Terms in this set (13)

Question 1 See full question

A client with an esophageal stricture is about to undergo esophageal dilatation. As the bougies are passed down the esophagus, the nurse should instruct the client to do which action to minimize the vomiting urge?

You Selected:

Take long, slow breaths
Correct response:

Take long, slow breaths
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1253.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1253

Question 2 See full question

To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction?

You Selected:

"Take antacids with meals."
Correct response:

"Avoid coffee and alcoholic beverages."
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, pp. 1251-1252.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1251-1252

Question 3 See full question

When caring for a client with the nursing diagnosis Impaired swallowing related to neuromuscular impairment, the nurse should:

You Selected:

elevate the head of the bed 90 degrees during meals.
Correct response:

elevate the head of the bed 90 degrees during meals.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1255.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1255

Question 4 See full question

Which of the following is the primary symptom of achalasia?

You Selected:

Difficulty swallowing
Correct response:

Difficulty swallowing
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1250.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1250

Question 5 See full question

The term for a reddened circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis is a

You Selected:

chancre.
Correct response:

chancre.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1238.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1238

Question 6 See full question

A client has a cheesy white plaque in the mouth. The plaque looks like milk curds and can be rubbed off. The best nursing intervention is to

You Selected:

Instruct the client to swish prescribed nystatin (Mycostatin) solution for 1 minute.
Correct response:

Instruct the client to swish prescribed nystatin (Mycostatin) solution for 1 minute.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1238.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1238

Question 7 See full question

A client has a radical neck dissection to treat cancer of the neck. The nurse develops the care plan and includes all the following diagnoses. The nurse identifies the highest priority diagnosis as

You Selected:

Impaired tissue integrity related to surgical intervention
Correct response:

Ineffective airway clearance related to obstruction by mucus
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, pp. 1246-1247.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1246-1247

Question 8 See full question

The client has returned to the floor following a radical neck dissection. Anesthesia has worn off. It is most important for the nurse to

You Selected:

Place the client in the Fowler's position.
Correct response:

Place the client in the Fowler's position.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1246.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1246

Question 9 See full question

A client has a new order for metoclorpramide (Reglan). The nurse identifies that this medication should not be used long term and only in cases where all other options have been exhausted. This is because this medication has what type of potential side effect?

You Selected:

Extrapyramidal
Correct response:

Extrapyramidal
Explanation:

Reference:

Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 12th ed. Philadelphia: Lippincott Williams & Wilkins, 2010, Chapter 35: Management of Patients with Oral and Esophageal Disorders, p. 1015.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1015

Question 10 See full question

A client has a new order for metoclorpramide (Reglan). The nurse knows that this medication should not be used long term and only in cases where all other options have been exhausted. This is because this medication has the potential for extrapyramidal side effects. Extrapyramidal side effects include which of the following?

You Selected:

Uncontrolled rhythmic movements of the face or limbs
Correct response:

Uncontrolled rhythmic movements of the face or limbs
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1254.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1254

Question 11 See full question

A client with a disorder of the oral cavity cannot tolerate tooth brushing or flossing. Which of the following strategies can the nurse employ to assist this client?

You Selected:

Provide the client with an irrigating solution of baking soda and warm water.
Correct response:

Provide the client with an irrigating solution of baking soda and warm water.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1243.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1243

Question 12 See full question

A nurse is performing health assessment with a client during an outpatient clinic visit. The most concerning client statement to the nurse is:

You Selected:

"Food seems to be getting stuck in my throat."
Correct response:

"Food seems to be getting stuck in my throat."
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1250.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1250

Question 13 See full question

Cardiac complications, which may occur following resection of an esophageal tumor, are associated with irritation of which nerve at the time of surgery?

You Selected:

Vagus
Correct response:

Vagus
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1258.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1258

Question 14 See full question

Paul Cavanagh, a 63-year-old retired teacher, had oral cancer and had extensive surgery to excise the malignancy. Although his surgery was deemed successful, it was quite disfiguring and incapacitating. What is essential to Mr. Cavanagh and his family?

You Selected:

Having a courageous attitude
Correct response:

Time to mourn, accept, and adjust to the loss
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients with Oral and Esophageal Disorders, p. 1244.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1244

Question 15 See full question

A nurse is reviewing dietary guidelines with a client who recently had Roux-en-Y gastric bypass (RYGB) surgery. Which of the following would be included? Select all that apply.

You Selected:

Encourage consumption of foods such as doughy breads, pasta, rice, skins and seeds of fruits and vegetables, nuts, and popcorn.
Correct response:

Gradually progress to five or six small meals daily, with each feeding providing protein, fat, and complex carbohydrate. Restrict total amount to less than one cup.
Avoid all sweets.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1276.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1276

Question 16 See full question

Which of the following is an accurate statement regarding cancer of the esophagus?

You Selected:

Chronic irritation of the esophagus is a known risk factor.
Correct response:

Chronic irritation of the esophagus is a known risk factor.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1256.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1256

Question 17 See full question

An older adult patient who has been living at home alone is diagnosed with parotitis. What causative bacteria does the nurse suspect is the cause of the parotitis?

You Selected:

Staphylococcus aureus
Correct response:

Staphylococcus aureus
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1241.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1241

Question 18 See full question

An elderly patient is diagnosed with parotitis. The nurse is aware that this bacterial infection is most likely caused by:

You Selected:

Staphylococcus aureus.
Correct response:

Staphylococcus aureus.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1241.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1241

Question 19 See full question

Immediate medical and nursing management is necessary for a patient who has ingested a corrosive substance and experienced a chemical burn. Select the first response.

You Selected:

Maintain a patent airway.
Correct response:

Maintain a patent airway.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, pp. 1253.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1253

Question 20 See full question

One way for the nurse to confirm placement of a nasogastric tube is to test the pH of the tube aspirate. The nurse knows that tube placement in the lungs is indicated with a pH of:

You Selected:

4
Correct response:

6
Explanation:

The pH of gastric aspirate is less than 4. The pH of respiratory aspirate is 6 or greater.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 45: Digestive and Gastrointestinal Treatment Modalities, p. 1218.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1218

Question 1 See full question

When assessing a client during a routine checkup, the nurse reviews the history and notes that the client had aphthous stomatitis at the time of the last visit. Aphthous stomatitis is best described as:

You Selected:

a canker sore of the oral soft tissues.
Correct response:

a canker sore of the oral soft tissues.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1238.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1238

Question 2 See full question

Regarding oral cancer, the nurse provides health teaching to inform the patient that

You Selected:

a typical lesion is soft and craterlike.
Correct response:

many oral cancers produce no symptoms in the early stages.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1242.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1242

Question 3 See full question

A client has a new order for metoclorpramide (Reglan). The nurse identifies that this medication can be safely administered for which conditon?

You Selected:

Gastroesophageal reflux disease
Correct response:

Gastroesophageal reflux disease
Explanation:

Question 4 See full question

The nurse is reviewing the chart of a client with swallowing problems. Which of the following factors would raise suspicion that the client has cancer of the esophagus? Choose all that apply.

You Selected:

Age 72 years
Male gender
Previous treatment for gastroesophageal reflux disease
Smoking history of 20 years
Correct response:

Smoking history of 20 years
Male gender
Previous treatment for gastroesophageal reflux disease
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1242.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1242

Question 5 See full question

A client with anorexia complains of constipation. Which of the following nursing measures would be most effective in helping the client reduce constipation?

You Selected:

Assist client to increase dietary fiber.
Correct response:

Assist client to increase dietary fiber.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 45: Digestive and Gastrointestinal Treatment Modalities, p. 1220.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1220

Question 6 See full question

The most common symptom of esophageal disease is which of the following?

You Selected:

Dysphagia
Correct response:

Dysphagia
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1250.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1250

Question 7 See full question

A patient with gastroesophageal reflux disease (GERD) comes to the physician's office with complaints of a burning sensation in the esophagus. The nurse documents that the patient is experiencing which of the following?

You Selected:

Pyrosis
Correct response:

Pyrosis
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1254.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1254

Question 8 See full question

A nurse caring for a patient who has had radical neck surgery notices an abnormal amount of serosanguineous secretions in the wound suction unit during the first postoperative day. An expected normal amount of drainage is:

You Selected:

Between 120 and 160 mL.
Correct response:

Approximately 80 to 120 mL.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1247.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1247

Question 9 See full question

During postoperative neck dissection assessment, the nurse notices excessive bleeding from the dressing site. She suspects possible carotid artery rupture and takes the immediate first step to:

You Selected:

Apply pressure to the bleeding site or major associated vessel.
Correct response:

Apply pressure to the bleeding site or major associated vessel.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, pp. 1248-9.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1248-9

Question 10 See full question

A patient has been diagnosed with a hiatal hernia. The nurse explains the diagnosis to the patient and his family by telling them that a hernia is a (an):

You Selected:

Protrusion of the upper stomach into the lower portion of the thorax.
Correct response:

Protrusion of the upper stomach into the lower portion of the thorax.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, pp. 1251.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1251

Question 1 See full question

Which of the following is an accurate statement regarding cancer of the esophagus?

You Selected:

Chronic irritation of the esophagus is a known risk factor.
Correct response:

Chronic irritation of the esophagus is a known risk factor.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1256.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1256

Question 2 See full question

Postoperatively, a patient with a radical neck dissection should be placed in which position?

You Selected:

Fowler's
Correct response:

Fowler's
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1246.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1246

Question 3 See full question

The client is postoperative following a graft reconstruction of the neck. It is most important for the nurse to

You Selected:

Assess the graft for color and temperature.
Correct response:

Assess the graft for color and temperature.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1243.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1243

Question 4 See full question

Which of the following is one of the first clinical manifestations of esophageal cancer?

You Selected:

Increasing difficulty is swallowing
Correct response:

Increasing difficulty is swallowing
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1257.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1257

Question 5 See full question

James Jaeger, a 59-year-old carpenter, is being seen by a physician in your oncology group with a diagnosis of oral cancer. During your client education, Mr. Jaeger tells you that he is upset that he didn't recognize any early signs or symptoms of his disease. What do you tell Mr. Jaeger about the early stage of his cancer?

You Selected:

There are usually no symptoms.
Correct response:

There are usually no symptoms.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients with Oral and Esophageal Disorders, p. 1242.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1242

Question 6 See full question

Paul Cavanagh, a 63-year-old retired engineer, has oral cancer and is recovering from extensive surgery to excise the malignancy. While in the hospital where you practice nursing, you have specific goals for your nursing management of Mr. Cavanagh. Which of the following interventions is the focus of your attention? Select all that apply.

You Selected:

Maintaining Mr. Cavanagh's airway
Correct response:

Maintaining Mr. Cavanagh's airway
Promoting adequate caloric and fluid intake
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients with Oral and Esophageal Disorders, p. 1243.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1243

Question 7 See full question

Postoperatively, a patient with a radical neck dissection should be placed in which position?

You Selected:

Fowler's
Correct response:

Fowler's
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1246.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1246

Question 8 See full question

The nurse is caring for patient scheduled to undergo radical neck dissection. During preoperative teaching, the nurse includes that which of the following as associated complications?

You Selected:

Shoulder drop
Correct response:

Shoulder drop
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1245.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1245

Question 9 See full question

A nurse caring for a patient who has had radical neck surgery notices an abnormal amount of serosanguineous secretions in the wound suction unit during the first postoperative day. An expected normal amount of drainage is:

You Selected:

Approximately 80 to 120 mL.
Correct response:

Approximately 80 to 120 mL.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1247.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1247

Question 10 See full question

A nurse practitioner, who is treating a patient with GERD, knows that responsiveness to this drug classification is validation of the disease. The drug classification is:

You Selected:

Antacids
Correct response:

Proton pump inhibitors.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, pp. 1254.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1254

Question 1 See full question

Which of the following terms is used to describe stone formation in a salivary gland, usually the submandibular gland?

You Selected:

Sialolithiasis
Correct response:

Sialolithiasis
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1242.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1242

Question 2 See full question

A client in the emergency department reports that a piece of meat became stuck in the throat while eating. The nurse notes the client is anxious with respirations at 30 breaths/min, frequent swallowing, and little saliva in the mouth. An esophagogastroscopy with removal of foreign body is scheduled for today. The first activity of the nurse is to:

You Selected:

Assess lung sounds bilaterally.
Correct response:

Assess lung sounds bilaterally.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1253.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1253

Question 3 See full question

Which of the following assessment findings would be most important for indicating dumping syndrome in a postgastrectomy client?

You Selected:

Persistent loose stools, chills, hiccups after eating
Correct response:

Weakness, diaphoresis, diarrhea 90 minutes after eating
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients with Oral and Esophageal Disorders, p. 1258.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1258

Question 4 See full question

The nurse is creating a plan of care for a patient who is not able to tolerate brushing his teeth. The nurse includes in the plan of care which of the following mouth irrigations?

You Selected:

Baking soda and water
Correct response:

Baking soda and water
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1243.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1243

Question 5 See full question

The nurse is caring for a patient during the postoperative period following radical neck dissection. Which of the following should be reported to the physician?

You Selected:

Serous drainage on the dressing
Correct response:

High epigastric pain and/or discomfort
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 46: Management of Patients With Oral and Esophageal Disorders, p. 1248.

Chapter 46: Management of Patients With Oral and Esophageal Disorders - Page 1248
Question 1 See full question

A nurse is caring for a client with active upper GI bleeding. What is the appropriate diet for this client during the first 24 hours after admission?

You Selected:

Nothing by mouth
Correct response:

Nothing by mouth
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1263.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1263

Question 2 See full question

As a nurse completes the admission assessment of a client admitted for gastric bypass surgery, the client states, "Finally! I'll be thin and able to eat without much concern." How should the nurse intervene?

You Selected:

Evaluate the client's understanding of the procedure.
Correct response:

Evaluate the client's understanding of the procedure.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1274.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1274

Question 3 See full question

When caring for a client with an acute exacerbation of a peptic ulcer, the nurse finds the client doubled up in bed with severe pain to his right shoulder. The intial appropriate action by the nurse is to

You Selected:

Assess the client's abdomen and vital signs.
Correct response:

Assess the client's abdomen and vital signs.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1271.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1271

Question 4 See full question

Which of the following clients is at highest risk for peptic ulcer disease?

You Selected:

Client with blood type O
Correct response:

Client with blood type O
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1266.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1266

Question 5 See full question

A client with peptic ulcer disease must begin triple medication therapy. For how long will the client follow this regimen?

You Selected:

7 to 9 days
Correct response:

10 to 14 days
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1267.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1267

Question 6 See full question

A client is recovering from gastric surgery. Toward what goal should the nurse progress the client's enteral intake?

You Selected:

Six small meals daily with 120 mL fluid between meals
Correct response:

Six small meals daily with 120 mL fluid between meals
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1276.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1276

Question 7 See full question

Symptoms associated with pyloric obstruction include all of the following except:

You Selected:

Anorexia
Correct response:

Diarrhea
Explanation:

Question 8 See full question

Which of the following medications is classified as a proton pump inhibitor (PPI)?

You Selected:

Cimetidine
Correct response:

Omeprazole
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1264.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1264

Question 9 See full question

The nurse is conducting a community health education program on obesity. The nurse includes which of the following diseases/disorders in the program?

You Selected:

Obstructive sleep apnea
Correct response:

Obstructive sleep apnea
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1272.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1272

Question 10 See full question

A patient is in the hospital for the treatment of peptic ulcer disease. The nurse finds the patient vomiting and complaining of a sudden severe pain in the abdomen. The nurse then assesses a board-like abdomen. What does the nurse suspect these symptoms indicate?

You Selected:

Perforation of the peptic ulcer
Correct response:

Perforation of the peptic ulcer
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1271.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1271

Question 1 See full question

A nurse is providing follow-up teaching at a clinic visit for a client recovering from gastric resection. The client reports sweating, diarrhea, nausea, palpitations, and the desire to lie down 15 to 30 minutes after meals. The nurse suspects the client has:

You Selected:

dumping syndrome.
Correct response:

dumping syndrome.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1277.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1277

Question 2 See full question

A nurse is caring for a client who had gastric bypass surgery 2 days ago. Which assessment finding requires immediate intervention?

You Selected:

The client's right lower leg is red and swollen.
Correct response:

The client's right lower leg is red and swollen.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1276.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1276

Question 3 See full question

Symptoms associated with pyloric obstruction include all of the following except:

You Selected:

Diarrhea
Correct response:

Diarrhea
Explanation:

Question 4 See full question

A nurse is caring for a client who is undergoing a diagnostic workup for a suspected GI problem. The client reports gnawing epigastric pain following meals and heartburn. The nurse suspects the client has:

You Selected:

peptic ulcer disease.
Correct response:

peptic ulcer disease.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1266.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1266

Question 5 See full question

A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The nurse expects this client's stools to be:

You Selected:

bright red.
Correct response:

black and tarry.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, pp. 1262-1263.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1262-1263

Question 6 See full question

A nurse is teaching a group of middle-aged men about peptic ulcers. When discussing risk factors for peptic ulcers, the nurse should mention:

You Selected:

alcohol abuse and smoking.
Correct response:

alcohol abuse and smoking.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1268.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1268

Question 7 See full question

Which of the following is the most successful treatment for gastric cancer?

You Selected:

Removal of the tumor
Correct response:

Removal of the tumor
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1282.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1282

Question 8 See full question

The nurse determines that teaching for the client with peptic ulcer disease has been effective when the client states:

You Selected:

"I have learned some relaxation strategies that decrease my stress."
Correct response:

"I have learned some relaxation strategies that decrease my stress."
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1270.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1270

Question 9 See full question

A nurse is teaching a client with gastritis about the need to avoid the intake of caffeinated beverages. The client asks why this is so important. Which of the following explanations from the nurse would be most accurate?

You Selected:

"Caffeine stimulates the central nervous system and thus gastric activity and secretions, which need to be minimized to promote recovery."
Correct response:

"Caffeine stimulates the central nervous system and thus gastric activity and secretions, which need to be minimized to promote recovery."
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1263.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1263

Question 10 See full question

Peptic ulcer disease occurs more frequently in people with which blood type?

You Selected:

O
Correct response:

O
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1265-1266.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1265-1266

Question 11 See full question

A client is admitted to the hospital with an exacerbation of his chronic gastritis. When assessing his nutritional status, the nurse should expect a deficiency in:

You Selected:

vitamin B12.
Correct response:

vitamin B12.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1263.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1263

Question 12 See full question

A client weighs 215 lbs and is 5' 8" tall. The nurse would calculate this client's body mass index (BMI) as which of the following?

You Selected:

32.7
Correct response:

32.7
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 5: Adult Health and Nutritional Assessment, p. 68.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 68

Question 13 See full question

Which of the following is a true statement regarding gastric cancer?

You Selected:

The prognosis for gastric cancer is good.
Correct response:

Most patients are asymptomatic during the early stage of the disease.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1265, 1278.
Question 14 See full question

A patient has been diagnosed with acute gastritis and asks the nurse what could have caused it. What is the best response by the nurse? (Select all that apply.)

You Selected:

"Is it possible that you are overusing aspirin."
"You may have ingested some irritating foods."
"It is a hereditary disease."
"It can be caused by ingestion of strong acids."
Correct response:

"It can be caused by ingestion of strong acids."
"You may have ingested some irritating foods."
"Is it possible that you are overusing aspirin."
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1262.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1262

Question 15 See full question

Which of the following medications used for the treatment of obesity prevents the reuptake of serotonin and norepinephrine?

You Selected:

Orlistat (Xenical)
Correct response:

Sibutramine hydrochloride (Meridia)
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1273.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1273

Question 16 See full question

A nursing student is caring for a client with gastritis. Which of the following would the student recognize as a common cause of gastritis? Choose all that apply.

You Selected:

Irritating foods
Overuse of aspirin
Ingestion of strong acids
Correct response:

Ingestion of strong acids
Irritating foods
Overuse of aspirin
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, pp. 1262-1263.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1262-1263

Question 17 See full question

A nurse is providing care for a client recovering from gastric bypass surgery. During assessment, the client exhibits pallor, perspiration, palpitations, headache, and feelings of warmth, dizziness, and drowsiness. The client reports eating 90 minutes ago. The nurse suspects:

You Selected:

Vasomotor symptoms associated with dumping syndrome
Correct response:

Vasomotor symptoms associated with dumping syndrome
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1277.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1277

Question 18 See full question

A nurse practitioner is considering pharmacological treatment options for a client with gastritis. Which of the following might limit the use of metronidazole (Flagyl) for this client? Select all that apply.

You Selected:

Allergy to penicillin
History of alcoholism
Diet high in dairy products
Current use of warfarin (Coumadin)
Correct response:

History of alcoholism
Current use of warfarin (Coumadin)
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1264.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1264

Question 19 See full question

Which of the following appears to be a significant factor in the development of gastric cancer?

You Selected:

Diet
Correct response:

Diet
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1278.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1278

Question 20 See full question

A client undergoes total gastrectomy. Several hours after surgery, the nurse notes that the client's nasogastric (NG) tube has stopped draining. How should the nurse respond?

You Selected:

Notify the physician.
Correct response:

Notify the physician.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1271.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1271

Question 1 See full question

A nurse is performing discharge teaching with a client who had a total gastrectomy. Which statement indicates the need for further teaching?

You Selected:

"I will have to take vitamin B12 shots up to 1 year after surgery."
Correct response:

"I will have to take vitamin B12 shots up to 1 year after surgery."
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1265.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1265

Question 2 See full question

A nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to:

You Selected:

drink liquids only between meals.
Correct response:

drink liquids only between meals.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1280.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1280

Question 3 See full question

Which of the following statements correctly identifies a difference between duodenal and gastric ulcers?

You Selected:

Malignancy is associated with duodenal ulcer.
Correct response:

Vomiting is uncommon in patients with duodenal ulcers.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1266.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1266

Question 4 See full question

Which of the following is a true statement regarding the nursing considerations in administration of Metronidazole (Flagyl)?

You Selected:

Flagyl decreases the effect of Coumadin.
Correct response:

It leaves a metallic taste in the mouth.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1264.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1264

Question 5 See full question

The nurse is preparing the discharge of a client who is newly diagnosed with a duodenal ulcer. His diagnostic tests were negative for H. pylori. A prescription for Pepcid is included in the discharge instructions. The nurse will instruct the client that the duration of treatment with this drug for duodenal ulcers is for how long?

You Selected:

6 weeks
Correct response:

6 weeks
Explanation:

Question 6 See full question

A client admitted for treatment of a gastric ulcer is being prepared for discharge. The client will follow a regimen of antacid therapy. Discharge teaching should include which instructions? Choose all that apply.

You Selected:

"Continue to take antacids even if your symptoms subside."
"You may be prescribed H2-receptor antagonists for up to 1 year."
"Be sure to take antacids with meals."
Correct response:

"Continue to take antacids even if your symptoms subside."
"You may be prescribed H2-receptor antagonists for up to 1 year."
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1265.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1265

Question 7 See full question

A client returns from the operating room after receiving extensive abdominal surgery. He has 1,000 mL of lactated Ringer's solution infusing via a central line. The physician orders the IV fluid to be infused at 125 mL/hr plus the total output of the previous hour. The drip factor of the tubing is 15 gtt/min, and the output for the previous hour was 75 mL via Foley catheter, 50 mL via nasogastric tube, and 10 mL via Jackson Pratt tube. For how many drops per mintue should the nurse set the IV flow rate to deliver the correct amount of fluid? Enter the correct number ONLY.

Your Response:

65
Correct response:

65
Explanation:

Reference:

Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 12th ed. Philadelphia: Lippincott Williams & Wilkins, 2010, Chapter 37: Management of Patients With Gastric and Duodenal Disorders, pp. 1060-1063.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1060-1063

Question 8 See full question

A nurse is caring for a client who has had extensive abdominal surgery and is in critical condition. The nurse notes that the complete blood count shows an 8 G/dL hemoglobin and a 30% hematocrit. Dextrose 5% in half-normal saline solution is infusing through a triple lumen central catheter at 125 mL/hr. The physician orders include the following:

Gentamicin 80 mg IV piggyback in 50 mL D5W over 30 minutes
Zantac 50 mg IV piggyback in 50 mL D5W over 30 minutes
One unit of 250 mL of PRBCs (packed red blood cells) over 3 hours
Flush the nasogastric tube with 30 mL normal saline every 2 hours.

How many milliliters should the nurse record as the intake for the 8-hour shift? Enter the correct number ONLY.

Your Response:

380
Correct response:

1470
Explanation:

Reference:

Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 12th ed. Philadelphia: Lippincott Williams & Wilkins, 2010, Chapter 37: Management of Patients With Gastric and Duodenal Disorders, pp. 1060-1063.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1060-1063

Question 9 See full question

Which of the following interventions are appropriate for clients with gastritis? Select all that apply.

You Selected:

Discourage cigarette smoking.
Use a calm approach to reduce anxiety.
Provide general education about how to prevent recurrences.
Correct response:

Use a calm approach to reduce anxiety.
Discourage cigarette smoking.
Notify the physician of inidicators of hemorrhagic gastritis.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1263.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1263

Question 10 See full question

A client with acute gastritis asks the nurse what might have caused the problem. Which of the following are possible causes?

You Selected:

Excessive alcohol intake
Radiation therapy
Dietary indiscretion
Overuse of allergy medicine
Correct response:

Dietary indiscretion
Excessive alcohol intake
Radiation therapy
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, pp. 1262-1263.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1262-1263

Question 11 See full question

A nurse is assessing a client who is interested in undergoing bariatric surgery. Which of the following are criteria for candidacy? Select all that apply.

You Selected:

No history of psychiatric illness
Understanding of required lifestyle changes
Body mass index (BMI) of 27
Correct response:

No history of psychiatric illness
Understanding of required lifestyle changes
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1273.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1273

Question 12 See full question

A client with active schizophrenia has developed acute gastritis after ingesting a strongly alkaline solution during a psychotic episode. Corrosion is extensive. Which of the following emergency treatments might the team working with this client use? Select all that apply.

You Selected:

Gastric lavage
Aluminum hydroxide
Correct response:

Diluted lemon juice
Diluted vinegar
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1263.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1263

Question 13 See full question

A client with peptic ulcer disease must begin triple medication therapy. For how long will the client follow this regimen?

You Selected:

10 to 14 days
Correct response:

10 to 14 days
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1267.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1267

Question 14 See full question

Which of the following is included as a dietary guideline for a patient who has had bariatric surgery?

You Selected:

Restrict total meal size to less than 1 cup.
Correct response:

Restrict total meal size to less than 1 cup.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1276.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1276

Question 15 See full question

A patient sustained second- and third-degree burns over 30% of the body surface area approximately 72 hours ago. What type of ulcer should the nurse be alert for while caring for this patient?

You Selected:

Curling's ulcer
Correct response:

Curling's ulcer
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1266.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1266

Question 16 See full question

The nurse advises the patient who has just been diagnosed with acute gastritis to:

You Selected:

Refrain from food until the GI symptoms subside.
Correct response:

Refrain from food until the GI symptoms subside.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1263.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1263

Question 17 See full question

The nurse practitioner suspects that a patient may have a gastric ulcer after completing a history and physical exam. Select an indicator that can be used to help establish the distinction.

You Selected:

Presence of H. pylori
Correct response:

Amount of hydrochloric acid (HCL) secretion in the stomach
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1266.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1266

Question 18 See full question

The nurse practitioner prescribes a histamine-2 receptor for a critically ill patient with a peptic ulcer. Select the drug that is considered the best choice for this category of patient.

You Selected:

Axid
Correct response:

Pepcid
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1264.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1264

Question 19 See full question

A nurse practitioner prescribes drug therapy for a patient with peptic ulcer disease. Choose the drug that can be used for 4 weeks and has a 90% chance of healing the ulcer.

You Selected:

Cimetidine (Tagamet)
Correct response:

Omeprazole (Prilosec)
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1267.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1267

Question 20 See full question

A health care provider counsels a patient about bariatric surgery. He recommends the Roux-en-Y gastric bypass. The nurse explains to the patient that this procedure involves which of the following?

You Selected:

Separation of the jejunum with an anastomosis
Correct response:

Separation of the jejunum with an anastomosis
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1273-5.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1273-5

Question 1 See full question

A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The nurse expects this client's stools to be:

You Selected:

black and tarry.
Correct response:

black and tarry.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, pp. 1262-1263.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1262-1263

Question 2 See full question

A nurse is caring for a client with active upper GI bleeding. What is the appropriate diet for this client during the first 24 hours after admission?

You Selected:

Nothing by mouth
Correct response:

Nothing by mouth
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1263.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1263

Question 3 See full question

When caring for a client with an acute exacerbation of a peptic ulcer, the nurse finds the client doubled up in bed with severe pain to his right shoulder. The intial appropriate action by the nurse is to

You Selected:

Assess the client's abdomen and vital signs.
Correct response:

Assess the client's abdomen and vital signs.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1271.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1271

Question 4 See full question

A client is prescribed a histamine (H2)-receptor antagonist. The nurse understands that the following are H2-receptor antagonists. Choose all that apply.

You Selected:

Nizatidithene (Axid)
Ranitidine (Zantac)
Cimetidine (Tagamet)
Famotidine (Pepcid)
Correct response:

Nizatidithene (Axid)
Ranitidine (Zantac)
Famotidine (Pepcid)
Cimetidine (Tagamet)
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1264.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1264

Question 5 See full question

A physician has written an order for ranitidine (Zantac), 300 mg once daily. The nurse schedules the medication for which time?

You Selected:

Before breakfast
Correct response:

At bedtime
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1264.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1264

Question 6 See full question

Which of the following clients is at highest risk for peptic ulcer disease?

You Selected:

Client with blood type O
Correct response:

Client with blood type O
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1266.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1266

Question 7 See full question

A client has recently been diagnosed with gastric cancer. He has a history of tobacco use and was diagnosed 10 years ago with pernicious anemia. He and his family are shocked about the possibility of this diagnosis because he has been asymptomatic prior to recent complaints of pain and multiple gastrointestinal symptoms. On palpation, the nurse notes two signs that confirm metastasis to the liver. Which of the following are signs? Choose all that apply.

You Selected:

Ascites
Sister Mary Joseph's nodules
Hepatomegaly
Correct response:

Ascites
Hepatomegaly
Explanation:

Question 8 See full question

A client is recovering from gastric surgery. Toward what goal should the nurse progress the client's enteral intake?

You Selected:

Six small meals daily with 120 mL fluid between meals
Correct response:

Six small meals daily with 120 mL fluid between meals
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1276.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1276

Question 9 See full question

Which of the following are signs/symptoms of perforation?

You Selected:

Sudden, severe upper abdominal pain
Correct response:

Sudden, severe upper abdominal pain
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1271.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1271

Question 10 See full question

A patient has been diagnosed with acute gastritis and asks the nurse what could have caused it. What is the best response by the nurse? (Select all that apply.)

You Selected:

"It can be caused by ingestion of strong acids."
"Is it possible that you are overusing aspirin."
"You may have ingested some irritating foods."
Correct response:

"It can be caused by ingestion of strong acids."
"You may have ingested some irritating foods."
"Is it possible that you are overusing aspirin."
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1262.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1262

Question 1 See full question

A nurse is teaching a group of middle-aged men about peptic ulcers. When discussing risk factors for peptic ulcers, the nurse should mention:

You Selected:

alcohol abuse and smoking.
Correct response:

alcohol abuse and smoking.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1268.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1268

Question 2 See full question

Why are antacids administered regularly, rather than as needed, in peptic ulcer disease?

You Selected:

To keep gastric pH at 3.0 to 3.5
Correct response:

To keep gastric pH at 3.0 to 3.5
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1268.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1268

Question 3 See full question

A nurse is providing care for a client recovering from gastric bypass surgery. During assessment, the client exhibits pallor, perspiration, palpitations, headache, and feelings of warmth, dizziness, and drowsiness. The client reports eating 90 minutes ago. The nurse suspects:

You Selected:

Vasomotor symptoms associated with dumping syndrome
Correct response:

Vasomotor symptoms associated with dumping syndrome
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1277.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1277

Question 4 See full question

A client is prescribed tetracycline to treat peptic ulcer disease. Which of the following instructions would the nurse give the client?

You Selected:

"Be sure to wear sunscreen while taking this medicine."
Correct response:

"Be sure to wear sunscreen while taking this medicine."
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1264.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1264

Question 5 See full question

Symptoms associated with pyloric obstruction include all of the following except:

You Selected:

Diarrhea
Correct response:

Diarrhea
Explanation:

Question 6 See full question

Which of the following appears to be a significant factor in the development of gastric cancer?

You Selected:

Diet
Correct response:

Diet
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1278.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1278

Question 7 See full question

Which of the following is the most successful treatment for gastric cancer?

You Selected:

Removal of the tumor
Correct response:

Removal of the tumor
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1282.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1282

Question 8 See full question

The nurse in the ED admits a patient with suspected gastric outlet obstruction. The patient's symptoms include nausea and vomiting. The nurse anticipates that the physician will issue which of the following orders?

You Selected:

Oral contrast
Correct response:

Nasogastric (NG) tube insertion
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1271.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1271

Question 9 See full question

A patient is scheduled for a Billroth I procedure for ulcer management. What does the nurse understand will occur when this procedure is performed?

You Selected:

A partial gastrectomy is performed with anastomosis of the stomach segment to the duodenum.
Correct response:

A partial gastrectomy is performed with anastomosis of the stomach segment to the duodenum.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1269.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1269

Question 10 See full question

A patient has a BMI ranger greater than 40 kg/m2. What would this patient's obesity classification be?

You Selected:

Class I
Correct response:

Class III
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 47: Management of Patients With Gastric and Duodenal Disorders, p. 1272.

Chapter 47: Management of Patients With Gastric and Duodenal Disorders - Page 1272
Question 1 See full question

A nurse is teaching an elderly client about good bowel habits. Which statement by the client indicates to the nurse that additional teaching is required?

You Selected:

"I need to use laxatives regularly to prevent constipation."
Correct response:

"I need to use laxatives regularly to prevent constipation."
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1288.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1288

Question 2 See full question

Which of the follow statements provide accurate information regarding cancer of the colon and rectum?

You Selected:

Rectal cancer affects more than twice as many people as colon cancer.
Correct response:

Cancer of the colon and rectum is the second most common type of internal cancer in the United States.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1318.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1318

Question 3 See full question

Which of the following is the most common presenting symptom of colon cancer?

You Selected:

Change in bowel habits
Correct response:

Change in bowel habits
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1318.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1318

Question 4 See full question

A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location?

You Selected:

Right lower quadrant
Correct response:

Right lower quadrant
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1295.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1295

Question 5 See full question

Which of the following is the most common symptom of a polyp?

You Selected:

Rectal bleeding
Correct response:

Rectal bleeding
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1327.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1327

Question 6 See full question

In women, which of the following types of cancer exceeds colorectal cancer?

You Selected:

Breast
Correct response:

Breast
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1319.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1319

Question 7 See full question

A client presents to the ED with acute abdominal pain, fever, nausea, and vomiting. During the client's examination, the lower left abdominal quadrant is palpated, causing the client to report pain in the RLQ. This positive sign is referred to as ________ and suggests the client may be experiencing ________.

You Selected:

McBurney's sign; acute appendicitis
Correct response:

Rovsing's sign; acute appendicitis
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1295.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1295

Question 8 See full question

The nurse is performing a community screening for colorectal cancer. Which of the following characteristics should the nurse include in the screening?

You Selected:

Familial polyposis
Correct response:

Familial polyposis
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1318.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1318

Question 9 See full question

The nurse is reinforcing diet teaching for a patient diagnosed with IBS. The nurse instructs the patient to include which of the following in his diet?

You Selected:

High-fiber diet
Correct response:

High-fiber diet
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1292.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1292

Question 10 See full question

The nurse is teaching a patient with an ostomy how to change the pouching system. Which of the following should the nurse include in the teaching of a patient with no peristomal skin irritation?

You Selected:

Apply barrier powder
Correct response:

Dry skin thoroughly after washing
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1313.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1313

Question 1 See full question

A nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. Which statement describes a healthy stoma?

You Selected:

"The stoma should remain swollen distal to the abdomen."
Correct response:

"At first, the stoma may bleed slightly when touched."
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1308.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1308

Question 2 See full question

A client is readmitted with an exacerbation of celiac disease 2 weeks after discharge. Which statement by the client indicates the need for a dietary consult?

You Selected:

"I didn't eat anything I shouldn't have; I just ate roast beef on rye bread."
Correct response:

"I didn't eat anything I shouldn't have; I just ate roast beef on rye bread."
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1293.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1293

Question 3 See full question

A patient who has undergone colostomy surgery is experiencing constipation. Which of the following interventions should a nurse consider for such a patient?

You Selected:

Suggest fluid intake of at least 2 L per day
Correct response:

Suggest fluid intake of at least 2 L per day
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1323.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1323

Question 4 See full question

A longitudinal tear or ulceration in the lining of the anal canal is termed a (an)

You Selected:

anal fissure.
Correct response:

anal fissure.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1328.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1328

Question 5 See full question

Celiac sprue is an example of which category of malabsorption?

You Selected:

Mucosal disorders causing generalized malabsorption
Correct response:

Mucosal disorders causing generalized malabsorption
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1293.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1293

Question 6 See full question

A client with anorexia complains of constipation. Which of the following nursing measures would be most effective in helping the client reduce constipation?

You Selected:

Provide adequate quantity of food.
Correct response:

Assist client to increase dietary fiber.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1286.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1286

Question 7 See full question

A nurse is preparing a presentation for a local community group of older adults about colon cancer. Which of the following would the nurse include as the primary characteristic associated with this disorder?

You Selected:

A change in bowel habits
Correct response:

A change in bowel habits
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1318.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1318

Question 8 See full question

The nurse is assessing a client for constipation. Which of the following is the first review that the nurse should conduct to identify the cause of constipation? Choose the correct option.

You Selected:

Review the client's current medications.
Correct response:

Review the client's usual pattern of elimination.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1286.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1286

Question 9 See full question

A client comes to the clinic complaining of not having a bowel movement in several days, abdominal cramping, and nausea. When the nurse puts the client on the stretcher, he vomits a large amount of fecal material. What should the first action by the nurse be?

You Selected:

Notify the physician.
Correct response:

Notify the physician.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1311.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1311

Question 10 See full question

A patient with irritable bowel syndrome has been having more frequent symptoms lately and is not sure what lifestyle changes may have occurred. What suggestion can the nurse provide to identify a trigger for the symptoms?

You Selected:

Keep a 1- to 2-week symptom and food diary to identify food triggers.
Correct response:

Keep a 1- to 2-week symptom and food diary to identify food triggers.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1293.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1293

Question 1 See full question

A client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, the nurse notes that the client's stoma appears dusky. How should the nurse interpret this finding?

You Selected:

Blood supply to the stoma has been interrupted.
Correct response:

Blood supply to the stoma has been interrupted.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1323.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1323

Question 2 See full question

A client with complaints of right lower quadrant pain is admitted to the emergency department. Blood specimens are drawn and sent to the laboratory. Which laboratory finding should be reported to the physician immediately?

You Selected:

White blood cell (WBC) count 22.8/mm3
Correct response:

White blood cell (WBC) count 22.8/mm3
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, pp. 1295-1296.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1295-1296

Question 3 See full question

Which client requires immediate nursing intervention? The client who:

You Selected:

presents with a rigid, boardlike abdomen.
Correct response:

presents with a rigid, boardlike abdomen.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1297.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1297

Question 4 See full question

Which of the following characteristics are risk factors for colorectal cancer?

You Selected:

Familial polyposis
Correct response:

Familial polyposis
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1318.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1318

Question 5 See full question

A client realizes that regular use of laxatives has greatly improved his bowel pattern. However, the nurse cautions this client against the prolonged use of laxatives for which reason?

You Selected:

The client's natural bowel function may become sluggish.
Correct response:

The client's natural bowel function may become sluggish.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1286.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1286

Question 6 See full question

When interviewing a client with internal hemorrhoids, which of the following would the nurse expect the client to report?

You Selected:

Pain
Correct response:

Rectal bleeding
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1329.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1329

Question 7 See full question

The nurse is caring for a patient diagnosed with abdominal perforation. Which of the following is a clinical manifestation of this disease process?

You Selected:

Hypotension
Correct response:

Hypotension
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1307.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1307

Question 8 See full question

A 74-year-old gentleman is a client on the hospital unit where you practice nursing. He is scheduled to undergo rhinoplasty in the morning, and you are completing his admission assessment and paperwork. He reports medications he uses on a daily basis, which you record on his chart. Which of his daily medications have the potential to result in constipation?

You Selected:

Laxative
Correct response:

Laxative
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1286.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1286

Question 9 See full question

A client realizes that regular use of laxatives has greatly improved his bowel pattern. However, the nurse cautions this client against the prolonged use of laxatives for which reason?

You Selected:

The client's natural bowel function may become sluggish.
Correct response:

The client's natural bowel function may become sluggish.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1286.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1286

Question 10 See full question

Common clinical manifestations of Crohn's disease include:

You Selected:

Abdominal pain and diarrhea.
Correct response:

Abdominal pain and diarrhea.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1302.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1302

Question 1 See full question

A nurse is caring for a client immediately following an appendectomy. The nurse should assign which nursing diagnosis the highest priority?

You Selected:

Excess fluid volume
Correct response:

Acute pain
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1296.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1296

Question 2 See full question

An elderly patient diagnosed with diarrhea is taking digoxin (Lanoxin). Which of the following electrolyte imbalances should the nurse be alert to?

You Selected:

Hypokalemia
Correct response:

Hypokalemia
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1290.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1290

Question 3 See full question

Which of the following would a nurse expect to assess in a client with peritonitis?

You Selected:

Board-like abdomen
Correct response:

Board-like abdomen
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, pp. 1296-1297.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1296-1297

Question 4 See full question

Effie Geitgey, a 93-year-old retired waitress, obsesses about the regularity of her bowel movements, which is a common complaint among the residents of the long-term care facility where you practice nursing. During one of your education sessions, you reinforce the medically acceptable definition of "regularity." What is the actual measurement of "regular"?

You Selected:

One bowel movement every other day
Correct response:

Stool consistency and client comfort are the proper measurements.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1286.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1286

Question 5 See full question

A client has noticed increased incidence of constipation since he broke his ankle and cannot complete his daily 3-mile walk. As his home care nurse, you complete your assessment and discuss the potential causes. During your client education session, what do you explain as the mechanical cause of his constipation?

You Selected:

Stool remaining in the large intestine too long
Correct response:

Stool remaining in the large intestine too long
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1286.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1286

Question 6 See full question

A client has developed an anorectal abscess. Which client is at most risk for the development of this type of abscess?

You Selected:

A client with Crohn's disease
Correct response:

A client with Crohn's disease
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1328.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1328

Question 7 See full question

The nurse is performing a rectal assessment and notices a longitudinal tear or ulceration in the lining of the anal canal. The nurse documents the finding as which of the following?

You Selected:

Anal fissure
Correct response:

Anal fissure
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1328.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1328

Question 8 See full question

The nurse is conducting a community education program on colorectal cancer. Which of the following statements should the nurse include in the program?

You Selected:

It is the third most common cancer in the United States.
Correct response:

It is the third most common cancer in the United States.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1318.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1318

Question 9 See full question

The nurse caring for an elderly patient diagnosed with diarrhea is administering and monitoring the patient's medications. Because one of the patient's medications is digitalis (digoxin [Lanoxin]), the nurse monitors the patient closely for which of the following?

You Selected:

Hypokalemia
Correct response:

Hypokalemia
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1290.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1290

Question 10 See full question

The nurse is teaching a patient with an ostomy how to change the pouching system. Which of the following should the nurse include in the teaching of a patient with no peristomal skin irritation?

You Selected:

Dry skin thoroughly after washing
Correct response:

Dry skin thoroughly after washing
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1313.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1313

Question 1 See full question

A client is admitted from the emergency department with complaints of severe abdominal pain and an elevated white blood cell count. The physician diagnoses appendicitis. The nurse knows the client is at greatest risk for:

You Selected:

rupture of the appendix.
Correct response:

rupture of the appendix.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1296.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1296

Question 2 See full question

A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, the nurse should stress the importance of:

You Selected:

increasing fluid intake to prevent dehydration.
Correct response:

increasing fluid intake to prevent dehydration.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1308, 1311.
Question 3 See full question

A patient is being treated for diverticulosis. Which of the following information should the nurse include in this patient's teaching plan?

You Selected:

Drink at least 8 to 10 large glasses of fluid every day
Correct response:

Drink at least 8 to 10 large glasses of fluid every day
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1299.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1299

Question 4 See full question

Which of the following is one of the primary symptoms of Irritable Bowel Syndrome (IBS)?

You Selected:

Diarrhea
Correct response:

Diarrhea
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1292.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1292

Question 5 See full question

A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location?

You Selected:

Right lower quadrant
Correct response:

Right lower quadrant
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1295.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1295

Question 6 See full question

Which of the following will the nurse observe as symptoms of perforation in a patient with intestinal obstruction?

You Selected:

Decreased blood pressure
Correct response:

Sudden, sustained abdominal pain
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1299.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1299

Question 7 See full question

Vomiting results in which of the following acid-base imbalances?

You Selected:

Metabolic alkalosis
Correct response:

Metabolic alkalosis
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1317.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1317

Question 8 See full question

A 43-year-old man is seen in the office where you work with complaints of severe pain and bleeding while having a bowel movement. Upon inspection, his healthcare provider notes a linear tear in the anal canal tissue. While reviewing with him the medical management for his condition, he asks you to repeat the name of the condition. The nurse will most likely tell him that he has been diagnosed with a ________.

You Selected:

fistula
Correct response:

fissure
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1328.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1328

Question 9 See full question

The nurse is assessing a patient for constipation. Which of the following is the first factor the nurse should review to identify the cause of constipation?

You Selected:

Usual pattern of elimination
Correct response:

Usual pattern of elimination
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1289.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1289

Question 10 See full question

The nurse is performing a community screening for colorectal cancer. Which of the following characteristics should the nurse include in the screening?

You Selected:

Familial polyposis
Correct response:

Familial polyposis
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1318.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1318

Question 1 See full question

Diet therapy for patients diagnosed with IBS include which of the following?

You Selected:

High-fiber diet
Correct response:

High-fiber diet
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1292.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1292

Question 2 See full question

Which of the following is the most common presenting symptom of colon cancer?

You Selected:

Change in bowel habits
Correct response:

Change in bowel habits
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1318.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1318

Question 3 See full question

A nurse is preparing a presentation for a local community group of older adults about colon cancer. Which of the following would the nurse include as the primary characteristic associated with this disorder?

You Selected:

A change in bowel habits
Correct response:

A change in bowel habits
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1318.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1318

Question 4 See full question

A 68-year-old resident at a long-term care facility lost the ability to swallow following a stroke 4 years ago. She receives nutrition via a PEG tube. The client remains physically and socially active and has adapted well to the tube feedings. Occasionally, the client develops constipation that requires administration of a laxative to restore regular bowel function. Which of the following is the most likely cause of this client's constipation?

You Selected:

Lack of solid food
Correct response:

Lack of free water intake
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 45: Digestive and Gastrointestinal Treatment Modalities, p. 1222.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1222

Question 5 See full question

Post appendectomy, a nurse should assess the patient for abdominal rigidity and tenderness, fever, loss of bowel sounds, and tachycardia, all clinical signs of:

You Selected:

Peritonitis
Correct response:

Peritonitis
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 48: Management of Patients With Intestinal and Rectal Disorders, p. 1297.

Chapter 48: Management of Patients With Intestinal and Rectal Disorders - Page 1297
Question 1 See full question

A client is color blind. The nurse understands that this client has a problem with:

You Selected:

cones.
Correct response:

cones.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1845.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1845

Question 2 See full question

Which type of glaucoma presents an ocular emergency?

You Selected:

Ocular hypertension
Correct response:

Acute angle-closure glaucoma
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1855.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1855

Question 3 See full question

When undergoing testing of visual acuity with a Snellen chart, the client can read the line labeled 20/50 but misses three letters on the line. The nurse documents this finding as which of the following?

You Selected:

20/50
Correct response:

20/50-3
Explanation:

Reference:

Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 12th ed. Philadelphia: Lippincott Williams & Wilkins, 2009, Chapter 58: Assessment and Management of Patients with Eye and Vision Disorders, p. 1760.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1760

Question 4 See full question

A client comes to the eye clinic for a routine check-up. The client tells the nurse they think they are color blind. What screening test does the nurse know will be performed on this client to assess for color-blindness?

You Selected:

Ishihara
Correct response:

Ishihara
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1845.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1845

Question 5 See full question

Which of the following types of conjunctivitis is preceded by symptoms of an upper respiratory infection?

You Selected:

Viral
Correct response:

Viral
Explanation:

Question 6 See full question

A client is being discharged after successful same-day cataract surgery. The nurse instructs the client about permitted activities and which activities to avoid. Which of the following activities would be permitted in the postoperative instructions by the client?

You Selected:

Vacuuming flat surfaces and avoiding stairs.
Correct response:

Cooking.
Explanation:

Question 7 See full question

James Robertson, a 62-year-old retired customer service agent, is awaiting elective surgery in the hospital unit where you practice nursing. Mr. Robertson is blind. What would you do to promote Mr. Robertson's control over his hospital environment?

You Selected:

Ask Mr. Robertson where to store his self-care items.
Correct response:

Ask Mr. Robertson where to store his self-care items.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1849.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1849

Question 8 See full question

What patient activity indicates to the nurse that a patient understands how to correctly instill ophthalmic medications?

You Selected:

Client pulls the tissue near the cheek downward to instill medication.
Correct response:

Client pulls the tissue near the cheek downward to instill medication.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1853.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1853

Question 9 See full question

A patient comes to the clinic with a suspected eye infection. The nurse recognizes that the patient most likely has conjunctivitis, as evidenced by what symptom?

You Selected:

A mucopurulent ocular discharge
Correct response:

A mucopurulent ocular discharge
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1872.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1872

Question 10 See full question

The nurse is administering an ophthalmic ointment to a patient with conjunctivitis. What disadvantage of the application of an ointment does the nurse explain to the patient?

You Selected:

Blurred vision results after application.
Correct response:

Blurred vision results after application.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1850.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1850

Question 1 See full question

When obtaining the health history from a client with retinal detachment, a nurse expects the client to report:

You Selected:

light flashes and floaters in front of the eye.
Correct response:

light flashes and floaters in front of the eye.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1847.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1847

Question 2 See full question

A client has just been diagnosed with early glaucoma. During a teaching session, the nurse should:

You Selected:

demonstrate eyedrop instillation.
Correct response:

demonstrate eyedrop instillation.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1853.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1853

Question 3 See full question

When assessing the pressure of the anterior chamber of the eye, a nurse normally expects to find a pressure of:

You Selected:

10 to 20 mm Hg.
Correct response:

10 to 20 mm Hg.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1841.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1841

Question 4 See full question

Which of the following is the term for swelling of the optic disc due to increased IOP?

You Selected:

Papilledema
Correct response:

Papilledema
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1845.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1845

Question 5 See full question

The nurse is giving a visual field examination to a 55-year-old male client. The client asks what this test is for. What would be the nurse's best answer?

You Selected:

"This test measures peripheral vision and detects gaps in the visual field."
Correct response:

"This test measures peripheral vision and detects gaps in the visual field."
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1846.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1846

Question 6 See full question

The nurse admits a client to the Emergency Department who has been referred by the eye clinic. Which condition is an emergency where the nurse should refer the client for medical treatment immediately?

You Selected:

Acute angle-closure glaucoma
Correct response:

Acute angle-closure glaucoma
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1855.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1855

Question 7 See full question

A 13-year-old client is visiting the ophthalmologist after severe eye injuries. The client suffered trauma to her sclera and is being treated for a subsequent infection. During your client education, you indicate where the sclera is attached. Which of the following structures would you NOT include?

You Selected:

Eyelids
Correct response:

Eyelids
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, pp. 1840-1841.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1840-1841

Question 8 See full question

A nurse in a primary care office is getting a client ready for an examination with a health care provider. While talking to the client, she notices that her left upper eyelid is drooping. She records on the client's record that she observed which of the following?

You Selected:

Ptosis
Correct response:

Ptosis
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1844.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1844

Question 9 See full question

The nurse is assisting the eye surgeon in completing an examination of the eye. Which piece of equipment would the nurse provide to the physician to examine the fundus and interior of the eye?

You Selected:

Ophthalmoscope
Correct response:

Ophthalmoscope
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1844.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1844

Question 10 See full question

A nurse is assessing a pediatric client in a public health clinic. The parent states that the client has been sneezing and rubbing the eyes. The nurse looks at the client's eyes and documents objective symptoms of watery and red eyes. When reporting to the physician the assessment findings, which word is appropriate?

You Selected:

Conjunctivitis
Correct response:

Conjunctivitis
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1871.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1871

Question 11 See full question

A client has undergone enucleation. What complication of enucleationshould be addressed by the nurse?

You Selected:

Hemorrhage
Correct response:

Hemorrhage
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1876.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1876

Question 12 See full question

Following an ophthalmologic exam, an anxious client asks the nurse, "How serious is a refraction error?" Which of the following is the best response from the nurse?

You Selected:

"It means corrective lenses are required."
Correct response:

"It means corrective lenses are required."
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1846.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1846

Question 13 See full question

Following cataract removal, discharge instructions will be provided to the client. Which of the following instructions is most important?

You Selected:

Avoid any activity that can increase intraocular pressure.
Correct response:

Avoid any activity that can increase intraocular pressure.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1860.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1860

Question 14 See full question

Miotic eye solutions are often ordered in the treatment of glaucoma. Which is the best nursing rationale for the use of this medication?

You Selected:

Dilates the pupil
Correct response:

Constricts pupil
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1839.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1839

Question 15 See full question

A patient's vision is assessed at 20/200. The patient asks what that means. Which of the following is the most appropriate response by the nurse?

You Selected:

"You see an object from 20 feet away that a person with normal vision sees from 200 feet away."
Correct response:

"You see an object from 20 feet away that a person with normal vision sees from 200 feet away."
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1842.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1842

Question 16 See full question

Which of the following types of glaucoma presents an ocular emergency?

You Selected:

Acute angle-closure glaucoma
Correct response:

Acute angle-closure glaucoma
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1853.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1853

Question 17 See full question

A patient presents to the ED complaining of a chemical burn to both eyes. Which of the following is the priority nursing intervention?

You Selected:

Irrigate both eyes.
Correct response:

Irrigate both eyes.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1870.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1870

Question 18 See full question

A patient has had cataract extractions and the nurse is providing discharge instructions. What should the nurse encourage the patient to do at home?

You Selected:

Avoid bending the head below the waist.
Correct response:

Avoid bending the head below the waist.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1860.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1860

Question 19 See full question

A patient is to have an angiography done using fluorescein as a contrast agent to determine if the patient has macular edema. What laboratory work should the nurse monitor prior to the angiography?

You Selected:

BUN and creatinine
Correct response:

BUN and creatinine
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1845.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1845

Question 20 See full question

A nurse practitioner examines a patient and documents a best corrected visual acuity (BCVA) ratio in his better eye that qualifies him for government financial assistance based on the definition of legal blindness. What is that ratio?

You Selected:

20/200
Correct response:

20/200
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1846.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1846

Question 1 See full question

Which of the following terms refers to the absence of the natural lens?

You Selected:

Aphakia
Correct response:

Aphakia
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1863.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1863

Question 2 See full question

The nurse asks a client to follow the movement of a pencil up, down, right, left, and both ways diagonally. The nurse is assessing which of the following?

You Selected:

Eyeball oscillation movements
Correct response:

Extraocular muscle function
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. (2014) Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 12th ed. Philadelphia: Lippincott Williams & Wilkins, 2009, Chapter 58: Assessment and Management of Patients with Eye and Vision Disorders, p. 1761.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1761

Question 3 See full question

A client has undergone tonometry to evaluate for possible glaucoma. Which result would the nurse record as abnormal?

You Selected:

25 mm Hg
Correct response:

25 mm Hg
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. (2014) Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients with Eye and Vision Disorders, p. 1856.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1856

Question 4 See full question

An aging client is brought to the eye clinic by the son. The son states he has seen his parent holding reading materials at an increasing distance to focus properly. What age-related changes does this indicate?

You Selected:

Presbyopia
Correct response:

Presbyopia
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1847.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1847

Question 5 See full question

Which of the following is an accurate statement regarding refractive surgery?

You Selected:

Refractive surgery is an elective, cosmetic surgery performed to reshape the cornea.
Correct response:

Refractive surgery is an elective, cosmetic surgery performed to reshape the cornea.
Explanation:

Question 6 See full question

=To avoid the side effects of corticosteroids, which medication classification is used as an alternative to treating inflammatory conditions of the eyes?

You Selected:

Nonsteroidal anti-inflammatory drugs (NSAIDs)
Correct response:

Nonsteroidal anti-inflammatory drugs (NSAIDs)
Explanation:

Question 7 See full question

Which of the following medications needs to be withheld for 5 to 7 days prior to cataract surgery?

You Selected:

Coumadin
Correct response:

Coumadin
Explanation:

Question 8 See full question

Which of the following surgical procedures involves taking a piece of silicone plastic or sponge and sewing it onto the sclera at the site of a retinal tear?

You Selected:

Scleral buckle
Correct response:

Scleral buckle
Explanation:

Question 9 See full question

When an impaled object is in the eye, which of the following steps should be taken to ensure that no further damage occurs? Select all that apply.

You Selected:

Protect object from jarring
No attempt should be made to remove the object
Correct response:

No attempt should be made to remove the object
Protect object from jarring
Use metal shield
Explanation:

Question 10 See full question

Marshall Dunbar, a 7-year-old second grader, is being seen by the pediatric ophthalmologist due to a recent skateboarding accident that resulted in trauma to his right cornea and he is now at risk of developing an infection. Of the following nursing interventions, which one would be contraindicated for a client at risk for infection?

You Selected:

To ensure correct application of antibiotic ointment, gently drag tip of tube along lower lid while squeezing ointment on to lid.
Correct response:

To ensure correct application of antibiotic ointment, gently drag tip of tube along lower lid while squeezing ointment on to lid.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1852.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1852

Question 11 See full question

A 63-year-old client has developed diabetic retinopathy and is seeing the physician regularly to prevent further loss of sight. From where do the nerve cells of the retina extend?

You Selected:

Optic nerve
Correct response:

Optic nerve
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1841.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1841

Question 12 See full question

Which of the following surgical procedures involves flattening the anterior curvature of the cornea by removing a stromal lamella layer?

You Selected:

Laser-assisted stromal in situ keratomileusis (LASIK)
Correct response:

Laser-assisted stromal in situ keratomileusis (LASIK)
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1863.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1863

Question 13 See full question

Which is the term for swelling of the optic disc due to increased intraocular pressure (IOP)?

You Selected:

Papilledema
Correct response:

Papilledema
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1845.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1845

Question 14 See full question

To avoid the side effects of corticosteroids, which of the following medication classifications is used as an alternative to treating inflammatory conditions of the eyes?

You Selected:

Nonsteroidal anti-inflamatory drugs (NSAIDS)
Correct response:

Nonsteroidal anti-inflamatory drugs (NSAIDS)
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1851.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1851

Question 15 See full question

A patient has been prescribed eye drops for the treatment of glaucoma. At the yearly follow-up appointment, the patient tells the nurse that she has stopped using the medication because her vision did not improve. Which of the following is the appropriate action to be taken by the nurse?

You Selected:

Explain the therapeutic effect and expected outcome of the medication.
Correct response:

Explain the therapeutic effect and expected outcome of the medication.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1857.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1857

Question 16 See full question

A patient is brought into the emergency department with chemical burns to both eyes. What is the priority action of the nurse for this patient's care?

You Selected:

Flushing the lids, conjunctiva, and cornea with tap water or normal saline
Correct response:

Flushing the lids, conjunctiva, and cornea with tap water or normal saline
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1869.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1869

Question 17 See full question

During assessment of a patient with a hearing loss, the nurse notes a defect in the tympanic membrane. The nurse documents this disturbance as a loss known as:

You Selected:

Functional.
Correct response:

Conductive.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1885.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1885

Question 18 See full question

On ocular examination, the health care provider notes severely elevated IOP, corneal edema, and a pupil that is fixed in a semi-dilated position. The nurse knows that these clinical signs are diagnostic of the type of glaucoma known as:

You Selected:

Acute angle-closure.
Correct response:

Acute angle-closure.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1855.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1855

Question 19 See full question

A major role for nursing in the management of glaucoma is health education. Which of the following is the most important teaching point that the nurse should advise the patient of?

You Selected:

Adhere to the medication regimen.
Correct response:

Adhere to the medication regimen.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1857.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1857

Question 20 See full question

During assessment of the eyes, the nurse noted __________, a diagnostic sign of a mild case of bacterial conjunctivitis.

You Selected:

Mucopurulent ocular discharge
Correct response:

Mucopurulent ocular discharge
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1872.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1872

Question 1 See full question

Assessment of visual acuity reveals that the client has blurred vision when looking at distant objects but no difficulty seeing near objects. The nurse documents this as which of the following?

You Selected:

Myopia
Correct response:

Myopia
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1846.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1846

Question 2 See full question

Leslie Waterman, a 57-year-old corrections officer, is being seen at the ophthalmic group where you practice nursing. Leslie is concerned about his vision changes because recently, he has started to see distance much more clearly than nearby sights. What is the term used to describe his visual condition?

You Selected:

Hyperopia
Correct response:

Hyperopia
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1846.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1846

Question 3 See full question

A nurse is performing an eye examination. Which of the following questions would not be included in the examination?

You Selected:

"What medications are you taking?"
Correct response:

"Are you able to raise both eyebrows?"
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1843.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1843

Question 4 See full question

The nurse should monitor for which of the following manifestations in a patient who has had LASIK surgery?

You Selected:

Halos and glare
Correct response:

Halos and glare
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1863.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1863

Question 5 See full question

The nurse is performing an assessment of the visual fields for a patient with glaucoma. When assessing the visual fields in acute glaucoma, what would the nurse expect to find?

You Selected:

Marked blurring of vision
Correct response:

Marked blurring of vision
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1854.

Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1854
Question 1 See full question

A client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the stapedectomy, the nurse should provide which client instruction?

You Selected:

"Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days."
Correct response:

"Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days."
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1896.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1896

Question 2 See full question

Which of the following terms refers to surgical repair of the tympanic membrane?

You Selected:

Tympanoplasty
Correct response:

Tympanoplasty
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1892-1893.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1892-1893

Question 3 See full question

Which terms refers to the progressive hearing loss associated with aging?

You Selected:

Presbycusis
Correct response:

Presbycusis
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1889.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1889

Question 4 See full question

Which of the following preattack symptoms may a patient with Meniere's disease report prior to an attack?

You Selected:

A full feeling in the ear
Correct response:

A full feeling in the ear
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1897.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1897

Question 5 See full question

A nurse is preparing to assess a client's gross auditory acuity. Which of the following would be most appropriate to use?

You Selected:

Radio
Correct response:

Ticking watch
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1885.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1885

Question 6 See full question

The nurse is developing a plan of care for a client with Meniere's disease and identifies a nursing diagnosis of excess fluid volume related to fluid retention in the inner ear. Which intervention would be most appropriate to include in the plan of care?

You Selected:

Limit foods that are high in sodium.
Correct response:

Limit foods that are high in sodium.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1898.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1898

Question 7 See full question

A client comes to the walk-in clinic complaining of a "bug in my ear." What action should be taken when there is an insect in the ear?


You Selected:

Use of a small forceps
Correct response:

Instillation of mineral oil
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1890.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1890

Question 8 See full question

A nursing instructor is teaching pre-nursing students in a pathophysiology class. What would the instructor teach the students about Ménière's disease?

You Selected:

It is referred to as endolymphatic hydrops.
Correct response:

It is referred to as endolymphatic hydrops.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1897.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1897

Question 9 See full question

A patient is participating in aural rehabilitation. The nurse understands that this type of training emphasizes which of the following?

You Selected:

Listening skills
Correct response:

Listening skills
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1902.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1902

Question 10 See full question

Acoustic neuromas are benign tumors of which of the following cranial nerves?

You Selected:

VIII
Correct response:

VIII
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1902.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1902

Question 11 See full question

Which of the following is the treatment of choice for acoustic neuromas?

You Selected:

Surgery
Correct response:

Surgery
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1902.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1902

Question 12 See full question

Which of the following instructions regarding swimming should the nurse give to the client who is recovering from otitis externa? Choose the correct option.

You Selected:

Wear soft plastic earplugs.
Correct response:

Wear soft plastic earplugs.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1891.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1891

Question 13 See full question

An 88-year-old client has a history of hearing loss and is returning for his annual hearing examination. During your client education session, you explain to the client that hearing involves which areas of the ear?

You Selected:

All sections of the ear are involved in perceiving sound.
Correct response:

All sections of the ear are involved in perceiving sound.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, pp. 1881-1883.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1881-1883

Question 14 See full question

Audiometry is testing that measures hearing acuity precisely. Who does the nurse know can perform audiometric testing?

You Selected:

Audiologist
Correct response:

Audiologist
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1886.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1886

Question 15 See full question

The nurse is working in the emergency department when a physician asks for help as the client is performing a Romberg test. In which position would the nurse stand to be most helpful?

You Selected:

The nurse would stand laterally to the client, opposite side to where the physician is standing.
Correct response:

The nurse would stand laterally to the client, opposite side to where the physician is standing.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 65: Assessment of Neurologic Function, p. 1924.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1924

Question 16 See full question

The client is consulting with a physician regarding a potential diagnosis of Ménière's disease. The nurse is assisting in positional testing and documentation. Which diagnostic test would the nurse anticipate to obtain a more precise evaluation of vestibular function?

You Selected:

Romberg test
Correct response:

Electronystagmography
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1886.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1886

Question 17 See full question

You are teaching a class on diseases of the ear. What would you teach the class is the most characteristic symptom of otosclerosis?

You Selected:

A progressive, bilateral loss of hearing
Correct response:

A progressive, bilateral loss of hearing
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1896.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1896

Question 18 See full question

A patient is diagnosed with otitis externa. Which of the following instructions is most appropriate for the nurse to give?

You Selected:

Avoid swimming for 7 to 10 days.
Correct response:

Avoid swimming for 7 to 10 days.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1891.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1891

Question 19 See full question

The nurse is developing a plan of care for a patient with severe vertigo. What expected outcome statement would be a priority for this patient?

You Selected:

Patient will experience no falls due to balance disorder.
Correct response:

Patient will experience no falls due to balance disorder.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1899.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1899

Question 20 See full question

A nurse practitioner in an emergency room receives a telephone call from a mother whose 4-year-old child has a mosquito stuck in his external ear canal. Which of the following is the best information the nurse could give the mother?


You Selected:

Use an aural suction cup to pull out the insect.
Correct response:

Instill a few drops of warmed mineral oil to cover the insect.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1890.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1890

Question 1 See full question

Which nursing diagnosis takes highest priority for a client admitted for evaluation for Ménière's disease?

You Selected:

Risk for injury related to vertigo
Correct response:

Risk for injury related to vertigo
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1897.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1897

Question 2 See full question

A client complains of vertigo. The nurse anticipates that the client may have a problem with which portion of the ear?

You Selected:

Inner ear
Correct response:

Inner ear
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1897.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1897

Question 3 See full question

Which of the following is a definition of ossiculoplasty?

You Selected:

Surgical reconstruction of the middle ear bones
Correct response:

Surgical reconstruction of the middle ear bones
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1894.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1894

Question 4 See full question

Which of the following tests uses a tuning fork between two positions to assess hearing?

You Selected:

Weber's
Correct response:

Rinne's
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1886.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1886

Question 5 See full question

Which of the following describes a condition characterized by abnormal spongy bone formation around the stapes?

You Selected:

Otosclerosis
Correct response:

Otosclerosis
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1896.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1896

Question 6 See full question

Which of the following is a correct rationale for encouraging a patient with otitis externa to eat soft foods?

You Selected:

Chewing may cause discomfort.
Correct response:

Chewing may cause discomfort.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1891.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1891

Question 7 See full question

A client is diagnosed as having serous otitis media. When describing this condition to the client, which of the following would be most accurate?

You Selected:

"You have some fluid that has collected in your middle ear but no infection."
Correct response:

"You have some fluid that has collected in your middle ear but no infection."
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1893.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1893

Question 8 See full question

You are teaching a class on diseases of the ear. What would you teach the class is the most characteristic symptom of otosclerosis?

You Selected:

A progressive, bilateral loss of hearing
Correct response:

A progressive, bilateral loss of hearing
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1896.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1896

Question 9 See full question

The nurse is doing discharge teaching with a client newly diagnosed with Ménière's disease. Why would the nurse advise a low-sodium diet to this client?

You Selected:

To reduce the production of fluid in the inner ear
Correct response:

To reduce the production of fluid in the inner ear
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1898.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1898

Question 10 See full question

During a pharmacology class, the students are told that some drugs need to be closely monitored. What aspect should the nurse closely monitor for in clients who have been administered salicylates, loop diuretics, quinidine, quinine, or aminoglycosides?

You Selected:

Tinnitus and sensorineural hearing loss
Correct response:

Tinnitus and sensorineural hearing loss
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, pp. 1889, 1901-1902.
Question 11 See full question

There are several types of hearing loss. Which type of hearing loss benefits most from the use of a hearing aid?

You Selected:

Conductive
Correct response:

Conductive
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, pp. 1902-1903.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1902-1903

Question 12 See full question

What kind of otitis media is a pathogen-free fluid behind the tympanic membrane, resulting from irritation associated with respiratory allergies and enlarged adenoids?

You Selected:

Serous otitis media
Correct response:

Serous otitis media
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1893.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1893

Question 13 See full question

Hearing aids help with which of the following problems?

You Selected:

Makes sounds louder
Correct response:

Makes sounds louder
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1902.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1902

Question 14 See full question

The nurse is instructing a patient with Ménière's disease on dietary management to include as an adjunct to other more traditional therapies. The nurse would include which of the following? Select all that apply.

You Selected:

Limit foods high in salt and sugar.
Avoid aspirin and aspirin products.
Correct response:

Limit foods high in salt and sugar.
Avoid aspirin and aspirin products.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1898.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1898

Question 15 See full question

High doses of which of the following medications can produce bilateral tinnitus?

You Selected:

Aspirin
Correct response:

Aspirin
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1901.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1901

Question 16 See full question

A patient newly diagnosed with otitis media reports the pain and pressure in the ear has suddenly disappeared. What is the best action by the nurse?

You Selected:

Assess tympanic membrane.
Correct response:

Assess tympanic membrane.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1892.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1892

Question 17 See full question

A patient is newly diagnosed with otitis externa. Which of the following should the nurse teach the patient before the patient leaves the clinic?

You Selected:

Side effects of oral antibiotics
Correct response:

Proper instillation of prescribed ear drops
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1891.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1891

Question 18 See full question

The nurse is caring for a patient with Ménière's disease who is hospitalized with severe vertigo. What medication does the nurse anticipate administering to shorten the attack?

You Selected:

Meclizine (Antivert)
Correct response:

Meclizine (Antivert)
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1898.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1898

Question 19 See full question

A nurse is asked to assess a patient's need for a hearing aid. The nurse knows that a general guideline to determine need would be a hearing loss of:

You Selected:

30 dB in the range of 400 to 1,500 Hz.
Correct response:

40 dB in the range of 500 to 2,000 Hz.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1902.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1902

Question 20 See full question

A nurse needs to change a dressing on an abdominal wound for a patient who is hearing-impaired and whose speech is difficult to understand. Which of the following is the best approach for the nurse?

You Selected:

Write down the steps of the procedure for the patient to read before beginning the treatment.
Correct response:

Write down the steps of the procedure for the patient to read before beginning the treatment.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1890.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1890

Question 1 See full question

High doses of this medication can produce bilateral tinnitus?

You Selected:

Aspirin
Correct response:

Aspirin
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1901.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1901

Question 2 See full question

A client comes to the walk-in clinic complaining of an earache. The cause is found to be impacted cerumen. The client asks the nurse what they can do at home to soften hardened cerumen. What should the nurse recommend to a client to soften hardened cerumen?

You Selected:

Take nonprescription preparations.
Correct response:

Take nonprescription preparations.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1890.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1890

Question 3 See full question

The nursing student hopefuls are taking a pre-nursing anatomy and physiology class. What will they learn is the anatomical feature that equalizes air pressure in the middle ear?

You Selected:

Eustachian tube
Correct response:

Eustachian tube
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, pp. 1881-1882.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1881-1882

Question 4 See full question

When caring for a client status post ear surgery, what is an important aspect of nursing care?

You Selected:

Assess social support.
Correct response:

Validate client's feelings of discomfort.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1894.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1894

Question 5 See full question

When discussing diseases of the middle ear, the nursing instructor distinguishes the different types of otitis media. What generally causes purulent otitis media?

You Selected:

Irritation associated with respiratory allergies and enlarged adenoids
Correct response:

Upper respiratory infections
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1892.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1892

Question 6 See full question

When performing the Weber test, where would the nurse place the vibrating tuning fork? Identify the area on the accompanying figure.

You Selected:


Your selection and the correct area, market by the green box.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1885.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1885

Question 7 See full question

Which of the following manifestations is most problematic for the patient diagnosed with Ménière's disease?

You Selected:

Vertigo
Correct response:

Vertigo
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1897.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1897

Question 8 See full question

The nurse is examining the area behind the patient's auricle and sees a flaky scaliness. What disorder does the nurse suspect the patient has?

You Selected:

Seborrheic dermatitis
Correct response:

Seborrheic dermatitis
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1883.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1883

Question 9 See full question

A nurse practitioner explains to a patient recently diagnosed with noise-induced hearing loss that the basic altered physiology in the ear is the result of:

You Selected:

Damage to the hair cells inside the cochlea.
Correct response:

Damage to the hair cells inside the cochlea.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1889.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1889

Question 10 See full question

Health teaching for a patient who suffers from motion sickness would include recommending the use of which one of the following over-the-counter drugs?

You Selected:

Dramamine
Correct response:

Dramamine
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, p. 1897.

Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1897
Question 1 See full question
A client undergoes extracorporeal shock wave lithotripsy. Before discharge, the nurse should provide which instruction?
You Selected:
"Increase your fluid intake to 2 to 3 L per day."
Correct response:
"Increase your fluid intake to 2 to 3 L per day."
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1592.
Chapter 55: Management of Patients With Urinary Disorders - Page 1592
Question 2 See full question
A client is frustrated and embarrassed by urinary incontinence. Which measure should the nurse include in a bladder retraining program?
You Selected:
Assessing present voiding patterns
Correct response:
Assessing present voiding patterns
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1586.
Chapter 55: Management of Patients With Urinary Disorders - Page 1586
Question 3 See full question
After undergoing retropubic prostatectomy, a client returns to his room. The client is on nothing-by-mouth status and has an I.V. infusing in his right forearm at a rate of 100 ml/hour. The client also has an indwelling urinary catheter that's draining light pink urine. While assessing the client, the nurse notes that his urine output is red and has dropped to 15 ml and 10 ml for the last 2 consecutive hours. How can the nurse best explain this drop in urine output?
You Selected:
It's an abnormal finding that requires further assessment.
Correct response:
It's an abnormal finding that requires further assessment.
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1582.
Chapter 55: Management of Patients With Urinary Disorders - Page 1582
Question 4 See full question
A male patient, who is 82 years of age, suffers from urinary incontinence. Which of the following factors should the nurse assess before beginning a bladder training program for the patient?
You Selected:
Physical and environmental conditions
Correct response:
Physical and environmental conditions
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1587.
Chapter 55: Management of Patients With Urinary Disorders - Page 1587
Question 5 See full question
Bladder retraining following removal of an indwelling catheter begins with
You Selected:
instructing the patient to follow a 2 to 3 hour timed voiding schedule.
Correct response:
instructing the patient to follow a 2 to 3 hour timed voiding schedule.
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1590.
Chapter 55: Management of Patients With Urinary Disorders - Page 1590
Question 6 See full question
Which of the following is a characteristic of a normal stoma?
You Selected:
Pink color
Correct response:
Pink color
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1600.
Chapter 55: Management of Patients With Urinary Disorders - Page 1600
Question 7 See full question
The nurse is giving discharge instructions to the client with uric acid renal calculi. Which statement by the client indicates the client understands the prescribed diet?
You Selected:
"I should limit my intake of meat and fish."
Correct response:
"I should limit my intake of meat and fish."
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1593.
Chapter 55: Management of Patients With Urinary Disorders - Page 1593
Question 8 See full question
A client comes to the clinic for a follow-up visit. During the interview, the client states, "Sometimes when I have to urinate I can't control it, and do not reach the bathroom in time." The nurse suspects that the client is experiencing which type of incontinence?
You Selected:
Urge
Correct response:
Urge
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1583.
Chapter 55: Management of Patients With Urinary Disorders - Page 1583
Question 9 See full question
A group of students are reviewing information about disorders of the bladder and urethra. The students demonstrate understanding of the material when they identify which of the following as a voiding dysfunction?
You Selected:
Urinary retention
Correct response:
Urinary retention
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1582.
Chapter 55: Management of Patients With Urinary Disorders - Page 1582
Question 10 See full question
A nurse has been asked to speak to a local women's group about preventing cystitis. Which of the following would the nurse include in the presentation?
You Selected:
Need to urinate after engaging in sexual intercourse
Correct response:
Need to urinate after engaging in sexual intercourse
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1576.
Chapter 55: Management of Patients With Urinary Disorders - Page 1576
Question 11 See full question
Examination of a client's bladder stones reveal that they are primarily composed of uric acid. The nurse would expect to provide the client with which type of diet?
You Selected:
Low purine
Correct response:
Low purine
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1593.
Chapter 55: Management of Patients With Urinary Disorders - Page 1593
Question 12 See full question
After teaching a group of students about the types of urinary incontinence and possible causes, the instructor determines that the student have understood the material when they identify which of the following as a cause of stress incontinence?
You Selected:
Decreased pelvic muscle tone due to multiple pregnancies
Correct response:
Decreased pelvic muscle tone due to multiple pregnancies
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1583.
Chapter 55: Management of Patients With Urinary Disorders - Page 1583
Question 13 See full question
Which of the following is the most common symptom of bladder cancer?
You Selected:
Painless gross hematuria
Correct response:
Painless gross hematuria
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1597.
Chapter 55: Management of Patients With Urinary Disorders - Page 1597
Question 14 See full question
A 32-year-old client has a history of neurogenic bladder and presents with fever, burning, and suprapubic pain. What would you suspect is the problem?
You Selected:
Urinary tract infection
Correct response:
Urinary tract infection
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, pp. 1574-1575.
Chapter 55: Management of Patients With Urinary Disorders - Page 1574-1575
Question 15 See full question
A client undergoes surgery for removing a malignant tumor followed by a urinary diversion procedure. Which of the following postoperative procedures is the most important for the nurse to perform?
You Selected:
Maintain skin and stomal integrity.
Correct response:
Maintain skin and stomal integrity.
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1600.
Chapter 55: Management of Patients With Urinary Disorders - Page 1600
Question 16 See full question
Which of the following would be included in a teaching plan for a patient diagnosed with a UTI?
You Selected:
Drink liberal amount of fluids.
Correct response:
Drink liberal amount of fluids.
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1580.
Chapter 55: Management of Patients With Urinary Disorders - Page 1580
Question 17 See full question
A patient with a UTI is having burning and pain when urinating. What urinary analgesic is prescribed for relief of these symptoms?
You Selected:
Pyridium
Correct response:
Pyridium
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1578.
Chapter 55: Management of Patients With Urinary Disorders - Page 1578
Question 18 See full question
A nurse is conducting a health history on a patient who is seeing her health care provider for symptoms consistent with a UTI. The nurse understands that the most common route of infection is which of the following?
You Selected:
By ascending infection (transurethral)
Correct response:
By ascending infection (transurethral)
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1576.
Chapter 55: Management of Patients With Urinary Disorders - Page 1576
Question 19 See full question
The nurse advises a patient with renal stones to avoid eating shellfish, asparagus, and organ meats. She emphasizes these foods because she knows that his renal stones are composed of which of the following substances?
You Selected:
Uric acid
Correct response:
Uric acid
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1593.
Chapter 55: Management of Patients With Urinary Disorders - Page 1593
Question 20 See full question
The nurse is participating in a bladder retraining program for a patient who had an indwelling catheter for 2 weeks. The nurse knows that, during this process, straight catheterization, after catheter-free intervals, can be discontinued when residual urine is:
You Selected:
<100 mL
Correct response:
<100 mL
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1590.
Chapter 55: Management of Patients With Urinary Disorders - Page 1590
Question 1 See full question
Which client is at highest risk for developing a hospital-acquired infection?
You Selected:
A client with an indwelling urinary catheter
Correct response:
A client with an indwelling urinary catheter
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1588.
Chapter 55: Management of Patients With Urinary Disorders - Page 1588
Question 2 See full question
A nurse is caring for a client with acute pyelonephritis. Which nursing intervention is the most important?
You Selected:
Increasing fluid intake to 3 L/day
Correct response:
Increasing fluid intake to 3 L/day
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1581.
Chapter 55: Management of Patients With Urinary Disorders - Page 1581
Question 3 See full question
A nurse is caring for a client who had a stroke. Which nursing intervention promotes urinary continence?
You Selected:
Encouraging intake of at least 2 L of fluid daily
Correct response:
Encouraging intake of at least 2 L of fluid daily
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1586.
Chapter 55: Management of Patients With Urinary Disorders - Page 1586
Question 4 See full question
Which of the following terms is used to refer to inflammation of the renal pelvis?
You Selected:
Pyelonephritis
Correct response:
Pyelonephritis
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1574.
Chapter 55: Management of Patients With Urinary Disorders - Page 1574
Question 5 See full question
The most common presenting objective symptoms of a urinary tract infection in older adults, especially in those with dementia, include?
You Selected:
Change in cognitive functioning
Correct response:
Change in cognitive functioning
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1577.
Chapter 55: Management of Patients With Urinary Disorders - Page 1577
Question 6 See full question
A client presents at the clinic with complaints of urinary retention. What question should the nurse ask to obtain additional information about the client's complaint?
You Selected:
"When did you last urinate?"
Correct response:
"When did you last urinate?"
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1586.
Chapter 55: Management of Patients With Urinary Disorders - Page 1586
Question 7 See full question
The nurse is caring for a client who is scheduled for the creation of an ileal conduit. Which statement by the client provides evidence that client teaching was effective?
You Selected:
"My urine will be eliminated through a stoma."
Correct response:
"My urine will be eliminated through a stoma."
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, pp. 1599-1600.
Chapter 55: Management of Patients With Urinary Disorders - Page 1599-1600
Question 8 See full question
The nurse recognizes that urinalysis results that most likely indicate a urinary tract infection include:
You Selected:
WBC 50
Correct response:
WBC 50
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, pp. 1577-1578.
Chapter 55: Management of Patients With Urinary Disorders - Page 1577-1578
Question 9 See full question
The nurse is caring for a postoperative client who has a Kock pouch. Nursing assessment findings reveal abdominal pain, absence of bowel sounds, fever, tachycardia, and tachypnea. The nurse suspects which of the following?
You Selected:
Peritonitis
Correct response:
Peritonitis
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1605.
Chapter 55: Management of Patients With Urinary Disorders - Page 1605
Question 10 See full question
A nurse is reviewing the history and physical examination of a client with a suspected malignant tumor of the bladder. Which finding would the nurse identify as the most common initial symptom?
You Selected:
Painless hematuria
Correct response:
Painless hematuria
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1597.
Chapter 55: Management of Patients With Urinary Disorders - Page 1597
Question 11 See full question
A urinary diversion procedure follows a cystectomy and is performed to divert urine to another collecting system. In addition to the use with bladder tumors, it is also used for extensive pelvic malignancies and severe traumatic injury to the bladder. The type of urinary diversion that requires an external ostomy bag to collect the urine is called a
You Selected:
continent urinary diversion.
Correct response:
cutaneous urinary diversion.
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1599.
Chapter 55: Management of Patients With Urinary Disorders - Page 1599
Question 12 See full question
A nurse has been asked to speak to a local women's group about preventing cystitis. Which of the following would the nurse include in the presentation?
You Selected:
Need to urinate after engaging in sexual intercourse
Correct response:
Need to urinate after engaging in sexual intercourse
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1576.
Chapter 55: Management of Patients With Urinary Disorders - Page 1576
Question 13 See full question
The nurse is caring for a client who is describing urinary symptoms of needing to go to the bathroom with little notice. When the nurse is documenting these symptoms, which medical term will the nurse document?
You Selected:
Urinary urgency
Correct response:
Urinary urgency
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1585.
Chapter 55: Management of Patients With Urinary Disorders - Page 1585
Question 14 See full question
The nurse is conducting a history and assessment related to a patient's incontinence. Which of the following should the nurse include in the assessment before beginning a bladder training program?
You Selected:
Medication usage
Correct response:
Medication usage
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1583.
Chapter 55: Management of Patients With Urinary Disorders - Page 1583
Question 15 See full question
The nurse is conducting a community education program on UTIs. The nurse determines that the participants understand the teaching when they identify which of the following as a contributing factor for UTIs in older adults?
You Selected:
Immunocompromise
Correct response:
Immunocompromise
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1576.
Chapter 55: Management of Patients With Urinary Disorders - Page 1576
Question 16 See full question
Which of the following medications may be ordered to relieve discomfort associated with a UTI?
You Selected:
Phenazopyridine (Pyridium)
Correct response:
Phenazopyridine (Pyridium)
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1578.
Chapter 55: Management of Patients With Urinary Disorders - Page 1578
Question 17 See full question
A patient has been diagnosed with a UTI and is prescribed an antibiotic. What first-line fluoroquinolone antibacterial agent for UTIs has been found to be significantly effective?
You Selected:
Cipro
Correct response:
Cipro
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1578.
Chapter 55: Management of Patients With Urinary Disorders - Page 1578
Question 18 See full question
A nurse who is taking care of a patient with a spinal cord injury documents the frequency of reflex incontinence. The nurse understands that this is most likely due to:
You Selected:
Loss of motor control of the detrusor muscle.
Correct response:
Loss of motor control of the detrusor muscle.
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1587.
Chapter 55: Management of Patients With Urinary Disorders - Page 1587
Question 19 See full question
A major goal when caring for a catheterized patient is to prevent infection. Select all the nursing actions that apply.
You Selected:
Empty the collection bag at least every 8 hours to reduce bacterial growth.
Suspend the drainage bag off the floor.
Wash the perineal area with soap and water at least twice daily.
Correct response:
Empty the collection bag at least every 8 hours to reduce bacterial growth.
Suspend the drainage bag off the floor.
Wash the perineal area with soap and water at least twice daily.
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1589.
Chapter 55: Management of Patients With Urinary Disorders - Page 1589
Question 20 See full question
A woman comes to her health care provider's office with signs and symptoms of kidney stones. Which of the following should be the primary medical management goal?
You Selected:
Relieve the pain.
Correct response:
Relieve the pain.
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1592.
Chapter 55: Management of Patients With Urinary Disorders - Page 1592
Question 1 See full question
A client comes to the emergency department complaining of sudden onset of sharp, severe pain in the lumbar region that radiates around the side and toward the bladder. The client also reports nausea and vomiting and appears pale, diaphoretic, and anxious. The physician tentatively diagnoses renal calculi and orders flat-plate abdominal X-rays. Renal calculi can form anywhere in the urinary tract. What is their most common formation site?
You Selected:
Kidney
Correct response:
Kidney
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1586.
Chapter 55: Management of Patients With Urinary Disorders - Page 1586
Question 2 See full question
All of the following are risk factors toward the development of kidney stones except
You Selected:
hypoparathyroidism.
Correct response:
hypoparathyroidism.
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1595.
Chapter 55: Management of Patients With Urinary Disorders - Page 1595
Question 3 See full question
If an indwelling catheter is necessary, the nursing interventions that should be implemented to prevent infection include
You Selected:
performing meticulous perineal care daily with soap and water.
Correct response:
performing meticulous perineal care daily with soap and water.
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1579.
Chapter 55: Management of Patients With Urinary Disorders - Page 1579
Question 4 See full question
A female client who is diagnosed with a malignant tumor in her bladder is advised to undergo cystectomy followed by a urinary diversion procedure. Which of the following would be most important for the nurse to assess preoperatively?
You Selected:
History of allergy to iodine and seafood
Correct response:
Client's manual dexterity and vision
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1601.
Chapter 55: Management of Patients With Urinary Disorders - Page 1601
Question 5 See full question
The nurse is conducting a community education program on urinary incontinence. The nurse determines that the participants understand the teaching when they identify which of the following as risk factors for urinary incontinence?
You Selected:
Sedatives
Correct response:
Sedatives
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 55: Management of Patients With Urinary Disorders, p. 1583.
Chapter 55: Management of Patients With Urinary Disorders - Page 1583
Question 1 See full question
A nurse is caring for a client who's ordered continuous ambulatory peritoneal dialysis (CAPD). Which finding should lead the nurse to question the client's suitability for CAPD?
You Selected:
The client has a history of diverticulitis.
Correct response:
The client has a history of diverticulitis.
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1558.
Chapter 54: Management of Patients With Kidney Disorders - Page 1558
Question 2 See full question
A client with a history of chronic renal failure receives hemodialysis treatments three times per week through an arteriovenous (AV) fistula in the left arm. Which intervention should the nurse include in the care plan?
You Selected:
Assess the AV fistula for a bruit and thrill.
Correct response:
Assess the AV fistula for a bruit and thrill.
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1550.
Chapter 54: Management of Patients With Kidney Disorders - Page 1550
Question 3 See full question
A client admitted with a gunshot wound to the abdomen is transferred to the intensive care unit after an exploratory laparotomy. I.V. fluid is being infused at 150 ml/hour. Which assessment finding suggests that the client is experiencing acute renal failure (ARF)?
You Selected:
Urine output of 250 ml/24 hours
Correct response:
Urine output of 250 ml/24 hours
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1537.
Chapter 54: Management of Patients With Kidney Disorders - Page 1537
Question 4 See full question
A client with chronic renal failure (CRF) is admitted to the urology unit. Which diagnostic test results are consistent with CRF?
You Selected:
Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/dl
Correct response:
Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/dl
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1541.
Chapter 54: Management of Patients With Kidney Disorders - Page 1541
Question 5 See full question
A history of infection specifically caused by group A beta-hemolytic streptococci is associated with which of the following disorders?
You Selected:
Acute glomerulonephritis
Correct response:
Acute glomerulonephritis
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1530.
Chapter 54: Management of Patients With Kidney Disorders - Page 1530
Question 6 See full question
The nurse expects which of the following assessment findings in the client in the diuretic phase of acute renal failure?
You Selected:
Dehydration
Correct response:
Dehydration
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1539.
Chapter 54: Management of Patients With Kidney Disorders - Page 1539
Question 7 See full question
A client has end-stage renal failure. Which of the following should the nurse include when teaching the client about nutrition to limit the effects of azotemia?
You Selected:
Increase carbohydrates and limit protein intake.
Correct response:
Increase carbohydrates and limit protein intake.
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1543.
Chapter 54: Management of Patients With Kidney Disorders - Page 1543
Question 8 See full question
When caring for the patient with acute glomerulonephritis, which of the following assessment findings should the nurse anticipate?
You Selected:
Tea-colored urine
Correct response:
Tea-colored urine
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1530.
Chapter 54: Management of Patients With Kidney Disorders - Page 1530
Question 9 See full question
A nurse identifies a nursing diagnosis of Risk for Ineffective Breathing Pattern related to incision pain and restricted positioning for a client who has had a nephrectomy. Which of the following would be most appropriate for the nurse to include in the client's plan of care?
You Selected:
Encourage use of incentive spirometer every 2 hours.
Correct response:
Encourage use of incentive spirometer every 2 hours.
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1563.
Chapter 54: Management of Patients With Kidney Disorders - Page 1563
Question 10 See full question
Following a nephrectomy, which assessment finding is most important in determining nursing care for the client?
You Selected:
SpO2 at 90% with fine crackles in the lung bases
Correct response:
SpO2 at 90% with fine crackles in the lung bases
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1539.
Chapter 54: Management of Patients With Kidney Disorders - Page 1539
Question 11 See full question
A client with end-stage renal disease is scheduled to undergo a kidney transplant using a sibling donated kidney. The client asks if immunosuppressive drugs can be avoided. Which is the best response by the nurse?
You Selected:
"Even a perfect match does not guarantee organ rejection."
Correct response:
"Even a perfect match does not guarantee organ rejection."
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1568.
Chapter 54: Management of Patients With Kidney Disorders - Page 1568
Question 12 See full question
The nurse is providing supportive care to a client receiving hemodialysis in the management of acute renal failure. Which statement from the nurse best reflects the ability of the kidneys to recover from acute renal failure?
You Selected:
The kidneys can improve over a period of months.
Correct response:
The kidneys can improve over a period of months.
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1537.
Chapter 54: Management of Patients With Kidney Disorders - Page 1537
Question 13 See full question
A nurse is caring for an acutely ill patient. The nurse understands that the most accurate indicator of fluid loss or gain in an acutely ill patient is which of the following?
You Selected:
Weight
Correct response:
Weight
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1527.
Chapter 54: Management of Patients With Kidney Disorders - Page 1527
Question 14 See full question
A patient diagnosed AKI has a serum potassium level of 6.5 mEq/L. The nurse anticipates administering which of the following?
You Selected:
Kayexalate
Correct response:
Kayexalate
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1539.
Chapter 54: Management of Patients With Kidney Disorders - Page 1539
Question 15 See full question
Which of the following is an integumentary manifestation of chronic renal failure?
You Selected:
Gray-bronze skin color
Correct response:
Gray-bronze skin color
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 15410.
Chapter 54: Management of Patients With Kidney Disorders - Page 15410
Question 16 See full question
Following are complications the nurse should monitor for during dialysis except for which of the following?
You Selected:
Hypertension
Correct response:
Hypertension
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1550.
Chapter 54: Management of Patients With Kidney Disorders - Page 1550
Question 17 See full question
The nurse notes that a patient who is retaining fluid had a 1-kg weight gain. The nurse knows that this is equivalent to about how many mL?
You Selected:
1,000 mL
Correct response:
1,000 mL
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1527.
Chapter 54: Management of Patients With Kidney Disorders - Page 1527
Question 18 See full question
The nurse is caring for a patient in the oliguric phase of AKI. What does the nurse know would be the daily urine output?
You Selected:
Less than 400 mL
Correct response:
Less than 400 mL
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1537.
Chapter 54: Management of Patients With Kidney Disorders - Page 1537
Question 19 See full question
The nurse weighs a patient daily and measures urinary output every hour. The nurse notices a weight gain of 1.5 kg in a 74-kg patient over 48 hours. The nurse is aware that this weight gain is equivalent to the retention of:
You Selected:
1,500 mL of fluid
Correct response:
1,500 mL of fluid
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1527.
Chapter 54: Management of Patients With Kidney Disorders - Page 1527
Question 20 See full question
When assessing the impact of medications on the etiology of ARF, the nurse recognizes which of the following as the drug that is not nephrotoxic?
You Selected:
Penicillin
Correct response:
Penicillin
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1536.
Chapter 54: Management of Patients With Kidney Disorders - Page 1536
Question 1 See full question
A client with decreased urine output refractory to fluid challenges is evaluated for renal failure. Which condition may cause the intrinsic (intrarenal) form of acute renal failure?
You Selected:
Nephrotoxic injury secondary to use of contrast media
Correct response:
Nephrotoxic injury secondary to use of contrast media
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1536.
Chapter 54: Management of Patients With Kidney Disorders - Page 1536
Question 2 See full question
The client with polycystic kidney disease asks the nurse, "Will my kidneys ever function normally again?" The best response by the nurse is:
You Selected:
"As the disease progresses, you will most likely require renal replacement therapy."
Correct response:
"As the disease progresses, you will most likely require renal replacement therapy."
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1533.
Chapter 54: Management of Patients With Kidney Disorders - Page 1533
Question 3 See full question
Which of the following causes should the nurse suspect in a client is diagnosed with intrarenal failure?
You Selected:
Glomerulonephritis
Correct response:
Glomerulonephritis
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1536.
Chapter 54: Management of Patients With Kidney Disorders - Page 1536
Question 4 See full question
Which nursing intervention should the nurse caring for the client with pyelonephritis implement?
You Selected:
Teach client to increase fluid intake up to 3 liters per day.
Correct response:
Teach client to increase fluid intake up to 3 liters per day.
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, pp. 1538-1539.
Chapter 54: Management of Patients With Kidney Disorders - Page 1538-1539
Question 5 See full question
After teaching a group of students about how to perform peritoneal dialysis, which statement would indicate to the instructor that the students need additional teaching?
You Selected:
"It is appropriate to warm the dial sate in a microwave."
Correct response:
"It is appropriate to warm the dial sate in a microwave."
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1555.
Chapter 54: Management of Patients With Kidney Disorders - Page 1555
Question 1 See full question
A nurse assesses a client shortly after living donor kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?
You Selected:
Urine output of 20 ml/hour
Correct response:
Urine output of 20 ml/hour
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1565.
Chapter 54: Management of Patients With Kidney Disorders - Page 1565
Question 2 See full question
A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is the most appropriate for this client?
You Selected:
Risk for infection
Correct response:
Risk for infection
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1556.
Chapter 54: Management of Patients With Kidney Disorders - Page 1556
Question 3 See full question
What is the term for the concentration of urea and other nitrogenous wastes in the blood?
You Selected:
Uremia
Correct response:
Azotemia
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1530.
Chapter 54: Management of Patients With Kidney Disorders - Page 1530
Question 4 See full question
Which of the following nursing actions is most important in caring for the client following lithotripsy?
You Selected:
Strain the urine carefully for stone fragments.
Correct response:
Strain the urine carefully for stone fragments.
Explanation:
Question 5 See full question
A male client has doubts about performing peritoneal dialysis at home. He informs the nurse about his existing upper respiratory infection. Which of the following suggestions can the nurse offer to the client while performing an at-home peritoneal dialysis?
You Selected:
Wear a mask when performing exchanges.
Correct response:
Wear a mask when performing exchanges.
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1558.
Chapter 54: Management of Patients With Kidney Disorders - Page 1558
Question 6 See full question
A nurse is reviewing the history of a client who is suspected of having glomerulonephritis. Which of the following would the nurse consider significant?
You Selected:
Recent history of streptococcal infection
Correct response:
Recent history of streptococcal infection
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1530.
Chapter 54: Management of Patients With Kidney Disorders - Page 1530
Question 7 See full question
A chronic renal failure client complains of generalized bone pain and tenderness. Which assessment finding would alert the nurse to an increased potential for the development of spontaneous bone fractures?
You Selected:
Hyperphosphatemia
Correct response:
Hyperphosphatemia
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1547.
Chapter 54: Management of Patients With Kidney Disorders - Page 1547
Question 8 See full question
The nurse is performing acute intermittent peritoneal dialysis (PD) on a patient who is experiencing uremic signs and symptoms. The peritoneal fluid is not draining as expected. Which of the following is the nurse's best action?
You Selected:
Turn the patient from side to side.
Correct response:
Turn the patient from side to side.
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1557.
Chapter 54: Management of Patients With Kidney Disorders - Page 1557
Question 9 See full question
A patient has stage 3 chronic kidney failure. What would the nurse expect the patient's glomerular filtration rate (GFR) to be?
You Selected:
A GFR of 30-59 mL/min/1.73 m2
Correct response:
A GFR of 30-59 mL/min/1.73 m2
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1528.
Chapter 54: Management of Patients With Kidney Disorders - Page 1528
Question 10 See full question
Hyperkalemia is a serious side effect of acute renal failure. Identify the electrocardiogram (ECG) tracing that is diagnostic for hyperkalemia.
You Selected:
Tall, peaked T waves
Correct response:
Tall, peaked T waves
Explanation:
Reference:
Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 54: Management of Patients With Kidney Disorders, p. 1539.
Chapter 54: Management of Patients With Kidney Disorders - Page 1539
Question 1 See full question

A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note:

You Selected:

yellow sclerae.
Correct response:

yellow sclerae.
Explanation:

Yellow sclerae are an early sign of jaundice, which occurs when the common bile duct is obstructed. Urine normally is light amber. Circumoral pallor and black, tarry stools don't occur in common bile duct obstruction; they are signs of hypoxia and GI bleeding, respectively.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1393.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1393

Question 2 See full question

A nurse is providing dietary instructions to a client with a history of pancreatitis. Which instruction is correct?

You Selected:

"Maintain a high-carbohydrate, low-fat diet."
Correct response:

"Maintain a high-carbohydrate, low-fat diet."
Explanation:

A client with a history of pancreatitis should avoid foods and beverages that stimulate the pancreas, such as fatty foods, caffeine, and gas-forming foods; should avoid eating large meals; and should eat plenty of carbohydrates, which are easily metabolized. Therefore, the only correct instruction is to maintain a high-carbohydrate, low-fat diet. An increased sodium or fluid intake isn't necessary because chronic pancreatitis isn't associated with hyponatremia or fluid loss.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1404.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1404

Question 3 See full question

When caring for a client with acute pancreatitis, the nurse should use which comfort measure?

You Selected:

Positioning the client on the side with the knees flexed
Correct response:

Positioning the client on the side with the knees flexed
Explanation:

The nurse should place the client with acute pancreatitis in a side-lying position with knees flexed; this position promotes comfort by decreasing pressure on the abdominal muscles. The nurse should administer an analgesic, as needed and ordered, before pain becomes severe, rather than once each shift. Because the client needs a quiet, restful environment during the acute disease stage, the nurse should discourage frequent visits from family and friends. Frequent oral feedings are contraindicated during the acute stage to allow the pancreas to rest.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1404.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1404

Question 4 See full question

A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority?

You Selected:

Acute pain related to biliary spasms
Correct response:

Acute pain related to biliary spasms
Explanation:

The chief symptom of cholecystitis is abdominal pain or biliary colic. Typically, the pain is so severe that the client is restless and changes positions frequently to find relief. Therefore, the nursing diagnosis of Acute pain related to biliary spasms takes highest priority. Until the acute pain is relieved, the client can't learn about prevention, may continue to experience anxiety, and can't address nutritional concerns.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1391.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1391

Question 5 See full question

A client with a history of alcohol abuse comes to the emergency department and complains of abdominal pain. Laboratory studies help confirm a diagnosis of acute pancreatitis. The client's vital signs are stable, but the client's pain is worsening and radiating to his back. Which intervention takes priority for this client?

You Selected:

Administering morphine I.V. as ordered
Correct response:

Administering morphine I.V. as ordered
Explanation:

The nurse should address the client's pain issues first by administering morphine I.V. as ordered. Placing the client in a Semi-Fowler's position, maintaining NPO status, and providing mouth care don't take priority over addressing the client's pain issues.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1403.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1403

Question 6 See full question

Total parental nutrition (TPN) should be used cautiously in patients with pancreatitis due to which of the following?

You Selected:

They cannot tolerate high-glucose concentration.
Correct response:

They cannot tolerate high-glucose concentration.
Explanation:

Total parental nutrition (TPN) is used carefully in patients with pancreatitis because some patients cannot tolerate a high-glucose concentration, even with insulin coverage. Intake of coffee increases the risk for gallbladder contraction, while intake of high protein increases risk for hepatic encephalopathy in patients with cirrhosis. Patients with pancreatitis should not be given high-fat foods because they are difficult to digest.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1404.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1404

Question 7 See full question

Which of the following is clinical manifestation of cholelithiasis?

You Selected:

Clay-colored stools
Correct response:

Clay-colored stools
Explanation:

The patient with gallstones has clay-colored stools, and excruciating upper right quadrant pain that radiates to the back or right shoulder. The excretion of bile pigments by the kidneys makes urine very dark. The feces, no longer colored with bile pigments, are grayish (like putty) or clay colored. The patient develops a fever and may have a palpable abdominal mass.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1393.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1393

Question 8 See full question

The digestion of carbohydrates is aided by

You Selected:

amylase.
Correct response:

amylase.
Explanation:

Amylase is secreted by the exocrine pancreas. Lipase aids in the digestion of fats. Trypsin aids in the digestion of proteins. Secretin is the major stimulus for increased bicarbonate secretion from the pancreas.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1390.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1390

Question 9 See full question

From the following profiles of clients, which client would be most likely to undergo the diagnostic test of cholecystography?

You Selected:

Mark, suspected of having stones in the gallbladder
Correct response:

Mark, suspected of having stones in the gallbladder
Explanation:

Cholecystography will be most appropriate for Mark because the test is used to detect stones in the gallbladder. Most likely, Andrew would require barium swallow test to detect any abnormalities in the esophagus. Steven would need a barium enema for to identify a tumor in the colon. Sandra would undergo a radionuclide image test for her lesions in the liver.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1389.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1389

Question 10 See full question

A client is admitted to the healthcare facility suspected of having acute pancreatitis and undergoes laboratory testing. Which of the following would the nurse expect to find?

You Selected:

Elevated urine amylase levels
Correct response:

Elevated urine amylase levels
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1402.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1402

Question 11 See full question

The nurse knows that the client with cholelithiasis can have a nutritional deficiency. The obstruction of bile flow due to cholelitiasis can interfere with the absorption of

You Selected:

Vitamin A
Correct response:

Vitamin A
Explanation:

Obstruction of bile flow interferes with absorption of the fat-soluble vitamins A, D, E, and K. Clients may exhibit deficiencies of these vitamins if biliary obstruction has been prolonged. Vitamins B6, B12, and C are not fat soluable.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1393.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1393

Question 12 See full question

A nurse has admitted a client suspected of having acute pancreatitis. The nurse knows that mild acute pancreatitis is characterized by:

You Selected:

Pleural effusion
Correct response:

Edema and inflammation
Explanation:

Severe abdominal pain is the major symptom of pancreatitis that causes the client to seek medical care. Abdominal pain and tenderness and back pain result from irritation and edema of the inflamed pancreas.

Reference:

Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 12th ed. Philadelphia: Lippincott Williams & Wilkins, 2010, Chapter 40: Assessment and Management of Patients With Biliary Disorders, p. 1182.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1182

Question 13 See full question

Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray?

You Selected:

Hot roast beef sandwich with gravy
Correct response:

Hot roast beef sandwich with gravy
Explanation:

The diet immediately after an episode of acute cholecystitis is initially limited to low-fat liquids. Cooked fruits, rice or tapioca, lean meats, mashed potatoes, bread, and coffee or tea may be added as tolerated. The client should avoid fried foods such as fried chicken, because fatty foods may bring on an episode of cholecystitis.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1395.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1395

Question 14 See full question

A student nurse is preparing a plan of care for a client with chronic pancreatitis. What nursing diagnosis related to the care of a client with chronic pancreatitis is the priority?

You Selected:

Impaired nutrition: less than body requirements
Correct response:

Impaired nutrition: less than body requirements
Explanation:

While each diagnosis may be applicable to this client, the priority nursing diagnosis is impaired nutrition: less than body requirements. The physician, nurse, and dietitian emphasize to the client and family the importance of avoiding alcohol and foods that have produced abdominal pain and discomfort in the past. Oral food or fluid intake is not permitted during the acute phase.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1409.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1409

Question 15 See full question

A critical care nurse is caring for a client with acute pancreatitis. One potentially severe complication involves the respiratory system. Which of the following would be an appropriate intervention to prevent complications associated with the respiratory system?

You Selected:

Maintain the client in a semi-Fowler's position.
Correct response:

Maintain the client in a semi-Fowler's position.
Explanation:

The nurse maintains the client in the semi-Fowler's position to decrease pressure on the diaphragm by a distended abdomen and to increase respiratory expansion. Respiratory distress and hypoxia are common, and the client may develop diffuse pulmonary infiltrates, dyspnea, tachypnea, and abnormal blood gas values. The client who has undergone surgery may have multiple drains or an open surgical incision and is at risk for skin breakdown and infection. Oral food or fluid intake is not permitted; therefore, enteral or parenteral feedings may be prescribed.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1403.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1403

Question 16 See full question

A nursing instructor is explaining the pathophysiology and clinical manifestations of pancreatitis to a group of nursing students. The instructor evaluates the teaching as effective when a student correctly identifies which of the following symptoms as the most common complaints of patients with pancreatitis?

You Selected:

Severe, radiating abdominal pain
Correct response:

Severe, radiating abdominal pain
Explanation:

Severe abdominal pain is the major symptom of pancreatitis that causes the patient to seek medical care. The pain occurs in the midepigastrium. Abdominal pain and tenderness and back pain result from irritation and edema of the inflamed pancreas. Pain is frequently acute in onset, occurring 24 to 48 hours after a very heavy meal or alcohol ingestion; it may be diffuse and difficult to localize.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1402.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1402

Question 17 See full question

A patient with acute pancreatitis has been started on total parenteral nutrition (TPN). Following the administration of the TPN, which of the following should the nurse plan to monitor?

You Selected:

Blood glucose levels every 4 to 6 hours
Correct response:

Blood glucose levels every 4 to 6 hours
Explanation:

Enteral or parenteral nutrition may be prescribed. In addition to administering enteral or parenteral nutrition, the nurse monitors serum glucose levels every 4 to 6 hours.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1404.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1404

Question 18 See full question

The physician has written the following orders: bed rest, nothing by mouth (NPO), and administration of total parenteral nutrition (TPN) for a new patient admitted with pancreatitis. The nurse attributes which of the following as the cause for NPO status?

You Selected:

To avoid inflammation of the pancreas
Correct response:

To avoid inflammation of the pancreas
Explanation:

Pancreatic secretion is increased by food and fluid intake and may cause inflammation of the pancreas.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1406.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1406

Question 19 See full question

Which of the following conditions in a patient with pancreatitis makes it necessary for the nurse to check fluid intake and output, hourly urine output, and monitor electrolyte levels?

You Selected:

Frequent vomiting leading to loss of fluid volume
Correct response:

Frequent vomiting leading to loss of fluid volume
Explanation:

Fluid and electrolyte disturbances are common complications because of nausea, vomiting, movement of fluid from the vascular compartment to the peritoneal cavity, diaphoresis, fever, and the use of gastric suction. The nurse assesses the patient's fluid and electrolyte status by noting skin turgor and moistness of mucous membranes. The nurse weighs the patient daily and carefully measures fluid intake and output, including urine output, nasogastric secretions, and diarrhea.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1404.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1404

Question 20 See full question

A patient is suspected to have pancreatic carcinoma and is having diagnostic testing to determine insulin deficiency. What would the nurse determine is an indicator for insulin deficiency in this patient? (Select all that apply.)

You Selected:

Hyperglycemia
An abnormal glucose tolerance
Glucosuria
Correct response:

An abnormal glucose tolerance
Glucosuria
Hyperglycemia
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1410.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1410

Question 1 See full question

A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. The physician diagnoses acute pancreatitis. What is the primary goal of nursing care for this client?

You Selected:

Relieving abdominal pain
Correct response:

Relieving abdominal pain
Explanation:

The predominant clinical feature of acute pancreatitis is abdominal pain, which usually reaches peak intensity several hours after onset of the illness. Therefore, relieving abdominal pain is the nurse's primary goal. Because acute pancreatitis causes nausea and vomiting, the nurse should try to prevent fluid volume deficit, not overload. The nurse can't help the client achieve adequate nutrition or understand the disease and its treatment until the client is comfortable and no longer in pain.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1402.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1402

Question 2 See full question

A nurse is providing preoperative teaching to a client undergoing a cholecystectomy. Which topic should the nurse include in her teaching plan?

You Selected:

Improve nutritional status during recovery.
Correct response:

Increase respiratory effectiveness.
Explanation:

The nurse must teach the client about using an incentive spirometer to promote lung expansion. The high abdominal incision used in a cholecystectomy interferes with respirations postoperatively, increasing the risk of atelectasis. The client will need to use incentive spirometry to promote lung expansion, increase alveolar inflation, and strengthen respiratory muscles. Most clients don't have a nasogastric tube in place after a cholecystectomy. It isn't appropriate to teach improved nutritional status before surgery. It isn't important for the client to be aware of how to decrease the amount of postoperative analgesia, because this is the responsibility of the health care team.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1398.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1398

Question 3 See full question

Which condition is most likely to have a nursing diagnosis of fluid volume deficit?

You Selected:

Pancreatitis
Correct response:

Pancreatitis
Explanation:

Hypovolemic shock from fluid shifts is a major factor in acute pancreatitis. Appendicitis, cholecystitis, and gastric ulcer are less likely to exhibit fluid volume deficit.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, pp. 1404-1405.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1404-1405

Question 4 See full question

A client diagnosed with acute pancreatitis is being transferred to another facility. The nurse caring for the client completes the transfer summary, which includes information about the client's drinking history and other assessment findings. Which assessment findings confirm his diagnosis?

You Selected:

Recent weight loss and temperature elevation
Correct response:

Recent weight loss and temperature elevation
Explanation:

Assessment findings associated with pancreatitis include recent weight loss and temperature elevation. Inflammation of the pancreas causes a response that elevates temperature and leads to abdominal pain that typically occurs with eating. Nausea and vomiting may occur as a result of pancreatic tissue damage that's caused by the activation of pancreatic enzymes. The client may experience weight loss because of the lost desire to eat. Blood in stools and recent hypertension aren't associated with pancreatitis; fatty diarrhea and hypotension are usually present. Presence of easy bruising and bradycardia aren't found with pancreatitis; the client typically experiences tachycardia, not bradycardia. Adventitious breath sounds and hypertension aren't associated with pancreatitis.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1402.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1402

Question 5 See full question

A client being treated for pancreatitis faces the risk of atelectasis. Which of the following interventions would be important to implement to minimize this risk?

You Selected:

Reposition the client every 2 hours.
Correct response:

Reposition the client every 2 hours.
Explanation:

Repositioning the client every 2 hours minimizes the risk of atelectasis in a client who is being treated for pancreatitis. The client should be instructed to cough every 2 hours to reduce atelectasis. Monitoring the pulse oximetry helps show changes in respiratory status and promote early intervention, but it would do little to minimize the risk of atelectasis. Withholding oral feedings limits the reflux of bile and duodenal contents into the pancreatic duct.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1397.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1397

Question 6 See full question

A client with calculi in the gallbladder is said to have

You Selected:

Cholelithiasis
Correct response:

Cholelithiasis
Explanation:

Calculi, or gallstones, usually form in the gallbladder from the solid constituents of bile; they vary greatly in size, shape, and composition. Cholecystitis is acute inflammation of the gallbladder. Choledocholithiasis is a gallstone in the common bile duct. Choledochotomy is an incision into the common bile duct.

Reference:

Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 12th ed. Philadelphia: Lippincott Williams & Wilkins, 2010, Chapter 40: Assessment and Management of Patients With Biliary Disorders, p. 1172.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1172

Question 7 See full question

Clinical manifestations of common bile duct obstruction include all of the following except:

You Selected:

Amber-colored urine
Correct response:

Amber-colored urine
Explanation:

The excretion of the bile pigments by the kidneys gives the urine a very dark color. The feces, no longer colored with bile pigments, are grayish, like putty, or clay-colored. The symptoms may be acute or chronic. Epigastric distress, such as fullness, abdominal distention, and vague pain in the right upper quadrant of the abdomen, may occur. If it goes untreated jaundice and pruritus can occur.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1400.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1400

Question 8 See full question

Increased appetite and thirst may indicate that a client with chronic pancreatitis has developed diabetes melitus. Which of the following explains the cause of this secondary diabetes?

You Selected:

Dysfunction of the pancreatic islet cells
Correct response:

Dysfunction of the pancreatic islet cells
Explanation:

Diabetes mellitus resulting from dysfunction of the pancreatic islet cells is treated with diet, insulin, or oral antidiabetic agents. The hazard of severe hypoglycemia with alcohol consumption is stressed to the client and family. When secondary diabetes develops in a client with chronic pancreatitis, the client experiences increased appetite, thirst, and urination. A standard treatment with pancreatitis is to make the client NPO. The dysfunction is related to the pancreas, not the liver.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1409.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1409

Question 9 See full question

A nursing instructor is lecturing to a class about chronic pancreatitis. Which of the following does the instructor list as major causes?

You Selected:

Alcohol consumption and smoking
Correct response:

Alcohol consumption and smoking
Explanation:

Alcohol consumption in Western societies and malnutrition worldwide are the major causes of chronic pancreatitis. Smoking is another factor in the development of chronic pancreatitis. Because heavy drinkers usually smoke, it is difficult to separate the effects of the alcohol abuse and smoking. Obesity is a form of malnutrition. Acute pancreatitis does not usually lead to chronic pancreatitis unless complications develop.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1405.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1405

Question 10 See full question

A 70-year-old patient is admitted with acute pancreatitis. The nurse understands that the mortality rate associated with acute pancreatitis increases with advanced age and attributes this to which of the following gerontologic considerations associated with the pancreas?

You Selected:

Decreases in the physiologic function of major organs
Correct response:

Decreases in the physiologic function of major organs
Explanation:

Acute pancreatitis affects people of all ages, but the mortality rate associated with acute pancreatitis increases with advancing age. The pattern of complications changes with age. Younger patients tend to develop local complications; the incidence of multiple organ failure increases with age, possibly as a result of progressive decreases in physiologic function of major organs with increasing age.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1401.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1401

Question 11 See full question

Ursodeoxycholic acid (UDCA) has been used to dissolve small, radiolucent gallstones. Which duration of therapy is required to dissolve the stones?

You Selected:

6 to 12 months
Correct response:

6 to 12 months
Explanation:

Six to 12 months of therapy with UDCA is recommended in patients to dissolve the stones.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1395.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1395

Question 12 See full question

A nurse is planning care for a patient with acute pancreatitis. Which of the following patient outcomes does the nurse assign as the highest priority?

You Selected:

Maintaining satisfactory pain control
Correct response:

Maintenance of normal respiratory function
Explanation:

Airway and breathing are always the priority assessment. Acute pancreatitis produces retroperitoneal edema, elevation of the diaphragm, pleural effusion, and inadequate lung ventilation. Intra-abdominal infection and labored breathing increase the body's metabolic demands, which further decreases pulmonary reserve and can lead to respiratory failure. Maintenance of adequate respiratory function is the priority goal. The other outcomes would also be appropriate for the patient.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1406.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1406

Question 13 See full question

The nurse is planning care for a patient following an incisional cholecystectomy for cholelithiasis. Which of the following interventions is the highest nursing priority for this patient?

You Selected:

Assisting the patient to turn, cough, and deep breathe every 2 hours
Correct response:

Assisting the patient to turn, cough, and deep breathe every 2 hours
Explanation:

Assessment should focus on the patient's respiratory status. If a traditional surgical approach is planned, the high abdominal incision required during surgery may interfere with full respiratory excursion. The other nursing actions are also important, but are not as high a priority as ensuring adequate ventilation.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1399.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1399

Question 14 See full question

A patient who has been having recurrent attacks of severe abdominal pain over the past few months informs the physician about a 25-pound weight loss in the last year. The nurse attributes which of the following as the most likely cause of this weight loss?

You Selected:

Skipping meals out of fear of painful attacks
Correct response:

Skipping meals out of fear of painful attacks
Explanation:

Weight loss is a major problem in chronic pancreatitis: More than 80% of patients experience significant weight loss, which is usually caused by decreased dietary intake secondary to anorexia or fear that eating will precipitate another attack.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1405.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1405

Question 15 See full question

A patient is admitted to the hospital with possible cholelithiasis. What diagnostic test of choice will the nurse prepare the patient for?

You Selected:

Ultrasonography
Correct response:

Ultrasonography
Explanation:

Ultrasonography has replaced cholecystography (discussed later) as the diagnostic procedure of choice because it is rapid and accurate and can be used in patients with liver dysfunction and jaundice. It does not expose patients to ionizing radiation.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1393.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1393

Question 16 See full question

A patient is diagnosed with mild acute pancreatitis. What does the nurse understand is characteristic of this disorder?

You Selected:

Edema and inflammation
Correct response:

Edema and inflammation
Explanation:

Mild acute pancreatitis is characterized by edema and inflammation confined to the pancreas. Minimal organ dysfunction is present, and return to normal function usually occurs within 6 months.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1401.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1401

Question 17 See full question

The nurse is caring for a patient with acute pancreatitis. The patient has an order for an anticholinergic medication. The nurse explains that the patient will be receiving that medication for what reason?

You Selected:

To reduce gastric and pancreatic secretions
Correct response:

To reduce gastric and pancreatic secretions
Explanation:

Anticholinergic medications reduce gastric and pancreatic secretion.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1406.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1406

Question 18 See full question

The patient admitted with acute pancreatitis has passed the acute stage and is now able to tolerate solid foods. What type of diet will increase caloric intake without stimulating pancreatic enzymes beyond the ability of the pancreas to respond?

You Selected:

High-carbohydrate, low-protein, low-fat diet
Correct response:

High-carbohydrate, low-protein, low-fat diet
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1407.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1407

Question 19 See full question

A patient with acute pancreatitis puts the call bell on to tell the nurse about an increase in pain. The nurse observes the patient guarding; the abdomen is boardlike and no bowel sounds are detected. What is the major concern for this patient?

You Selected:

The patient is developing a paralytic ileus.
Correct response:

The patient has developed peritonitis.
Explanation:

Abdominal guarding is present. A rigid or boardlike abdomen may develop and is generally an ominous sign, usually indicating peritonitis (Privette et al., 2011).

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1402.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1402

Question 20 See full question

The severity of pancreatitis is directly proportional to the number of indicators present. A patient with five to six signs indicative of pancreatitis would have a __________% chance of mortality.

You Selected:

20%
Correct response:

40%
Explanation:

Refer to Box 25-12 in the text.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1402.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1402

Question 1 See full question

The nurse knows that serum amylase levels return to normal within which timeframe?

You Selected:

48 hours
Correct response:

48 hours
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1402.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1402

Question 2 See full question

Which of the following interventions should be included in the plan of care for a patient who has undergone a cholecystectomy?

You Selected:

Placing the patient in the semi-Fowler's position immediately following surgery
Correct response:

Assessing the color of the sclera every shift
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1399.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1399

Question 3 See full question

Which of the following is the major cause of morbidity and mortality in patients with acute pancreatitis?

You Selected:

Shock
Correct response:

Pancreatic necrosis
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1404.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1404

Question 4 See full question

A nurse is teaching a patient about the cause of acute pancreatitis. The nurse evaluates the teaching as effective when the patient correctly identifies which of the following conditions as a cause of acute pancreatitis?

You Selected:

Self-digestion of the pancreas by its own proteolytic enzymes
Correct response:

Self-digestion of the pancreas by its own proteolytic enzymes
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1401.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1401

Question 5 See full question

When the nurse is caring for a patient with acute pancreatitis, what intervention can be provided in order to prevent atelectasis and prevent pooling of respiratory secretions?

You Selected:

Frequent changes of positions
Correct response:

Frequent changes of positions
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1404.

Chapter 50: Assessment and Management of Patients With Biliary Disorders - Page 1404
Question 1 See full question

The nurse is caring for a client with hepatitis. Which of the following would lead the nurse to suspect that the client is in the prodromal phase?

You Selected:

Rash
Correct response:

Rash
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients with Hepatic Disorders, p. 1359.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1359

Question 2 See full question

Which of the following medications is used to decrease portal pressure, halting bleeding of esophageal varices?

You Selected:

Vasopressin (Pitressin)
Correct response:

Vasopressin (Pitressin)
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1346.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1346

Question 3 See full question

Ammonia, the major etiologic factor in the development of encephalopathy, inhibits neurotransmission. Increased levels of ammonia are damaging to the body. The largest source of ammonia is from:

You Selected:

The digestion of dietary and blood proteins.
Correct response:

The digestion of dietary and blood proteins.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1355.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1355

Question 4 See full question

A patient with end-stage liver disease who is scheduled to undergo a liver transplant tells the nurse, "I am worried that my body will reject the liver." Which of the following statements is the nurse's best response to the patient?

You Selected:

"You will need to take daily medication to prevent rejection of the transplanted liver. The new liver has a good chance of survival with the use of these drugs."
Correct response:

"You will need to take daily medication to prevent rejection of the transplanted liver. The new liver has a good chance of survival with the use of these drugs."
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1383.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1383

Question 5 See full question

Which of the following is the most effective strategy to prevent hepatitis B infection?

You Selected:

Vaccine
Correct response:

Vaccine
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1361.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1361

Question 6 See full question

A nurse is preparing a presentation for a local community group about hepatitis. Which of the following would the nurse include?

You Selected:

Hepatitis C increases a person's risk for liver cancer.
Correct response:

Hepatitis C increases a person's risk for liver cancer.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1364.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1364

Question 7 See full question

Which of the following would be the least important assessment in a patient diagnosed with ascites?

You Selected:

Foul-smelling breath
Correct response:

Foul-smelling breath
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1367.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1367

Question 8 See full question

The most common cause of esophageal varices includes which of the following?

You Selected:

Portal hypertension
Correct response:

Portal hypertension
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1349.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1349

Question 9 See full question

To reduce risk of injury for a patient with liver disease, what initial measure can the nurse implement?

You Selected:

Pad the side rails on the bed
Correct response:

Pad the side rails on the bed
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1369.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1369

Question 10 See full question

A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has:

You Selected:

cirrhosis.
Correct response:

cirrhosis.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1367.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1367

Question 11 See full question

Which of the following symptoms would indicate that a client with chronic pancreatitis has developed secondary diabetes?

You Selected:

Increased appetite and thirst
Correct response:

Increased appetite and thirst
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 51: Assessment and Management of Patients With Diabetes, p. 1420.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1420

Question 12 See full question

A nurse is preparing a presentation for a local community group about hepatitis. Which of the following would the nurse include?

You Selected:

Hepatitis C increases a person's risk for liver cancer.
Correct response:

Hepatitis C increases a person's risk for liver cancer.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients with Hepatic Disorders, p. 1364.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1364

Question 13 See full question

A client is suspected of having cirrhosis of the liver. What diagnostic procedure will the nurse prepare the client for in order to obtain a confirmed diagnosis?

You Selected:

A liver biopsy
Correct response:

A liver biopsy
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1368.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1368

Question 14 See full question

The nurse is caring for a client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease?

You Selected:

Purpura and petechiae
Correct response:

Purpura and petechiae
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1367.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1367

Question 15 See full question

A client is being prepared to undergo laboratory and diagnostic testing to confirm the diagnosis of cirrhosis. Which test would the nurse expect to be used to provide definitive confirmation of the disorder?

You Selected:

Liver biopsy
Correct response:

Liver biopsy
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients with Hepatic Disorders, p. 1342.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1342

Question 16 See full question

Which of the following indicates an overdose of lactulose?

You Selected:

Watery diarrhea
Correct response:

Watery diarrhea
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1356.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1356

Question 17 See full question

What test should the nurse prepare the client for that will locate stones that have collected in the common bile duct?

You Selected:

Endoscopic retrograde cholangiopancreatography (ERCP)
Correct response:

Endoscopic retrograde cholangiopancreatography (ERCP)
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, p. 1394.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1394

Question 18 See full question

A nurse is gathering equipment and preparing to assist with a sterile bedside procedure to withdraw fluid from a patient's abdomen. The procedure tray contains the following equipment: trocar, syringe, needles, and drainage tube. The patient is placed in a high Fowler's position and a BP cuff is secured around the arm in preparation for which of the following procedures?

You Selected:

Paracentesis
Correct response:

Paracentesis
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1347.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1347

Question 19 See full question

The nurse identifies which of the following types of jaundice in an adult experiencing a transfusion reaction?

You Selected:

Hemolytic
Correct response:

Hemolytic
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1342.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1342

Question 20 See full question

A client has a blockage of the passage of bile from a stone in the common bile duct. What type of jaundice does the nurse suspect this client has?

You Selected:

Obstructive jaundice
Correct response:

Obstructive jaundice
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1344.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1344

Question 1 See full question

A patient has an elevated serum ammonia level and is exhibiting mental status changes. The nurse should suspect which of the following conditions?

You Selected:

Hepatic encephalopathy
Correct response:

Hepatic encephalopathy
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1354-1355.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1354-1355

Question 2 See full question

Which of the following medications are used to decrease portal pressure, halting bleeding of esophageal varices?

You Selected:

Vasopressin (Pitressin)
Correct response:

Vasopressin (Pitressin)
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1351.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1351

Question 3 See full question

A client with severe and chronic liver disease is showing manifestations related to inadequate vitamin intake and metabolism. He reports difficulty driving at night because he cannot see well. Which of the following vitamins is most likely deficient for this client?

You Selected:

Vitamin A
Correct response:

Vitamin A
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1358.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1358

Question 4 See full question

When assessing a client with cirrhosis of the liver, which of the following stool characteristics is the client likely to report?

You Selected:

Clay-colored or whitish
Correct response:

Clay-colored or whitish
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1344.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1344

Question 5 See full question

The nurse is administering medications to a patient that has elevated ammonia due to cirrhosis of the liver. What medication will the nurse give to detoxify ammonium and to act as an osmotic agent?

You Selected:

Lactulose (Cephulac)
Correct response:

Lactulose (Cephulac)
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1376.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1376

Question 6 See full question

A client with cirrhosis has portal hypertension, which is causing esophageal varices. What is the goal of the interventions that the nurse will provide?

You Selected:

Reduce fluid accumulation and venous pressure.
Correct response:

Reduce fluid accumulation and venous pressure.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1344.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1344

Question 7 See full question

When caring for a patient with advanced cirrhosis and hepatic encephalopathy, which of the following assessment findings should the nurse report immediately?

You Selected:

Change in the patient's handwriting and or cognitive performance
Correct response:

Change in the patient's handwriting and or cognitive performance
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1355.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1355

Question 8 See full question

Which of the following would be the most important nursing assessment in a patient diagnosed with ascites?

You Selected:

Daily weight and measurement of abdominal girth
Correct response:

Daily weight and measurement of abdominal girth
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1345.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1345

Question 9 See full question

The nurse is providing care to a patient with gross ascites who is maintaining a position of comfort in the high semi-Fowler's position. What is the nurse's priority assessment of this patient?

You Selected:

Respiratory assessment related to increased thoracic pressure
Correct response:

Respiratory assessment related to increased thoracic pressure
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1348.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1348

Question 10 See full question

The nurse is caring for a patient with cirrhosis of the liver and observes that the patient is having hand-flapping tremors. What does the nurse document this finding as?

You Selected:

Asterixis
Correct response:

Asterixis
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1355.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1355

Question 1 See full question

A physician orders spironolactone (Aldactone), 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect?

You Selected:

Loss of 2.2 lb (1 kg) in 24 hours
Correct response:

Loss of 2.2 lb (1 kg) in 24 hours
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1369.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1369

Question 2 See full question

A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds him very difficult to arouse. The diagnostic information which best explains the client's behavior is:

You Selected:

subnormal serum glucose and elevated serum ammonia levels.
Correct response:

subnormal serum glucose and elevated serum ammonia levels.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1373.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1373

Question 3 See full question

A nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice?

You Selected:

Clay-colored stools
Correct response:

Clay-colored stools
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1344.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1344

Question 4 See full question

When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which of the following interventions should the nurse consider?

You Selected:

Measure abdominal girth according to a set routine.
Correct response:

Measure abdominal girth according to a set routine.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients with Hepatic Disorders, p. 1340.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1340

Question 5 See full question

A client is actively bleeding from esophageal varices. Which of the following medications would the nurse most expect to be administered to this client?

You Selected:

Vasopressin (Pitressin)
Correct response:

Vasopressin (Pitressin)
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1351.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1351

Question 6 See full question

Why should total parental nutrition (TPN) be used cautiously in clients with pancreatitis?

You Selected:

Such clients cannot tolerate high-glucose concentration.
Correct response:

Such clients cannot tolerate high-glucose concentration.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients with Biliary Disorders, p. 1407.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1407

Question 7 See full question

A female client with chronic hepatitis B has been prescribed recombinant interferon alfa-2b (Intron A, Roferon-A) in combination with ribavirin (Rebetol). Which of the following instructions should a nurse provide this client?

You Selected:

Use strict birth control methods.
Correct response:

Use strict birth control methods.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1364.
Question 8 See full question

A client with carcinoma of the head of the pancreas is scheduled for surgery. Which of the following should a nurse administer to the client before surgery?

You Selected:

Vitamin K
Correct response:

Vitamin K
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 50: Assessment and Management of Patients With Biliary Disorders, pp. 1396-1397.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1396-1397

Question 9 See full question

A patient with cirrhosis has a massive hemorrhage from esophageal varices. Balloon tamponade therapy is used temporarily to control hemorrhage and stabilize the patient. In planning care, the nurse gives the highest priority to which of the following goals?

You Selected:

Controlling bleeding
Correct response:

Maintaining the airway
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1351.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1351

Question 10 See full question

A patient who had a recent myocardial infarction was brought to the emergency department with bleeding esophageal varices and is presently receiving fluid resuscitation. What first-line pharmacologic therapy does the nurse anticipate administering to control the bleeding from the varices?

You Selected:

Vasopressin (Pitressin)
Correct response:

Octreotide (Sandostatin)
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 49: Assessment and Management of Patients With Hepatic Disorders, p. 1351.

Chapter 49: Assessment and Management of Patients With Hepatic Disorders - Page 1351
Question 1 See full question

Your client informs you that he has been struggling with depression; however, he does not know if it is severe enough to start on medication. Your best response would be:

You Selected:

Antidepressant therapy may be indicated if depressive symptoms persist at least 2 weeks, impair social relationships or work performance, and occur independently of life events.
Correct response:

Antidepressant therapy may be indicated if depressive symptoms persist at least 2 weeks, impair social relationships or work performance, and occur independently of life events.
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1002.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1002

Question 2 See full question

A deficiency of a biogenic amine in key brain areas is believed to result in depression.

You Selected:

True
Correct response:

True
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1001.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1001

Question 3 See full question

A client who ingests foods high in tyramine while taking a selective serotonin reuptake inhibitor is at risk for developing severe hypertensive crisis.


You Selected:

True
Correct response:

False
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1012.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1012

Question 4 See full question

How long does a patient need to wait after stopping a phenelzine (Nardil) before starting paroxetine (Paxil)?

You Selected:

14 days
Correct response:

14 days
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1009.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1009

Question 5 See full question

A client has been taking Prozac for the past two months for depression. She is seeing her gynecologist for premenopausal symptoms and during the interview with the nurse she says "I'm interested in trying Sarafem because my friend is taking it and she says it works great." The nurse's best response is what?


You Selected:

"Sarafem and Prozac are different brand names for the same generic medication."
Correct response:

"Sarafem and Prozac are different brand names for the same generic medication."
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1008.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1008

Question 6 See full question

A patient with a severe depression has been hospitalized, and the physician has ordered amitriptyline. What common adverse effect might this patient have?

You Selected:

Dry mouth
Correct response:

Dry mouth
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1006.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1006

Question 7 See full question

A 79-year-old male client is brought to the emergency department by his family because he is "talking to people who aren't there." During the initial admission assessment, his daughter mentions that her mother died 4 months ago and "Dad just hasn't been the same. The doctor has even put him on antidepressant medication. I go by the house every day to make sure he takes his medication." What would the nurse suspect is happening to this client?


You Selected:

The client is having hallucinations as an adverse effect of antidepressant therapy
Correct response:

The client is having hallucinations as an adverse effect of antidepressant therapy
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1005.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1005

Question 8 See full question

Which of the following should be reported to the physician once identified by the nurse observing a client taking an antidepressant? Select all that apply:

You Selected:

Insomnia
Indirect threats of suicide
Expressions of guilt
Correct response:

Expressions of guilt
Indirect threats of suicide
Insomnia
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1019.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1019

Question 9 See full question

A nurse is caring for a patient with depression. Which symptom should the nurse closely monitor for in the patient?

You Selected:

Extreme sadness
Correct response:

Extreme sadness
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1002.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1002

Question 10 See full question

In patients requiring sertraline therapy, which patient would require the closest monitoring by the nurse?

You Selected:

A 45-year-old man with liver impairment
Correct response:

A 45-year-old man with liver impairment
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1008.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1008

Question 11 See full question

A 12-year-old child who has been taking sertraline for the past 2 weeks has returned to the clinic to be seen. It will be critical for the nurse to assess for

You Selected:

onset of suicidal ideation.
Correct response:

onset of suicidal ideation.
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1088.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1088

Question 12 See full question

A nurse is working with a Chinese immigrant who is taking an MAOI. The most important instruction to the patient by the nurse will be to

You Selected:

avoid use of soy sauce in the diet.
Correct response:

avoid use of soy sauce in the diet.
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1013.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1013

Question 13 See full question

A nurse is assigned to a patient who is taking lithium. Which of the following drug serum levels would indicate that the patient is at risk for adverse effects of the drug?

You Selected:

1.7 mEq/L
Correct response:

1.7 mEq/L
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1016.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1016

Question 14 See full question

Why are selective serotonin reuptake inhibitors considered the first line of drug therapy for patients with depression?

You Selected:

The medications have fewer anticholinergic effects than alternatives.
Correct response:

The medications have fewer anticholinergic effects than alternatives.
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1008.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1008

Question 15 See full question

Mark has been prescribed nortriptyline for depression. Your nursing assessment of Mark reveals a thin male, age 52, with decreased albumin, BUN, creatinine, and protein levels. He has a prior history of alcohol abuse. His history also includes asthma and gastroesophageal reflux. When prescribing nortriptyline, which condition do you know puts Mark at risk for toxicity?

You Selected:

Alcohol abuse, because the medication is metabolized in the liver
Correct response:

His malnutrition
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, pp. 1004-1005.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1004-1005

Question 16 See full question

A nurse is reviewing a client's serum lithium level. Which finding would indicate that the client is experiencing lithium toxicity?

You Selected:

1.8 mEq/L
Correct response:

1.8 mEq/L
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1017.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1017

Question 17 See full question

A client has been taking fluoxetine (Prozac) for the last ten days and calls the clinic reporting not feeling any better. What is the nurse's best response to this client?

You Selected:

"I realize this is frustrating but most medications for mood disorders aren't fully effective for two to three months."
Correct response:

"It may take another two to three weeks before the medication is completely effective."
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1008.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1008

Question 18 See full question

The health care provider would not prescribe duloxetine (Cymbalta) for a client with a mood disorder if the client took which other medication?

You Selected:

A medication for hypertension
Correct response:

A medication for hypertension
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1011.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1011

Question 19 See full question


A 35-year-old male client is slowly recovering from an abdominal aortic aneurysm repair and cerebral vascular accident 6 weeks ago. His physical condition is unstable at this time. His physician prescribes a low-dose antidepressant for him based on a diagnosis of situational depression. The client's wife asks if a higher dose might be more beneficial. What would the nurse teach the family regarding this client's dosage?

You Selected:

Dosage must be cautious and slow and the client's responses carefully monitored.
Correct response:

Dosage must be cautious and slow and the client's responses carefully monitored.
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1008, 1011.
Question 20 See full question

The nurse is interviewing a 75-year-old client and knows that what antidepressant drug class is the first choice for older adults?

You Selected:

SSRIs
Correct response:

SSRIs
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1008.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1008

Question 1 See full question

The adverse effects of selective serotonin reuptake inhibitors are less than other antidepressants.

You Selected:

True
Correct response:

True
Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1008.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1008

Question 2 See full question

A 11-year-old client has been hospitalized on the adolescent psychiatry unit with severe depression. For the past several weeks, the client has been prescribed a selective serotonin reuptake inhibitor (SSRI). What is the priority nursing action?


You Selected:

Monitor food intake and eliminate potential sources of tyramine.
Correct response:

Implement suicide precautions.
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1019.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1019

Question 3 See full question

Venlafaxine (Effexor) is an antidepressant that has become more popular with adults in treating their depression. Why has it become more popular?

You Selected:

An extended release form is available.
Correct response:

An extended release form is available.
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1011.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1011

Question 4 See full question

A woman in her twenties has been accompanied to her primary care provider by her mother, who states that her daughter has been experiencing increasingly severe episodes of irritable grandiose behavior. The care provider has consequently begun a treatment regimen that includes pharmacological therapies. This patient is most likely experiencing which of the following mood disorders?

You Selected:

Bipolar disorder
Correct response:

Bipolar disorder
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1004.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1004

Question 5 See full question

A 33-year-old woman has been diagnosed with major depression and has recently begun treatment with citalopram (Celexa). What teaching point should the nurse emphasize when providing health education for this patient?

You Selected:

"Most people don't experience severe side effects with this drug, but it may have an effect on your sexual functioning."
Correct response:

"Most people don't experience severe side effects with this drug, but it may have an effect on your sexual functioning."
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1008.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1008

Question 6 See full question

A female client has been diagnosed with depression. She also has a history of alcoholism. She has been sober now for 4 months, but at her last physical examination, the physician noted right-upper-quadrant tenderness and elevated liver enzyme levels. The physician has prescribed sertraline to treat Ms. Tooka's depression. Which factor would need to be considered prior to administering this medication to her?

You Selected:

The medication should be started at a lower dose due to liver dysfunction, and the patient should be monitored for side effects.
Correct response:

The medication should be started at a lower dose due to liver dysfunction, and the patient should be monitored for side effects.
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1008.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1008

Question 7 See full question

The physician has prescribed lithium to Mr. Johnson, a 34-year-old male with a history of obesity, cirrhosis of the liver secondary to alcohol abuse, diabetes, and hypertension. Which condition places him at highest risk of lithium toxicity?

You Selected:

Cirrhosis of the liver
Correct response:

Cirrhosis of the liver
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1016.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1016

Question 8 See full question

The nurse knows that antidepressant therapy is prescribed very cautiously for children, adolescents, and young adults aged 18 to 24 because they have an increased risk of:

You Selected:

suicidal episodes.
Correct response:

suicidal episodes.
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1008.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1008

Question 9 See full question

A client is receiving an SSRI. The nurse would inform the client that the full benefits of the drug may not occur for which time period?

You Selected:

2 weeks
Correct response:

4 weeks
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1003.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1003

Question 10 See full question

Following a thorough health history and assessment, a client's health care provider has diagnosed the client with depression. The nurse should anticipate that the client will likely be prescribed what classification of antidepressant?


You Selected:

Selective serotonin reuptake inhibitor
Correct response:

Monoamine oxidase inhibitor
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1003.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1003

Question 1 See full question

A BLACK BOX WARNING alerts health care providers to the increased risk of suicidal ideation in children, adolescents, and young adults 18 to 24 years of age when taking antidepressant medications. Symptoms of concern include:

You Selected:

Anxiety, agitation, panic attacks, insomnia, irritability, hostility, impulsivity, akathisia, hypomania, and mania.
Correct response:

Anxiety, agitation, panic attacks, insomnia, irritability, hostility, impulsivity, akathisia, hypomania, and mania.
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1005.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1005

Question 2 See full question

Tricyclic antidepressants reduce the reuptake of serotonin and norepinephrine.

You Selected:

True
Correct response:

True
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1005.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1005

Question 3 See full question

Which class of antidepressants exerts its effects by inhibiting reuptake serotonin?

You Selected:

Selective serotonin reuptake inhibitors
Correct response:

Selective serotonin reuptake inhibitors
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1011.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1011

Question 4 See full question

Which drug exerts its effect by inhibiting the activity of monoamine oxidase leading to increases in epinephrine, norepinephrine, dopamine and serotonin?

You Selected:

Phenelzine (Nardil)
Correct response:

Phenelzine (Nardil)
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1012.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1012

Question 5 See full question

A client comes to the mental health clinic for a regular appointment. The client tells the nurse he has been taking oral fluoxetine (Prozac) 20 mg daily for the past 3 weeks and that he has lost 3 pounds during that time due to a loss of appetite. What action should the nurse take?


You Selected:

Reassuring the client that this is a common adverse effect with this medication
Correct response:

Reassuring the client that this is a common adverse effect with this medication
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1008.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1008

Question 6 See full question

The client has been depressed since her father died 6 months ago and the health care provider has prescribed amitriptyline.What aspect of this client's health history should prompt the nurse to contact the prescriber?


You Selected:

Ischemic heart disease
Correct response:

Ischemic heart disease
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1005.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1005

Question 7 See full question

A 30-year-old woman is taking phenelzine (Nardil) 30mg PO tid. The nurse knows that at that dosage, the patient will need to be carefully monitored for

You Selected:

dizziness.
Correct response:

dizziness.
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1012.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1012

Question 8 See full question

Ms. Bloom is a 35-year-old woman with depression. What is a realistic goal of antidepressant therapy?

You Selected:

To bring about the greatest relief of symptoms while minimizing unpleasant adverse effects as much as possible
Correct response:

To bring about the greatest relief of symptoms while minimizing unpleasant adverse effects as much as possible
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1019.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1019

Question 9 See full question

The nurse provides care for several clients who are taking antidepressants. Which client should the nurse assess most closely for signs of addiction and anxiety?


You Selected:

A client for whom electroconvulsive therapy (ECT) is being considered
Correct response:

A client who was recently prescribed venlafaxine (Effexor)
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1007.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1007

Question 10 See full question


The nurse is caring for a client who has been diagnosed with bipolar disorder type II. The nurse knows that this disorder is characterized by episodes of major depression plus hypomanic episodes and occurs more frequently in what category of clients?

You Selected:

Children
Correct response:

Women
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1004.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1004

Question 1 See full question

Major depression is associated with:

You Selected:

An impaired ability to function in usual activities and relationships.
Correct response:

An impaired ability to function in usual activities and relationships.
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1001.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1001

Question 2 See full question

A client is receiving a tricyclic antidepressant for treatment of obsessive-compulsive disorder. Which agent most likely would be prescribed?


You Selected:

Clomipramine
Correct response:

Clomipramine
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1008.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1008

Question 3 See full question

A nurse is caring for a patient with suicidal tendencies and severe depression. The nurse is to prepare a report after monitoring the patient's condition. What should the nurse look for in the patient while preparing the report?

You Selected:

Signs of insomnia
Correct response:

Signs of insomnia
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1002.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1002

Question 4 See full question

The antidepressant drug paroxetine (Paxil) can be used to treat which medical conditions? (Select all that apply.)

You Selected:

Bulimia nervosa
Depressive episodes
Obsessive-compulsive disorders
Correct response:

Depressive episodes
Obsessive-compulsive disorders
Bulimia nervosa
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1008.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1008

Question 5 See full question

A nurse is caring for a patient with suicidal tendencies. What intervention should the nurse perform immediately after the patient self-administers the oral antidepressant drug?

You Selected:

Inspect the oral cavity to ensure that the drug is swallowed.
Correct response:

Inspect the oral cavity to ensure that the drug is swallowed.
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1019.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1019

Question 6 See full question

A male client has a history of hepatic dysfunction secondary to alcoholism. Based on the client's diagnostic history, what would the nurse expect his physician to order?

You Selected:

A lower dose of the antidepressant
Correct response:

A lower dose of the antidepressant
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1008, 1011.
Question 7 See full question

A nurse is preparing a presentation about the use of antidepressants in children and adolescents. What would the nurse need to keep in mind?

You Selected:

Studies have shown a clear link between suicide and the use of antidepressants.
Correct response:

The smallest amount of drug that is feasible should be dispensed.
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1005, 1008, 1011, 1020.
Question 8 See full question

A client is prescribed a tricyclic antidepressant. The nurse would anticipate administering this drug by which route?

You Selected:

Oral
Correct response:

Oral
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1005.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1005

Question 9 See full question

A client is prescribed isocarboxazid. The nurse is teaching the client about foods to avoid. Which would the nurse include in the teaching? (Select all that apply.)

You Selected:

Red wine
Fresh shellfish
Aged blue cheese
Whole milk
Correct response:

Aged blue cheese
Red wine
Pepperoni
Sour cream
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1013, 1014.
Question 10 See full question


A female client's bipolar disorder symptoms have been successfully managed with lithium for many years. She is scheduled for a CABG and is instructed to stop her lithium 1 to 2 days before surgery and resume when full oral intake of food and fluids is allowed. She asks why she must stop the medication. What is the nurse's best response?

You Selected:

"Lithium may cause cardiac complications during surgery."
Correct response:

"Lithium may prolong the effects of anesthetics and neuromuscular blocking drugs."
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1016.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1016

Question 1 See full question

A deficiency of a biogenic amine in key brain areas is believed to result in depression.

You Selected:

True
Correct response:

True
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1001.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1001

Question 2 See full question

A patient with a severe depression has been hospitalized, and the physician has ordered amitriptyline. What common adverse effect might this patient have?

You Selected:

Dry mouth
Correct response:

Dry mouth
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1006.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1006

Question 3 See full question

A 79-year-old male client is brought to the emergency department by his family because he is "talking to people who aren't there." During the initial admission assessment, his daughter mentions that her mother died 4 months ago and "Dad just hasn't been the same. The doctor has even put him on antidepressant medication. I go by the house every day to make sure he takes his medication." What would the nurse suspect is happening to this client?


You Selected:

The client is having hallucinations as an adverse effect of antidepressant therapy
Correct response:

The client is having hallucinations as an adverse effect of antidepressant therapy
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1005.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1005

Question 4 See full question

The administration of the H2 blocker cimetidine (Tagamet) to a client receiving which of the following antidepressants can cause increased anticholinergic symptoms? Select all that apply:

You Selected:

Escitalopram (Lexapro)
Sertraline (Zoloft)
Correct response:

Sertraline (Zoloft)
Venlafaxine (Effexor)
Clomipramine (Anafranil)
Escitalopram (Lexapro)
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1010.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1010

Question 5 See full question

A nurse is caring for a patient who has been prescribed a monoamine oxidase inhibitor (MAOI). What should the nurse ask the patient to avoid?

You Selected:

Yogurt
Correct response:

Yogurt
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1013.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1013

Question 6 See full question

A nurse is caring for a 38-year-old female patient who just started taking lithium for bipolar disorder. Which of the following outcomes would be most appropriate for this patient?

You Selected:

The patient will adopt strategies to maintain proper fluid balance.
Correct response:

The patient will adopt strategies to maintain proper fluid balance.
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1017.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1017

Question 7 See full question

In patients requiring sertraline therapy, which patient would require the closest monitoring by the nurse?

You Selected:

A 45-year-old man with liver impairment
Correct response:

A 45-year-old man with liver impairment
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1008.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1008

Question 8 See full question

A nurse is working with a Chinese immigrant who is taking an MAOI. The most important instruction to the patient by the nurse will be to

You Selected:

avoid use of soy sauce in the diet.
Correct response:

avoid use of soy sauce in the diet.
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1013.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1013

Question 9 See full question

The health care provider would not prescribe duloxetine (Cymbalta) for a client with a mood disorder if the client took which other medication?

You Selected:

A medication for hypertension
Correct response:

A medication for hypertension
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1011.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1011

Question 10 See full question

A client is receiving an SSRI. The nurse would inform the client that the full benefits of the drug may not occur for which time period?

You Selected:

2 weeks
Correct response:

4 weeks
Explanation:

Reference:

Frandsen, G., & Pennington, S.S. Abrams' Clinical Drug Therapy: Rationales for Nursing Practice, 10th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 54: Drug Therapy for Depression and Mood Stabilization, p. 1003.

Chapter 54: Drug Therapy for Depression and Mood Stabilization - Page 1003
Question 1 See full question

Which client has the highest risk of ovarian cancer?

You Selected:

30-year-old woman taking hormonal contraceptives
Correct response:

45-year-old woman who has never been pregnant
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1667.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1667

Question 2 See full question

A female client has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client?

You Selected:

This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually.
Correct response:

This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1652.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1652

Question 3 See full question

Which of the following is the main cause of anemia in a patient with active uterine leiomyoma?

You Selected:

Menorrhagia
Correct response:

Menorrhagia
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1664.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1664

Question 4 See full question

The nurse providing education regarding sexually transmitted diseases. Which of the following statements regarding herpes virus 2 (herpes genitalis) is accurate?

You Selected:

In pregnant women with active herpes virus, babies delivered vaginally may become infected with the virus.
Correct response:

In pregnant women with active herpes virus, babies delivered vaginally may become infected with the virus.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1654.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1654

Question 5 See full question

A client who underwent an anterior colporrhaphy 6 hours ago has not voided. She reports some discomfort in her suprapubic area. Which of the following would the nurse expect to do?

You Selected:

Catheterize the client.
Correct response:

Catheterize the client.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1661.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1661

Question 6 See full question

A client has just been diagnosed with endometriosis. Which of the following would be most appropriate to provide the client with support and guidance about treatment options?

You Selected:

"It might help to include your partner in any of the discussions about options."
Correct response:

"It might help to include your partner in any of the discussions about options."
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 56: Assessment and Management of Female Physiologic Processes, p. 1637.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1637

Question 7 See full question

Assessment of a client reveals evidence of a cystocele. The nurse interprets this as which of the following?

You Selected:

Bulging of the bladder into the vagina
Correct response:

Bulging of the bladder into the vagina
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 56: Assessment and Management of Female Physiologic Processes, p. 1621.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1621

Question 8 See full question

A pelvic examination reveals that a woman's uterus is retroflexed. Which of the following best depicts this position?

You Selected:


Correct response:


Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1661.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1661

Question 9 See full question

A patient is receiving chemotherapy with paclitaxel as treatment for ovarian cancer. The patient arrives at the facility for laboratory testing prior to her next dose of chemotherapy. The results are as follows:

Hemoglobin: 12.9 gm/dL
White blood cell count: 2,200 /cu mm
Platelets: 250,000 /cu mm
Red blood cell count: 4,400,00/cu mm

Which result would be a cause for concern?

You Selected:

White blood cell count
Correct response:

White blood cell count
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1674.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1674

Question 10 See full question

Which of the following is the extrusion of the rectum into the posterior vagina?

You Selected:

Rectocele
Correct response:

Rectocele
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1659.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1659

Question 11 See full question

Veronica, a 17-year-old high school student, has a history of dysmenorrhea. During her monthly menses, she experiences incapacitating cramping and passes large clots. Veronica's primary care physician explains to her and her mother that he will initiate conservative treatment. What interventions would you expect the physician to recommend?

You Selected:

NSAID use
Correct response:

NSAID use
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 56: Assessment and Management of Female Physiologic Processes, p. 1629.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1629

Question 12 See full question

Samantha Velasquez, a 24-year-old preschool teacher, is being seen by the physician in the primary care group where you practice nursing. Over the past 2 months, she has been receiving treatment for multiple ear infections and tonsillitis. She reports a curdy white vaginal discharge and burning with urination. What is the most likely cause of her symptoms?

You Selected:

Candida albicans
Correct response:

Candida albicans
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, pp. 1648-1649.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1648-1649

Question 13 See full question

While caring for a client who is being treated for severe pelvic inflammatory disease (PID), the nurse insists on keeping her in a semisitting position. What would be the best possible reason for the nurse's advice?

You Selected:

To facilitate pelvic drainage and to minimize the upward extension of infection
Correct response:

To facilitate pelvic drainage and to minimize the upward extension of infection
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, pp. 1656-1657.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1656-1657

Question 14 See full question

A client, who wishes to preserve childbearing, asks the nurse to explain how taking oral contraceptives will work in the management of endometriosis. Which is the best response by the nurse?

You Selected:

"Symptoms of endometriosis are increased during normal menstrual cycle."
Correct response:

"Symptoms of endometriosis are increased during normal menstrual cycle."
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1665.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1665

Question 15 See full question

While caring for a patient who is being treated for severe pelvic inflammatory disease (PID), which of the following nursing actions minimizes transmission of infection?

You Selected:

Keeping the patient in a sitting position
Correct response:

Performing hand hygiene when entering the room
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1657.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1657

Question 16 See full question

A woman in her late thirties has been having unusually heavy menstrual periods combined with occasional urine and stool leakage over the last few weeks. On further enquiry, she reveals that she also has postcoital pain and bleeding. To which of the following diagnoses do you think the investigations are most likely to lead?

You Selected:

Cervical cancer
Correct response:

Cervical cancer
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1667.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1667

Question 17 See full question

During a routine sports physical examination, the nurse practitioner recommends HPV vaccination for an 11-year-old girl. Which of the following statements made by the patient's mother demonstrates understanding of HPV vaccinations?

You Selected:

"I will track follow-up appointments in my smart phone so she receives all three injections."
Correct response:

"I will track follow-up appointments in my smart phone so she receives all three injections."
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1652.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1652

Question 18 See full question

Which of the following statements made by the nurse demonstrates effective communication techniques when initiating a discussion about sex with a 25-year-old female patient?

You Selected:

"What questions do you have related to your sexual health?"
Correct response:

"What questions do you have related to your sexual health?"
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1655.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1655

Question 19 See full question

A patient reports to the nurse that she has a sense of pelvic pressure and urinary problems such as incontinence, frequency, and urgency. The problem has gotten much worse since the birth of her third child. What does the nurse suspect the patient is experiencing?

You Selected:

A cystocele
Correct response:

A cystocele
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1659.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1659

Question 20 See full question

A patient is diagnosed with the most common type of uterine fibroid, an intramural fibroid. The nurse includes which of the following information in teaching the patient about this type of fibroid?

You Selected:

It grows within the wall of the uterine muscle.
Correct response:

It grows within the wall of the uterine muscle.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1664.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1664

Question 1 See full question

A client has undergone a total abdominal hysterectomy and bilateral salpingo-oopherectomy as treatment for endometrial cancer. When providing postoperative care to this client the nurse would be alert for signs and symptoms of which of the following?

You Selected:

Clotting deficiencies
Correct response:

Bladder dysfunction
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1666.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1666

Question 2 See full question

An elderly client, who can void only while standing and pushing upward on the vagina, is ordered a pessary. Which comment from the client indicates a need for further teaching about this device?

You Selected:

"I will remove and clean it every day."
Correct response:

"I will remove and clean it every day."
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1659.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1659

Question 3 See full question

A 32-year-old client has been diagnosed with an ovarian cyst and asks the nurse, "Should I be worried about cancer?" Which response by the nurse would be most appropriate?

You Selected:

"Most cysts are benign in younger women, but it's good to have it checked out."
Correct response:

"Most cysts are benign in younger women, but it's good to have it checked out."
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1662.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1662

Question 4 See full question

A patient with HIV has recently completed a 7-day regimen of use of antibiotics. She reports vaginal itching and irritation. In addition, the patient has a white, cottage cheese-like vaginal discharge. Which of the following is the patient most likely suffering?

You Selected:

Vulvovaginal candidiasis
Correct response:

Vulvovaginal candidiasis
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1648.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1648

Question 5 See full question

A female client is diagnosed with carcinoma in situ of the endometrium. The nurse interprets this as which of the following?

You Selected:

The malignancy is localized.
Correct response:

The malignancy is localized.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients with Female Reproductive Disorders, p. 1667.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1667

Question 6 See full question

Following a colposcopy, the confirmation of in situ carcinoma of the cervix has been determined. Which comment by the client indicates an appropriate understanding of the diagnosis?

You Selected:

"The cancer has not spread."
Correct response:

"The cancer has not spread."
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1667.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1667

Question 7 See full question

A patient has been diagnosed with an invasive vulvar malignancy. What primary treatment for invasive vulvar malignancy will the nurse prepare the patient for?

You Selected:

Wide excision
Correct response:

Wide excision
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1670.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1670

Question 8 See full question

A patient has been diagnosed with genital herpes. Knowing patient education is an essential part of nursing care of the patient with a genital herpes infection, the nurse plans to include which of the following methods to minimize HIV transmission? Select all that apply.

You Selected:

Avoiding unprotected sexual intercourse
Avoiding multiple partners for sexual intercourse
Avoiding IV drug use
Correct response:

Avoiding unprotected sexual intercourse
Avoiding multiple partners for sexual intercourse
Avoiding IV drug use
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1653.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1653

Question 9 See full question

A perimenopausal woman informs the nurse that she is having irregular vaginal bleeding. What should the nurse encourage the patient to do?

You Selected:

See her gynecologist as soon as possible.
Correct response:

See her gynecologist as soon as possible.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1670.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1670

Question 10 See full question

Which of the following is a downward displacement of the bladder toward the vaginal orifice?

You Selected:

Cystocele
Correct response:

Cystocele
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1658-1659.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1658-1659

Question 11 See full question

A client with vaginitis complains of itching and burning of the perineum. Which suggestion would be most appropriate to relieve the client's symptoms?

You Selected:

Take sitz baths frequently.
Correct response:

Take sitz baths frequently.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1651.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1651

Question 12 See full question

Culture of client's vaginal discharge reveals Gardnerella vaginalis. Which of the following would the nurse expect to assess?

You Selected:

Fishy smelling watery discharge
Correct response:

Fishy smelling watery discharge
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1650.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1650

Question 13 See full question

A 24-year-old client is being seen by the physician in the primary care group where you practice nursing. Over the past 2 months, the client has been receiving treatment for multiple ear infections and tonsillitis. She reports vaginal discharge and itching at this appointment. What would you expect to be the cause of her vaginitis?

You Selected:

Antibiotics
Correct response:

Antibiotics
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1648.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1648

Question 14 See full question

Which of the following is the most effective treatment for trichomoniasis?

You Selected:

Metronidazole (Flagyl)
Correct response:

Metronidazole (Flagyl)
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1650.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1650

Question 15 See full question

A nurse who works in a gynecologist's office frequently cares for patients who are diagnosed with vulvovaginal candidiasis. The nurse should teach the patients how to manage and treat the most common symptom of:

You Selected:

Vulvar pruritus.
Correct response:

Vulvar pruritus.
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1648.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1648

Question 16 See full question

During consultations with the oncologist, a patient with cervical cancer is informed that radioactive materials will be inserted in the area of her tumor. She has to undergo these sessions over a period of 3 weeks. Which of the following methods of cancer treatment is being described here?

You Selected:

Brachytherapy
Correct response:

Brachytherapy
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1672.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1672

Question 17 See full question

The nurse is collecting assessment data on a client who is reporting a vaginal discharge that is cottage cheese-like in appearance. Which pathogen is the most likely cause for this symptom?

You Selected:

Candida albicans
Correct response:

Candida albicans
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1649.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1649

Question 18 See full question

The nurse is preparing a teaching plan for a client with a vulvovaginal infection. Which of the following would be least appropriate for the nurse to include?

You Selected:

Wearing cotton underwear that is loose-fitting and allows for air flow
Correct response:

Performing douching with a dilute vinegar solution twice a day
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1651.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1651

Question 19 See full question

A nurse is reviewing a client's medical history. Which factor indicates the client is at risk for candidiasis?

You Selected:

Use of corticosteroids
Correct response:

Use of corticosteroids
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1648.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1648

Question 20 See full question

Which of the following is a reason why ovarian cancer is largely considered to be a lethal cancer of the female reproductive system?

You Selected:

All of the above
Correct response:

All of the above
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1673.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1673

Question 1 See full question

Which type of yeast infection is manifested by white, cottage cheese like discharge?

You Selected:

Candidiasis
Correct response:

Candidiasis
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1648.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1648

Question 2 See full question

Which of the following is an early symptom of vulvar cancer?

You Selected:

Pruritus with genital burning
Correct response:

Pruritus with genital burning
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, p. 1623,1670.
Question 3 See full question

A client reports loss of interest in sexual relations and discomfort during intercourse. Which is the best response by the nurse?

You Selected:

"You need to discuss this with your spouse."
Correct response:

"These are normal, manageable symptoms of menopause."
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 56: Assessment and Management of Female Physiologic Processes, p. 1642.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1642

Question 4 See full question

A young client presenting at the health clinic with fever and mucopurulent vaginal drainage is diagnosed with acute pelvic inflammatory disease (PID). Which long-term affect is of greatest concern in the care of this client?

You Selected:

Infertility
Correct response:

Infertility
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1656.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1656

Question 5 See full question

Following a radical vulvectomy, the nurse is preparing the client for discharge to home. Which care intervention would be considered the priority for this client?

You Selected:

Prevention of wound complications
Correct response:

Prevention of wound complications
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1670.

Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1670
Question 1 See full question

A nurse is caring for a client who has just had a modified radical mastectomy with immediate reconstruction. She's in her 30s and has two young children. Although she's worried about her future, she seems to be adjusting well to her diagnosis. What should the nurse do to support her coping?

You Selected:

Refer the client to the American Cancer Society's Reach for Recovery program or another support program.
Correct response:

Refer the client to the American Cancer Society's Reach for Recovery program or another support program.
Explanation:

The client isn't withdrawn and doesn't show other signs of anxiety or depression. Therefore, the nurse can probably safely approach her about talking with others who have had similar experiences, either through Reach for Recovery or another formal support group. The nurse may educate the client's spouse or partner and listen to his concerns, but the nurse shouldn't tell the client's spouse what to do. The client must consult with her physician and make her own decisions about further treatment. The client needs to express her sadness, frustration, and fear. She can't be expected to be cheerful at all times.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1698.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1698

Question 2 See full question

A client tells the nurse that she has found a painless lump in her right breast during her monthly self-examination. Which assessment finding would strongly suggest that this client's lump is cancerous?

You Selected:

Nonmobile mass with irregular edges
Correct response:

Nonmobile mass with irregular edges
Explanation:

Breast cancer tumors are fixed, hard, and poorly delineated with irregular edges. A mobile mass that is soft and easily delineated is most commonly a fluid-filled benign cyst. Axillary lymph nodes may or may not be palpable on initial detection of a cancerous mass. Nipple retraction — not eversion — may be a sign of cancer.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1691.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1691

Question 3 See full question

A 54-year-old woman presents to her healthcare provider's office where you practice nursing. She is very concerned that she might have breast cancer, especially after caring for her sister that recently died from the disease. Included in your discussion is the primary and most common sign of breast cancer. Which of the following would meet this criterion?

You Selected:

A painless mass in the breast, most often in the upper outer quadrant
Correct response:

A painless mass in the breast, most often in the upper outer quadrant
Explanation:

The primary sign of breast cancer is a painless mass in the breast, most often in the upper outer quadrant.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1694.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1694

Question 4 See full question

A female client is diagnosed with breast abscess. She would like to continue to breast-feed her newborn. Which of the following would be most appropriate in this situation?

You Selected:

Assist the client to pump the breasts to remove breast milk.
Correct response:

Assist the client to pump the breasts to remove breast milk.
Explanation:

The nurse should help the client pump the breasts and remove breast milk to prevent engorgement. Because the client has decided to continue breastfeeding, the client should wear a loose-fitting bra. Including protein content in the diet would be unrelated to the client's current situation. Frequency of dressing changes does not play a role in the intervention.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1689.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1689

Question 5 See full question

The client arrives at a public health clinic worried that she has breast cancer since finding a lump in her breast. When assessing the breast, which assessment finding is characteristic of fibrocystic disease?

You Selected:

The lump is round and movable.
Correct response:

The lump is round and movable.
Explanation:

When assessing a breast with fibrocystic disease, the lumps typically are different from cancerous lumps. The characteristic breast mass of fibrocystic disease is soft to firm, circular, movable, and unlikely to cause nipple retraction. A cancerous mass is typically irregular in shape, firm, and nonmovable. Lumps typically do not make one breast larger than the other. Nipple retractions are suggestive of cancerous masses.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1690.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1690

Question 6 See full question

A suspicious breast lump is noted on a mammogram. The client asks the nurse which diagnostic test confirms if the lump is cancerous or benign. Which response by the nurse is most correct?

You Selected:

A biopsy
Correct response:

A biopsy
Explanation:

To confirm whether a breast lump is cancerous or benign, a tissue sample must be obtained to examine the cells. Although an ultrasound, MRI, and clinical breast exam provides data on the characteristics of the lump, only examining the tissue can specifically identify if and what type of cancer is present.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1694.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1694

Question 7 See full question

On a follow-up visit, the patient is informed that her breast cancer has recurred. The nurse knows which of the following situations places the patient at risk for developing bone metastases?

You Selected:

Recurrence within 2 years of the original diagnosis
Correct response:

Recurrence within 2 years of the original diagnosis
Explanation:

Local recurrence may be an indicator that systemic disease will develop in the future, particularly if it occurs within 2 years of the original diagnosis. Local recurrence in the absence of systemic disease is treated aggressively with surgery, radiation, and hormonal therapy. Overall prognosis and optimal treatment are determined by a variety of factors such as the time to recurrence from the original diagnosis and history of prior treatments.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1705.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1705

Question 8 See full question

A patient is told that she has a common form of breast cancer where the tumor arises from the duct system and invades the surrounding tissues, often forming a solid irregular mass. What type of cancer does the nurse prepare to discuss with the patient?

You Selected:

Infiltrating ductal carcinoma
Correct response:

Infiltrating ductal carcinoma
Explanation:

Infiltrating ductal carcinoma—the most common histologic type of breast cancer accounts for 80% of all cases. The tumors arise from the duct system and invade the surrounding tissues. They often form a solid irregular mass in the breast.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1692.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1692

Question 9 See full question

During a teaching demonstration on BSE, the nurse should always explain that the majority of breast cancers are found in the:

You Selected:

Upper, outer quadrant.
Correct response:

Upper, outer quadrant.
Explanation:

Breast cancers are usually found in the upper outer quadrant where the majority of breast tissue is located.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1694.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1694

Question 10 See full question

A nurse who works in an oncology practice prepares patients for the side effects of adjuvant hormonal therapy to treat breast cancer. Which of the following is the hormonal agent that has an increased risk of pulmonary embolism and deep vein thrombosis?

You Selected:

Tamoxifen
Correct response:

Tamoxifen
Explanation:

Deep vein thrombosis, pulmonary embolism, and superficial phlebitis are all thromboembolic events that are adverse reactions to tamoxifen. Refer to Table 33-2 in the text.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1704.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1704

Question 1 See full question

Several days before admission, a client reports finding a small lump in the left breast near the nipple. What should the nurse tell the client to do?

You Selected:

Inform the physician immediately.
Correct response:

Inform the physician immediately.
Explanation:

The client should notify the physician immediately because a breast lump may be a sign of breast cancer. The client shouldn't squeeze the nipple to check for drainage until the physician examines the area. The client shouldn't wait until after the next menstrual period to inform the physician of the breast lump because prompt treatment may be necessary. Placing a heating pad on the area would have no effect on a breast lump.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1682.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1682

Question 2 See full question

A nurse is providing breast cancer education at a community facility. The American Cancer Society recommends that women get mammograms:

You Selected:

yearly starting at age 40.
Correct response:

yearly starting at age 40.
Explanation:

The American Cancer Society recommends a mammogram yearly for women age 40 and older. It's recommended that women between ages 20 and 39 have a professional breast examination (not a mammogram) every 3 years.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1682.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1682

Question 3 See full question

How can breast cancer prevention programs best serve at-risk women from lower socioeconomic backgrounds?

You Selected:

Develop screening and educational programs.
Correct response:

Develop screening and educational programs.
Explanation:

Breast cancer prevention programs can best serve at-risk women from lower socioeconomic backgrounds by developing screening and educational programs tailored to their needs. Without increasing educational awareness and screening, access to insurance, access to health care, and support services don't help these women. According to the National Breast and Cervical Cancer Early Detection Program, research shows that without better screening and education programs, women with low incomes are three to seven times more likely to die from cancer than those with higher incomes.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1691.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1691

Question 4 See full question

Sentinel lymph node mapping is done to validate the lack of lymph node metastasis. Which of the following complications does this technique help avoid?

You Selected:

Lymphedema
Correct response:

Lymphedema
Explanation:

Validating the lack of lymph node metastasis allows the surgeon to preserve more breast and axillary tissue and chest muscle. Leaving more normal lymph nodes intact reduces the potential for complications, such as lymphedema caused by the extensive disruption of lymphatic circulation.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1695, 1698.
Question 5 See full question

Which of the following terms refers to breast pain?

You Selected:

Mastalgia
Correct response:

Mastalgia
Explanation:

Mastalgia refers to breast pain. Mastitis is an inflammation or infection of the breast. Gynecomastia refers to overdeveloped breast tissue typically seen in adolescent boys. Mammoplasty refers to a surgical procedure to reconstruct or change the size or shape of the breast.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1690.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1690

Question 6 See full question

A client has had a right modified radical mastectomy and axillary lymph node dissection. The nurse is teaching the client about measures to reduce the risk of complications. The client demonstrates understanding of the instructions when she states which of the following?

You Selected:

"I need to use an electric shaver when shaving my right armpit."
Correct response:

"I need to use an electric shaver when shaving my right armpit."
Explanation:

To prevent complications after a right modified radical mastectomy and axillary lymph node dissection, the client should shave her right axillary area with an electric razor rather than a straight razor to reduce the risk of trauma to or breaks in the skin. Blood sampling should be done with the client's left arm, not the right one. The client should not lift objects more than 5 to 10 pounds with the right arm, and cuticles on the affected hand should be pushed back, not cut.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1699.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1699

Question 7 See full question

The nurse is assessing the surgical site of a client who has had a mastectomy. Which of the following would lead the nurse to suspect that the client is developing a seroma?

You Selected:

Tightness
Correct response:

Sloshing of fluid
Explanation:

Signs and symptoms of a seroma include swelling, heaviness, discomfort, and a sloshing of fluid. Bruising of the skin and tightness would suggest a hematoma. Fever would suggest an infection.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1699.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1699

Question 8 See full question

The nurse is providing care to a client who has had surgery as treatment for breast cancer. The nurse would be alert for the development of which of the following?

You Selected:

Lymphedema
Correct response:

Lymphedema
Explanation:

Lymphedema occurs in some women after breast cancer surgery. It causes disfigurement and increases the lifetime potential for infection and poor healing. Fibrocystic breast disease and fibroadenoma are two benign breast conditions that occur usually in premenopausal woman. Breast abscess is the infectious and inflammatory breast condition that is common among breast-feeding mothers.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1697.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1697

Question 9 See full question

After teaching a group of students about the signs and symptoms of breast cancer, the instructor determines that additional teaching is needed when the group identifies which of the following?

You Selected:

Breast symmetry
Correct response:

Breast symmetry
Explanation:

The primary sign of breast cancer is a painless mass in the breast. Other signs of breast cancer include a bloody discharge from the nipple, a dimpling of the skin over the lesion, retraction of the nipple, peau d'orange (orange peel) appearance of the skin, and a difference in size between the breasts.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1694.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1694

Question 10 See full question

A nurse is reviewing a female patient's history, which includes the following information:

Age at menarche: 14 years
Cesarean delivery: 2 pregnancies
Age at first pregnancy: 35 years
Alcohol use: approximately 1 to 2 glasses of wine/month

The nurse identifies which of the following as a possible risk factor for developing breast cancer?

You Selected:

Age at first pregnancy
Correct response:

Age at first pregnancy
Explanation:

Risk factors for breast cancer include an early menarche (before 12 years), nulliparity, late age at first full-term pregnancy, and an alcohol intake of 2 to 5 drinks daily.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1693.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1693

Question 11 See full question

Breast cancers are usually found in which area of the breast?

You Selected:

Upper outer quadrant
Correct response:

Upper outer quadrant
Explanation:

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1694.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1694

Question 12 See full question

A client returns to the recovery room following a mastectomy. An initial postoperative assessment is performed by the nurse. What is the nurse's priority assessment?

You Selected:

Checking the dressing, drain, and amount of drainage.
Correct response:

Assessing the vital signs and oxygen saturation levels.
Explanation:

The nurse prioritizes vital signs and breathing based on principles of ABCs.

Question 13 See full question

A 32-year-old client is concerned with the lumps that have developed in her breasts and is fearful of cancer. She reports variability in the size of the lumps. What could be causing her condition?

You Selected:

Cyclical hormonal changes
Correct response:

Cyclical hormonal changes
Explanation:

Fibrocystic disease results from hormonal changes during the menstrual cycle. The likely cause is fibrocystic disease, which results from hormonal changes during the menstrual cycle.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1690.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1690

Question 14 See full question

A 67-year-old client underwent a lumpectomy for a breast lesion that was determined to be malignant. Which of the following are factors in the client's history that may have increased her risk of breast cancer?

You Selected:

All options are correct.
Correct response:

All options are correct.
Explanation:

The risk for breast cancer in women increases with age. Certain factors appear to increase the risk of breast cancer. Being female, being older than 50 years of age, and having a family history of breast cancer are the most common risk factors. Additional factors include obesity, and having no children or having children after 30 years of age. The risk for breast cancer in women increases with age. Certain factors appear to increase the risk of breast cancer including obesity and having no children or having children after 30 years of age.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1693.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1693

Question 15 See full question

A nurse is meeting with a woman scheduled to have a modified radical mastectomy to remove an aggressive breast tumor. The woman tells the nurse that she agreed to have the surgery before considering alternative options. Which of the following statements is the nurse's best response?

You Selected:

"Tell me more about your fears and concerns."
Correct response:

"Tell me more about your fears and concerns."
Explanation:

The type of surgery recommended depends on the stage of the tumor and the client's informed decision about treatment options. The client should be encouraged to express her concerns. Surgery should not be performed until the client is comfortable with the scheduled procedure. The type of surgery recommended depends on the stage of the tumor. A less invasive procedure may not remove all of the affected tissue. The nurse should not share her opinion with the client but rather support the client in making the best decision.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1709.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1709

Question 16 See full question

A client complains of having tender and painful breasts, often feeling multiple lumps within her breast tissue. The nurse would need to gather additional information about which of the following?

You Selected:

Timing of symptoms in relation to the menstrual cycle
Correct response:

Timing of symptoms in relation to the menstrual cycle
Explanation:

Considering that the client has tender and painful breasts and that she often feels lumps within her breast tissue, it is most likely that she suffers from fibrocystic breast disease. To confirm these findings, the nurse should ask relevant questions about the characteristics and timing of symptoms in relation to the menstrual cycle. Symptoms of fibrocystic breast disease are noticeable before menstruation and usually abate during menstruation. The size of the cyst becomes larger before menstruation and often changes with the menstrual cycle. The nurse should further ask the client about her habits of smoking and consuming coffee, chocolate, and caffeinated soft drinks, not alcohol, because they aggravate the condition. Workplace surroundings or cleanliness habits do not matter because fibrocystic breast disease is not infectious.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1690.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1690

Question 17 See full question

The nurse is caring for a group of breast cancer survivors post mastectomy. Which teaching point should the nurse include?

You Selected:

Do not lift objects greater than 15 lb
Correct response:

Do not lift objects greater than 15 lb
Explanation:

The nurse should instruct post mastectomy clients to avoid lifting objects greater than 15 lb. Tight-fitting or constrictive clothing is to be avoided. The client is encouraged to place cream on any area of the breast which is dry, and discouraged to sleep on the affect side.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1708.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1708

Question 18 See full question

The nurse is completing the admission history for a client who is admitted for a reduction mammoplasty. Which of the following client statements is uncommon when explaining the rationale for the procedure?

You Selected:

Others disapprove
Correct response:

Others disapprove
Explanation:

The rationale for a reduction mammoplasty most often comes from the client herself as she is experiencing a complication due to the size of the breast. Back pain, low self-esteem and a self-consciousness, and skin irritation are common rationales.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1710.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1710

Question 19 See full question

The nurse working on a woman's cancer treatment floor performs nursing assessments on her assigned patients. It is most important for the nurse to report which of the following assessment findings?

You Selected:

Immediate postoperative reports of throat tenderness
Correct response:

Coolness and mottling of a newly constructed breast site
Explanation:

Mottling or an obvious decrease in skin temperature may signify flap loss and needs to be reported to the surgeon immediately. Throat discomfort immediately following surgery is an expected effect of airway management during surgery. A small amount of bloody drainage is an expected finding 12 hours postoperatively. Vital signs are within acceptable range for a postoperative patient.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1707.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1707

Question 20 See full question

A female patient comes to the clinic with the complaint that she is having a greenish-colored discharge from the nipple and the breast feels warm to touch. What does the nurse suspect these symptoms may indicate?

You Selected:

Infection
Correct response:

Infection
Explanation:

A green discharge could indicate an infection. Any discharge that is spontaneous, persistent, or unilateral is of concern. Although bloody discharge can indicate a malignancy, it is often caused by a benign wartlike growth on the lining of the duct called an intraductal papilloma.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1689.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1689

Question 1 See full question

During a breast examination, which finding most strongly suggests that a client has breast cancer?

You Selected:

A fixed nodular mass with dimpling of the overlying skin
Correct response:

A fixed nodular mass with dimpling of the overlying skin
Explanation:

A fixed nodular mass with dimpling of the overlying skin is common during late stages of breast cancer. Many women have slightly asymmetrical breasts. Bloody nipple discharge is a sign of intraductal papilloma, a benign condition. Multiple firm, round, freely movable masses that change with the menstrual cycle indicate fibrocystic breasts, a benign condition.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1682.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1682

Question 2 See full question

On discharge, a client who underwent left modified radical mastectomy expresses relief that "the cancer" has been treated. When discussing this issue with the client, the nurse should stress that she:

You Selected:

should continue to perform breast self-examination on her right breast.
Correct response:

should continue to perform breast self-examination on her right breast.
Explanation:

Having breast cancer on her left side puts the client more at risk for cancer on the opposite side and chest wall. Therefore, the nurse should stress the importance of monthly breast self-examinations and annual mammograms. Although the tumor was found, it was large enough to require a mastectomy, and could put the patient at risk for metastasis. Follow-up appointments should be monthly for the first few months and then scheduled at the direction of her health care provider. Modified radical mastectomy shouldn't affect the menstrual cycle.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1682.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1682

Question 3 See full question

The nurse recognizes which of the following statements as accurately reflecting a risk factor for breast cancer?

You Selected:

Mother affected by cancer before 60 years of age
Correct response:

Mother affected by cancer before 60 years of age
Explanation:

Risk for breast cancer increases twofold if first-degree female relatives (sister, mother, or daughter) have had breast cancer. Increased risk is associated with early menarche (i.e. menses beginning before 12 years of age). Nulliparity and later maternal age for first birth are associated with increased risk for breast cancer. Alcohol use remains controversial; however, a slightly increased risk is found in women who consume even one drink daily and doubles among women drinking three drinks daily.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1693, 1698.
Question 4 See full question

Which of the following would be inconsistent as a risk factor for breast cancer?

You Selected:

Multiparity
Correct response:

Multiparity
Explanation:

Nulliparity is a risk factor for breast cancer, along with late menopause, increased age, and family history of breast cancer.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1693.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1693

Question 5 See full question

A group of students are reviewing the anatomy and physiology of the breasts. The students demonstrate understanding of breast structure when they identify the tail of Spence as an extension of which quadrant?

You Selected:

Upper outer
Correct response:

Upper outer
Explanation:

The tail of Spence is an area of breast tissue that extends from the upper outer quadrant of the breast into the axilla. The upper and lower inner quadrants are closer to the midline. The lower outer quadrant is below the upper outer quadrant.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1694.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1694

Question 6 See full question

A nurse is reviewing a client's history for possible risk factors associated with breast cancer. Which of the following would the nurse identify as increasing the client's risk?

You Selected:

First full-term pregnancy at age 34 years
Correct response:

First full-term pregnancy at age 34 years
Explanation:

Risk factors associated with breast cancer include menarche before age 12 years, menopause after age 55 years, nulliparity, and late age at first full-term pregnancy.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1693.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1693

Question 7 See full question

A client comes to the clinic for a routine evaluation. During the physical examination, the nurse palpates the client's breast and finds a small lump. Which of the following would lead the nurse to suspect possible breast cancer?

You Selected:

The lump is irregularly shaped.
Correct response:

The lump is irregularly shaped.
Explanation:

Generally, breast cancer lesions are nontender, fixed rather than mobile, and hard with irregular borders. Diffuse breast pain and tenderness with menstruation are usually associated with benign breast disease.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1694.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1694

Question 8 See full question

Students are reviewing information about the use of adjuvant hormonal therapy for breast cancer. They demonstrate understanding of this information when they identify which of the following as an example of a selective estrogen receptor modulator (SERM)?

You Selected:

Tamoxifen
Correct response:

Tamoxifen
Explanation:

Tamoxifen is an example of a SERM. It acts by competing for estrogen-receptor binding sites. Anastrozole, letrozole, and exemestane are examples of aromatase inhibitors, drugs that block estrogen production.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1704.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1704

Question 9 See full question

A nurse is preparing a presentation for a health fair about preventing breast cancer. Which of the following would the nurse include?

You Selected:

Maintaining an ideal weight
Correct response:

Maintaining an ideal weight
Explanation:

Maintaining an ideal weight decreases the risk of breast cancer. Having no children or having children after age 30 is associated with an increased risk for breast cancer. Some breast tumors are hormone dependent, such that estrogen (or progesterone) enhances tumor growth. Women are advised to avoid the consumption of alcohol, not caffeine, because alcohol correlates with an increased risk of breast cancer

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 57: Management of Patients With Female Reproductive Disorders, p. 1693.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1693

Question 10 See full question

A client is considering breast augmentation. Which of the following would the nurse recommend to the client to ensure that there are no malignancies?

You Selected:

Breast biopsy
Correct response:

Mammogram
Explanation:

When caring for a client considering breast augmentation, the nurse should provide her with a general guideline to have a mammogram to verify that there are no malignancies. Mastopexy involves a breast life for drooping breasts. Ultrasound or breast biopsy would not be necessary unless there was evidence of a problem.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1687,1693.
Question 11 See full question

A 28-year-old woman is learning about breast self-examination. The nurse teaches the woman that the best time of each month to examine her breasts is during the:

You Selected:

First week after menstruation.
Correct response:

First week after menstruation.
Explanation:

It is recommended that a woman examine the breasts during the first week after menstruation. During this period, the breasts are least likely to be tender or swollen because the secretion of estrogen, which prepares the uterus for implantation, is at its lowest level.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1685.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1685

Question 12 See full question

A ductal carcinoma in situ (DCIS) is considered to be which stage of breast cancer?

You Selected:

0
Correct response:

0
Explanation:

DCIS is frequently manifested on a mammogram with the appearance of calcifications, and it is considered breast cancer stage 0.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1692.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1692

Question 13 See full question

Kara Carpenter is a 54-year-old woman who just had a left radical mastectomy. The nurse caring for her is providing information on complications that may arise due to removing the axillary lymph nodes. Which of the following would not be included?

You Selected:

All would be included in the discussion.
Correct response:

All would be included in the discussion.
Explanation:

Impaired lymphatic circulation predisposes to disfigurement, reduced range of motion, heaviness of the limb, skin changes, infection, and, in severe cases, tissue necrosis that may require amputation of the limb. Reduced range of motion is a potential consequence from removing the axillary lymph nodes. Tissue necrosis that may require amputation of the limb is a potential consequence from removing the axillary lymph nodes. Infection is a potential consequence from removing the axillary lymph nodes.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1695.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1695

Question 14 See full question

The nurse is caring for a client who is ordered a sentinel lymph node biopsy. The physician explained the procedure and desired outcome. Which statement, made by the client, indicates a need for further instruction?

You Selected:

The procedure removes all cancer from the body.
Correct response:

The procedure removes all cancer from the body.
Explanation:

Sentinel lymph node mapping involves identifying the first (sentinel) lymph nodes through which the breast cancer cells would spread to regional lymph nodes in the axilla. Validating the lack of lymph node metastasis allows the surgeon to preserve more breast tissue, axillary tissue and chest muscle. Further instruction would be needed to explain that the sentinel lymph node biopsy does not remove cancer from the body.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1695.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1695

Question 15 See full question

The nurse is caring for a client who is beginning doxorubicin (Adriamycin) therapy for breast cancer. When preparing the client for probable side effects, which would the nurse include?

You Selected:

Information regarding wigs from the American Cancer Society
Correct response:

Information regarding wigs from the American Cancer Society
Explanation:

Alopecia is a common side effect from the use of doxorubicin (Adriamycin). It is best for the client to be proactive in planning for hair loss so that the client has a suitable plan. Also, the American Cancer Society in some areas offers financial support and guidance in obtaining a wig or head covering. Blood donation is not completed during chemotherapy because anemia is common. Due to recent antiemetic medications, nausea is less common not as prolonged. Client's rarely need a high-calorie diet. Emphasis is placed on nutrient dense, not calorie dense. Depression may be a concern, and a support group is an excellent resource. A mental health association may be more than what is needed.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1703.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1703

Question 16 See full question

The nurse is caring for a client diagnosed with ductal carcinoma and lymph node involvement. Which diagnostic test, ordered by the physician, does the nurse identify as assessing possible metastasis?

You Selected:

A chest x-ray
Correct response:

A chest x-ray
Explanation:

A chest x-ray can identify any tumors present in the lung fields. Lymph nodes containing cancers cells are commonly involved in metastasis, which most frequently spreads to the skeletal and pulmonary systems (in that order). In addition, metastases may be found in the brain, adrenals, and liver. A blood count will not detect metastasis. A bone density study or MUGA scan will not detect metastasis.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1694.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1694

Question 17 See full question

A patient is receiving adjuvant chemotherapy for breast cancer. Which of the following is most likely her node status and tumor size?

You Selected:

Node negative, tumor size 1.2 cm
Correct response:

Node negative, tumor size 1.2 cm
Explanation:

Adjuvant chemotherapy is recommended for patients who have positive lymph nodes or who have invasive tumors greater than 1 cm in size, regardless of nodal status.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1702.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1702

Question 18 See full question

Which of the following psychosocial nursing diagnoses are common in the patient with breast cancer? Select all that apply.

You Selected:

Fear
Body image disturbance
Spiritual distress
Hopelessness
Correct response:

Fear
Body image disturbance
Hopelessness
Explanation:

Fear, anxiety, body image disturbance, hopelessness, and powerlessness are all common psychosocial nursing diagnoses for patients with breast cancer.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1709.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1709

Question 19 See full question

A health care provider recommends that a patient with breast cancer undergo a modified radical mastectomy. The nurse explains that this procedure involves removal of the entire breast:

You Selected:

And the nipple-areola complex without lymph node removal.
Correct response:

And the nipple-areola complex along with the axillary node dissection.
Explanation:

Modified radical mastectomy is performed to treat invasive breast cancer. The procedure involves removal of the entire breast tissue, including the nipple-areola complex. In addition, a portion of the axillary lymph nodes is also removed in ALND.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1695.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1695

Question 20 See full question

Hematoma and seroma formation are complications of breast surgery. Which of the following is the indicator that should be reported to the surgeon?

You Selected:

Gross swelling
Correct response:

Gross swelling
Explanation:

The presence of gross swelling or increased bloody output from the drain are abnormal and should be immediately reported to the surgeon.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1699.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1699

Question 1 See full question

Which type of biopsy is used for nonpalpable lesions found on mammography?

You Selected:

Stereotactic
Correct response:

Stereotactic
Explanation:

Stereotactic biopsy utilizes computer location of the suspicious area found on biopsy, followed by core needle insertion and sampling of tissue for pathologic examination. An excisional biopsy is the usual procedure for any palpable breast mass. Incisional biopsy is performed on a palpable mass when tissue sampling alone is required. Tru-Cut core biopsy is used when a tumor is relatively large and close to the skin surface.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1688.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1688

Question 2 See full question

The nurse is providing shift report related to a client newly received back to the unit from the post anesthesia care unit (PACU). The nurse is stating that the client had breast tissue removed with 7 of 14 lymph nodes, the lining of the chest muscles and pectoralis minor muscle removed. The oncoming nurse documents which procedure completed?

You Selected:

A total mastectomy
Correct response:

A modified radical mastectomy
Explanation:

A modified radical mastectomy is a procedure in which the breast, some lymph nodes, the lining over the chest muscles, and the pectoralis minor muscle is removed. A segmental mastectomy is where the tumor and some breast tissue and lymph nodes are removed. A total mastectomy includes only breast tissue. A radical mastectomy includes the breast axillary lymph nodes, and pectoralis major and minor muscles are removed. Sternal lymph nodes may also be removed with this procedure.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1695.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1695

Question 3 See full question

The nurse is assessing the breast of a female patient and observes a prominent venous pattern on the left breast. What does the nurse understand that this can be indicative of?

You Selected:

Increased blood supply required by a tumor
Correct response:

Increased blood supply required by a tumor
Explanation:

A prominent venous pattern can signal increased blood supply required by a tumor.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1682.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1682

Question 4 See full question

The nurse is assessing an older adult female who has not seen her physician in 2 years. The nurse is assisting the patient into a gown and notices that the patient has edema and pitting of the skin on the right breast. What does the nurse understand is the significance of this finding?

You Selected:

It may result from a neoplasm blocking lymphatic drainage, giving the skin an orange-peel appearance, a classic sign of advanced breast cancer.
Correct response:

It may result from a neoplasm blocking lymphatic drainage, giving the skin an orange-peel appearance, a classic sign of advanced breast cancer.
Explanation:

Edema and pitting of the skin may result from a neoplasm blocking lymphatic drainage, giving the skin an orange peel appearance (peau d'orange)—a classic sign of advanced breast cancer.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1682.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1682

Question 5 See full question

The nurse is discussing mammography with a female patient at the clinic. The patient asks at what age she should begin getting yearly mammograms. What answer should the nurse provide to the patient?

You Selected:

40
Correct response:

40
Explanation:

The American College of Obstetricians and Gynecologists (ACOG, 2011), the American Cancer Society (ACS, 2010), and the National Comprehensive Cancer Network (NCCN, 2012) recommend annual clinical breast examination for women 40 years and older.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 58: Assessment and Management of Patients With Breast Disorders, p. 1682.

Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1682
Question 1 See full question

A nurse is caring for a client admitted to the unit with a seizure disorder. The client seems upset and asks the nurse, "What will they do to me? I'm scared of the tests and of what they'll find out." The nurse should focus her teaching plans on which diagnostic tests?

You Selected:

EEG, blood cultures, and neuroimaging studies
Correct response:

EEG, blood cultures, and neuroimaging studies
Explanation:

Physicians use EEG and neuroimaging studies to diagnose neurologic problems. Blood cultures can identify infection that can cause seizures. Electrocardiography, TEE, and troponin levels are cardiac-specific diagnostic tests. X-ray of the brain reveals skeletal condition. Bone marrow aspiration isn't indicated for seizure disorder. PT and INR reflect blood coagulation.

Question 2 See full question

A client with benign prostatic hyperplasia doesn't respond to medical treatment and is admitted to the facility for prostate gland removal. Before providing preoperative and postoperative instructions to the client, the nurse asks the surgeon which prostatectomy procedure will be done. What is the most widely used procedure for prostate gland removal?

You Selected:

Transurethral resection of the prostate (TURP)
Correct response:

Transurethral resection of the prostate (TURP)
Explanation:

TURP is the most widely used procedure for prostate gland removal. Because it requires no incision, TURP is especially suitable for men with relatively minor prostatic enlargements and for those who are poor surgical risks. Suprapubic prostatectomy, retropubic prostatectomy, and transurethral laser incision of the prostate are less common procedures; each requires an incision.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1725.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1725

Question 3 See full question

A client underwent a transurethral resection of the prostate gland 24 hours ago and is on continuous bladder irrigation. Which nursing intervention is appropriate?

You Selected:

Use sterile technique when irrigating the catheter.
Correct response:

Use sterile technique when irrigating the catheter.
Explanation:

If the catheter is blocked by blood clots, it may be irrigated according to physician's orders or facility protocol. The nurse should use sterile technique to reduce the risk of infection. Urinating around the catheter can cause painful bladder spasms. The nurse should encourage the client to drink fluids to dilute the urine and maintain urine output. The catheter remains in place for 2 to 4 days after surgery and is removed only with a physician's order.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, pp. 1738-1739.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1738-1739

Question 4 See full question

Which of the following should be included as part of the home care instructions for a patient with epididymitis and orchitis?

You Selected:

Take prescribed antibiotics
Correct response:

Take prescribed antibiotics
Explanation:

Home care for a patient with epididymitis and orchitis includes instructions to continue administering prescribed antibiotics, and to take sitz baths, apply local heat after scrotal swelling subsides, avoid lifting, and to refrain from sexual intercourse until symptoms are relieved.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1741.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1741

Question 5 See full question

Which of the following is accurate regarding sildenafil (Viagra)?

You Selected:

There does not need to be sexual stimulation to produce an erection.
Correct response:

Its side effects include headache, flushing, and dizziness.
Explanation:

Side effects of Viagra include headache, flushing, and dizziness. Is should be taken 30 minutes to 4 hours prior to intercourse. Taking this medication more than once a day will not have an increased effect. The patient will have no erection if there is no stimulation.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1718-1719.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1718-1719

Question 6 See full question

Which of the following involves implantation of interstitial radioactive seeds under anesthesia to treat prostate cancer?

You Selected:

Chemotherapy
Correct response:

Brachytherapy
Explanation:

Brachytherapy involves the implantation of interstitial radioactive seeds under anesthesia. Hormone therapy for advanced prostate cancer suppresses androgenic stimuli to the prostate by decreasing the level of circulating plasma testosterone or interrupting the conversion to or binding of DHT. Teletherapy involves 6 to 7 weeks of daily radiation treatments. High-dose ketoconazole (HDK) lowers testosterone through its abilities to decrease both testicular and endocrine production of androgen.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1730-1731.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1730-1731

Question 7 See full question

A client comes to the clinic reporting urinary symptoms. Which statement would most likely alert the nurse to suspect benign prostatic hyperplasia (BPH)?

You Selected:

"I've had trouble getting started when I urinate, often straining to do so."
Correct response:

"I've had trouble getting started when I urinate, often straining to do so."
Explanation:

Symptoms that might alert the nurse to BPH include difficulty initiating urination and abdominal straining with urination. Although fever, urinary frequency, nocturia, pelvic pain, nausea, vomiting, and fatigue may be noted, they also may suggest other conditions such as urinary tract infection. Fever, nausea, vomiting, and fatigue are general symptoms that can accompany many conditions.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1723.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1723

Question 8 See full question

A client diagnosed with prostate cancer is to receive brachytherapy. Which of the following would the nurse include when discussing this therapy with the client?

You Selected:

Use of radioactive seeds implanted into the prostate
Correct response:

Use of radioactive seeds implanted into the prostate
Explanation:

Brachytherapy involves the implantation of interstitial radioactive seeds under anesthesia. External beam radiation therapy (teletherapy) involves the use of radiation treatments, usually 5 days/week over 7 to 8 weeks. Surgical castration is a type of androgen-deprivation therapy. Cryosurgery invovles the insertion of transperineal probes into the prostate to freeze the tissue directly.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1731.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1731

Question 9 See full question

A client is having prostate-specific antigen (PSA) testing done. Which result would the nurse identify as abnormal?

You Selected:

4.6 nanograms/milliliter
Correct response:

4.6 nanograms/milliliter
Explanation:

Normal prostate-specific antigen (PSA) levels are less than 4.0 nanograms/milliliter (ng/mL). A level of 4.6 ng/mL would be considered abnormal.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1717.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1717

Question 10 See full question

Which of the following would a nurse include in a teaching plan for a client with benign prostatic hyperplasia who is not yet a candidate for surgery?

You Selected:

Maintaining optimal bladder emptying
Correct response:

Maintaining optimal bladder emptying
Explanation:

For the client with benign prostatic hyperplasia who is not yet a candidate for surgery, the nurse would teach a client how to maintain optimal bladder emptying. The surgical client requires support and information to allay anxiety. The nurse teaches deep breathing and leg exercises for the client who is to have surgery.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, pp. 1723-1724.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1723-1724

Question 11 See full question

The physician orders an alpha-adrenergic blocker for a client with benign prostatic hypertrophy. The nurse understands that this drug acts to achieve which of the following?

You Selected:

Relieve urinary symptoms
Correct response:

Relieve urinary symptoms
Explanation:

Alpha-adrenergic blockers help relax the muscles in the prostate and relieve urinary symptoms. Androgen hormone inhibitors (also classified as 5-alpha reductase inhibitors) can be used to decrease symptoms and also appear to arrest the progression of prostate enlargement in some clients. These agents inhibit the conversion of testosterone into a potent androgen, causing the gland to shrink.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1724.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1724

Question 12 See full question

Which of the following may result if prostate cancer invades the urethra or bladder?

You Selected:

Hematuria
Correct response:

Hematuria
Explanation:

Hematuria may result if the cancer invades the urethra or bladder. Symptoms related to metastases include backache, hip pain, perineal and rectal discomfort, anemia, weight loss, weakness, nausea, and oliguria.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1726.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1726

Question 13 See full question

Which of the following are dominant findings related to a transurethral resection syndrome?

You Selected:

Hyponatremia
Hypervolemia
Hypo-osmolality
Correct response:

Hyponatremia
Hypervolemia
Hypo-osmolality
Explanation:

Hyponatremia, hypo-osmolality, and hypervolemia are dominant findings of transurethral resection syndrome.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1732.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1732

Question 14 See full question

A 51-year-old client is being seen by an urologist for perineal pain, low back pain, fever lasting 5 days, and painful urination. The physician confirms a diagnosis of prostatitis and orders treatment. During your client education session, which of the following recommendations do you make?

You Selected:

All options are correct.
Correct response:

All options are correct.
Explanation:

The nurse instructs the client to avoid caffeine, prolonged sitting, and constipation and regularly to drain the prostate gland through masturbation or intercourse. The nurse instructs the client to comply with antibiotic therapy and use a mild analgesic for pain. The nurse instructs the client to avoid caffeine. The nurse instructs the client to drain the prostate gland through masturbation or intercourse. The nurse instructs the client to comply with antibiotic therapy and use a mild analgesic for pain.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, pp. 1723, 1728.
Question 15 See full question

Which of the following would be most important to include in a teaching plan for a client who has had a vasectomy?

You Selected:

Using a reliable method of contraception for several weeks.
Correct response:

Using a reliable method of contraception for several weeks.
Explanation:

It may take several weeks or more after surgery before the ejaculatory fluid is free of sperm, and the client is informed to use a reliable method of contraception until sperm no longer are present. The client should apply ice packs to the scrotum to reduce swelling and use a mild analgesic such as aspirin or acetaminophen for pain relief. The client typically can resume sexual activity when comfortable, usually in 1 week.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1744.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1744

Question 16 See full question

Which of the following is a component of the patient teaching that helps the nurse assist a patient following treatment for cancer of the prostate gland to manage and minimize the possibility of a recurrence of the primary cancer or metastasis?

You Selected:

Have regular prostate-specific antigen (PSA) levels tested and repeat lymph node biopsies.
Correct response:

Have regular prostate-specific antigen (PSA) levels tested and repeat lymph node biopsies.
Explanation:

Regular monitoring of PSA levels after treatment aids in the early detection of cancer recurrence or metastasis. Repeat lymph node biopsies may be part of the surgical follow-up. Cancer cells are spread via the lymphatic system. Exercise routines and avoiding sexual intercourse are not known to have any role in recurrence of the primary cancer or metastasis.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1717.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1717

Question 17 See full question

Which of the following instructions regarding future sexual activity should a nurse give a patient with a vasectomy?

You Selected:

Use a reliable method of contraception until the physician ensures that sperm are no longer present.
Correct response:

Use a reliable method of contraception until the physician ensures that sperm are no longer present.
Explanation:

For a patient with a vasectomy, the nurse advises to use a reliable method of contraception until the physician ensures that sperm are no longer present, which may be determined after 10 or more ejaculations. The patient should resume sexual activity when comfort allows, usually in 1 week. Administer a mild analgesic, such as aspirin or acetaminophen, for discomfort and not before the sexual activity. The patient should expect some bruising and incisional soreness after the local anesthetic wears off.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1745.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1745

Question 18 See full question

A patient has been scheduled to undergo a transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH). The nurse knows that the patient understands preoperative teaching when he makes which of the following statements.

You Selected:

"I will have my wife come with me to drive me home following the outpatient procedure."
Correct response:

"I understand I may develop urethral strictures as a result of having the TURP."
Explanation:

Urethral strictures are more frequent for TURP than with nontransurethral procedures. TURP rarely causes erectile dysfunction. It requires an overnight stay. There is chance of retrograde ejaculation.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1732.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1732

Question 19 See full question

A patient is having a DRE in the physician's office and the nurse is to assist in the examination. What can the nurse instruct the client to do to decrease the discomfort from the exam?

You Selected:

When bending over the examining table, point the feet outward to decrease the discomfort.
Correct response:

Take a deep breath and exhale when the physician inserts a gloved finger into the rectum.
Explanation:

To minimize discomfort and relax the anal sphincter during the rectal examination, the patient is instructed to take a deep breath and exhale slowly as the practitioner inserts a finger. If possible, he should turn his feet inward so his toes are touching.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1716.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1716

Question 20 See full question

A patient is planning to use a negative-pressure (vacuum) device to maintain and sustain an erection. What should the nurse caution the patient about with the use of this device?

You Selected:

Do not leave the constricting band in place for longer than 1 hour to avoid penile injury.
Correct response:

Do not leave the constricting band in place for longer than 1 hour to avoid penile injury.
Explanation:

Negative-pressure (vacuum) devices may also be used to induce an erection. A plastic cylinder is placed over the flaccid penis, and negative pressure is applied. When an erection is attained, a constriction band is placed around the base of the penis to maintain the erection. To avoid penile injury, the patient is instructed not to leave the constricting band in place for longer than 1 hour.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1721.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1721

Question 1 See full question

What should a male client older than age 50 do to help ensure early identification of prostate cancer?

You Selected:

Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly.
Correct response:

Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly.
Explanation:

The incidence of prostate cancer increases after age 50. The digital rectal examination, which identifies enlargement or irregularity of the prostate, and PSA test, a tumor marker for prostate cancer, are effective diagnostic measures that should be done yearly. Testicular self-examinations won't identify changes in the prostate gland because of its location in the body. A transrectal ultrasound, CBC, and BUN and creatinine levels are usually done after diagnosis to identify the extent of the disease and potential metastasis.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1715.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1715

Question 2 See full question

After a radical prostatectomy for prostate cancer, a client has an indwelling catheter removed. The client then begins to have periods of incontinence. During the postoperative period, which intervention should be implemented first?

You Selected:

Kegel exercises
Correct response:

Kegel exercises
Explanation:

Kegel exercises are noninvasive and are recommended as the initial intervention for incontinence. Fluid restriction is useful for the client with increased detrusor contraction related to acidic urine. Artificial sphincter use isn't a primary intervention for post-prostatectomy incontinence. Self-catheterization may be used as a temporary measure but isn't a primary intervention.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1738.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1738

Question 3 See full question

Which of the following terms refers to the surgical removal of one of the testes?

You Selected:

Orchiectomy
Correct response:

Orchiectomy
Explanation:

Orchiectomy is required when the testicle has been damaged. Circumcision is excision of the foreskin, or prepuce, of the glans penis. Vasectomy is the ligation and transection of part of the vas deferens to prevent the passage of the sperm from the testes. Hydrocelectomy describes the surgical repair of a hydrocele, a collection of fluid in the tunica vaginalis.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1731.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1731

Question 4 See full question

A client is scheduled for a transurethral rescection of the prostate (TURP). Which statement demonstrates that the expected outcome of "client demonstrates understanding of the surgical procedure and aftercare" has been met?

You Selected:

"The surgeon is going to insert a scope through my urethra to remove a portion of the gland."
Correct response:

"The surgeon is going to insert a scope through my urethra to remove a portion of the gland."
Explanation:

TURP involves the surgical removal of the inner portion of the gland through an endoscope inserted through the urethra. There is no external skin incision. Typically, the procedure is performed in an outpatient setting but may require an overnight hospital stay.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1732.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1732

Question 5 See full question

The nurse is providing care to a client who has had a transurethral resection of the prostate. The client has a three-way catheter drainage system in place for continuous bladder irrigation. The nurse anticipates that the catheter may be removed when the urine appears as which of the following?

You Selected:

Light yellow and clear
Correct response:

Light yellow and clear
Explanation:

Typically a three-way catheter drainage system is removed when the urine appears clear and amber (light yellow). Reddish-pink urine with clots usually occurs in the immediate postoperative period. Eventually the urine becomes light pink within 24 hours after surgery. Dark amber urine suggests concentrated urine commonly associated with dehydration.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1737.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1737

Question 6 See full question

A client is receiving leuprolide as part of his treatment for prostate cancer. The nurse would be alert for which of the following as a possible adverse effect?

You Selected:

Gynecomastia
Correct response:

Gynecomastia
Explanation:

Adverse effects associated with leuprolide, a luteinizing hormone-releasing hormone agonist, are related to hypogonadism and include vasomotor flushing, loss of libido, decreased bone density, anemia, fatigue, increased fat mass, decreased muscle mass, gynecomastia, and mastodynia (breast/nipple tenderness).

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1724.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1724

Question 7 See full question

After teaching a group of students about erectile dysfunction, the instructor determines that the teaching was successful when the students identify which of the following as true?

You Selected:

Erectile dysfunction may be due to testosterone insufficiency.
Correct response:

Erectile dysfunction may be due to testosterone insufficiency.
Explanation:

Common causes of erectile dysfunction include neurologic disorder like spinal cord injury, perineal trauma, testosterone insufficiency, side effects of drug therapy such as antihypertensives or antidepressants, atherosclerosis, hypertension, and complications of diabetes mellitus. Erectile dysfunction may be related to anxiety or depression. It is not a normal aspect of aging.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1717.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1717

Question 8 See full question

The nurse is preparing a presentation for a local community group about prostate cancer and possible dietary risk factors. Which of the following would the nurse most likely include?

You Selected:

High-fat diet
Correct response:

High-fat diet
Explanation:

Although the case of prostatic cancer is unknown, there seems to be a relationship with increased testosterone levels and a diet high in fat. No other dietary links have been suggested.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1726.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1726

Question 9 See full question

A client with Stage IV prostate cancer is to receive hormone therapy. The nurse would inform the client about possible adverse effects including which of the following?

You Selected:

Breast tenderness
Correct response:

Breast tenderness
Explanation:

Feminizing side effects occur with hormone therapy. The client's voice may become higher, hair and fat distribution may change, and breasts may become tender and enlarged. Libido and potency also are diminished.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1731.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1731

Question 10 See full question

Which of the following would be most important to include in a teaching plan for a client who has had a vasectomy?

You Selected:

Using a reliable method of contraception for several weeks.
Correct response:

Using a reliable method of contraception for several weeks.
Explanation:

It may take several weeks or more after surgery before the ejaculatory fluid is free of sperm, and the client is informed to use a reliable method of contraception until sperm no longer are present. The client should apply ice packs to the scrotum to reduce swelling and use a mild analgesic such as aspirin or acetaminophen for pain relief. The client typically can resume sexual activity when comfortable, usually in 1 week.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1744.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1744

Question 11 See full question

Which of the following is the obstructive and irritative symptom complex caused by benign prostatic hypertrophy?

You Selected:

Prostatism
Correct response:

Prostatism
Explanation:

Symptoms of prostatism include increased frequency of urination, nocturia, urgency, dribbling, and a sensation that the bladder has not completely emptied. Prostatitis is an inflammation of the prostate gland. Prostaglandins are physiologically active substances present in tissues with vasodilator properties. Prostatectomy refers to the surgical removal of the prostate gland.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1715.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1715

Question 12 See full question

Consuming a diet high in which of the following has been found to increase the risk for prostate cancer?

You Selected:

Red meats
Correct response:

Red meats
Explanation:

Data suggest that men who consume a diet containing excessive amounts of red meat or dairy products that are high in fat are at increased risk for prostate cancer.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1726.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1726

Question 13 See full question

The diagnosis of prostate cancer is confirmed by which of the following?

You Selected:

Histologic exam of tissue
Correct response:

Histologic exam of tissue
Explanation:

The diagnosis of prostate cancer is confirmed by a histologic examination of tissue. Other tests that may be used to establish the extent of the disease include bone scans to detect metastases to the bones, and computed tomography scan to identify metastases in the pelvic lymph nodes.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1717.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1717

Question 14 See full question

Which of the following is not a definition of erectile dysfunction?

You Selected:

The inability to sustain erection for a satisfactory period of time
Correct response:

The inability to achieve an erection after sexual activity
Explanation:

The ability to achieve an erection after sexual activity varies and depends on the man's age, health, and sexual excitement. This statement is included in the definition of erectile dysfunction. Additionally, there must be multiple or persistent incidences of failed erection for the disorder to be considered pathologic.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1717.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1717

Question 15 See full question

Which of the following cancers rank second as the cause of death in American men?

You Selected:

Prostate
Correct response:

Prostate
Explanation:

Prostatic cancer is second to skin cancer in frequency among American men. It ranks second as the cause of deaths from cancer. Cancer of the testes is a malignancy seen in men between 18 and 40 years of age. Although this cancer is relatively rare, accounting for approximately 1% of cancers in men, it is the most common type in men between 15 and 34 years of age and is the leading cause of cancer deaths in men between 25 and 34 years of age. Skin cancer ranks first in frequency among American men. Penile cancer is rare and occurs more often in men who are uncircumcised.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1725.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1725

Question 16 See full question

The nurse is providing instruction for testicular self-examination to a group of young adolescents. Which is the most correct examination technique?

You Selected:

Palpate each testicle separately, following a warm shower.
Correct response:

Palpate each testicle separately, following a warm shower.
Explanation:

It is best to examine and palpate each testicle following a warm shower, when the testes are relaxed and not retracted. Because one testicle is normally larger and hangs lower, comparing the two sides is not indicated. Both testes should be oval in shape, smooth, and firm without masses or tenderness. Most tumors are located on the lateral aspect of the testicles.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1742.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1742

Question 17 See full question

Which of the following should be included as part of the home care instructions for a patient with epididymitis and orchitis?

You Selected:

Take prescribed antibiotics.
Correct response:

Take prescribed antibiotics.
Explanation:

Home care for a patient with epididymitis and orchitis includes instructions to continue administering prescribed antibiotics, and to take sitz baths, apply local heat after scrotal swelling subsides, avoid lifting, and refrain from sexual intercourse until symptoms are relieved.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1740.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1740

Question 18 See full question

A 57-year-old Caucasian man is being treated in the outpatient community center. The patient reports that he wakes up twice most nights to urinate. In addition, he reports occasional blood in his urine. The patient's laboratory levels reveal a PSA level of 3.8 ng/mL, and a white blood cell count (WBC) of 6,000 mm3. The nurse most likely suspects that the patient is experiencing which of the following conditions?

You Selected:

Prostatism
Correct response:

Prostatism
Explanation:

Symptoms of prostatism include increased frequency of urination, nocturia, urgency, dribbling, hematuria, and a sensation that the bladder has not completely emptied. PSA and WBC levels are within expected ranges. Prostatitis is an inflammation of the prostate gland. Prostaglandins are physiologically active substances present in tissues with vasodilator properties. Prostatectomy refers to the surgical removal of the prostate gland.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1713.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1713

Question 19 See full question

The nurse is demonstrating the technique for performing a testicular self examination (TSE) to a group of men for a company health fair. One of the men asks the nurse at what age a man should begin performing TSE. What is the best answer by the nurse?

You Selected:

"It should begin in adolescence."
Correct response:

"It should begin in adolescence."
Explanation:

TSE should begin during adolescence.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1716.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1716

Question 20 See full question

The nurse is educating a patient about performing testicular self-examination (TSE). The nurse informs the patient that the best time to perform the exam is when?

You Selected:

After a warm bath or shower
Correct response:

After a warm bath or shower
Explanation:

Testicular self-examination is to be performed once a month. The test is neither difficult nor time-consuming. A convenient time is usually after a warm bath or shower when the scrotum is more relaxed.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1742.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1742

Question 1 See full question

A client is undergoing a diagnostic workup for suspected testicular cancer. When obtaining the client's history, the nurse checks for known risk factors for this type of cancer. Testicular cancer has been linked to:

You Selected:

cryptorchidism.
Correct response:

cryptorchidism.
Explanation:

Cryptorchidism (failure of one or both testes to descend into the scrotum) appears to play a role in testicular cancer, even when corrected surgically. Other significant history findings for testicular cancer include mumps orchitis, inguinal hernia during childhood, and maternal use of diethylstilbestrol or other estrogen-progestin combinations during pregnancy. Testosterone therapy during childhood, sexually transmitted disease, and early onset of puberty aren't risk factors for testicular cancer.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1741.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1741

Question 2 See full question

Nursing students are reviewing information about the male reproductive system and normal age-related changes. They demonstrate understanding of the topic when they identify which of the following as occurring?

You Selected:

Plasma testosterone levels decrease.
Correct response:

Plasma testosterone levels decrease.
Explanation:

With aging, plasma testosterone levels decrease, prostatic secretions increase, testes decrease in weight, and spermatogenesis continues.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1715.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1715

Question 3 See full question

The nurse is preparing a discharge teaching plan for a client who has had a prostatectomy. Which of the following would be appropriate to include?

You Selected:

Performing perineal exercises frequently throughout the day
Correct response:

Performing perineal exercises frequently throughout the day
Explanation:

After a prostatectomy, the client should be instructed in how to perform perineal exercises and to perform them hourly throughout the day, each day. In addition, the client should avoid bearing down (straining) to urinate because of the increased risk for hematuria. He should also avoid strenuous exercise, which increases the tendency to rebleed. The client should be instructed to urinate as soon as he feels the first urge to do so.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1739.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1739

Question 4 See full question

Which client would the nurse identify as being at highest risk for the development of testicular cancer?

You Selected:

A 25-year-old male with a history of cryptorchidism
Correct response:

A 25-year-old male with a history of cryptorchidism
Explanation:

Testicular cancer is most common in between 15 and 34 years of age and is the leading cause of cancer deaths in men between 25 to 34 years of age. Its incidence is higher in Caucasians and men with a history of cryptorchidism. Other clients at risk are those with a family history of the disease, those who are HIV-positive or have developed AIDS, and those who already have had cancer in one testicle.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1741.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1741

Question 5 See full question

Which of the following patients is most likely to develop prostate cancer according to a nurse working at a health screening at the local mall?

You Selected:

A 56-year-old African American man
Correct response:

A 56-year-old African American man
Explanation:

Being over the age of 40 and being African American are both risk factors for prostate cancer. Being under the age of 40 and being of Asian heritage reduce the risk of prostate cancer.

Reference:

Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed., Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes, p. 1725.

Chapter 59: Assessment and Management of Problems Related to Male Reproductive Processes - Page 1725
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