Chapter 36 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 36

Question 1

Type: MCSA

Which question would the nurse ask to most effectively assess the patients pattern of elimination?

1. Are you having any bowel problems?

2. Have you had any recent difficulties with your stools?

3. Tell me about your usual bowel habits.

4. Are your bowel movements normal?

Correct Answer: 3

Rationale 1: Open-ended questions elicit the greatest amount of information. Questions that allow the patient to respond with a yes or no can limit communication and data gathering.

Rationale 2: Open-ended questions elicit the greatest amount of information. Questions that allow the patient to respond with a yes or no can limit communication and data gathering.

Rationale 3: Open-ended questions elicit the greatest amount of information.

Rationale 4: Open-ended questions elicit the greatest amount of information. Questions that allow the patient to respond with a yes or no can limit communication and data gathering.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-2

Question 2

Type: SEQ

Arrange the four parts of abdominal assessment in the order the nurse should follow.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Percussion

Choice 2. Inspection

Choice 3. Palpation

Choice 4. Auscultation

Correct Answer: 2,4,1,3

Rationale 1: Percussion in each quadrant is the third step in the assessment sequence.

Rationale 2: First, the nurse should look at the abdomen for symmetry, contour, and general appearance.

Rationale 3: Palpation is the final step. It may cause discomfort and should be performed last.

Rationale 4: Second, the abdomen should be assessed for the presence of bowel sounds (auscultation).

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-3

Question 3

Type: MCSA

During an assessment of a patients abdomen, frequent pulsations are noted in the epigastric region. What action by the nurse is indicated?

1. Document the findings as hyperactive bowel sounds.

2. Review the patients medical records for signs and symptoms of cirrhosis, which may indicate ascites.

3. Note the time when the patient last voided.

4. Auscultate for a bruit.

Correct Answer: 4

Rationale 1: Bowel sounds are audible, not visible.

Rationale 2: Ascites is the collection of fluid.

Rationale 3: Bladder distention is not manifested as a pulsation. Bladder distention can be detected by palpation.

Rationale 4: The nurse should carefully listen over this area for a bruit that can be associated with aortic aneurysm.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-4

Question 4

Type: MCSA

The nurse evaluates which patient observation as indicating the patient correctly understands the functions of the stomach?

1. The process of absorption of nutrients begins in my stomach.

2. My stomach turns food into liquid so it can be digested.

3. My stomach begins the digestion of carbohydrates.

4. Sulfuric acid is secreted by the stomach.

Correct Answer: 2

Rationale 1: The process of absorption begins in the small intestine.

Rationale 2: In the stomach, food continues to be turned to liquid so that it may ultimately be absorbed into the bloodstream.

Rationale 3: Carbohydrate digestion begins in the mouth.

Rationale 4: The stomach secretes hydrochloride, not sulfuric acid.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 36-1

Question 5

Type: MCSA

A nurse preceptor is reviewing the skill of percussing a patients abdomen with a newly licensed nurse. The preceptor will intervene when the nurse makes which statement?

1. I will percuss the abdomen using a systematic path.

2. I anticipate hearing tympany over stool-filled intestines.

3. Dullness is the expected percussion over the liver.

4. Percussion is a useful tool for assessing the spleen, kidneys, and liver.

Correct Answer: 2

Rationale 1: The nurse should establish a system of assessment.

Rationale 2: Tympany is heard over air-filled organs such as gas-filled intestines. Intestines that are stool-filled, such as in a patient with an ileus or constipation, present dull sounds.

Rationale 3: The liver gives off a dull sound.

Rationale 4: The nurse would percuss over the spleen, kidneys, and liver.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 36-3

Question 6

Type: MCSA

When assessing a patient who is scheduled to have a CT scan of the kidneys, which finding would prompt the nurse to notify the primary health care provider?

1. Allergy to iodine and seafood

2. Urinary output of 1,200 mL in 24 hours

3. Last bowel movement one day ago

4. Height 58 and weight 160 pounds

Correct Answer: 1

Rationale 1: A CT scan of the kidneys requires the injection of a radiopaque dye that contains iodine.

Rationale 2: This is a normal finding and does not require that the physician be notified.

Rationale 3: This is a normal finding and does not require that the physician be notified.

Rationale 4: These are normal findings and do not require that the physician be notified.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 36-5

Question 7

Type: MCSA

The nurse is assessing a 68-year-old female patient who states, I am having episodes of urinary incontinence. The nurse should recognize that this statement indicates which situation?

1. An abnormal finding requiring further testing

2. The presence of a urinary infection

3. A normal outcome of the aging process

4. The result of having several children

Correct Answer: 1

Rationale 1: Incontinence is not a normal part of the aging process and will require further investigation to identify the cause.

Rationale 2: Although frequency and urgency can be symptoms of a urinary tract infection, a culture and sensitivity test is necessary to determine the presence of infection.

Rationale 3: Incontinence is not normal.

Rationale 4: Incontinence is not normal and is not necessarily the result of having had several children.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-2

Question 8

Type: MCSA

The nurse is teaching a patient who has a diagnosis of a kidney stone in the left ureter. The nurse knows the patient understands the instruction when the patient makes which statement?

1. My kidney stone is in the tube that empties my bladder.

2. The stone in my kidney is causing my pain.

3. If my kidney stone keeps moving down the ureter, it will eventually move into my bladder.

4. The kidney contracts and pushes the stone down my ureter.

Correct Answer: 3

Rationale 1: The patients statement identifies the urethra, not the ureter.

Rationale 2: The stone is not in the patients kidney.

Rationale 3: The ureter connects to the bladder, so if the stone continues to move, it will eventually fall into the bladder.

Rationale 4: The ureter itself is muscular and produces peristaltic waves that propel the stone along its length. The kidney does not contract.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 36-1

Question 9

Type: MCSA

Which assessment finding alerts the nurse to the likelihood that the patient has a distended bladder?

1. Percussion in the middle of the lower abdomen elicits a dull sound.

2. The patient states, My back is killing me.

3. Percussion over the costovertebral angle produces pain.

4. The patient complains of colicky pain in the side.

Correct Answer: 1

Rationale 1: Percussion over a full bladder produces a dull percussion sound.

Rationale 2: Kidney pain is experienced in the back and the costovertebral angle (the angle between the lower ribs and adjacent vertebrae) and may spread toward the umbilicus. Discomfort from a distended bladder would more likely be felt elsewhere.

Rationale 3: Pain elicited by percussion over the costovertebral angle is likely due to kidney damage or infection.

Rationale 4: Colicky pain may be due to a kidney stone.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-2

Question 10

Type: MCSA

A newly licensed nurse is assessing a patient who reports constant dull pain over the lower abdomen. The nurse inspects, percusses, palpates, and auscultates the patients abdomen. After leaving the patients room, the preceptor says, Your assessment findings may not be accurate. What is the rationale for the preceptors statement?

1. The nurse palpated prior to auscultating.

2. The nurse inspected prior to palpating.

3. The nurse inspected prior to auscultating.

4. The nurse percusses before palpating.

Correct Answer: 1

Rationale 1: Auscultation should follow immediately after inspection because percussion or palpation may increase bowel motility and

interfere with sound transmission during auscultation.

Rationale 2: Inspection is performed prior to palpating.

Rationale 3: Inspection is performed prior to auscultation.

Rationale 4: Percussion is performed before palpation.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 36-3

Question 11

Type: MCMA

The nurse is caring for an adolescent who experienced trauma to the spleen that requires its removal. When discussing the proposed surgery with the patients parents, the nurse would provide which information?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The spleen is located in the left upper abdominal quadrant.

2. The spleen is involved in the return of bile to the liver.

3. The spleen has a minimal vascular system.

4. The spleen acts as a blood filtration system.

5. The spleen destroys aged red blood cells.

Correct Answer: 1,4,5

Rationale 1: The spleen can be found in the left upper quadrant of the abdomen.

Rationale 2: A primary purpose of the spleen is to filter blood, destroy aged red blood cells, and return their by-products, particularly bilirubin, to the liver.

Rationale 3: Because of its extensive vascular nature, trauma to the spleen can be life- threatening.

Rationale 4: A primary purpose of the spleen is to filter blood.

Rationale 5: A primary purpose of the spleen is to destroy aged red blood cells.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 36-1

Question 12

Type: MCSA

An older adult patient states, My mouth is always dry. The nurse recognizes that which priority health promotion problem should be addressed?

1. Poorly chewed food will remain in the patients mouth, supporting bacterial growth.

2. The normal aging process reduces the antibacterial properties of saliva.

3. A lack of salivary gland lubrication makes chewing the food difficult, resulting in gum trauma.

4. A dry mouth lacks bacteria-fighting immunoglobulin A.

Correct Answer: 4

Rationale 1: While poorly chewed food that remains in the oral cavity does support bacterial growth and a lack of oral lubrication may make chewing food more difficult, they are not the primary risk factors in this scenario.

Rationale 2: Normal aging does not appear to have an effect on the antibacterial properties of saliva.

Rationale 3: There is no indication of gum trauma.

Rationale 4: Saliva contains large amounts of ions, such as immunoglobulin A, a vital component for destroying oral bacteria. A lack of saliva increases the risk of infection from oral pathogens.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-1

Question 13

Type: MCSA

The patient reports feeling pain in the right lower quadrant. The nurse shows an understanding of the anatomical location of organs in the abdomen by asking the patient which question?

1. Do you have any problems eating fatty foods?

2. Can you tell me about your bowel habits?

3. When you eat, do you experience any nausea?

4. Do you get clammy when you miss a meal?

Correct Answer: 2

Rationale 1: Problems eating fatty food would relate to the gallbladder, which is located in the right upper quadrant.

Rationale 2: The right lower quadrant contains the ascending colon. Discussing bowel habits is indicated.

Rationale 3: Nausea after eating is not a primary assessment finding associated with the bowels located in the right lower quadrant.

Rationale 4: Clamminess after missing a meal could be related to blood glucose abnormalities, which are associated with the pancreas. The pancreas is located in the left upper quadrant.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-1

Question 14

Type: MCSA

The nurse is preparing to assess a patient who reports abdominal pain as 6 on a scale of 0 to 10. To best facilitate the abdominal assessment, what nursing action is indicated?

1. First medicate the patient for the pain.

2. Palpate the patients abdomen last.

3. Assist the patient into the knees-bent supine position.

4. Encourage the patient to take slow, deep breaths.

Correct Answer: 3

Rationale 1: Medication for pain may not be prescribed if the cause of the pain is still undetermined.

Rationale 2: Palpation of the abdomen may cause pain and should be performed last, but the patient is already experiencing pain, so palpation will not have as much impact on the assessment as will another action.

Rationale 3: The nurse should work with the patient in establishing a comfortable position. This will make the examination more productive and help the patient to be cooperative during the procedure. The knees-bent supine position is often more comfortable than lying flat on the back.

Rationale 4: Slow, deep breathing may help the patient manage the pain, but it would not have the same impact on the assessment as another action.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 36-3

Question 15

Type: MCMA

The nurse is initiating a history and physical assessment on a patient who reports intermittent right-sided abdomen pain, especially after eating fatty foods. How should the nurse conduct the history?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Encourage the patient to express his or her concerns.

2. Include documentation of the patients own words.

3. Direct questions toward ruling out a gallbladder problem

4. Use direct questioning so the interview remains nurse-driven.

5. Establish the nursepatient relationship.

Correct Answer: 1,2,5

Rationale 1: It is important to allow the patient to express concerns and explain the problem in his or her own words during the history interview.

Rationale 2: Direct patient quotes should be documented as a part of the interview process.

Rationale 3: The nurse should keep an open mind, because sometimes information that is initially thought of as trivial can be the answer to the problem.

Rationale 4: It is important to allow the patient to direct the history interview by expressing concerns and explaining the problem in his or her own words. Interruptions should be kept to a minimum, but clarifying questions should be asked.

Rationale 5: Taking a history is a very important encounter with a patient. This is when the relationship with a patient begins.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 36-2

Question 16

Type: MCMA

A patient is reporting intermittent pain in the left upper abdomen. To best assess the characteristics of the pain, the nurse would ask which questions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Can you describe the pain for me?

2. What do you think is causing the pain?

3. When did you first notice the pain?

4. Can you do anything that makes the pain go away?

5. Does anything make the pain worse?

Correct Answer: 1,3,4,5

Rationale 1: An interview regarding the characteristics of pain should include questions directed toward a description of how it feels.

Rationale 2: While asking the patients opinion as to the cause of the pain is appropriate, it does not contribute to the understanding of the characteristics of the pain itself.

Rationale 3: An interview regarding the characteristics of pain should include questions directed toward the onset and duration of the pain.

Rationale 4: Actions that affect the pain (increase, decrease, or eliminate) are important to the interview.

Rationale 5: Actions that affect the pain (increase, decrease, or eliminate) are important to the interview.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-2

Question 17

Type: MCSA

When assessing a patients abdomen, the nurse recognizes the importance of reserving palpation as the last technique. What rationale would the nurse provide for this sequence?

1. Early palpation may result in rebound pain.

2. The technique is likely to increase the patients level of anxiety.

3. Most patients do not like being touched.

4. The pressure of palpation can interfere with hearing bowel sounds.

Correct Answer: 4

Rationale 1: The technique does not cause rebound pain, although it can cause general pain in the abdomen.

Rationale 2: Palpation itself does not generally contribute to a patients anxiety.

Rationale 3: While some patients may be uncomfortable with being touched, that is not the reason for delaying the technique until last.

Rationale 4: Palpation is performed last in the assessment sequence because pressure on the abdominal wall and contents may interfere with bowel sounds and cause pain.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 36-3

Question 18

Type: MCSA

The nurse is percussing a patients kidneys as part of the physical assessment. Which nursing action displays a need for further instruction regarding this assessment technique?

1. The nurse focuses the examination at the patients costal vertebral angles.

2. The nurse asks the patient to sit on the side of the examination table.

3. The nurse gently strikes the patient with the palmar surface of the hand.

4. The nurse applies the technique to either side of the spine between the last rib and the lumbar vertebrae.

Correct Answer: 3

Rationale 1: Percussion should take place at the costal vertebral angle.

Rationale 2: The patient must be lying on one side or be in a sitting position.

Rationale 3: The nurse should make a fist and gently strike the patient with the ulnar surface of the fist.

Rationale 4: The nurse should gently strike in the costal vertebral angle on either side of the vertebral column between the last rib and the lumbar vertebrae.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-2

Question 19

Type: MCSA

When percussing a patients abdomen to gather assessment data, the nurse must rely most heavily on which ability?

1. Locating the margins of the various abdominal organs

2. Differentiating the various elicited sounds

3. Supplementing the technique with fine finger dexterity

4. Observing subtle variations in the contour of the abdomen

Correct Answer: 2

Rationale 1: Locating the margins of organs is not the most important ability in percussion.

Rationale 2: Percussing the abdomen elicits different sounds. The nurse should be able to hear the difference between the sounds.

Rationale 3: Fine finger dexterity is not necessary for adequate percussion.

Rationale 4: Visual observation is not an essential component of percussion.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-3

Question 20

Type: MCSA

It is thought that a patient may be experiencing pancreatitis. Which nursing action would be useful in helping diagnose this disorder?

1. The patient bends the right knee and flexes the right hip, while the nurse flexes the thigh to a right angle and externally and internally rotates the leg.

2. The nurse inquires with radiology when an endoscopy can be scheduled for the patient.

3. The nurse anticipates that the patients health care provider will order a barium enema.

4. Placing the hand on the lateral surface of the patients flexed right thigh, the nurse asks the patient to push against the applied resistance.

Correct Answer: 4

Rationale 1: The obturator sign (painful external and internal rotation of a flexed hip and thigh) is positive in patients with inflammation along the obturator internus muscle. It is not a test for pancreatitis.

Rationale 2: Endoscopy allows the clinician to visualize the intraluminal space of the upper GI tract.

Rationale 3: A barium enema would enhance intraluminal processes such as colon cancer or diverticular disease.

Rationale 4: This option describes the iliopsoas sign test. A positive test (produces pain) indicates an inflammation of the iliopsoas muscle group. When there is intra-abdominal inflammation or disease of the pancreas or other structures, movement of the iliopsoas causes pain.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 36-4

Question 21

Type: MCSA

The nurse assesses for a positive Murphys sign in a patient suspected of having which disorder?

1. Urinary retention

2. Diverticulitis

3. Cholecystitis

4. Renal calculi

Correct Answer: 3

Rationale 1: A positive Murphys sign is not associated with urinary retention.

Rationale 2: A positive Murphys sign is not associated with diverticulitis.

Rationale 3: Murphys sign is positive when a person has inflammation of the gallbladder, as seen in cholecystitis.

Rationale 4: A positive Murphys sign is not associated with renal calculi.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-4

Question 22

Type: MCMA

Which data would the nurse document regarding a patients complaint of abdominal pain?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient fears losing her job if pain causes another absence.

2. The patient describes the pain as sharp and stabbing.

3. Walking exacerbates the pain.

4. Belching has lessened the pain.

5. The pain began 24 hours ago.

Correct Answer: 2,3,4,5

Rationale 1: While the patient is expressing a fear, it does not relate to the cause of the pain itself but rather a possible outcome of the pain.

Rationale 2: A description of the problem (what is wrong) helps define the chief complaint.

Rationale 3: The exacerbation of symptoms helps define the chief complaint.

Rationale 4: The diminishment of symptoms helps define the chief complaint.

Rationale 5: The duration of the problem helps define the chief complaint.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 36-4

Question 23

Type: MCSA

The nurse recognizes that a patient diagnosed with poorly controlled type 2 diabetes is at risk for developing which gastrointestinal complication?

1. Paralytic ileus

2. Peptic ulcer

3. Gastroparesis

4. Gastric reflux disease

Correct Answer: 3

Rationale 1: Paralytic ileus does not appear to have a direct connection to diabetes.

Rationale 2: Peptic ulcer does not appear to have a direct connection to diabetes.

Rationale 3: A person whose diabetes is poorly controlled may develop gastroparesis, a slowing in the emptying of the stomach due to the diabetes.

Rationale 4: Gastric reflux disease does not appear to have a direct connection to diabetes.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-4

Question 24

Type: MCMA

The nurse includes which data when documenting a patients biographic and demographic information?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient has a high school diploma.

2. The patient drinks two to three beers per day.

3. The patient is male.

4. The patient lives on a farm in a rural area.

5. The patient is 24 years old.

Correct Answer: 1,3,4,5

Rationale 1: Biographical data should include educational background.

Rationale 2: Alcohol consumption would be a part of the medical history.

Rationale 3: Biographical data should include gender.

Rationale 4: Demographic data such as whether the patient lives in an urban, rural, or suburban setting is appropriate.

Rationale 5: Biographical data should include age.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-2

Question 25

Type: MCMA

A patient is hospitalized with possible pancreatitis. The nurse would evaluate which laboratory test results as supporting that diagnosis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Increased serum amylase

2. Increased serum lipase

3. Decreased serum indirect bilirubin

4. Increased blood urea nitrogen

5. Increased partial thromboplastin time (PTT)

Correct Answer: 1,2

Rationale 1: Serum amylase increases may indicate pancreatitis.

Rationale 2: An increase in serum lipase is characteristic of pancreatitis.

Rationale 3: Indirect bilirubin increases with liver injury.

Rationale 4: BUN increases with renal disorders or dehydration.

Rationale 5: PTT increases with severe liver dysfunction or heparin therapy.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 36-5

Question 26

Type: MCMA

The nurse would recommend avoiding ginger as complimentary therapy for gastrointestinal distress in which individuals?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. A patient with peptic ulcer disease

2. Persons younger than 30 years of age

3. Persons taking anticoagulants for atrial fibrillation

4. Women

5. Patients with documented sun sensitivity

Correct Answer: 1,3

Rationale 1: Ginger can cause increased bleeding, which should be avoided in those with peptic ulcer disease.

Rationale 2: There is no age-related contraindication for ginger.

Rationale 3: Ginger can increase bleeding tendencies and should not be added to the regimen of a patient already taking anticoagulants.

Rationale 4: There is no gender-related contraindication for use of ginger.

Rationale 5: There is no relationship between ginger and sun sensitivity.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 36-2

Question 27

Type: MCSA

A patient reports epigastric pain that occurs after meals and often awakens the patient at night. The nurse would ask additional assessment questions about which disorder?

1. Urinary tract infection

2. Duodenal ulcer

3. Gastric ulcer

4. Intussusception

Correct Answer: 2

Rationale 1: Epigastric pain would not be a common assessment finding in urinary tract infection.

Rationale 2: Pain from a duodenal ulcer often is postprandial and awakens the patient at night.

Rationale 3: Pain from a gastric ulcer is often precipitated by food.

Rationale 4: Intussusception is a disorder of infants and is not seen in adults.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-4

Question 28

Type: MCMA

The preceptor would intervene if the newly licensed nurse planned to test for the iliopsoas sign in which patients?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. A patient immobilized after sustaining a neck injury

2. A 70-year-old patient hospitalized with abdominal pain

3. A patient who had hip-replacement surgery 6 years ago

4. A patient with suspected inflammation of the cecum

5. A patient who may have appendicitis

Correct Answer: 1,2,3

Rationale 1: The iliopsoas sign test should not be performed on an immobilized patient.

Rationale 2: The iliopsoas sign test should be performed only with great caution in older adults.

Rationale 3: Patients with hip replacements should not have the iliopsoas sign test.

Rationale 4: The iliopsoas sign test is useful in the assessment of a patient with suspected inflammation of the cecum.

Rationale 5: The iliopsoas sign test is useful in the assessment of a patient with suspected appendicitis.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 36-2

Question 29

Type: MCMA

Which techniques would the nurse use to elicit rebound tenderness in a patients abdomen?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Start in an area away from the painful area.

2. Start with deep palpation.

3. Release pressure on the abdomen quickly.

4. Stop the assessment as soon as rebound tenderness is elicited.

5. Start the assessment by gently stroking the painful area of the abdomen.

Correct Answer: 1,3,4

Rationale 1: The nurse should begin this testing in an area distant from the area reported to be painful.

Rationale 2: The nurse should start with light palpation.

Rationale 3: The nurse should release pressure quickly enough so that the underlying tissue rebounds against the abdominal wall, causing pain.

Rationale 4: Once the tenderness is noted, there is no reason to keep making the patient uncomfortable.

Rationale 5: The nurse should avoid touching the painful area until the test is in progress.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-2

Question 30

Type: MCSA

A patient is having diagnostic testing done after experiencing new-onset abdominal pain. Laboratory results reveal that the serum creatinine is elevated. The nurse would look for additional assessment findings of which disorder?

1. Appendicitis

2. Renal failure

3. GERD

4. Constipation

Correct Answer: 2

Rationale 1: Increased creatinine is not associated with appendicitis.

Rationale 2: Increased serum creatinine indicates renal failure.

Rationale 3: Increased creatinine is not associated with GERD.

Rationale 4: Increased creatinine is not associated with constipation.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-5

 

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