BIOLOGY 102Medical-Surgical Nursing Critical Thinking in Client Care, CHAPTER 46-52

Medical-Surgical Nursing Critical Thinking in Client Care, 4th Edition Priscilla LeMon

CHAPTER   46-52

Chapter 46

1. A client’s spouse states “I’ve noticed that my spouse doesn’t sleep well anymore and sometimes can’t find the right words when we’re visiting.” The nurse should correctly respond:

                a) “Does anyone in your family have Alzheimer’s disease?”

                b) “How long have you noticed these changes?”

                c) “These are common changes associated with age.”

                d) “Do you think your spouse is depressed?”

Application

Learning Outcome 2

2. A client is hospitalized with Guillain-Barré syndrome and the nursing diagnosis Spontaneous Ventilation, Impaired has been identified. In planning care for this client, the nurse will prioritize the following interventions, with 1 being the most critical and 4 the least:

                1) Careful airway suctioning to prevent infection

                2) Client education regarding residual problems

                3) Monitor arterial blood gases to identify changes.

                4) Maintain hydration and caloric intake.

3. A client comes to the clinic with complaints of blurred vision and muscle spasms that come and go, which have been occurring over the past several months. The client is scheduled for an MRI and lumbar puncture with examination of the CSF. A critical piece of the client history for the nurse to note is that:

                a) The client is from Canada.

                b) The client has a family history of epilepsy.

                c) The client has been depressed.

                d) The client’s father had Parkinson’s disease.

4. A nurse working in a fertility clinic reviews the health history of a client whose father had Huntington’s disease. What statement by the nurse would best address this client’s risk factors?

a)      “Have you ever been tested for this disease?”

b)      “What do you know about testing for this disease?”

c)       “Are you sure you want to have children?”

d)      “Your child has a 50% chance of getting this disease.”

5. A home health nurse visits a client with stage 2 Alzheimer’s disease who lives at home with a spouse. In order to meet the needs of the spouse, the nurse suggests:

a)      Making arrangements for the client to visit the local senior citizen’s center in the afternoon.

b)      Providing the client a list of daily activities to complete.

c)       Finding respite care to come into the home several days a week.

d)      Finding placement in a long-term care facility.

6. A client with stage 2 Alzheimer’s disease has lost 5 pounds over the past month. The best nursing intervention would be:

a)      Recommend referral to a nutritionist.

b)      Make sure the client is put on a mechanical soft diet.

c)       Give the client food choices he can select.

d)      Provide quick snacks throughout the day.

7. A client complains of periods of confusion and forgetfulness at times, and reports clear thought process at most times of the day. The symptoms have been gradually worsening. The best response by the nurse is:

a)      “You probably have nothing to worry about, it’s most likely stress-related.”

b)      “Everybody has a few problems with memory as they get older.”

c)       “Have you started any new medications since the symptoms began?”

d)      “You should probably have an MRI of your brain.”

8. A client states “My doctor said sometimes I would have an on/off problem with this medication—what does that mean?” The best response by the nurse is:

a)      “There will be times when you are depressed (off) and when you are happy (on).”

b)      “You will have to take breaks from this medicine by stopping (off) and starting it (on) again, so you don’t build up a tolerance to it.”

c)       “The on times will be when your symptoms are under control, the off times are when you will have increased problems with symptom management.”

d)      “I’m not a pharmacist, so I shouldn’t be answering this question.”

9. A client with myasthenia gravis is taking pyridostigmine (Mestinon). Teaching about this medication should include immediately reporting:

a)      Increased weakness.

b)      Problems with increased drooling.

c)       Orthostatic hypotension.

d)      Headache.

10. A client with stage 2 Alzheimer’s disease becomes very agitated in the evenings. Appropriate nursing interventions would include:

a)      Use of anti-anxiety medications or tranquilizers.

b)      Moving the client to an area of activity to provide distraction.

c)       Playing soft music in the client’s room.

d)      Recommending the client be moved to a more secure environment.

Learning Outcome 4

Chapter 47

1.            When the nurse was assessing a client for neurological changes from a head       trauma, which eye assessments are included? Select all that apply.

                1.        Ptosis

                2.        Extraocular movements                   

                3.        Accommodation

                4.        Color of iris

                5.        Nystagmus

2.            When teaching a community health class about eye safety, which statement by one of the participants would   reflect a need for additional teaching?

                1.        “I will wear goggles whenever I work around equipment such as lawnmowers, saws, and trimmers.”

                2.        “When I play sports, I should wear protective eyewear to minimize risks of eye injury.”

                3.        “When working with chemicals, if a splash occurs, I should first call 911 and then go to the emergency facility.”

                4.        “When working or playing in the outdoors, I should wear shades that have UV protection even if the day is cloudy.”

3.            The client was complaining of dizziness and disequilibrium with head      movements. The nurse understands which nursing diagnosis would be the top            priority based upon these findings?

                1.        Fluid Balance, Deficit

                2.        Adjustment Impairment

                3.        Coping, Ineffective

                4.        Falls, Risk for

4.            When the nurse is planning the health history questions to ask a client about     possible hearing changes that might have occurred due to frequent sinus         infections, which question would be appropriate? Select all that apply.

                1.        “Do you have any pain in your ears?”

                2.        “Have you ever had drainage from your ears?”

                3.        “Does anyone in your family have congenital deafness?”

                4.        “Have you noticed a change in your hearing, such as muffling of sounds?”

5.            When the nurse is assessing for a possible conductive hearing loss, which            assessment would be the first one to perform?

                1.        Inspection of the external ear

                2.        Weber test

                3.        Rinne test

                4.        Tympanogram

6.            The nurse suspects that a bone-conductive hearing loss is present in the client.                 Which diagnostic would best differentiate between bone conduction loss and air                conduction loss?

                1.        Rinne test

                2.        Weber test

                3.        Assessment of balance and body position

                4.        Palpation of mastoid process

7.            When planning home management for a client who recently lost vision after eye trauma, which of the following would be most appropriate to evaluate the emotional status of the client?

                1.        “Do you feel depressed about your vision loss?”

                2.        “Tell me how your change in vision has affected how you feel about           yourself.”

                3.        “Have you made arrangements for someone to help you around the house?”

                4.        “You know, a lot of people do very well with little help once they get home.”

8.            When explaining a tonometer test results of 28 mm Hg to a client, the nurse would use which explanation to be most accurate? The tonometer measures the pressure in the:

                1.        Posterior chamber of your eye, which is too low and requires medication to increase the pressure to prevent blindness from retinal damage.               

                2.        Inner ear, to evaluate the semicircular canals functions related to nerve damage, and 28 mm Hg is “within the normal range.”

                3.        Pressure in the middle ear that builds up with Mastoiditis, and 28 mm Hg is very high, and needs to be treated with surgical insertion of tubes to drain the fluid behind the tympanic membrane.

                4.        Anterior chamber of the eye that builds up from overproduction or decreased drainage of the aqueous humor, and could lead to possible retinal changes due to above-normal pressures, like yours, if not treated.

****NOTE TEXT contradicts itself for two different norms are given on page 5 of chapter 47 and page 39 of chapter 48…. Please clarify which range is desired for consistency in text readings.

9.            When performing the caloric test, nystagmus develops in the left eye while        irrigating the right ear. The nurse evaluates the client further for which condition    that contributes to the results of the caloric test?

                1.        Alcohol, CNS depression, or barbiturate use

                2.        Increased anterior pressure in the left eye

                3.        Nothing further, since nerves are intact in the inner ear

                4.        Increased pressure from brain lesions

10.          When assessing a 75-year-old client, which findings would require immediate    action by the nurse? A statement about:

                1.        Floaters being present at times.

                2.        Additional light and “reading glasses” being needed more often.

                3.        The development of a white circle around colored part of eye.

                4.        Frequent falls from tripping over items in the floor.

Chapter 48

1.            A young female who has a 2-year-old and a new baby has just lost all vision in one eye following a vehicle trauma. The client asks what she will do, since she has no help when she goes home. The nurse would choose which nursing diagnoses when planning care? Select all that apply.

                1. Post-Trauma Syndrome          

                2.    Grieving, Actual/Anticipatory

                3.    Family Processes, Interrupted

                4.    Self-Esteem, Situational Low

                5.    Injury, Risk for

2.            Upon admission when orienting a client who has been blind since birth to the hospital room, which activity by the nurse would be appropriate? Select all that apply.

                1.    Orient the client both verbally and physically to the layout of the room.

                2.    Describe everything in detail about how the equipment works.

                3.    Tell the client you will leave the light on 24 hours a day.

                4.    Place signs to remind staff to not move equipment without telling the client.

3.            Which instructions would be appropriate for the nurse to give to a client with acute conjunctivitis from Staphylococcus? Select all that apply.

                1.    You should wash your hands before cleansing the eye and giving eyedrops.

                2.    You can rub your eyes with a clean, soft cloth for itching.

                3.    You can soak your lids with warm saline to soften crusts and exudates.

                4.    You should not share towels, make-up, or contact lens with anyone else.

4.            Following a severe corneal ulcer, the client had keratoplasty (corneal transplant). What nursing care should be included in the plan of care? The client should: (Select all that apply.)

                1.    Wear an eye-shield the first 24 hours and then at night until several weeks postoperatively as directed by healthcare provider.

                2.    Be instructed to avoid lifting, sneezing, coughing or bending over at the waist.

                3.    Report any change, such as increased pain, drainage, bleeding, floaters, and cloudiness noted.

                4.    Be instructed on how to administer eyedrops and ointments in a sterile manner.

                5.    Be educated on the need for mydriatics during the postoperative period.

5.            Before teaching about home management for clients with open-angled glaucoma, which order would be questioned by the nurse?

                1.    Timolol (Timoptic), beta-adrenergic blocker, for a 60-year-old with congestive heart failure (CHF)

                2.    Dorzolamide (Trusopt), a carbonic anhydrase inhibitor, for a client with asthma and chronic obstructive pulmonary disease (COPD)

                3.    Acetazolamide (Diamox) for a 20-year-old male

                4.    Brimonidine (Alphagan), an adrenergic agonist, for a healthy 40-year-old

6.            In a client with human immunodeficiency virus (HIV), the nurse should assess for             which complications that might be present? Select all that apply.

                1.    Retinitis pigmentosa with retinal atrophy

                2.    Kaposi neoplasms of the external surfaces of the eyelid

                3.    Cotton-wool spots around the optic nerve

                4.    Exudative macular degeneration

                5.    Cytomegalovirus (CMV) retinitis

7.            Following myringotomy for acute otitis media, which topic would be appropriate for teaching about home management by the nurse?

                1.    Ear irrigations should be placed on the wall of the external canal, and not on the tympanic membrane.

                2.    Air travel and sudden barometric shifts will not affect the surgical procedure.

                3.    Sterile cotton-tipped swabs can be used to clean the ear drainage.

                4.    Shampooing and swimming are not restricted after a couple of weeks.

8.            The client with otosclerosis would be expected to have which potential finding by the nurse during assessment?

                1.    Rinne test results that bone conduction is equal or greater than air conduction

                2.    Severe vertigo is present when questioned.

                3.    Purulent drainage is observed or reported with cyanosis of the tympanic membrane.

                4.    Diminished hearing is noted in the lower tones, such as a man’s speaking voice.

9.            A client with severe symptoms of tinnitus, vertigo, sensorineural hearing deficit,              nausea, and vomiting would have which nursing diagnosis as a first priority?

                1.    Nutrition, Imbalanced, Less than Body Requirements

                2.    Trauma, Risk for

                3.    Disturbed Sleep Patterns

                4.    Sensory Perception, Disturbed: hearing

10.          A client with a nursing diagnosis of Communication: Impaired, Verbal related to hearing deficit would expect which action in the plan of care? Select all that apply.

                1.    Speak face-to-face, but do not overarticulate your words.

                2.    Offer alternative methods of communication, such as paper and pencil.

                3.    Speak loudly and in a higher pitch for easier understanding of words.

                4.    Restate in exactly the same words if not understood the first time.

                5.    Do not use facial and hand gestures that are distracting while talking.

Chapter 49

1. A client is scheduled to undergo a prostate biopsy. When providing education concerning postoperative care related to the procedure, which of the following should be included?

a. Avoid strenuous activity for 24 hours.

b. There may be discomfort for 24–48 hours after the procedure.

c. The client can immediately return to his preprocedure activity level.

d. The names of sexual contacts must be collected.

2. A male client reports to the clinic with an open area on his penis. Which of the following questions will be most important to include in the data collection?

a. “Have you had sexual intercourse recently?”

b. “Do you think you have a disease?”

c. “Are you promiscuous?”

d. “When did you initially notice this open area?”

3. While providing care to the parents of a baby boy who has the chromosomal makeup of XXY, which of the following should be included in the teaching plan?

a. The boy will have an enlarged penis and scrotum.

b. The boy will be at increased risk for the development of testicular cancer.

c. The child will be sterile.

d. The child might have altered development of secondary sex characteristics.

4. The nurse is obtaining a health history on a client complaining of recent-onset impotence. During the interview, which of the following questions will be most beneficial in identifying a potential cause of the manifestation?

a. “Does this occur often?”

b. “How does your partner feel about this problem?”

c. “For what diseases and disorders have you been treated?

d. “Are you on any medications?

5. A female client has reported to the clinic for an initial gynecological examination. The client reports feeling nervous. When beginning the interview, which of the following questions would be most appropriate?

a. “How many sexual partners have you had?”

b. “Are you OK?”

c. “How often are you intimate with your partner?”

d. “What concerns do you have about today’s examination?”

6. A client is approximately 4 weeks pregnant. The client reports noting a scant amount of vaginal bleeding. The examination reveals the cervix is closed. Based upon your knowledge, which of the following hormones do you anticipate will be lower than expected for the client?

a. Progesterone

b. Estrogen

c. Prostaglandin

d. Luteinizing hormone

7. A client is scheduled for a mammogram. Which of the following might adversely impact the testing?

a. The use of deodorant

b. The use of facial makeup

c. The administration of medications used to increase bleeding times

d. Eating breakfast the morning of the test

8. When providing education to a client concerning breast self-examinations, the client asks what days are best to perform the examination. What information should be included in the response given to the client?

a. It does not matter what day the examination is performed.

b. It is best to perform the examination on the first day of the menstrual period.

c. It is best to perform the examination in the days just prior to the menstrual period.

d. The examination is best performed after the menstrual period.

9. When obtaining the health history of a 60-year-old female, the client reports noting small red lesions on her vulva. Based upon your knowledge, which of these diagnoses is most likely correct?

a. Herpes simplex

b. Primary syphilis

c. Secondary syphilis

d. Vulvar carcinoma

10. The nurse is teaching a client how to perform a testicular self-examination. What information should be provided to the client?

a. Any painful lump should be reported.

b. Tenderness of the scrotal sac contents should be reported.

c. Most men have one testicle that is significantly larger than the other.

d. It is best to do the examination upon arising on the designated day.

CHAPTER 51

1. A 41-year-old client has reported to the clinic with clinical manifestations consistent with menopause. The client states that her menstrual periods have become irregular, with the last period occurring approximately four months ago. What information should be provided to the client concerning the use of contraceptives?

a. Contraceptives should continue to be utilized.

b. Contraceptives are no longer needed.

c. Contraceptives will only be needed in the months after menstruation is experienced.

d. Contraceptive use will only be needed for another two months.

2. The client who has been experiencing the clinical manifestations associated with menopause voices an interest in using alternative and complementary therapies to manage them. What initial response by the nurse is indicated?

a. “Those seldom work.”

b. “Many women report success with these measures.”

c. “What types of therapies are of interest to you?”

d. “Have you discussed this with the physician?

3. During the teaching session for a client who recently had a hysterectomy, the client states that she is nervous about taking the estrogen replacement therapy prescribed by her physician. She states that she is worried about developing breast cancer later in life. Which of the statements by the nurses will be most appropriate?

a. “The risk of breast cancer is somewhat increased for women with a family history who opt to take estrogen replacement therapy.”

b. “The risk of breast cancer is not increased for women who have had a hysterectomy and take estrogen replacement medications.”

c. “Perhaps you should consider an estrogen–progestin combination therapy.”

d. “Taking estrogen replacement is not required after a hysterectomy.”

4. A 30-year-old woman reports increasing difficulty during the days preceding the onset of her menstrual cycle. Which of the following might assist in the management of her condition? Select all that apply.

a. Increase dietary sugar intake to promote energy.

b. Increase intake of simple carbohydrates.

c. Reduce caffeine.

d. Utilize guided imagery.

5. A client who has been experiencing premenstrual syndrome reports to the clinic with a diet diary she has kept over the past several weeks. Which of the following findings should be reviewed with the client, with a recommendation made for dietary modification?

a. Daily intake of caffeine-free soda

b. Daily intake of low-fat yogurt

c. Foods rich in magnesium

d. Daily intake of white bread

6. A woman is scheduled to undergo a laparoscopic procedure. Which of the following statements by the client indicates the need for further education?

a. “I can expect to go home a few hours after the procedure.”

b. “I might experience some abdominal pain after the procedure.”

c. “There might be some vaginal bleeding after the procedure.”

d. “Shoulder pain should be reported, as it might signal a complication.”

7. A 13-year-old female reports to the school nurse with concerns about her menstrual cycle. The client states that she has not yet started her period, and asks if this is normal. Which of the following should be included in the nurse’s response?

a. The client should be referred to a gynecologist for a pelvic examination.

b. The client should have started her period by now.

c. It is not abnormal for the client to have not yet started her period.

d. The client should be tested for hormonal imbalances.

 8. The nurse is collecting data during a routine clinic visit. The client reports she has experienced bleeding between her menstrual periods. What initial action by the nurse is most appropriate?

a. Determine the timing of the bleeding episodes.

b. Determine the amount of the bleeding episodes.

c. Assess for the presence of sexually transmitted infections.

d. Review the length of the client’s normal menstrual cycles.

9. A client has been experiencing anovulatory dysfunctional uterine bleeding. The client is 25 years of age, and is concerned about maintaining her fertility. Based upon your knowledge, which management technique likely would be employed first?

a. Oral contraceptives

b. Progestin therapy

c. Therapeutic D and C

d. Endometrial ablation

10. A client is preparing to be discharged to home after a hysterectomy. Which of the following statements by the client indicates the teaching session has been successful?

a. “I will need to report temperature greater than 101 degrees.”

b. “I might experience vaginal bleeding for about one week.”

c. “I will need to report any hot flashes, as they indicate my hormone replacement therapy is not effective.”

d. “I will still need to see my physician for gynecological examinations.”

Chapter 52

1. A client recently diagnosed with herpes simplex II asks how to best manage the lesions. What information should be given to the client?

a. The use of soap should be restricted.

b. It is safe to use a solution of 50% rubbing alcohol and 50% water to clean the lesions.

c. Wearing nylon panties will reduce discomfort.

d. Gentle soap and water can be used to clean the lesions.

2. A client recently treated for pelvic inflammatory disease asks how she can best prevent a recurrence of the disease. What information should be provided to the client?

a. The physician will prescribe prophylactic antibiotic therapy.

b. The use of condoms will be beneficial.

c. Annual gynecological examinations should be scheduled.

d. Douching after intercourse will assist in removing potential pathogens from the genital area.

3. A client treated for pelvic inflammatory disease is preparing for discharge. During the teaching session, the use of tampons is discussed. Which of the following statements by the client indicate the understanding of the content provided? Select all that apply.

a. “I will be able to wear tampons.”

b. “The use of tampons is forever prohibited.”

c. “Tampons must be changed at least every four hours.”

d. “I should wear pads at night.”

4. A pregnant client reports to the clinic and learns she has tested positive for herpes simplex. The nurse develops a plan of care. Which of the following nursing diagnoses has the highest priority?

a. Injury, Risk for related to the disease process

b. Knowledge, Deficient related to the diagnosis

c. Anxiety related the diagnosis

d. Family Processes, Interrupted related to the effects of the diagnosis on her relationship with her partner

5. A client has been diagnosed with latent syphilis. During the counseling session, the client asks about transmitting the disease to his spouse. What information should be provided to the client?

a. “You will need to abstain from sexual relations until treatment is completed.”

b. “You will need to wear a condom.”

c. “At this late stage, the disease is contained to only you.”

d. “At this stage of the disease, transmission is by contact with blood.”

6. During a gynecological examination and testing, a female client is diagnosed with a Chlamydial infection. The client denies any symptoms of the disease, and asks when she contracted the disease. What information should be provided to the client?

a. The client has most likely had the infection for about 1–3 weeks.

b. The infection has been in her body for less than 1 month, since no symptoms are present.

c. The infection might have been in her body for an indefinite period of time.

d. Symptoms typically begin a few months after the infection enters the body.

7. The nurse is planning to teach a course about sexually transmitted infections. What information concerning genital warts should be included?

a. Handwashing will aid in the reducing the spread of genital warts.

b. Genital warts will result in cervical cancer for the majority of women who get them.

c. Women who have certain types of genital warts should be vaccinated against other types.

d. The risk for the development of penile cancer is high in men diagnosed with genital warts.

8. A client asks which method of contraception will provide the greatest protection against sexually transmitted infections. What method can the nurse recommend?

a. Oral contraceptives

b. Male condoms

c. Sponges

d. Spermicides

9. A client reports to the clinic with a painless, ulcerated area on her labia. Based upon your knowledge, what diagnosis do you anticipate?

a. Herpes simplex II

b. Syphilis

c. Condylomata acuminata

d. Gonorrhea

10. A client with herpes simplex II is concerned about sexual relations. What information should be provided to the client?

a. The infection can be transmitted only when the lesions present.

b. The infection can be prevented with condom use.

c. Sexual relations must be avoided during the prodromal period and for at least 10 days after the lesions are healed.

d. Sexual activity is permissible once the lesions have dried out.