of the following can the nurse do to help an elderly client scheduled for a
surgicalprocedure?
1. Work at a slower pace.
2. Speed up the pace so the client has time to rest.
3. Talk to family members and leave the client alone.
The client should be encouraged to adopt healthy dietary, rest, and exercise habits beforethe
surgery. A client who has not followed healthy lifestyle habits should not suddenly make
thesechanges before a surgical procedure. The nurse should encourage the client to eat
nutritious meals. A client who is obese should not be encouraged to cut calories before the
surgery. The client who is sedentary should not be encouraged to suddenly exercise before
the surgery. The client should not be instructed to stop prescribed medications unless a
physician has prescribedthis action.
PTS: 1 DIF: Apply REF: Time Frames and Tasks
6. The nurse wants to reduce the stress level for a preoperative client. Which of the
followingcommunication techniques can the nurse use to achieve this result?
1. Allow the client to be alone before the surgery.
2.
Observe and ask the client if there is anything that can be done to help
reduce heranxiety.
3. Refer to the client by her first name.
4. Make tasteful jokes or comments to help the client laugh.
ANS: 2
Strategies to reduce preoperative stress include observing and asking the client if there is
anything that can be done to help reduce her anxiety. Leaving the client alone before the
surgerywill not help reduce stress. Referring to the client by her first name might be
considered unprofessional and should not be done. Making jokes is also not a professional
behavior and should not be done by the nurse.
PTS: 1 DIF: Apply REF: Nurse/Patient Communication
7. Which of the following can the nurse do to help an elderly client scheduled for a
surgicalprocedure?
1. Work at a slower pace.
2. Speed up the pace so the client has time to rest.
3. Talk to family members and leave the client alone.
Loading page 30...
4. Send them to the surgical holding area inadvance.
ANS: 1
When caring for elderly clients, pace is important. Nurses should slow the pace. The nurse
should not ignore the client. The nurse should also not send the client to the surgical holding
areain advance since this could prove to be uncomfortable for the elderly client.
PTS:1DIF:ApplyREF:Age-Related Issues
8. The nurse is concerned that a client scheduled for surgery will be at risk for
hypothermia.Which of the following did the nurse assess in this client to determinethe
risk?
1. Client is a vegetarian.
2. Client exercises 5 days a week for 30 minutes.
3. Client has a history of congestive heart failure.
4. Clint is 48 years old.
ANS: 3
Clients at risk for hypothermia include the very young, the very old, those with a history of
heartdisease, those with a bleeding tendency, having complex surgery, and having surgeryon a
largebody area that will be exposed. Being a vegetarian or exercising does not predispose a
client to developing hypothermia during surgery.
PTS:1DIF:AnalyzeREF:Environmental Safety
9. The nurse is concerned that a client may have an undocumented allergy to latex when
which ofthe following is assessed?
1. Recent episode of appendicitis
2. Recovered from bronchitis 3 months ago
3. Allergy to specific foods
4. Does not like to wear wool clothing
ANS: 1
When caring for elderly clients, pace is important. Nurses should slow the pace. The nurse
should not ignore the client. The nurse should also not send the client to the surgical holding
areain advance since this could prove to be uncomfortable for the elderly client.
PTS:1DIF:ApplyREF:Age-Related Issues
8. The nurse is concerned that a client scheduled for surgery will be at risk for
hypothermia.Which of the following did the nurse assess in this client to determinethe
risk?
1. Client is a vegetarian.
2. Client exercises 5 days a week for 30 minutes.
3. Client has a history of congestive heart failure.
4. Clint is 48 years old.
ANS: 3
Clients at risk for hypothermia include the very young, the very old, those with a history of
heartdisease, those with a bleeding tendency, having complex surgery, and having surgeryon a
largebody area that will be exposed. Being a vegetarian or exercising does not predispose a
client to developing hypothermia during surgery.
PTS:1DIF:AnalyzeREF:Environmental Safety
9. The nurse is concerned that a client may have an undocumented allergy to latex when
which ofthe following is assessed?
1. Recent episode of appendicitis
2. Recovered from bronchitis 3 months ago
3. Allergy to specific foods
4. Does not like to wear wool clothing
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