Chapter 52 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 52

Question 1

Type: MCSA

A patient is admitted with a large, inflamed leg wound. The nurse explains that the inflammatory response is initiated by chemicals released by which white blood cell type?

1. Monocytes

2. Eosinophils

3. Basophils

4. Neutrophils

Correct Answer: 3

Rationale 1: Monocytes arrive at the site of an injury hours or days after the neutrophils and continue to consume large amounts of cellular debris.

Rationale 2: The number of eosinophils increases in the presence of parasites and allergies. They enhance the inflammatory response rather than initiate it.

Rationale 3: Basophils migrate from the bloodstream into tissue and mature into mast cells. When a body cell is injured, mast cells in the immediate vicinity release large quantities of histamine, stimulating the inflammatory response.

Rationale 4: Neutrophils are phagocytic and consume cellular debris and bacterial and viral particles. They are the first group of WBCs to arrive at a site of injury or cell death in response to chemical signals.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 52-1

Question 2

Type: MCSA

A patient tells the nurse that she washes her hands many times throughout the day because she wants to kill all the germs before she provides care to her small children. What is the nurses best response to this patient?

1. Thats a good thing, because hand washing kills all bacteria.

2. Make sure you use an antibiotic ointment on areas of skin breakdown.

3. Bacteria are always present on the skin, and too much hand washing could lead to skin breakdown.

4. When you have young children, theres no such thing as washing your hands too much.

Correct Answer: 3

Rationale 1: Skin is capable of inhibiting bacterial growth; however, bacteria are always present on the skin surface in various quantities.

Rationale 2: This response does not directly address the patients continual hand washing.

Rationale 3: Hand washing may reduce the amount of bacteria on the skin, but the nurse should counsel the patient that too much hand washing can lead to skin breakdown.

Rationale 4: The intent of this message may be to encourage sufficient hand washing, but it could be interpreted as encouraging the patient to wash her hands even more frequently.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 52-1

Question 3

Type: MCSA

A patient says, There are so many kinds of bacteria. How does my body know which ones to kill and how to kill them? What would be the nurses most accurate response?

1. The alkaline environment in the stomach kills any bacteria you might swallow on food or in drinks.

2. Chemicals on the skin kill many of the bacteria from the environment.

3. Special white blood cells called toll cells help your body identify disease-causing bacteria.

4. Your mucous membranes help to filter out and kill bacteria.

Correct Answer: 4

Rationale 1: The ideal stomach pH is acidic, not alkaline.

Rationale 2: The major action of the skin is to act as a barrier to bacteria rather than to kill them.

Rationale 3: Toll receptors are proteins on the surface of many types of immune and tissue cells. They initiate immune responses.

Rationale 4: Mucous membranes remove dirt and debris from the body. Mucous membranes in the mouth secrete lysozymes and immunoglobulins that are mildly antibiotic.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 52-1

Question 4

Type: MCSA

A patient is admitted with an autoimmune disorder. The nurse plans care for this patient based on which characteristics of autoimmune disorders?

1. The patients body does not recognize non-self antigens.

2. The patients body does not recognize its own tissues.

3. The patients body does not have enough white blood cells to combat infections.

4. The patients body overproduces histamine.

Correct Answer: 2

Rationale 1: The normal body response is to recognize non-self antigens. An intact immune system acts to eliminate non-self proteins and antigens from the body.

Rationale 2: When the body does not recognize its own tissues and works to eliminate self proteins and antigens, an autoimmune disorder exists.

Rationale 3: The number of white blood cells is not a factor in the development of an autoimmune disorder.

Rationale 4: The amount of histamine produced is not pertinent to the development of an autoimmune disorder.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 52-2

Question 5

Type: MCSA

A patient tells the nurse that he is 65 years old and has not had a cold or any other type of infection for at least 30 years. Which assumption can the nurse make about this patients immune system?

1. The patients lymph nodes must be engorged with bacteria.

2. The patient must have intact and functioning MHC receptors.

3. The patient has rapidly proliferating white blood cells.

4. The patients spleen is probably enlarged.

Correct Answer: 2

Rationale 1: Lymph nodes would be engorged if an infection or inflammatory process were occurring somewhere in the body.

Rationale 2: Major histocompatiblity complex (MHC) receptors on cells are one type of marker used by the immune system to determine whether a cell belongs to the organism. Because the patient claims he has not had a cold or other inflammatory response for at least 30 years, the nurse can surmise that his MHC receptors are functioning well.

Rationale 3: Rapidly proliferating white blood cells would not necessarily provide increased immune protection. If WBCs are immature, they do not work effectively against pathogens.

Rationale 4: It would be more likely that an enlarged spleen would indicate infection or inflammation somewhere in the body.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 52-2

Question 6

Type: MCSA

The nurse is instructing a female patient who is 6 weeks pregnant. Which information should the nurse include to best ensure the development of an intact immune system in the baby?

1. Engage in light physical activity during the pregnancy.

2. Limit alcohol consumption to one drink per day.

3. Reduce smoking.

4. Eliminate exposure to known toxins.

Correct Answer: 4

Rationale 1: It is usually recommended that women remain physically active during pregnancy. However, this recommendation is not specific to immunity.

Rationale 2: Women who are pregnant should avoid all alcohol consumption. This recommendation is not specific to immunity.

Rationale 3: Women are advised to eliminate smoking during pregnancy for a variety of reasons. This recommendation is not specific to immunity.

Rationale 4: The babys immune system in the prenatal and neonatal stages is immature and susceptible to environmental and chemical toxins. A list of toxins would include but would not be limited to those in alcohol and tobacco smoke.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 52-1

Question 7

Type: MCSA

A patient tells the nurse that hes happy that his wife did not catch the same cold from which he has recently recovered. The nurse realizes that what most likely occurred in his wife?

1. Release of cytokines

2. Proliferation of CD 8 cells

3. T-helper 1 stimulation to kill unidentified cells

4. T-helper 2 memory of a previous exposure to the same virus that caused the patients illness

Correct Answer: 4

Rationale 1: Cytokines are chemical messages that are produced by cells and communicate with other cells in the body. Cytokine release would have occurred if the wife did catch the cold.

Rationale 2: CD 8 cells slow or stop the immune response.

Rationale 3: T-helper 1 cells help upregulate immune activity and produce chemicals to destroy mutant cells. This may have occurred, but this is not the most complete answer.

Rationale 4: T-helper 2 cells stimulate B cells to make antibodies to specific antigens. These cells then have a memory of exposure that will lead to a quick response if another exposure occurs. The wife must have had a previous exposure to the same virus that caused the patients cold, but because of the memory, the body immediately eliminated the cold virus.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 52-3

Question 8

Type: MCSA

The nurse is providing care for a patient who has a respiratory infection. Because the infection is in the lung, the nurse expects which immunoglobulin level to be most elevated?

1. Immunoglobulin D

2. Immunoglobulin E

3. Immunoglobulin A

4. Immunoglobulin M

Correct Answer: 3

Rationale 1: Immunoglobulins are produced in response to a primary or initial exposure to an antigen. Immunoglobulin D is present in small quantities in the blood.

Rationale 2: Immunoglobulins are produced in response to a primary or initial exposure to an antigen. Immunoglobulin E is the primary antibody in the allergic response.

Rationale 3: Immunoglobulin A is most commonly found in secretions; its major function is to protect the eyes, mouth, nose, gastrointestinal tract, and lungs from disease caused by viruses and bacteria. For the patient with a lung infection, this immunoglobulin level will most likely be the highest.

Rationale 4: Immunoglobulins are produced in response to a primary or initial exposure to an antigen. Immunoglobulin M is the first antibody produced in the primary immune response and is first produced during embryonic development. It may be elevated, but another immunoglobulin will be more elevated.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 52-5

Question 9

Type: MCSA

While studying the antibodyantigen response, the nurse understands that an antibody can bind to different types of antigens to protect the body from illness and disease. How would the nurse describe the bodys ability to conform to the different antigens?

1. Humoral immunity

2. Natural immunity

3. Cell-mediated immunity

4. Immune tolerance

Correct Answer: 1

Rationale 1: Humoral immunity is a mechanism in which antibodies bind to antigens to immobilize or destroy them.

Rationale 2: Natural immunity is the term used to describe the cells, organs, and secretions of the body that provide protection from foreign particles or other non-self invaders.

Rationale 3: T cells are the regulatory cells of the immune system whose function is to start and stop the immune process. The functions of the T cells are known as the cell-mediated immune response.

Rationale 4: Immune tolerance is the immune systems ability to tolerate self antigens while retaining the ability to respond to non-self antigens.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome:

Question 10

Type: MCSA

A patient is diagnosed with a viral infection. The nurse understands that which chemical will act to prevent the spread of the virus to other cells?

1. Interleukin

2. Tissue factor

3. Tumor necrosis factor

4. Interferon

Correct Answer: 4

Rationale 1: Interleukin enables the cells of the immune system to communicate and coordinate the immune response.

Rationale 2: Tissue factor stimulates platelets to begin clot formation and stop blood loss from injured blood vessels.

Rationale 3: Tumor necrosis factor is a small peptide that is instrumental in the initiation of the inflammatory response.

Rationale 4: Interferons are proteins made and released by T cells when the invading organism is a virus. Interferons protect other cells from viral attack, inhibit the production of the virus within infected cells, prevent the spread of the virus to other cells, and enhance the activity of macrophages to kill the virus.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 52-4

Question 11

Type: MCSA

A patient is admitted with liver cirrhosis. The nurse realizes that this patients immunity might be affected for which reason?

1. Interferon will not function in this patient.

2. White blood cells are stored in the liver.

3. Complement is made in the liver and has a role in inflammatory and immune responses.

4. Red blood cells are made in the liver.

Correct Answer: 3

Rationale 1: There is no evidence that interferon will not function in this patient.

Rationale 2: White blood cells are not stored in the liver.

Rationale 3: Complement is a group of small proteins made in the liver and present in the blood. It is important in the inflammatory and immune response.

Rationale 4: Red blood cells are not made in the liver.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 52-4

Question 12

Type: MCSA

While reviewing a patients laboratory values, the nurse notes that the complement 3b level is below normal limits. The nurse would interpret this finding as increasing the risk of which patient response?

1. The body will not be able to summon phagocytic cells to areas of infection.

2. The body will not be able to inhibit tumor development caused by chronic inflammation.

3. The body will not recognize all offending cells or antigens for elimination.

4. The body will not recognize the need for platelets to stop blood loss from vessel injury.

Correct Answer: 3

Rationale 1: Complements 3b and 5a are responsible for summoning phagocytic cells to areas of infection.

Rationale 2: Tumor necrosis factor is the chemical that inhibits tumor development caused by chronic inflammation.

Rationale 3: The function of complement 3b is to coat or attach to antigens or offending cells to make them attractive to phagocytes. Levels falling below normal means the body might not be able to recognize all offending cells or antigens for elimination.

Rationale 4: Tissue factor is the chemical that stimulates platelets to clot and stop the flow of blood from injured vessels.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 52-4

Question 13

Type: MCSA

The parent of a young patient asks the nurse why the child should receive the measles-mumps-rubella vaccination. What is the nurses best response?

1. Your child will develop immunity to these illnesses even without the vaccination, but at a slower rate.

2. The child can always receive the vaccination later.

3. Receiving the vaccination will cause your child to develop active acquired immunity, which will protect against the development of these illnesses.

4. I know the Centers for Disease Control expects everyone to have this vaccination, but you can always refuse.

Correct Answer: 3

Rationale 1: The child is unlikely to develop immunity to these illnesses unless vaccinated or unless the child experiences the diseases.

Rationale 2: The measles-mumps-rubella vaccination is often administered to school-age children; suggesting the child may receive the vaccination at a later time does not answer the parents question.

Rationale 3: Acquired immunity is that which occurs after birth, after either contracting the disease or through a vaccination. The vaccination will stimulate the development of active immunity and prevent the development of the illnesses.

Rationale 4: The Centers for Disease Control does support that every person receive this immunization. The nurse should not encourage the parent to refuse this vaccination for the child.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 52-3

Question 14

Type: MCSA

A patient is demonstrating signs of a delayed immunological response to a virus. Which component of the immune system is responsible for beginning this response?

1. Complement

2. Intact functioning T cells

3. Functioning human leukocyte antigens

4. Intact functioning B cells

Correct Answer: 2

Rationale 1: Complement is a protein made in the liver that coats an offending organism or cell to stimulate phagocytic cells to digest the cell or organism.

Rationale 2: T lymphocytes are the regulatory cells of the immune system whose function is to start and stop the immune process. When these cells are not functioning correctly, they will not chemically bind to an offending organism or cell and present it to the B cells.

Rationale 3: Human leukocyte antigens are protein markers on the cell wall of white blood cells that inform the immune system if a cell belongs to the system or should be removed.

Rationale 4: The B cells are responsible for making antibodies to attach to the antigen.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 52-4

Question 15

Type: MCSA

A unit secretary is the only staff member of the emergency department who does not contract a viral upper respiratory illness during a recent outbreak. How would the nurse explain this phenomenon?

1. The secretary had been exposed before and responded with secondary immunity.

2. The secretary has immune tolerance.

3. The secretarys immune system is unable to differentiate self from non-self.

4. The secretarys immune system overproduces plasma cells.

Correct Answer: 1

Rationale 1: B cells must be activated to make specific antibodies. If a B cell recognizes an antigen and immediately makes antibodies, this means the body has been exposed to the organism before and responds with secondary immunity.

Rationale 2: Immune tolerance is defined as the ability of the immune system to tolerate all self antigens while retaining the ability to mount an effective immune response to non-self antigens.

Rationale 3: The inability to differentiate self from non-self is considered a lack of immune tolerance.

Rationale 4: Plasma cells are B cells found in the plasma that make a group of antibodies called immunoglobulins. Overproducing B cells would not account for the secretarys immunity to the viral illness.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 52-5

Question 16

Type: MCSA

A patient tells the nurse that this illness is much less than the last one. What is one way for the nurse to interpret this statement?

1. The patient now has natural immunity.

2. The patient has experienced a primary immune response.

3. The patients immune system has mounted a secondary response to the pathogen.

4. The patient experienced an inflammatory response.

Correct Answer: 3

Rationale 1: Natural immunity is defined as the organs, cells, and secretions of the body that provide protection from foreign proteins, chemicals, and other non-self particles. The patient was born with natural immunity.

Rationale 2: A primary immune response is the bodys first exposure to an antigen. The patient is not referring to a first exposure.

Rationale 3: A secondary immune response is the bodys response to an antigen to which it has been exposed in the past. The response is stronger, can be instantaneous or occur within 1 to 3 days, and is consistent with the description of the illness as much less.

Rationale 4: An inflammatory response is the bodys response to an injury or offending organism that leads to a histamine release and local responses of redness, edema, pain, and heat.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 52-5

Question 17

Type: MCSA

A 68-year-old patient tells the nurse she does not understand why she has had more colds over the last several years. The nurse considers which component of normal aging before replying?

1. There is a decrease in the number and function of T cells.

2. The flu vaccine given to the elderly is not as potent as that given to younger adults.

3. There is a decrease in complement.

4. The B cells respond more rapidly.

Correct Answer: 1

Rationale 1: The decline in T cell number and function with aging results in greater susceptibility to infection.

Rationale 2: The same type and dose of influenza vaccine is given to all adults.

Rationale 3: There is no evidence to suggest a change in the amount or function of complement with aging.

Rationale 4: The B cells have a slower response as a person ages.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 52-6

Question 18

Type: MCSA

The mother of a premature newborn asks the nurse why she needs to wear a protective gown, gloves, and mask when holding her baby. What is the nurses best response?

1. The baby might not have enough immunity because she was born premature.

2. It is to protect you from exposure to some of the medications the baby is receiving.

3. You may have hospital germs on your clothing.

4. We have to protect the baby from the outside environment.

Correct Answer: 1

Rationale 1: The newborns major protection against antigens comes from the transfer of maternal immunoglobulin G antibodies across the placenta, especially during the last weeks of pregnancy. Infants born prematurely may be significantly immune deficient.

Rationale 2: The function of the protective clothing is not to protect the mother.

Rationale 3: This statement is technically correct, but it does not provide a rationale for protecting the baby from those germs. The nurse must also take care to avoid making the mother feel dirty.

Rationale 4: This statement is technically correct, but it does not include a rationale. The nurse must also take care to avoid making the mother feel dirty.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 52-5

Question 19

Type: MCSA

The nurse is assessing a patient who appears fatigued and pale and says that he has lost 15 pounds over the last month. It is most important for the nurse to conduct additional assessment for which condition?

1. Depression

2. Malignancy

3. Oral cavity infection

4. Respiratory infection resulting in sensory losses

Correct Answer: 2

Rationale 1: Depression could result in fatigue and weight loss, but losing 15 pounds in one month is extreme. Pallor is less likely to be associated with depression.

Rationale 2: Fatigue, pallor, and a 15-pound unintentional weight loss over the last month comprise serious information. The patient should be further assessed for the presence of a malignancy.

Rationale 3: A patient with an oral infection may not eat normally, but a 15-pound weight loss in one month is extreme. An oral infection would also not explain the patients pallor.

Rationale 4: Sensory losses might result in an impaired sense of taste, but that is unlikely to lead to a 15-pound weight loss in one month. Sensory losses would also not explain the patients pallor or fatigue.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 52-6

Question 20

Type: MCSA

The nurse is having difficulty palpating a patients inguinal lymph nodes. How does the nurse interpret this finding?

1. The patient has a systemic infection and needs further assessment.

2. The patient will develop lymph edema in the coming years.

3. The inguinal lymph nodes are not functioning properly.

4. Lymph is draining appropriately without evidence of infection or inflammation.

Correct Answer: 4

Rationale 1: There is no evidence to suggest the patient has a systemic infection or needs further assessment.

Rationale 2: There is no evidence to suggest the patient will develop lymph edema.

Rationale 3: Inability to palpate the nodes does not mean they are not functioning correctly.

Rationale 4: Normally, inguinal lymph nodes are small, mobile, and difficult to palpate.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 52-6

Question 21

Type: MCSA

While percussing a patients left lung, the nurse detects a dull percussion note. How would the nurse interpret this finding?

1. The patient has hepatomegaly.

2. The patient might have fluid in the lung, which could indicate an infection.

3. The patient has emphysema.

4. The patient has normal lungs.

Correct Answer: 2

Rationale 1: There is no information about the precise location of this dullness, so it is not possible to determine if the percussion tone might be over the liver border.

Rationale 2: Percussion over the lungs is done to determine if fluid is present, which would change the normal resonant sound of the lung tissue. A dull sound may indicate an infection.

Rationale 3: Emphysemic lungs are overfilled with air and would not produce a dull percussion note.

Rationale 4: The normal percussion note over lung tissue is resonant. A dull percussion sound may indicate an abnormal condition.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 52-6

Question 22

Type: MCSA

A patient is admitted for an infected leg wound. The nurse notes that the patients band count on the CBC and differential is elevated. How does the nurse interpret this information?

1. The leg wound was caused by a parasite.

2. The patient could be developing sepsis.

3. The patient is healing.

4. The patient has lymphoma in addition to a leg wound.

Correct Answer: 2

Rationale 1: If the wound were caused by a parasite, the eosinophils would be elevated.

Rationale 2: Bands are immature neutrophils that, when elevated, indicate a large bacterial infection or sepsis.

Rationale 3: Elevated bands do not indicate that the patient is healing.

Rationale 4: Lymphocytes are elevated in a patient diagnosed with lymphoma in addition to an infection.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 52-7

Question 23

Type: MCMA

Which assessment findings would the nurse evaluate as indicating inflammation or infection of the superficial lymph nodes?

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

Standard Text: Select all that apply.

1. The nodes are easily palpable.

2. There is edema in the area of the node.

3. The contour of the lymph node is visible.

4. There is cyanosis in the area being assessed.

5. The area over the node is cool to the touch.

Correct Answer: 1,2,3

Rationale 1: Superficial lymph nodes are normally not palpable.

Rationale 2: Edema in the area indicates inflammation or infection.

Rationale 3: Lymph nodes are small and should not be visible.

Rationale 4: Cyanosis is an abnormal finding but is not associated with the lymph system.

Rationale 5: Infection or inflammation is more likely to manifest with warmth over the area.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 52-6

Question 24

Type: MCMA

Which lymph node assessment findings would increase the nurses concern that a patient has a malignancy?

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

Standard Text: Select all that apply.

1. The node is tender.

2. The node is hard.

3. The node is irregularly shaped.

4. The node is freely movable.

5. The node is easily palpable.

Correct Answer: 2,3

Rationale 1: Tenderness often indicates infection.

Rationale 2: Malignancy is indicated when enlarged nodes are hard to the touch. Infected nodes are slightly firm.

Rationale 3: Irregularity of shape indicates enlargement possibly because of a malignancy.

Rationale 4: Free movement is usually associated with infection. Malignant nodes are fixed to underlying tissue.

Rationale 5: Both malignant and nonmalignant causes of node enlargement result in nodes that are easily palpable.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 52-6

Question 25

Type: MCMA

Review of a patients medical record reveals the presence of petechiae. How would the nurse interpret this 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 will have a maculopapular rash that extends over at least 30% of the body.

2. The patient has sustained damage to capillary blood vessels.

3. The patient has sustained bruising trauma.

4. The patient will have small purple or red spots.

5. The patient probably has an infection distal to the point where the petechiae begin.

Correct Answer: 2,4

Rationale 1: Petechiae do not manifest as a maculopapular rash.

Rationale 2: Petechiae result from damage to capillary blood vessels.

Rationale 3: Petechiae are small areas of hemorrhage and are not considered bruising.

Rationale 4: Petechiae are small purple or red spots on the skin.

Rationale 5: Infection can cause petechiae, but they manifest in many areas, not just proximal to the infection site.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 52-6

Question 26

Type: FIB

The nurse would consider a provisional diagnosis of sepsis as supported by a band count of over ______ % of the total white blood cell count.

Standard Text:

Correct Answer: 10

Rationale : Bands are immature neutrophils. A proportion of more than 10% bands indicates a large bacterial infection such as an abscess, pneumonia, or sepsis.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 52-7

Question 27

Type: MCMA

An 85-year-old patients white blood cell count (WBC) is 3,000. How would the nurse interpret this finding?

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

Standard Text: Select all that apply.

1. The count is high, so the patient probably has an infection.

2. The patients immune system is intact.

3. This WBC count is normal for a patient this age.

4. This count is low and further assessment should be completed.

5. This patient is immunosuppressed.

Correct Answer: 4,5

Rationale 1: This WBC count is low.

Rationale 2: This low WBC may indicate immune system dysfunction.

Rationale 3: Older patients may have some suppression of immunity that may manifest as slightly lower WBC counts, but this count is significantly low.

Rationale 4: Further investigation into the reason for this low WBC level should be undertaken.

Rationale 5: Low WBC counts indicate immunosuppression.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 52-7

Question 28

Type: MCMA

A patient has a skin infection over the inner aspect of the left thigh. The nurse would anticipate finding enlargement when palpating which lymph nodes?

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

Standard Text: Select all that apply.

1. Inferior inguinal

2. Superior inguinal

3. Preauricular nodes

4. Supraclavicular nodes

5. Axillary nodes

Correct Answer: 1,2

Rationale 1: The inferior inguinal nodes receive drainage from the upper leg.

Rationale 2: The superior inguinal nodes receive drainage from the upper leg.

Rationale 3: The preauricular nodes are located in front of the ears. The nurse would not expect involvement of these nodes.

Rationale 4: Supraclavicular nodes drain the upper abdomen, lungs, breasts, and arms. The nurse would not anticipate enlargement of these nodes from an infection on the leg.

Rationale 5: The axillary nodes are located under the arm. The nurse would not anticipate finding enlargement of these nodes from an infection on the leg.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 52-6

Question 29

Type: MCMA

During an assessment, the nurse notes enlargement and tenderness of the right preauricular lymph nodes. This finding would suggest the need for additional assessment of which areas?

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

Standard Text: Select all that apply.

1. Face

2. Neck

3. Head

4. Breast

5. Upper arm

Correct Answer: 1,3

Rationale 1: The preauricular nodes drain tissues of the face.

Rationale 2: The preauricular nodes do not drain tissues of the neck.

Rationale 3: The preauricular nodes drain tissues of the head.

Rationale 4: The preauricular nodes do not drain tissues of the breast.

Rationale 5: The preauricular nodes do not drain tissues of the upper arm.

Global Rationale:

 

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