Chapter 37 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 37

Question 1

Type: MCSA

A patient has been diagnosed with type 1 herpes simplex lesions on the mouth and face. Which statement indicates that the patient understands the information provided by the nurse?

1. I will have this condition for life.

2. This was caused by a bacterial infection.

3. I have come into contact with some type of fungal infection.

4. An antibiotic will help heal these sores in about 3 days.

Correct Answer: 1

Rationale 1: Herpes simplex is a viral infection. There is no cure for the condition. When the sores heal, the virus lies dormant in the body.

Rationale 2: The condition is not caused by a bacterial infection.

Rationale 3: The condition is not caused by a fungus.

Rationale 4: The condition is not managed with antibiotic therapy.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 37-1

Question 2

Type: MCMA

Acyclovir (Zovirax) ointment has been prescribed for a patient with oral herpes lesions. What should the nurse include when instructing the patient regarding this medication?

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

Standard Text: Select all that apply.

1. Adverse effects include vomiting and diarrhea.

2. It can reduce the length of the herpes outbreak.

3. It is an antibiotic medication.

4. Repeated usage of the drug will lead to a permanent state of remission.

5. It is most effective when administered intravenously.

Correct Answer: 1,2

Rationale 1: Adverse effects include headache, nausea, vomiting, and diarrhea.

Rationale 2: Acyclovir is used to reduce the severity and length of an outbreak of herpes simplex.

Rationale 3: Acyclovir is an antiviral agent.

Rationale 4: Herpes simplex is a viral condition that is not curable, and outbreaks are likely to occur when the patient is physically and/or emotionally stressed.

Rationale 5: For patients with intact immune systems, oral acyclovir (Zovirax) is generally used.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 37-1

Question 3

Type: MCSA

A patient is experiencing manifestations consistent with an oral fungal infection. The patients health history is unremarkable. Which medication does the nurse anticipate being ordered to manage this condition initially?

1. Nystatin

2. Ciprofloxacin

3. Ampicillin

4. Viscous lidocaine

Correct Answer: 1

Rationale 1: Initial management of an oral fungal infection typically includes nystatin. The medication is administered as a swish and swallow.

Rationale 2: Ciprofloxacin in an antibiotic and would not be used for the initial management of a fungal infection.

Rationale 3: Ampicillin is an antibiotic and is used to manage bacterial infections.

Rationale 4: Viscous lidocaine is used to manage oral discomfort, but it is not first-line therapy for fungal infections.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 37-1

Question 4

Type: MCSA

The nurse is developing the postoperative plan of care for a patient recovering from surgery for oral cancer. Which nursing diagnosis has the highest priority?

1. Ineffective Airway Clearance

2. Impaired Verbal Communication

3. Body Image Disturbance

4. Risk for Imbalanced Nutrition: More than Body Requirements

Correct Answer: 1

Rationale 1: Ineffective Airway Clearance is appropriate for this patient and has the highest priority.

Rationale 2: Impaired Verbal Communication is an appropriate nursing diagnosis for this patient, but it is not of the highest priority.

Rationale 3: Depending on the extent of the resection, Body Image Disturbance may be an appropriate nursing diagnosis, but it does not hold the highest priority.

Rationale 4: The nutrition nursing diagnosis is more likely to be Risk for Imbalanced Nutrition: Less than Body Requirements.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 37-1

Question 5

Type: MCMA

Which instructions should the nurse provide for a patient diagnosed with gastroesophageal reflux disease (GERD)?

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

Standard Text: Select all that apply.

1. Limit last food intake to 4 hours before bedtime.

2. Eat the largest meal of the day at midday.

3. Sleep in a bed with the head elevated 6 to 8 inches.

4. Follow a daily exercise routine.

5. Include a caffeinated beverage with meals.

Correct Answer: 1,2,3,4

Rationale 1: The patient should avoid eating anything within 4 hours of bedtime.

Rationale 2: It is often helpful to eat small, frequent meals, with the largest meal at midday.

Rationale 3: The head of the bed should be elevated.

Rationale 4: A regular exercise program such as daily walking can promote digestion.

Rationale 5: Caffeine has been shown to lower LES pressure and so should be avoided.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 37-2

Question 6

Type: MCSA

A patient prescribed an antacid is experiencing muscle cramps. What should the nurse do to assist this patient?

1. Notify the health care provider.

2. Review the patients diet history.

3. Review the patients elimination patterns.

4. Provide reassurance to the patient.

Correct Answer: 1

Rationale 1: Antacids may cause imbalances of electrolytes including sodium, calcium, and magnesium. The nurse should notify the health care provider so serum electrolytes can be drawn and reviewed.

Rationale 2: There is no indication that the patients dietary history is an issue.

Rationale 3: There is no indication that the patients elimination patterns are an issue.

Rationale 4: Providing reassurance to the patient at this time would be premature, as the complaints are being reported but not yet adequately reviewed.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 37-2

Question 7

Type: MCMA

A patient, 4 weeks post gastric resection surgery, is experiencing cramping, nausea, and diarrhea within 10 minutes after eating. The nurse suspects that the patent is experiencing dumping syndrome and suggests which intervention?

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

Standard Text: Select all that apply.

1. Increase protein in the diet.

2. Lie down for 30 minutes immediately after eating.

3. Eat frequent, small meals.

4. Reduce the amount of carbohydrates eaten daily.

5. Drink a glass of water prior to each meal.

Correct Answer: 1,2,3,4

Rationale 1: Increasing the amount of protein and fat in the diet will help slow the transit time through the stomach.

Rationale 2: The patient should be instructed to lie down for 30 to 60 minutes after eating to slow the transit time.

Rationale 3: The symptoms can be managed by eating small, more frequent meals.

Rationale 4: Carbohydrates should be reduced to help slow the transit time.

Rationale 5: Drinking before eating might intensify the problem.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 37-2

Question 8

Type: MCSA

A patient diagnosed with peptic ulcer disease (PUD) asks if surgery will be necessary. How should the nurse respond?

1. The administration of the appropriate medications makes surgery rarely necessary.

2. Surgery is required in about 50% of cases.

3. Surgery has a higher success rate than medication therapy alone.

4. If you take your medications and follow the prescribed diet, surgery isnt usually needed.

Correct Answer: 1

Rationale 1: With the discovery of H. pylori infection as the major cause of peptic ulcers and the development of medications to eradicate this organism, surgery is rarely necessary.

Rationale 2: Surgery is required in fewer than half of cases.

Rationale 3: The success rate of pharmacologic intervention to eradicate H. pylori is 85% to 90%.

Rationale 4: There are no specific dietary modifications for PUD.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 37-2

Question 9

Type: MCSA

The nurse is providing emotional support to the spouse of a patient recently diagnosed with terminal esophageal cancer. The spouse expresses anger and confusion and questions why the patient did not seek help sooner. Which response by the nurse would be the most appropriate at this time?

1. Unfortunately, the early symptoms are often vague and not recognized as something serious.

2. Your spouse was probably afraid of getting bad news.

3. You will never know.

4. It is not important to know that right now.

Correct Answer: 1

Rationale 1: The manifestations of esophageal cancer are often vague.

Rationale 2: It is inappropriate for the nurse to make assumptions about the motivations and feelings of the individual with cancer.

Rationale 3: This response is inappropriate and does not offer any information to the spouse.

Rationale 4: It is inappropriate for the nurse to decide what is important for the patients spouse to know at this time.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 37-2

Question 10

Type: MCMA

The nurse has identified the goals of intact skin integrity and intact stoma integrity for a patient with a colostomy. Which evaluation parameters are best suited for these goals?

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

Standard Text: Select all that apply.

1. The stoma is pink and moist.

2. No excoriation is noted on skin surrounding the stoma.

3. The patient shows understanding of importance of preventing fecal leakage.

4. The patient demonstrates ability to apply the collecting appliance properly.

5. The stomal area is free of pain.

Correct Answer: 1,2

Rationale 1: The stoma should be pink and moist.

Rationale 2: The skin surrounding the stoma should be intact, with no excoriation.

Rationale 3: Teaching about the prevention of fecal leakage is an important part of the care of this patient but does not address the goals provided.

Rationale 4: The patient must know how to apply collection appliances, but this does not address the stated goals.

Rationale 5: The stomal area should not be painful, but this statement does not address the stated goals.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 37-6

Question 11

Type: MCMA

Which acid base and electrolyte complications are commonly associated with prolonged vomiting?

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

Standard Text: Select all that apply.

1. Hypokalemia

2. Metabolic alkalosis

3. Metabolic acidosis

4. Hypocalemia

5. Hyponatremia

Correct Answer: 1,2

Rationale 1: Decreased potassium occurs as a result of loss of hydrochloric acid from the stomach during vomiting. If not treated appropriately, patients can experience imbalances and cardiac arrhythmias.

Rationale 2: Metabolic alkalosis occurs as a result of loss of hydrochloric acid from the stomach during vomiting. If not treated appropriately, patients can experience imbalances and cardiac arrhythmias.

Rationale 3: Acidosis can occur when there is too much hydrochloric acid.

Rationale 4: While decreased calcium can be problematic, it is not associated with vomiting.

Rationale 5: While decreased sodium can be problematic, it is not associated with vomiting.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 37-4

Question 12

Type: MCMA

When teaching a patient with fungal stomatitis about performing oral care, the nurse would include which instructions?

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

Standard Text: Select all that apply.

1. Avoid tobacco and alcohol.

2. Use saline or sodium bicarbonate rinse after every meal.

3. Drink at least 8 ounces of orange juice daily.

4. Avoid cold beverages.

5. Oral care should be performed with a soft toothbrush.

Correct Answer: 1,2,5

Rationale 1: The patient with fungal stomatitis should avoid tobacco and alcohol as they damage the oral mucosa and increase the risk for oral mucositis.

Rationale 2: Saline or sodium bicarbonate rinses are buffering agents that are gentler on the mucosa than drying alcohol-based preparations or lemon glycerin swabs.

Rationale 3: Orange juice may be irritating to the damaged oral mucosa and should be avoided.

Rationale 4: Cold drinks generally are more soothing than hot drinks, which should be avoided.

Rationale 5: A soft toothbrush should be used to clean the teeth at least twice daily.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 37-1

Question 13

Type: MCMA

The nurse is teaching a patient about the major risk factors for peptic ulcer disease (PUD). Which risk factors should the nurse discuss?

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

Standard Text: Select all that apply.

1. Chronic H. pylori infection

2. Use of aspirin and NSAIDs

3. Cigarette smoking

4. Dietary intake of dairy products

5. Stress

Correct Answer: 1,2,3

Rationale 1: Chronic H. pylori infection is one of the major risk factors for PUD.

Rationale 2: The use of aspirin and NSAIDs is one of the major risk factors for PUD.

Rationale 3: Cigarette smoking stimulates acid production, contributing to duodenal ulcer formation and PUD.

Rationale 4: Dietary intake does not seem to cause PUD.

Rationale 5: The role of stress is uncertain in PUD.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 37-2

Question 14

Type: FIB

The physician has ordered metoclopramide (Reglan) 2 mg/kg IVP to be given 30 minutes before the start of chemotherapy. The patient weighs 54 kg. The metoclopramide (Reglan) is dispensed in a 10 mg/10 mL vial. The nurse will administer ________ mL of metoclopramide.

Standard Text:

Correct Answer: 10.8

Rationale : 54 2 divided by 10 mg/10 mL = 10.8 mL

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 37-5

Question 15

Type: MCSA

The nurse learns that an elderly patient with ill-fitting dentures has been using an over-the-counter preparation for a gum sore over the last month. What instruction should the nurse give this patient?

1. Make an appointment to see the physician.

2. Continue to use the preparation.

3. Change the preparation.

4. Stop wearing the dentures.

Correct Answer: 1

Rationale 1: The nurse should instruct the patient to seek medical attention for any oral lesion that does not heal within 1 week.

Rationale 2: Because the current over-the-counter (OTC) remedy is not effective, the patient should stop using it and see the physician before using a different OTC preparation.

Rationale 3: The patient should see the physician before using a different OTC preparation.

Rationale 4: Not wearing the dentures can lead to nutritional problems and social isolation.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 37-1

Question 16

Type: MCMA

The nurse is preparing to instruct a patient who is newly diagnosed with gastroesophageal reflux disease (GERD) about dietary considerations. What should the nurse include in these instructions?

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

Standard Text: Select all that apply.

1. Avoid peppermint.

2. Meals should be small and more frequent.

3. Avoid eating within 4 hours of bedtime.

4. Be sure to eat at least one citrus fruit per day.

5. Alcohol should be limited to two drinks per day.

Correct Answer: 1,2,3

Rationale 1: Peppermint relaxes the lower esophageal sphincter or delays gastric emptying, so it should be avoided.

Rationale 2: The patient should be advised to eat smaller meals, stay upright for 2 hours after meals, and maintain ideal body weight.

Rationale 3: The patient should be advised to refrain from eating for 3 hours before bedtime, stay upright for 2 hours after meals, and maintain an ideal body weight.

Rationale 4: Acidic foods such as tomato products, citrus fruits, spicy foods, and coffee should be eliminated from the diet.

Rationale 5: Alcohol relaxes the lower esophageal sphincter or delays gastric emptying, so it should be avoided.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 37-2

Question 17

Type: MCSA

The nurse is preparing the morning medications for a patient with gastroesophageal reflux disease (GERD). Which nursing intervention would be appropriate regarding this patients medications?

1. Hold the antacids for at least 2 hours after oral medications are taken.

2. Provide all prescribed medications at 1,000.

3. Provide the antacids first, and then follow with the oral medications.

4. Provide the antacids only at the hour of sleep.

Correct Answer: 1

Rationale 1: Antacids interfere with the absorption of many drugs given orally, and their administration should be separated by at least 2 hours.

Rationale 2: Antacids should not be given with other oral medications.

Rationale 3: Medication administration is not delayed; the timing of the antacid should be adjusted and maintained on a schedule so as not to interfere with other drugs being administered.

Rationale 4: Antacid administration should be arranged according to the schedule for other medications.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 37-2

Question 18

Type: MCSA

A patient is suspected of having sprue. Which instruction should the nurse provide this patient about diet?

1. Avoid all milk products.

2. A vegetarian diet is the best treatment for this condition.

3. Gluten products must be eliminated from the diet.

4. All whey products must be eliminated from the diet.

Correct Answer: 3

Rationale 1: Avoiding milk products is not relevant for the patient with sprue.

Rationale 2: A vegetarian diet is not relevant for the patient with sprue.

Rationale 3: The patient with celiac sprue is placed on a gluten-free diet. This treatment is generally successful as long as the patient entirely avoids gluten.

Rationale 4: The elimination of whey is not relevant for the patient with sprue.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 37-3

Question 19

Type: MCSA

A patient with cancer of the rectum is scheduled for surgery and the placement of a permanent ostomy. Which type of ostomy is most likely to be performed on this patient?

1. Ileostomy

2. Double-barrel colostomy

3. Sigmoid colostomy

4. Transverse loop colostomy

Correct Answer: 3

Rationale 1: An ileostomy is performed when the patient has a disorder in the area of the ileum.

Rationale 2: Double-barrel colostomies are performed in the transverse colon.

Rationale 3: A sigmoid colostomy is the most common permanent colostomy performed, particularly for cancer of the rectum. It is usually created during an abdominoperineal resection.

Rationale 4: A transverse loop colostomy is performed in the transverse colon.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 37-6

Question 20

Type: MCMA

A 24-year-old patient is admitted for treatment of celiac disease. The nurse would anticipate managing which symptoms?

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

Standard Text: Select all that apply.

1. Chronic constipation

2. Flatulence

3. Osteoporosis

4. Peptic ulcer disease (PUD)

5. Chronic hepatitis

Correct Answer: 2,3,5

Rationale 1: Diarrhea is the most common symptom of celiac disease.

Rationale 2: Flatulence is a common symptom of celiac disease.

Rationale 3: Most adults with celiac disease have signs and symptoms that are unrelated to the GI tract, such as symptoms of osteoporosis.

Rationale 4: PUD is not typically associated with celiac disease.

Rationale 5: Most adults with celiac disease have signs and symptoms that are unrelated to the GI tract, such as symptoms of chronic hepatitis.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 37-3

Question 21

Type: MCSA

The nurse recognizes that a patient diagnosed with celiac disease needs further education regarding the disease process when the patient makes which statement?

1. Its really difficult to maintain my gluten-free lifestyle.

2. The only way to truly diagnose this disease is through a biopsy of my small intestine.

3. The trouble Im having with the enamel on my teeth is a result of this disease.

4. I treat myself to a ham and cheese on rye with a light beer once a week.

Correct Answer: 4

Rationale 1: The patient with celiac disease is incapable of appropriately reacting to ingested gluten and so is placed on a gluten-free diet.

Rationale 2: A biopsy of the small intestine is the gold standard for diagnosing celiac disease.

Rationale 3: Dental enamel hypoplasia is a sign often seen in patients with celiac disease.

Rationale 4: Gluten is found in wheat, barley, and rye. The patient with celiac disease is placed on a gluten-free diet.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 37-3

Question 22

Type: MCSA

A patient is hospitalized during an acute exacerbation of symptoms related to Crohns disease. The nurse shows an understanding of the need for bowel rest by providing which instruction?

1. Select foods that are high in potassium.

2. You should eat a soft diet until the diarrhea subsides.

3. You may find a high-calorie, low-fat, high-fiber diet helpful.

4. Expect to be started on total parenteral nutrition (TPN).

Correct Answer: 4

Rationale 1: High-potassium foods are not part of a bowel rest regimen.

Rationale 2: The patient on bowel rest is not given soft foods.

Rationale 3: This diet would not provide bowel rest.

Rationale 4: During an acute exacerbation of IBD, particularly Crohns disease, the patient is allowed no food taken orally. During this period of bowel rest, total parenteral nutrition (TPN) is usually prescribed.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 37-4

Question 23

Type: MCMA

The nurse is reviewing dietary recommendations with a patient recovering from an acute episode of diverticular disease. The nurse identifies which topics for inclusion in the discussion?

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

Standard Text: Select all that apply.

1. Incorporating both soluble and insoluble fiber into the daily diet

2. Including raisins in the diet as a good source of iron to offset poor iron absorption

3. Ingesting at least 25 to 30 grams of fiber daily, as recommended for adults

4. Eating oatmeal-based cereals as breakfast and snack foods

5. Avoiding foods such as nuts or strawberries

Correct Answer: 1,3,4,5

Rationale 1: Once the acute phase has passed, dietary recommendations include eating a diet high in both soluble and insoluble fiber.

Rationale 2: For patients recovering from acute diverticular disease, foods containing small seeds, nuts, and foods with skins such as raisins are restricted because they may become lodged in a diverticulum and cause inflammation and an exacerbation of diverticulitis.

Rationale 3: The recommended fiber consumption for the general public of the United States is 25 to 30 grams and should be stressed for the person with diverticular disease.

Rationale 4: Oatmeal is a high-fiber food recommended for patients with diverticular disease.

Rationale 5: For patients recovering from acute diverticular disease, foods containing small seeds, nuts, and foods with skins such as grapes are restricted because they may become lodged in a diverticulum and cause inflammation and an exacerbation of diverticulitis.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 37-4

Question 24

Type: MCMA

The nurse is preparing information to be included in a community educational presentation regarding gastroesophageal reflux disease (GERD). Which information should be included?

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

Standard Text: Select all that apply.

1. A substantial number of people self-medicate with OTC medications.

2. GERD is more prevalent in adults over the age of 50.

3. Vomiting is a common sign of the disease.

4. A recurring sore throat may be a symptom of the disease.

5. Control of the symptoms is dependent on a change of diet.

Correct Answer: 1,2,4,5

Rationale 1: It is believed that the number of people experiencing reflux may actually be much higher than reported, but because many H2-receptor blockers are available without a prescription, a large number of cases go unreported.

Rationale 2: The incidence of GERD increases after age 50, but it can occur at any age, and the prevalence is equal across gender, ethnic, and cultural groups.

Rationale 3: Gastroesophageal reflux is the backward flow of stomach contents (chyme) into the esophagus without associated vomiting.

Rationale 4: Atypical symptoms of GERD include asthma or a sore throat.

Rationale 5: Lifestyle modifications including diet are key in the treatment of GERD. Many patients may have total symptom relief through these efforts alone.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 37-2

Question 25

Type: MCMA

A patient who has been diagnosed with a form of gastric carcinoma is concerned about the prospects of her adult children having the disease. Which questions by the nurse shows an understanding of the disease?

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

Standard Text: Select all that apply.

1. Do any of your children smoke either cigarettes or cigars?

2. Have any of your children ever been treated for a stomach ulcer?

3. Have your children ever been tested for asthma?

4. Are any of your children particularly fond of eating bacon, hot dogs, or luncheon meats?

5. Are any of your children exhibiting signs of depression or obsessive compulsive disorder?

Correct Answer: 1,2,4

Rationale 1: Smoking is a risk factor for the development of gastric cancer.

Rationale 2: Helicobacter pylori (H. pylori), a bacterium causing gastritis, is thought to be related to the development of gastric cancer.

Rationale 3: Asthma is not associated with the development of gastric cancer.

Rationale 4: Nitrates found in smoked meats, bacon, lunch meats, and hot dogs have been linked to the development of gastric cancer.

Rationale 5: Research has not shown any definitive links between depression or OCD and the development of gastric cancer.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 37-2

Question 26

Type: MCSA

Which nursing action is essential to reduce the patients risk of developing a postsurgical infection at the site of a permanent colostomy?

1. Change the dressing as ordered by the surgeon.

2. Administer intravenous antibiotics as prescribed.

3. Assesse the patients understanding of the importance of infection control measures.

4. Instruct the patient in the proper technique for handling hygiene of the colostomy site.

Correct Answer: 1

Rationale 1: Changing the dressing as ordered by the surgeon will have the greatest impact on keeping the incision clean and dry and helps prevent an infection at the site.

Rationale 2: IV antibiotics, while appropriate, do not have the same degree of impact as does good wound care.

Rationale 3: The patients understanding of the importance of infection control is more relevant to the long-term prevention of infection.

Rationale 4: Instructing the patient regarding proper hygiene techniques is more relevant to the long-term prevention of infections.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 37-6

Question 27

Type: MCSA

The nurse would assess for which risk factor in a patient hospitalized for a strangulated intestinal hernia?

1. Abdominal surgery

2. Hyperlipidemia

3. Intestinal infarctions

4. Family history

Correct Answer: 1

Rationale 1: Surgical adhesions are a common etiology of strangulated hernias.

Rationale 2: There is no research to support an increased risk related to high blood cholesterol levels.

Rationale 3: Impairment of arterial blood flow resulting from the strangulation leads to ischemic infarctions.

Rationale 4: There is no research to support a genetic link for strangulated hernias.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 37-5

Question 28

Type: MCMA

A patient is being assessed for a possible bowel obstruction. The nurse provides information regarding which diagnostic tests to confirm the presence of an obstruction?

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

Standard Text: Select all that apply.

1. Barium swallow

2. A CT scan of the abdomen

3. An abdominal X-ray series

4. Serum osmolality

5. CBC with differential

Correct Answer: 2,3

Rationale 1: A barium swallow is contraindicated because of the possibility of intestinal perforation or a worsening of the obstruction.

Rationale 2: The diagnosis can be confirmed with a CT scan.

Rationale 3: The diagnosis can be confirmed with X-rays.

Rationale 4: Serum osmolality is not diagnostic of bowel obstruction.

Rationale 5: A CBC with differential would be performed to determine the risk of infection but is not diagnostic of bowel obstruction.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 37-5

Question 29

Type: MCSA

The nurse is caring for a patient with a jejunostomy tube. Which statement by the nurse indicates the need for additional information to safely manage the medical intervention?

1. I will keep the patient on bed rest until the tube can be removed.

2. Its my habit to irrigate the jejunostomy tube just prior to administering the patients sleeping medication.

3. A pH of 5 or less indicates the tube is in the stomach, not the intestine.

4. I plan to assess the patients abdomen for distention at regular intervals.

Correct Answer: 1

Rationale 1: There is no indication that the patient should remain on bed rest.

Rationale 2: The tube should be irrigated prior to each medication administration and as ordered.

Rationale 3: A pH of 5 or less indicates gastric placement, while a pH or 7 or more indicates intestinal placement.

Rationale 4: If the patient is not tolerating feedings, abdominal distention may occur.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 37-5

Question 30

Type: MCSA

A patient who has had gastric surgery that affected the effectiveness of the alimentary system will be fed via a gastrostomy tube upon discharge to home. How would the nurse explain the rationale for this intervention?

1. A gastrostomy tube is less invasive than a jejunostomy tube.

2. Gastrostomy tubes are more cost effective than nasogastric feeding.

3. Gastrostomy feeding is less likely to produce side effects than parenteral nutrition.

4. Gastrostomy feeding is more supportive of the specialized diet the patient will require.

Correct Answer: 3

Rationale 1: The gastrostomy tube is as invasive as the jejunostomy tube.

Rationale 2: Gastrostomy tubes are not necessarily more cost effective than nasogastric feeding tubes.

Rationale 3: The purpose of a gastrostomy tube is to provide complete nutrition through the alimentary system. It is safer and has fewer side effects than total parenteral nutrition (TPN), particularly when the patient is to have feedings at home.

Rationale 4: Gastrostomy feeding is not necessarily more appropriate for specialized feeding needs.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 37-5

Question 31

Type: MCSA

What information should the nurse provide a patient regarding the patients newly created permanent ileostomy?

1. An additional surgery will be required in 2 to 3 months.

2. The stoma will initially produce dark green fecal matter.

3. The stoma should not produce any bloody discharge.

4. Because the condition required a gastroduodenostomy (Billroth I), an ileostomy was also necessary.

Correct Answer: 2

Rationale 1: A permanent ileostomy does not generally require follow-up surgery.

Rationale 2: Initially, the ileostomy will produce effluent that is dark green and viscous, gradually turning yellow-brown.

Rationale 3: Immediately postoperatively, the stoma may drain small amounts of blood.

Rationale 4: An ileostomy is not required as part of a gastroduodenostomy (Billroth I).

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 37-6

Question 32

Type: MCMA

What information should the nurse provide for the patient with a newly created Kock ileostomy (continent ileostomy)?

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

Standard Text: Select all that apply.

1. The stoma will be reversed when the bowels have had the time to heal.

2. Fecal matter will be removed by a catheter inserted through the stoma.

3. A nipple valve was created to control the flow of fecal matter.

4. The stoma should appear pink and moist.

5. The surgery involved manipulating a portion of the terminal ileum.

Correct Answer: 2,3,4,5

Rationale 1: This is not generally a reversible, temporary procedure.

Rationale 2: The reservoir is emptied by a catheter inserted through the stoma.

Rationale 3: The nipple valve prevents leaking of fecal contents through the stoma.

Rationale 4: As in any ostomy procedure, the stoma should appear pink and moist.

Rationale 5: A continent ileostomy, also known as Kock ileostomy or Kock pouch, involves folding the terminal ileum back on itself and removing the inner wall, thereby forming a reservoir and a nipple valve. The end is then brought through the abdominal wall to form a stoma.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 37-6

Question 33

Type: MCSA

A patient with Crohns disease is demonstrating the nursing diagnosis Imbalanced Nutrition: Less than Body Requirements. What intervention should the nurse include in this patients plan of care?

1. A low-calorie, high-milk diet

2. A low-calorie, low-residue diet

3. The DASH diet

4. A normal, well-balanced diet

Correct Answer: 4

Rationale 1: The diet should provide sufficient calories and nutrients to support healing and maintenance of a healthy weight. Milk may or may not be restricted, depending on patient tolerance.

Rationale 2: The Crohns patient needs an elevation in calories related to the nutrients lost as a result of diarrhea.

Rationale 3: The DASH diet is appropriate for the patient wanting to lower elevated blood pressure. It is a balanced diet but may have some restrictions not necessary for the patient with Crohns disease.

Rationale 4: The patient with Crohns needs sufficient calories and nutrients to retain a healthy weight. If a food is not tolerated, the patient is encouraged to eliminate it from the diet. As an example, some patients with Crohns disease do not tolerate dairy products.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 37-4

Question 34

Type: MCSA

A patient with Crohns disease is recovering from a bowel resection. What information should the nurse provide?

1. Surgery has ensured that you will never have another recurrence of the disease.

2. You need close follow-up because there is a possibility of recurrence in another portion of the bowel.

3. You may develop ulcerative colitis now that your Crohns is cured.

4. The surgery increases your risk of developing an intestinal stricture.

Correct Answer: 2

Rationale 1: The disease process tends to recur in other areas following the removal of affected bowel segments.

Rationale 2: The disease process tends to recur in other areas following the removal of affected bowel segments.

Rationale 3: The processes involving Crohns disease and ulcerative colitis are different.

Rationale 4: The most diseased portion of the bowel has been resected, which decreases the risk of obstruction or fistula development.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 37-4

Question 35

Type: MCSA

A patient learns that a small bowel obstruction was caused by an appendectomy 5 years ago. How would the nurse explain this development to the patient?

1. The infection in your appendix should have been treated earlier.

2. Abdominal surgery sometimes results in adhesion or scarring of tissues that can result in bowel obstruction.

3. You must have had an undiagnosed femoral hernia at the time of your appendectomy.

4. The surgeon did not irrigate your abdomen adequately when you had your appendectomy.

Correct Answer: 2

Rationale 1: An untreated infection would have resulted in peritonitis.

Rationale 2: In adults, adhesions develop following abdominal surgery or inflammatory processes. Adhesions usually produce a simple obstruction or single blockage in one portion of the intestine.

Rationale 3: There is inadequate information provided to support the possibility of femoral or umbilical hernia.

Rationale 4: There is no information to support this statement; it is also libelous.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 37-5

 

Leave a Reply