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cancer.
The leading health problems of elementary 13. Which of the following ethical principles
school children are injuries, infections, refers to the duty to do good?
malnutrition, dental disease, and cancer.
Beneficence
alcohol and drug abuse. Beneficence is the duty to do good and the
Alcohol and drug abuse are leading health active promotion of benevolent acts.
problems for high school students.
Fidelity
mental and emotional problems. Fidelity refers to the duty to be faithful to
Mental and emotional problems are leading one's commitments.
health problems for high school students.
Veracity
homicide. Veracity is the obligation to tell the truth.
Homicide is a leading health problem for high
school children. Nonmaleficence
Nonmaleficence is the duty not to inflict, as
well as to prevent and remove, harm; it is
11. Which skill needed by the nurse to think more binding than beneficence.
critically involves identification of patient
problems indicated by data?
14. During which step of the nursing process
Analysis does the nurse analyze data related to the
Analysis is used to identify patient problems patient's health status?
indicated by data.
Assessment
Interpretation Analysis of data is included as part of the
Interpretation is used to determine the assessment.
significance of data that is gathered.
Implementation
Inferencing Implementation is the actualization of the
Inferences are used by the nurse to draw plan of care through nursing interventions.
conclusions.
Diagnosis
Explanation Diagnosis is the identification of patient
Explanation is the justification of actions or problems.
interventions used to address patient
problems and to help a patient move toward Evaluation
desired outcomes. Evaluation is the determination of the
patient's responses to the nursing
interventions and the extent to which the
12. The ethics theory that focuses on ends or outcomes have been achieved.
consequences of actions is the
Physical examination
The physical examination is helpful but often 23. In which range of body mass index (BMI)
only validates the information obtained from are patients considered to have increased
the history. risk for problems associated with poor
nutritional status?
Diagnostic test results
Diagnostic test results can be helpful, but Below 24
they often only verify rather than establish Additionally, higher mortality rates in
the diagnosis. hospitalized patients and community-
dwelling elderly are associated with
Biographical data individuals who have low BMI.
Biographical information puts the health
history in context but does not focus the 25-29
diagnosis. Those who have a BMI of 25 to 29 are
considered overweight.
homeostasis. hypertrophy.
When a change occurs that causes a body Hypertrophy is an increase in size and bulk of
function to deviate from its stable range, tissue that does not result from an increased
processes are initiated to restore and number of cells.
maintain the steady state or homeostasis.
atrophy.
constancy. Atrophy refers to reduction in size of a
Constancy refers to the balanced internal structure after having come to full maturity.
state of the human body maintained by
physiologic and biochemical processes. neoplasia.
With neoplasia, the increase in the number of
adaptation. new cells in an organ or tissue continues
Adaptation refers to a constant, ongoing after the stimulus is removed.
process that requires change in structure,
function, or behavior so that the person is
better suited to the environment. 28. Which of the following types of cells have
a latent ability to regenerate?
stress.
Stress refers to a state produced by a change Stable
in the environment that is perceived as Stable cells have a latent ability to
challenging, threatening, or damaging to the regenerate if they are damaged or destroyed
person's dynamic balance or equilibrium. and are found in the kidney, liver, and
pancreas, among other body organs.
Coping Epithelial
Coping consists of both cognitive and Epithelial cells are a type of labile cell that
behavioral efforts made to manage the multiply constantly to replace cells worn out
specific external or internal demand that by normal physiologic processes.
taxes a person's resources.
Mental disorder
The definition was adopted by the American 33. Which of the following statements
Psychiatric Association in 1994. accurately describes a risk factor for
depression?
Emotional disorder
There is no universally accepted definition of History of physical or sexual abuse
what constitutes an emotional disorder. History of physical or sexual abuse and
current substance abuse are risk factors for
Anxiety depression.
Anxiety is defined as fear of the unknown.
Male gender
Schizophrenia A risk factor for depression is female gender.
Schizophrenia is a specific disorder
characterized by psychosis. Age over 50 years
A risk factor for depression is onset before 40
years.
31. Establishing financial security has been
identified as a developmental task of which Negative family history of depression
of the following groups? Family history of depression is a risk factor.
Middle adult
The middle adult's tasks also include 34. Of the following stages of grieving as
launching children, and refocusing on one's described by Kubler-Ross, which is the initial?
marital relationship.
Denial
Older adult The stages include: denial, anger, bargaining,
The older adult's tasks include adapting to depression, and acceptance.
retirement and declining physical stamina.
Anger
Young adult Anger is the second stage of the process.
The young adult's tasks include establishing
a lifestyle and independence. Bargaining
Bargaining is the third stage of the process.
Teenager
The teenager's primary developmental tasks Depression
include developing an identity and intimacy. Depression is the fourth stage of the process.
32. When up to a 6-month period elapses 35. Which of the following terms refers to
between the experience of trauma and the Leininger's description of the learned and
onset of symptoms of posttraumatic stress transmitted knowledge about values, beliefs,
disorder (PTSD), the episode is termed rules of behavior, and lifestyle practices that
guide a designated group in their thinking
delayed. and actions in patterned ways?
Arabs
Culture Arabs may consider direct eye contact
Leininger was the founder of the specialty impolite or aggressive.
called transcultural nursing and advocated
culturally competent nursing care. Asians
Asians may consider direct eye contact
Minority impolite or aggressive.
Minority refers to a group of people whose
physical or cultural characteristics differ from
the majority of people in a society. 38. For which of the following religious
groups is all meat prohibited?
Race
Race refers to a group of people Hinduism
distinguished by genetically transmitted Hinduism prohibits consumption of all meats
characteristics. and animal shortening.
Judaism
36. The inability of a person to recognize his Judaism prohibits consumption of pork.
or her own values, beliefs, and practices and
those of others because of strong Islam
ethnocentric tendencies is termed Islam prohibits the consumption of pork and
animal shortening.
cultural blindness.
Cultural blindness results in bias and
stereotyping. 39. The paradigm that explains the cause of
illness as an imbalance in the forces of
acculturation. nature is the
Acculturation is the process by which
members of a culture adapt or learn how to holistic perspective.
take on the behaviors of another group. The naturalist or holistic perspective believes
that health exists when all aspects of a
cultural imposition. persona are in perfect balance or harmony.
Cultural imposition is the tendency to impose
one's cultural beliefs, values, and patterns of magico-religious view.
behavior on a person from a different culture. The magico-religious view holds that illness is
caused by forces of evil.
cultural taboo.
Cultural taboos are those activities governed biomedical view.
by rules of behavior that are avoided, The biomedical view holds life events as
forbidden, or prohibited by a particular cause and effect and incorporates the
cultural group. bacterial or viral explanation of
communicable disease.
Biofeedback Stage I
Cognitively intact patients who have stress or A stage I pressure ulcer is an area of
urge incontinence may gain bladder control nonblanchable erythema, tissue swelling, and
through biofeedback. congestion, and the patient complains of
discomfort.
Kegel exercises
Kegel exercises are pelvic floor exercises that
strengthen the pubococcygeus muscle. 53. Which type of incontinence is associated
with weakened perineal muscles that permit
Habit training leakage of urine when intra-abdominal
Habit training is used to try to keep the pressure is increased?
patient dry by strictly adhering to a toileting
schedule and may be successful with stress, Stress incontinence
urge, or functional incontinence. Stress incontinence may occur with coughing
or sneezing.
Bladder training
Habit training is a type of bladder training. Urge incontinence
Urge incontinence is involuntary elimination
of urine associated with a strong perceived
51. During which stage of pressure ulcer need to void.
development does the ulcer extend into the
subcutaneous tissue? Reflex (neurogenic) incontinence
Neurogenic incontinence is associated with a
Stage III spinal cord lesion.
Clinically, a deep crater with or without
undermining of adjacent tissues is noted. Functional incontinence
Functional incontinence refers to
Stage IV incontinence in patients with intact urinary
A stage IV pressure ulcer extends into the physiology who experience mobility
underlying structure, including the muscle impairment, environmental barriers, or
and possibly the bone. cognitive problems.
Stage II
A stage II ulcer exhibits a break in the skin 54. Ageism refers to
through the epidermis or dermis.
Bias against older people based solely on
chronological age
Individuals demonstrating ageism base their isolated systolic.
beliefs and attitudes about older people Isolated systolic hypertension is
based upon chronological age without demonstrated by readings in which the
consideration of functional capacity. systolic pressure exceeds 140 mm Hg and
the diastolic measurement is normal or near
fear of old age. normal (less than 90 mm Hg).
Fear of aging and the inability of many to
confront their own aging process may trigger
ageist beliefs. 57. Which of the following terms refers to the
decrease in lens flexibility that occurs with
loss of memory. age, resulting in the near point of focus
Age-related loss of memory occurs more with getting farther away?
short-term and recent memory.
Presbyopia
benign senescent forgetfulness. Presbyopia usually begins in the fifth decade
Benign senescent forgetfulness refers to the of life, when reading glasses are required to
age-related loss of memory in the absence of magnify objects.
a pathologic process.
Presbycusis
Presbycusis refers to age-related hearing
55. When assessing the older adult, the loss.
nurse anticipates increase in which of the
follow components of respiratory status? Cataract
Cataract is the development of opacity of the
Residual lung volume lens of the eye.
As a result, patient experience fatigue and
breathlessness with sustained activity. Glaucoma
Glaucoma is a disease characterized by
Vital capacity increased intraocular pressure.
The nurse anticipates decreased vital
capacity.
58. Which of the following states is
Gas exchange and diffusing capacity characterized by a decline in intellectual
The nurse anticipates decreased gas functioning?
exchange and diffusing capacity resulting in
impaired healing of tissues due to decreased Dementia
oxygenation. Dementia is an acquired syndrome in which
progressive deterioration in global
Cough efficiency intellectual abilities is of such severity that it
The nurse anticipates difficulty coughing up interferes with the person's customary
secretions due to decreased cough efficiency. occupational and social performance.
Depression
56. According to the classification of Depression is a mood disorder that disrupts
hypertension diagnosed in the older adult, quality of life.
hypertension that can be attributed to an
underlying cause is termed Delirium
Delirium is often called acute confusional
secondary. state.
Secondary hypertension may be caused by a
tumor of the adrenal gland (e.g., Delusion
pheochromacytoma). Delusion is a symptom of psychoses.
primary.
Primary hypertension has no known 59. When a person who has been taking
underlying cause. opioids becomes less sensitive to their
analgesic properties, that person is said to
essential. have developed a (an)
Essential hypertension has no known
underlying cause. tolerance.
Tolerance is characterized by the need for
increasing dose requirements to maintain the A positive response to a placebo indicates
same level of pain relief. that the person's pain is not real.
Reduction in pain as a response to placebo
addiction. should never be interpreted as an indication
Addiction refers to a behavioral pattern of that the person's pain is not real.
substance use characterized by a compulsion
to take the drug primarily to experience its
psychic effects. 62. Regarding tolerance and addiction, the
nurse understands that
dependence.
Dependence occurs when a patient who has although patients may need increasing
been taking opioids experiences a withdrawal levels of opioids, they are not addicted.
syndrome when the opioids are discontinued. Physical tolerance usually occurs in the
absence of addiction.
balanced analgesia.
Balanced analgesia occurs when the patient tolerance to opioids is uncommon.
is using more than one form of analgesia Tolerance to opioids is common.
concurrently to obtain more pain relief with
fewer side effects. addiction to opioids commonly develops.
Addiction to opioids is rare.
60. Prostaglandins are chemical substances the nurse must be primarily concerned about
thought to development of addiction by the patient in
pain.
increase sensitivity of pain receptors. Addiction is rare and should never be the
Prostaglandins are believed to increase primary concern for a patient in pain.
sensitivity to pain receptors by enhancing the
pain-provoking effect of bradykinin.
63. The preferred route of administration of
reduce the perception of pain. medication in the most acute care situations
Endorphins and enkephalins reduce or inhibit is which of the following routes?
transmission or perception of pain.
Intravenous
inhibit the transmission of pain. The IV route is the preferred parenteral route
Endorphins and enkephalins reduce or inhibit in most acute care situations because it is
transmission or perception of pain. much more comfortable for the patient, and
peak serum levels and pain relief occur more
inhibit the transmission of noxious stimuli. rapidly and reliably.
Morphine and other opioid medications
inhibit the transmission of noxious stimuli by Epidural
mimicking enkephalin and endorphin. Epidural administration is used to control
postoperative and chronic pain.
Distributive
67. Oncotic pressure refers to Distributive or vasogenic shock results from
displacement of blood volume, creating a
the osmotic pressure exerted by relative hypovolemia.
proteins.
Oncotic pressure is a pulling pressure Cardiogenic
exerted by proteins, such as albumin. Cardiogenic shock results from the failure of
a heart as a pump.
the number of dissolved particles contained
in a unit of fluid. Hypovolemic
Osmolality refers to the number of dissolved In hypovolemic shock, there is a decrease in
particles contained in a unit of fluid. the intravascular volume.
71. Which stage of shock is best described as 73. Which of the following vasoactive drugs
that stage when the mechanisms that used in treating shock results in reduced
regulate blood pressure fail to sustain a preload and afterload, reducing oxygen
systolic pressure above 90 mm Hg? demand of the heart?
82. For individuals known to be dying by demonstrates cells that are well-
virtue of age and/or diagnoses, which of the differentiated.
following signs indicate approaching death: Cells of malignant tumors are
undifferentiated.
Increased restlessness
As the oxygen supply to the brain decreases, is usually slow growing.
the patient may become restless. Malignant tumors demonstrate variable rate
of growth; however, the more anaplastic the
Increased wakefulness tumor, the faster its growth.
As the body weakens, the patient will sleep
more and begin to detach from the grows by expansion.
environment. A malignant tumor grows at the periphery
and sends out processes that infiltrate and
Increased eating destroy surrounding tissues.
For many patients, refusal of food is an
indication that they are ready to die.
85. Which of the following classes of
Increased urinary output antineoplastic agents is cell--cycle-specific?
Based upon decreased intake, urinary output
generally decreases in amount and Antimetabolites (5-FU)
frequency. Antimetabolites are cell--cycle-specific (S
phase).
Flushed face
Pallor is an indicator of shock. 100. Which of the following terms is used to
describe inability to breathe easily except in
Warm, dry skin an upright position?
Skin is generally cool and moist in shock.
Orthopnea
Increased urine output Patients with orthopnea are placed in a high
Usually, a low blood pressure and Fowler's position to facilitate breathing.
concentrated urine are observed in the
patient in shock. Dyspnea
Dyspnea refers to labored breathing or
shortness of breath.
98. When the nurse observes that the
postoperative patient demonstrates a Hemoptysis
constant low level of oxygen saturation, Hemoptysis refers to expectoration of blood
although the patient's breathing appears from the respiratory tract.
normal, the nurse identifies that the patient
may be suffering which type of hypoxemia? Hypoxemia
Hypoxemia refers to low oxygen levels in the
Subacute blood.
Supplemental oxygen may be indicated.
101. In relation to the structure of the larynx, funnel chest.
the cricoid cartilage is A funnel chest occurs when there is a
depression in the lower portion of the
the only complete cartilaginous ring in sternum.
the larynx.
The cricoid cartilage is located below the kyphoscoliosis.
thyroid cartilage. Kyphoscoliosis is characterized by elevation
of the scapula and a corresponding S-shaped
used in vocal cord movement with the spine.
thyroid cartilage.
The arytenoid cartilages are used in vocal
cord movement with the thyroid cartilage. 104. When the nurse auscultates chest
sounds that are harsh and cracking,
the largest of the cartilage structures. sounding like two pieces of leather being
The thyroid cartilage is the largest of the rubbed together, she records her finding as
cartilage structures; part of it forms the
Adam's apple. pleural friction rub.
A pleural friction rub is heard secondary to
the valve flap of cartilage that covers the inflammation and loss of lubricating pleural
opening to the larynx during swallowing. fluid.
The epiglottis is the valve flap of cartilage
that covers the opening to the larynx during crackles.
swallowing. Crackles are soft, high-pitched, discontinuous
popping sounds that occur during inspiration.
Rhinorrhea
103. The individual who demonstrates Rhinorrhea refers to drainage of a large
displacement of the sternum is described as amount of fluid from the nose.
having a
Dysphagia
pigeon chest. Dysphagia refers to difficulties in swallowing.
Pigeon chest may occur with rickets, Marfan's
syndrome, or severe kyphoscoliosis.
106. The herpes simplex virus (HSV-1), which
barrel chest. produces a cold sore (fever blister), has an
A barrel chest is seen in patients with incubation period of
emphysema as a result of over-inflation of
the lungs. 2-12 days.
HSV-1 is transmitted primarily by direct
contact with infected secretions.
109. When the patient who has undergone
0-3 months. laryngectomy suffers wound breakdown, the
The time period 0-3 months exceeds the nurse monitors him very carefully because
incubation period. he is identified as being at high risk for
aphonia.
Aphonia refers to the inability to use one's 110. Which of the following terms refers to
voice. lung tissue that has become more solid in
nature due to a collapse of alveoli or
atrophic pharyngitis. infectious process?
Atrophic pharyngitis is characterized by a
membrane that is thin, white, glistening, and Consolidation
at times wrinkled. Consolidation occurs during an infectious
process such as pneumonia.
hypertrophic pharyngitis.
Hypertrophic pharyngitis is characterized by Atelectasis
general thickening and congestion of the Atelectasis refers to collapse or airless
pharyngeal mucous membrane. condition of the alveoli caused by
hypoventilation, obstruction to the airways,
or compression.
108. Which type of sleep apnea is
characterized by lack of airflow due to Bronchiectasis
pharyngeal occlusion? Bronchiectasis refers to chronic dilation of a
bronchi or bronchi in which the dilated airway
Obstructive becomes saccular and a medium for chronic
Obstructive sleep apnea occurs usually in infection.
men, especially those who are older and
overweight. Empyema
Empyema refers to accumulation of purulent
Simple material in the pleural space.
Types of sleep apnea do not include a simple
characterization.
111. Which of the following community-
Mixed acquired pneumonias demonstrates the
Mixed sleep apnea is a combination of highest occurrence during summer and fall?
central and obstructive apnea with one
apneic episode. Legionnaires' disease
Legionnaires' disease accounts for 15% of
Central community-acquired pneumonias.
In central sleep apnea, the patient
demonstrates simultaneous cessation of both Streptococcal (pneumococcal) pneumonia
airflow and respiratory movements. Streptococcal pneumonia demonstrates the
highest occurrence in winter months.
Mycoplasma pneumonia 114.
Mycoplasma pneumonia demonstrates the Which of the following types of lung cancer is
highest occurrence in fall and early winter. characterized as fast growing and tending to
arise peripherally?
Viral pneumonia
Viral pneumonia demonstrates the greatest Large cell carcinoma
incidence during winter months. Large cell carcinoma is a fast-growing tumor
that tends to arise peripherally.
Apply a compression dressing to the area. Placement of external end of tube under
Subcutaneous emphysema is a typical post- water
operative finding in the patient after chest Placement of external end of tube under
surgery. water and watching for air bubbles is not a
reliable method for determining nasogastric
Measure the patient's pulse oximetry. tube placement in the stomach.
Subcutaneous emphysema is absorbed by
the body spontaneously after the underlying
leak is treated or halted. 116. Which of the following types of lung
cancer is the most prevalent carcinoma of
Report the finding to the physician the lung for both men and women?
immediately.
Subcutaneous emphysema results from air Adenocarcinoma
entering the tissue planes. Adenocarcinoma presents more peripherally
as peripheral masses or nodules and often
metastasizes.
Cigarette smoking
Pipe, cigar and other types of tobacco 121. Of the following oxygen administration
smoking are also risk factors. devices, which has the advantage of
providing high oxygen concentration?
Occupational exposure
While a risk factor, occupational exposure is Non-rebreather mask
not the most important risk factor for The non-rebreather mask provides high
development of COPD. oxygen concentration but is usually poor
fitting.
Air pollution
Air pollution is a risk factor for development Venturi mask
of COPD, but it is not the most important risk The Venturi mask provides low levels of
factor. supplemental oxygen.
Left atrium
127. Which of the following terms describes The left atrium receives oxygenated blood
the amount of blood ejected per heartbeat? from the pulmonary circulation.
132. When the nurse observes that the Premature ventricular contraction
patient's heart rate increases during A PVC is an impulse that starts in a ventricle
inspiration and decreases during expiration, before the next normal sinus impulse.
the nurse reports that the patient is
demonstrating Ventricular bigeminy
Ventricular bigeminy is a rhythm in which
sinus dysrhythmia. every other complex is a PVC.
Sinus dysrhythmia occurs when the sinus
node creates an impulse at an irregular Ventricular tachycardia
rhythm. Ventricular tachycardia is defined as three or
more PVCs in a row, occurring at a rate
normal sinus rhythm. exceeding 100 beats per minute.
Normal sinus rhythm occurs when the
electrical impulse starts at a regular rate and Ventricular fibrillation
rhythm in the SA node and travels through Ventricular fibrillation is a rapid but
the normal conduction pathway. disorganized ventricular rhythm that causes
ineffective quivering of the ventricles.
sinus bradycardia.
Sinus bradycardia occurs when the sinus
node regularly creates an impulse at a 135. Premature ventricular contractions are
slower-than-normal rate. considered precursors of ventricular
tachycardia when they
sinus tachycardia.
Sinus tachycardia occurs when the sinus occur at a rate of more than six per
node regularly creates an impulse at a faster- minute.
than-normal rate. When PVCs occur at a rate of more than six
per minute they indicate increasing
ventricular irritability and are considered
133.Which of the following terms is used to forerunners of ventricular tachycardia (VT).
describe a tachycardia characterized by
abrupt onset, abrupt cessation, and a QRS of occur during the QRS complex.
normal duration? PVCs are dangerous when they occur on the
T wave.
Paroxysmal atrial tachycardia
PAT is often caused by a conduction problem have the same shape.
in the AV node and is now called AV nodal PVCs are dangerous when they are multifocal
reentry tachycardia. (have different shapes).
First degree
In first degree heart block, all the atrial 139.When the patient with known angina
impulses are conducted through the AV node pectoris complains that he is experiencing
into the ventricles at a rate slower than chest pain more frequently even at rest, the
normal. period of pain is longer, and it takes less
stress for the pain to occur, the nurse
Second degree, type I recognizes that the patient is describing
In second degree AV block, type I, all but one
of the atrial impulses are conducted through unstable angina.
the AV node into the ventricles. Unstable angina is also called crescendo or
pre-infarction angina and indicates the need
Second degree, type II for a change in treatment.
In second degree AV block, type II, only some
of the atrial impulses are conducted through intractable angina.
the AV node into the ventricles. Intractable or refractory angina produces
severe, incapacitating chest pain that does
not respond to conventional treatment.
137. Which of the following terms refers to
chest pain brought on by physical or variant angina.
emotional stress and relieved by rest or Variant angina is described as pain at rest
medication? with reversible ST-segment elevation and is
thought to be caused by coronary artery
angina pectoris vasospasm.
Angina pectoris is a symptom of myocardial
ischemia. refractory angina.
Intractable or refractory angina produces
atherosclerosis severe, incapacitating chest pain that does
Atherosclerosis is an abnormal accumulation not respond to conventional treatment.
of lipid deposits and fibrous tissue within
arterial walls and lumens.
140. Heparin therapy is usually considered
atheroma therapeutic when the patient's activated
Atheromas are fibrous caps composed of partial thromboplasin time (aPTT) is how
smooth muscle cells that form over lipid many times normal?
deposits within arterial vessels.
1.5 to 2
ischemia The amount of heparin administered is based
Ischemia is insufficient tissue oxygenation on aPTT results, which should be obtained in
and may occur in any part of the body. follow-up to any alteration of dosage.
.5 to 1
138. Of the following risk factors, which is The patient's aPTT value would have to be
considered modifiable? greater than .5 to 1 times normal to be
considered therapeutic.
Diabetes mellitus
While diabetes mellitus cannot be cured, 2.5 to 3
blood sugars and symptomatology can be An aPTT value that is 2.5 to 3 times normal
managed through healthy heart living. would be too high to be considered
therapeutic. will not be used again in the same patient for
acute MI.
.25 to .75
The patient's aPTT value would have to be
greater than .25 to .75 times normal to be 143. Which of the following statements
considered therapeutic. reflect a goal of rehabilitation for the patient
with an MI:
141. When the post-cardiac surgery patient To improve the quality of life
demonstrates restlessness, nausea, Overall, cardiac rehabilitation is a complete
weakness, and peaked T waves, the nurse program dedicated to extending and
reviews the patient's serum electrolytes improving quality of life.
anticipating which abnormality?
To limit the effects and progression of
Hyperkalemia atherosclerosis
Hyperkalemia is indicated by mental An immediate objective of rehabilitation of
confusion, restlessness, nausea, weakness, the MI patient is to limit the effects and
and dysrhythmias (tall, peaked T waves). progression of atherosclerosis.
Regurgitation
150. When the valve used in valve Mitral valve regurgitation, in its acute stage,
replacement surgery is made from the usually presents as severe heart failure.
patient's own heart valve, which of the
following terms is used? Infection
Mitral valve infection, when acute, will
Autograft produce symptoms typical of infective
An example of autograft is found when the endocarditis.
surgeon excises the pulmonic valve and uses
it for an aortic valve replacement.
153.In which type of cardiomyopathy does
Allograft the heart muscle actually increase in size
Allograft refers to replacement using human and mass weight, especially along the
tissue and is a synonym for homograft. septum?
Homograft Hypertrophic
Homograft refers to replacement using Because of the structural changes,
human tissue and is a synonym for allograft. hypertrophic cardiomyopathy had also been
called idiopathic hypertrophic subaortic
Xenograft stenosis (IHSS) or asymmetric septal
Xenograft refers to replacement of tissue hypertrophy (ASH).
from animal tissue.
Dilated
Because of the structural changes,
151. Which of the following procedures most hypertrophic cardiomyopathy had also been
specifically describes splitting or separating called idiopathic hypertrophic subaortic
fused cardiac valve leaflets? stenosis (IHSS) or asymmetric septal
hypertrophy (ASH).
Commisurotomy
Commisurotomy is frequently used for mitral Restrictive
stenosis. Restrictive cardiomyopathy is characterized
by diastolic dysfunction caused by rigid
Annuloplasty ventricular walls that impair ventricular
Annuloplasty refers to repair of a cardiac stretch and diastolic filling
valve's outer ring.
Arrhythmogenic right ventricular
Chordoplasty cardiomyopathy
Chordoplasty refers to repair of the chordae Arrhythmogenic right ventricular
cardiomyopathy (ARVC) occurs when the pumped out (ejected) with each contraction
myocardium of the right ventricle is of the heart (heart beat). Stroke volume
progressively infiltrated and replaced by times heart rate equals cardiac output.
fibrous scar and adipose tissue
Afterload
Afterload is the amount of resistance to
154.Which of the following patient behaviors, ejection of blood from a ventricle.
if observed by the nurse, would indicate that
the cardiac patient's level of anxiety has Cardiac output
decreased? Cardiac output is the amount of blood
pumped out of the heart in one minute.
Answers questions regarding status
with no problem. Preload
Generally, when anxiety begins to increase, Preload is the pressure created by a volume
the patient will be less likely to want to of blood within a ventricle before contraction.
discuss prognosis.
Persistent cough
Persistent cough may indicate an onset of
left-heart failure. 163.Which of the following terms refers to a
muscular, cramp-like pain in the extremities
Increased appetite consistently reproduced with the same
Loss of appetite should be reported degree of exercise and relieved by rest?
immediately.
Intermittent claudication
Weight loss Intermittent claudication is a sign of
Weight gain should be reported immediately. peripheral arterial insufficiency.
Bruit
161.A classic sign of cardiogenic shock is A bruit is the sound produced by turbulent
blood flow through an irregular, tortuous,
Tissue hypoperfusion stenotic, or dilated vessel.
Tissue hypoperfusion is manifested as
cerebral hypoxia (restlessness, confusion, Ischemia
agitation). Ischemia is a term used to denote deficient
blood supply.
High blood pressure
Low blood pressure is a classic sign of
cardiogenic shock. 164.Which of the following observations
regarding ulcer formation on the patient's
Hyperactive bowel sounds lower extremity indicate to the nurse that the
Hypoactive bowel sounds are classic signs of ulcer is a result of venous insufficiency?
aneurysms results in bleeding into the layers
The border of the ulcer is irregular. of the arterial wall?
The border of an ulcer caused by arterial
insufficiency is circular. Dissecting
Dissection results from a rupture in the
The ulcer is very painful to the patient, even intimal layer, resulting in bleeding between
though superficial. the intimal and medial layers of the arterial
Superficial venous insufficiency ulcers cause wall.
minimal pain.
Saccular
The ulcer base is pale to black. Saccular aneurysms collect blood in the
The base of a venous insufficiency ulcer weakened outpouching.
shows beefy red to yellow fibrinous color.
False
The ulcer is deep, involving the joint space. In a false aneurysm, the mass is actually a
Venous insufficiency ulcers are usually pulsating hematoma.
superficial.
Anastomotic
An anastomotic aneurysm occurs as a result
165.A diagnostic test that involves injection of infection at arterial suture or graft sites.
of a contrast media into the venous system
through a dorsal vein in the foot is termed
168.Which of the following terms refers to
contrast phlebography. enlarged, red, and tender lymph nodes?
When a thrombus exists, an x-ray image will
disclose an unfilled segment of a vein. Lymphadenitis
Acute lymphadenitis is demonstrated by
air plethysmography enlarged, red and tender lymph nodes.
Air plethysmography quantifies venous reflux
and calf muscle pump ejection. Lymphangitis
Lymphangitis is an acute inflammation of the
lymphangiography. lymphatic channels.
In lymphangiography, contrast media are
injected into the lymph system. Lymphedema
Lymphedema is demonstrated by swelling of
lymphoscintigraphy. tissues in the extremities because of an
In lymphoscintigraphy, a radioactive-labeled increased quantity of lymph that results from
colloid is injected into the lymph system. an obstruction of lymphatic vessels.
Elephantiasis
166.The nurse teaches the patient with Elephantiasis refers to a condition in which
peripheral vascular disease to refrain from chronic swelling of the extremity recedes
smoking because nicotine causes only slightly with elevation.
vasospasm.
Nicotine causes vasospasm and can thereby 169.Which of the following terms is given to
dramatically reduce circulation to the hypertension in which the blood pressure,
extremities. which is controlled with therapy, becomes
uncontrolled (abnormally high) with the
slowed heart rate. discontinuation of therapy?
Nicotine has stimulant effects.
Rebound
depression of the cough reflex. Rebound hypertension may precipitate a
Nicotine does not suppress cough. Smoking hypertensive crisis.
irritates the bronchial tree, causing coughing.
Essential
diuresis. Essential or primary hypertension denotes
Nicotine does not cause diuresis. high blood pressure from an unidentified
source.
Furosemide (Lasix)
170.Officially, hypertension is diagnosed Lasix causes loss of potassium from the
when the patient demonstrates a systolic body.
blood pressure greater than ______ mm Hg
and a diastolic blood pressure greater than Chlorothiazide (Diuril)
_____ mm Hg over a sustained period. Diuril causes mild hypokalemia.
Thrombocytopenia Hypersplenism
Thrombocytopenia refers to a lower-than- Hypersplenism results in an acquired
normal platelet count. hemolytic anemia.
spherocyte. Pepsin
A spherocyte is a red blood cell without Pepsin is a gastric enzyme important in
central pallor. protein digestion.
reticulocyte. Trypsin
A reticulocyte is a slightly immature red Trypsin is an enzyme that aids in the
blood cell. digestion of protein.
177.Of the following hemolytic anemias, 180.When bowel sounds are heard about
which is categorized as inherited? every 15 seconds, the nurse would record
that the bowel sounds are
Sickle cell anemia
Glucose 6-phosphate dehydrogenase normal.
deficiency is an inherited abnormality Normal bowel sounds are heard every 5-20
resulting in hemolytic anemia. seconds.
chancre.
181.When gastric analysis testing reveals A chancre is demonstrated as a reddened
excess secretion of gastric acid, which of the circumscribed lesion that ulcerates and
following diagnoses is supported? becomes crusted and is a primary lesion of
syphilis.
Duodenal ulcer
Patients with duodenal ulcers usually secrete
an excess amount of hydrochloric acid. 184.Regarding oral cancer, the nurse
provides health teaching to inform the
Chronic atrophic gastritis patient that
Patients with chronic atrophic gastritis
secrete little or no acid. many oral cancers produce no
symptoms in the early stages.
Gastric cancer As the cancer progresses, the patient may
Patients with gastric cancer secrete little or complain of tenderness or difficulty in
no acid. chewing, swallowing, or speaking.
Elevate the foot of the bed on 6- to 8-inch 191.To ensure patency of central venous line
blocks ports, dilute heparin flushes are used in
The patient should be instructed to elevate which of the following situations?
Nasoenteric tubes are used for
Daily when not in use gastrointestinal aspiration.
Daily instillation of dilute heparin flush when
a port is not in use will maintain the port. Emptying
Gastric sump tubes are used to decompress
With continuous infusions the stomach and keep it empty.
Continuous infusion maintains the patency of
each port. Heparin flushes are used after
each intermittent infusion. 194.Mercury is typically used in the
placement of which of the following tubes?
Before blood drawing
Heparin flushes are used after blood drawing Miller-Abbott
in order to prevent clotting of blood within Most nasoenteric tubes use mercury to carry
the port. the tube by gravity to its desired location.
Dobbhoff
192.For which of the following medications Dobbhoff tubes are used for enteric feeding.
must the nurse contact the pharmacist in
consultation when the patient receives all EnterafloW
oral medications by feeding tube? Enteraflow tubes are used for enteric feeding
.
Enteric-coated tablets
Enteric-coated tablets are meant to be 195.The most significant nursing problem
digested in the intestinal tract and may be related to continuous tube feedings is
destroyed by stomach acids. A change of
form of medication is required by patients potential for aspiration
with tube feedings. Because the normal swallowing mechanism
is bypassed, consideration of the danger of
Simple compressed tablets aspiration must be foremost in the mind of
Simple compressed tablets may be crushed the nurse caring for the patient receiving
and dissolved in water for patient receiving continuous tube feedings.
oral medications by feeding tube.
interruption of GI integrity
Buccal or sublingual tablets Tube feedings preserve GI integrity by
Buccal or sublingual tablets are absorbed by intraluminal delivery of nutrients.
mucous membranes and may be given as
intended to the patient undergoing tube disturbance in the sequence of intestinal and
feedings. hepatic metabolism
Tube feedings preserve the normal sequence
Soft gelatin capsules filled with liquid of intestinal and hepatic metabolism.
The nurse may make an opening in the
capsule and squeeze out contents for interruption in fat metabolism and lipoprotein
administration by feeding tube. synthesis
Tube feedings maintain fat metabolism and
lipoprotein synthesis.
193.Medium -length nasoenteric tubes are
used for:
196.When the nurse prepares to give a bolus
Feeding tube feeding to the patient and determines
Placement of the tube must be verified prior that the residual gastric content is 150 cc,
to any feeding. her best action is to
Pyrosis
197.If tube feeding is continuous, the Pyrosis refers to heartburn.
placement of the feeding tube should be
checked
200.Which of the following statements
every shift. accurately reflects a rule of thumb upon
Each nurse caring for the patient is which the nurse may rely in assessing the
responsible for verifying that the tube is patient's fluid balance?
located in the proper area for continuous
feeding. Minimal intake of 1.5 liters per day
If food and fluids are withheld, IV fluids
every hour. (3L/day) are usually prescribed.
Checking for placement each hour is
unnecessary unless the patient is extremely Minimal urine output of 50 milliliters per hour
restless or there is basis for rechecking the Minimal urine output may be less than 50
tube based on other patient activities. mL/hr.
C hemorrhage.
Lack of vitamin C may cause development of Hemorrhage is less likely in the patient with
signs and symptoms of scurvy. duodenal ulcer than the patient with gastric
ulcer.
D
Vitamin D deficiency results in an inability to weight loss.
absorb calcium. The patient with a duodenal ulcer may
experience weight gain. antidepressant medication.
Antacids
Antacids are given to manage gastric acidity. 205.Of the following bariatric surgical
procedures, which is the best procedure for
Proton pump inhibitors long-term weight loss?
Proton pump inhibitors are given to decrease
acid secretion. Roux-en-Y
The Roux-en-Y gastric bypass is the
Histamine-2 receptor antagonists recommended procedure for long-term
Histamine-2 receptor antagonists are given weight loss. In this procedure, a horizontal
to decrease the acid secretion in the row of staples creates a stomach pouch with
stomach. a 1-cm stoma that is anastomosed with a
portion of distal jejunum, creating a
gastroenterostomy.
203.Which of the following medications
represents the category proton (gastric acid) Vertical banded gastroplasty
pump inhibitors? In vertical banded gastroplasty, a double row
of staples is applied vertically along the
Omeprazole (Prilosec) lesser curvature of the stomach, beginning at
Omeprazole decreases gastric acid by the angle of His. Over time, the gastric
slowing the hydrogen-potassium-adenosine- restriction may fail.
triphosphatase pump on the surface of the
parietal cells. Gastric ring application
Application of a silicone ring to the fundus of
Sucralfate (Carafate) the stomach may fail.
Sucralfate is a cytoprotective drug.
Jejuno-ileal bypass
Famotidine (Pepcid) The first surgical procedure to treat morbid
Famotidine is a histamine-2 receptor obesity was the jejuno-ileal bypass. This
antagonist. procedure, which resulted in significant
complications, has been largely replaced by
Metronidazole (Flagyl) gastric restriction procedures
Metronidazole is an antibiotic, specifically an
amebicide.
206.Which of the following statements
regarding gastric cancer is accurate?
204.Which of the following medications used
for the treatment of obesity prevents the The incidence of cancer of the stomach
absorption of triglycerides? continues to decrease in the United
States.
Orlistat (Xenical) While the incidence continues to decrease,
Orlistat (Xenical) prevents the absorption of gastric cancer still accounts for 12,800
triglycerides. Side effects of Xenical may deaths annually.
include increased bowel movements, gas
with oily discharge, decreased food Most gastric cancer deaths occur in people
absorption, decreased bile flow, and younger than 40 years.
decreased absorption of some vitamins. While gastric cancer deaths occasionally
occur in younger people, most occur in
bupropion hydrochloride (Wellbutrin) people older than 40 years.
buproprion hydrochloride (Wellbutrin) is an
Females have a higher incidence of gastric surgery will result in a sigmoid colostomy
cancers than males. that the feces expelled through the
Males have a higher incidence of gastric colostomy will be
cancers than females.
solid.
A diet high in smoked foods and low in fruits With a sigmoid colostomy, the feces are
and vegetables may decrease the risk of solid.
gastric cancer.
More accurately, a diet high in smoked foods semi-mushy.
and low in fruits and vegetables may With a descending colostomy, the feces are
increase the risk of gastric cancer. semi-mushy.
mushy.
207.Which of the following categories of With a transverse colostomy, the feces are
laxatives draw water into the intestines by mushy.
osmosis?
fluid.
Saline agents (milk of magnesia) With an ascending colostomy, the feces are
Saline agents use osmosis to stimulate fluid.
peristalsis and act within 2 hours of
consumption.
210.When irrigating a colostomy, the nurse
Bulk-forming agents (Metamucil) lubricates the catheter and gently inserts it
Bulk-forming agents mix with intestinal into the stoma no more than _______ inches
fluids, swell, and stimulate peristalsis.
3”
Stimulants (Dulcolax) The nurse should insert the catheter no more
Stimulants irritate the colon epithelium. than 3 inches.
Osmotic diarrhea
Osmotic diarrhea occurs when water is pulled 215.Celiac sprue is an example of which
into the intestines by the osmotic pressure of category of malabsorption?
nonabsorbed particles, slowing the
reabsorption of water. Mucosal disorders causing generalized
malabsorption
Mixed diarrhea In addition to celiac sprue, regional enteritis
Mixed diarrhea is caused by increased and radiation enteritis are examples of
peristalsis (usually from inflammatory bowel mucosal disorders.
disease) and a combination of increased
secretion or decreased absorption in the Infectious diseases causing generalized
bowel. malabsorption
Examples of infectious diseases causing
Diarrheal disease generalized malabsorption include small
The most common cause of diarrheal disease bowel bacterial overgrowth, tropical sprue,
is contaminated food. and Whipple's disease.
Neoplasms Hemolytic
Neoplasms are one the second most common Hemolytic jaundice results because, although
causes of small bowel obstruction. the liver is functioning normally, it cannot
excrete the bilirubin as quickly as it is
Volvulus formed.
Volvulus (twisting of the bowel) is a less
common cause of small bowel obstruction. Hepatocellular
Hepatocellular jaundice is the result of liver
disease.
219.Which of the follow statements provides
accurate information regarding cancer of the Obstructive
colon and rectum? Obstructive jaundice is the result of liver
disease.
Cancer of the colon and rectum is the
second most common type of internal Non-obstructive
cancer in the United States. Non-obstructive jaundice occurs with
Cancer of the colon and rectum is the second hepatitis.
most common type of internal cancer in the
United States.
222.The nurse places the patient after liver
Rectal cancer affects more than twice as biopsy in which of the following positions?
On the right side Ascites
In this position, the liver capsule at the site of Ascites refers to accumulation of serous fluid
penetration is compressed against the chest within the peritoneal cavity.
wall, and the escape of blood or bile through
the perforation made for the biopsy is Dialysis
impeded. Dialysis refers to a form of filtration to
separate crystalloid from colloid substances.
On the left side
Positioning the patient on his left side is not
indicated. 225.Which of the following terms most
precisely refers to the incision of the
Trendelenburg common bile duct for removal of stones?
Positioning the patient in the Trendelenburg
position may be indicated if the patient is in Choledocholithotomy
shock, but is not the position designed for the Choledocholithotomy refers to incision of the
patient after liver biopsy. common bile duct for the removal of stones
(liths).
High Fowler's
High Fowler's position is not indicated for the Cholecystostomy
patient after liver biopsy. Cholecystostomy refers to opening and
drainage of the gallbladder.
Postnecrotic cirrhosis
In postnecrotic cirrhosis, there are broad 226.Which of the following clinical
bands of scar tissue, which are a late result characteristics is associated with Type 1
of a previous acute viral hepatitis. diabetes (previously referred to as insulin-
dependent diabetes mellitus [IDDM])?
Biliary cirrhosis
In biliary cirrhosis, scarring occurs in the liver Presence of islet cell antibodies
around the bile ducts. Individuals with Type 1 diabetes often have
islet cell antibodies.
Compensated cirrhosis
Compensated cirrhosis is a general term Obesity
given to the state of liver disease in which Individuals with Type 1 diabetes are usually
the liver continues to be able to function thin or demonstrate recent weight loss at the
effectively. time of diagnosis
Rare ketosis
224.Which of the following terms describes Individuals with Type 1 diabetes are ketosis-
the passage of a hollow instrument into a prone when insulin is absent.
cavity for the withdrawal of fluid?
Requirement for oral hypoglycemic agents
Paracentesis Individuals with Type 1 diabetes need insulin
Paracentesis may be used to withdraw ascitic to preserve life.
fluid if the fluid accumulation is causing
cardiorespiratory compromise.
227.Which of the following clinical
Astrerixis characteristics is associated with Type 2
Asterixis refers to involuntary flapping diabetes (previously referred to as non-
movements of the hands associated with insulin-dependent diabetes mellitus
metabolic liver dysfunction. [NIDDM])?
absorption of glucose in the intestinal
Can control blood glucose through diet system, resulting in a lower postprandial
and exercise blood glucose level.
Oral hypoglycemic agents may improve
blood glucose levels if dietary modification
and exercise are unsuccessful. 230.The nurse teaches the patient about
diabetes including which of the following
Usually thin at diagnosis statements?
Individuals with Type 2 diabetes are usually
obese at diagnosis. Elevated blood glucose levels contribute
to complications of diabetes, such as
Ketosis-prone diminished vision.
Individuals with Type 2 diabetes rarely When blood glucose levels are well
demonstrate ketosis, except in stress or controlled, the potential for complications of
infection. diabetes is reduced.
228.Of the following types of insulin, which is The only diet change needed in the
the most rapid acting? treatment of diabetes is to stop eating sugar.
It is not feasible, nor is it advisable, to
Humalog remove all sources of sugar from the diet.
The onset of action of rapid-acting Humalog
is within 10-15 minutes. Once insulin injections are started in the
treatment of Type 2 diabetes, they can never
Regular be discontinued.
The onset of action of short-acting regular If the diabetes had been well controlled
insulin is 30 minutes-1 hour. without insulin prior to the period of acute
stress causing the need for insulin, the
NPH patient may be able to resume previous
The onset of action of intermediate acting methods for control of diabetes when the
NPH is 3-4 hours. stress is resolved.
Ultralente
The onset of action of long-acting Ultralente 231.The nurse teaches the patient about
is 6-8 hours. glargine (Lantus), a "peakless" basal insulin
including which of the following statements?
229.Of the following categories of oral Do not mix the drug with other insulins
antidiabetic agents, which exert their Because glargine is in a suspension with a pH
primary action by directly stimulating the of 4, it cannot be mixed with other insulins
pancreas to secrete insulin? because this would cause precipitation. When
administering glargine (Lantus) insulin it is
Sulfonylureas very important to read the label carefully and
Therefore, a functioning pancreas is to avoid mistaking Lantus insulin for Lente
necessary for sulfonylureas to be effective. insulin and vice versa.
Cushing's syndrome
The patient with Cushing's syndrome 235.Trousseau's sign is positive when
demonstrates truncal obesity, moon face,
acne, abdominal striae, and hypertension. carpopedal spasm is induced by
occluding the blood flow to the arm for
Addison's disease 3 minutes with the use of a blood
In Addison's disease, the patient experiences pressure cuff.
chronic adrenocortical insufficiency. A positive Trousseau's sign is suggestive of
latent tetany.
Graves' disease
In Graves' disease, the patient experiences a sharp tapping over the facial nerve just in
hyperthyroidism. front of the parotid gland and anterior to the
ear causes spasm or twitching of the mouth,
Hashimoto's disease nose, and eye.
The individual with Hashimoto's disease A positive Chvostek's sign is demonstrated
demonstrates inflammation of the thyroid when a sharp tapping over the facial nerve
gland, resulting in hypothyroidism. just in front of the parotid gland and anterior
to the ear causes spasm or twitching of the
mouth, nose, and eye.
233.Of the following disorders, which results
from excessive secretion of somatotropin? after making a clenched fist, the palm
remains blanched when pressure is placed
Acromegaly over the radial artery.
The patient with acromegaly demonstrates A positive Allen's test is demonstrated by the
progressive enlargement of peripheral body palm remaining blanched with the radial
parts, most commonly the face, head, hands, artery occluded. The radial artery should not
and feet. be used for an arterial puncture.
Vasopressin trypsin.
Vasopressin causes contraction of smooth Trypsin aids in the digestion of proteins.
muscle, particularly blood vessels.
secretin.
Calcitonin Secretin is the major stimulus for increased
bicarbonate secretion from the pancreas.
240.When the nurse observes the patient's
urine to be orange, she further assesses the
237.The term used to describe total urine patient for
output of less than 400 mL in 24 hours is
intake of medication such as phenytoin
oliguria. (Dilantin).
Oliguria is associated with acute and chronic Urine that is orange may be caused by intake
renal failure. of Dilantin or other medications. Orange to
amber colored urine may also indicate
anuria. concentrated urine due to dehydration or
Anuria is used to describe total urine output fever.
of less than 50 mL in 24 hours.
bleeding.
nocturia. Urine that is pink to red may indicate lower
Nocturia refers to awakening at night to urinary tract bleeding.
urinate.
intake of multiple vitamin preparations.
dysuria. Urine that is bright yellow is an anticipated
Dysuria refers to painful or difficult urination. abnormal finding in the patient taking a
multiple vitamin preparation.
Cylindruria Hematocrit
Casts may be identified through microscopic Hemoglobin is recommended as it is more
examination of the urine sediment after accurate in the assessment of circulating
centrifuging. oxygen than hematocrit.
Overflow 400 cc
Overflow incontinence refers to the Residual urine that is greater than 100 cc
involuntary loss of urine associated with indicates that the suprapubic catheter cannot
overdistention of the bladder. be discontinued.
Urge
Urge incontinence refers to involuntary loss 245.When providing care to the patient with
of urine associated with urgency. bilateral nephrostomy tubes, the nurse never
does which of the following?
Reflex
Reflex incontinence refers to the involuntary Clamps each nephrostomy tube when
loss of urine due to involuntary urethral the patient is moved
relaxation in the absence of normal The nurse must never clamp a nephrostomy
sensations. tube because it could cause obstruction and
resultant pyelonephritis.
243.To facilitate entry of a catheter into the Reports a dislodged nephrostomy tube
male urethra, the penis should be positioned immediately
at which of the following degree angles (in A dislodged nephrostomy tube must be
relation to the body)? reported immediately to allow the surgeon to
replace the tube immediately to prevent the
90 degrees opening from contracting.
A right angle straightens the urethra and
makes it easier to insert the catheter. Measures urine output from each tube
separately
45 degrees The output from each tube is assessed,
A 45-degree angle will not straighten the indicating the functioning of the tube.
urethra.
Irrigates each nephrostomy tube with 30 cc
180 degrees of normal saline q8h as ordered
A 180-degree angle will result in the penis The nurse may irrigate a nephrostomy tube
being parallel to the body and with specific orders to do so.
inappropriately positioned for catheterization.
Constipation. Pyelonephritis
Constipation is a reversible cause of urinary Pyelonephritis is an upper urinary tract
incontinence in the older adult. Other inflammation, which may be acute or chronic.
reversible causes include acute urinary tract
infection, infection elsewhere in the body, Cystitis
decreased fluid intake, a change in a chronic Cystitis is inflammation of the urinary
disease pattern, and decreased estrogen bladder.
levels in the menopausal women.
Urethritis
Increased fluid intake Urethritis is inflammation of the urethra.
A decreased fluid intake, rather than
increased fluid intake, is a reversible cause of Interstitial nephritis
urinary incontinence in the older adult. Interstitial nephritis is inflammation of the
kidney.
Age
Age is a risk factor for urinary incontinence,
not a reversible cause. 250.If an indwelling catheter is necessary,
nursing interventions that should be
Decreased progesterone level in the implemented to prevent infection include
menopausal woman.
A decreased estrogen, not progresterone, performing meticulous perineal care
level in the menopausal woman is a daily with soap and water.
reversible cause of urinary incontinence in Cleanliness of the area will reduce potential
the older woman. for infection.
the areola (a darker tissue ring around on day 2 to day 4, counting the first day of
the nipple) develops. menses as day 1.
Stage 3 also involves further enlargement of Because the tenderness, lumpiness, and fluid
breast tissue. retention problems noticed by women in
relation to onset of menses generally
breast budding begins. continue through menses, BSE is not
Breast budding is the first sign of puberty in recommended during that time.
a female.
any time during the month.
the areola and nipple form a secondary Because most women notice increased
mound on top of breast tissue. tenderness, lumpiness, and fluid retention
In stage 4, the nipple and areola form a before their menstrual period, BSE is best
secondary mound on top of breast tissue. performed when the time for menses is taken
into account.
the breast develops into a single contour
In stage 5, the female demonstrates
continued development of a larger breast 270.Which type of biopsy is used for
with a single contour. nonpalpable lesions found on
mammography?
Onset of menses before 14 years of age screening women over age 65.
Increased risk is associated with early Ductal lavage is used for women at higher
menarche (i.e., menses beginning before 12 risk for benign proliferative breast disease; it
years of age). is not used as a screening tool.
Multiparity
Nulliparity and later maternal age for first women with breast implants.
birth are associated with increased risk for Ductal lavage is used for women at higher
breast cancer. risk for benign proliferative breast disease; it
is not specific for women with breast
No alcohol consumption implants.
Alcohol use remains controversial; however,
a slightly increased risk is found in women
who consume even one drink daily and 274.The 2000 NIH Consensus Development
doubles among women drinking three drinks Conference Statement states that what
daily. percentage of women with invasive breast
cancer should consider the option of
systemic chemotherapy, not just women
272.Which of the following terms is used to whose tumors are greater than 1cm in size?
describe removal of the breast tissue and an
axillary lymph node dissection leaving 100% (all)
muscular structure intact as surgical The 2000 Consensus Development
treatment of breast cancer? Conference Statement states that all women
with invasive breast cancer should consider
Modified radical mastectomy the option of systemic chemotherapy, not
A modified radical mastectomy leaves the just women whose tumors are greater than 1
pectoralis major and minor muscles intact. cm in size.
women at higher risk for benign 275.Which of the following terms refers to
proliferative breast disease. surgical removal of one of the testes?
Performed in the doctor's office, a
microcatheter is inserted through the nipple Orchiectomy
while instilling saline and retrieving the fluid Orchiectomy is required when the testicle
for analysis. It has been shown to identify has been damaged.
atypical cells in this population and has been
found to be adept at detecting cellular Circumcision
changes within the breast tissue. Circumcision is excision of the foreskin, or
prepuce, of the glans penis.
women at low risk for breast cancer.
Vasectomy sexually transmitted disease.
Vasectomy is the ligation and transection of
part of the vas deferens to prevent the
passage of the sperm from the testes. 278.The nurse teaches the patient who has
been prescribed Viagra which of the
Hydrocelectomy following guidelines?
Hydrocelectomy describes the surgical repair
of a hydrocele, a collection of fluid in the Do not take more than one tablet per
tunica vaginalis. day of your prescribed dose.
Taking Viagra more than once a day will not
improve its effects and the patient may
276.The term or disease associated with experience back and leg aches as well as
buildup of fibrous plaques in the sheath of nausea and vomiting.
the corpus cavernosum causing curvature of
the penis when it is erect is known as Viagra should be taken immediately before
intercourse.
Peyronie's disease. Viagra should be taken one hour before
Peyronie's disease may require surgical intercourse.
removal of the plaques when the disease
makes sexual intercourse painful, difficult, or Viagra will result in erection formation.
impossible. Viagra will not create the erection; the
erection must be created by sexual
Bowen's disease stimulation.
Bowen's disease refers to a form of Viagra will restore sex drive.
squamous cell carcinoma in situ of the penile Viagra will not restore desire or sex drive.
shaft.
phimosis.
Phimosis refers to the condition in which the 279.The obstructive and irritative symptom
foreskin is constricted so that it cannot be complex caused by benign prostatic
retracted over the glans. hypertrophy is termed
priapism. prostatism.
Priapism refers to an uncontrolled, persistent Symptoms of prostatism include increased
erection of the penis occurring from either frequency of urination, nocturia, urgency,
neural or vascular causes. dribbling, and a sensation that the bladder
has not completely emptied.
Epispadias prostaglandin.
Epispadias is a congenital anomaly in which Prostaglandins are physiologically active
the urethral opening is on the dorsum of the substances present in tissues with
penis and is usually repaired through plastic vasodilator properties.
surgery when the boy is very young.
prostatectomy.
Hypospadias Prostatectomy refers to the surgical removal
Hypospadias is a congenital anomaly in of the prostate gland.
which the urethral opening is on the
underside of the penis and is usually repaired
through plastic surgery when the boy is very 280.Proteins formed when cells are exposed
young. to viral or foreign agents that are capable of
activating other components of the immune
Urethral stricture system are referred to as
Urethral stricture is a condition in which a
section of urethra is narrowed. interferons.
Interferons are biologic response modifiers
Urethritis with nonspecific viricidal proteins.
Urethritis refers to inflammation of the
urethra and is commonly associated with antibodies.
Antibodies are protein substances developed invader.
by the body in response to and interacting
with a specific foreign substance.
283.Which of the following responses
antigens. identifies a role of T lymphocytes?
Antigens are substances that induce
formation of antibodies. Transplant rejection
Transplant rejection and graft-versus-host
complements. disease are cellular response roles of T cells.
Complement refers to a series of enzymatic
proteins in the serum that, when activated, Anaphylaxis
destroy bacteria and other cells. Anaphylaxis is a humoral response role of B-
lymphocytes.
occur most commonly in the aged 289.Ataxia is the term that refers to
population.
Primary immunodeficiencies are seen uncoordinated muscle movement.
primarily in infants and young children. Ataxia-telangiectasia is an autosomal
recessive disorder affecting both T-cell and
develop as a result of treatment with B-cell immunity.
antineoplastic agents.
Primary immunodeficiencies are rare vascular lesions caused by dilated blood
disorders with genetic origins. vessels.
Telangiectasia is the term that refers to
disappear with age. vascular lesions caused by dilated blood
Without treatment, infants and children with vessels.
these disorders seldom survive to adulthood.
inability to understand the spoken word.
Receptive aphasia is an inability to
287.Agammaglobulinemia is also known as understand the spoken word.
Pneumocystic carinii
Pneumocystic carinii is an organism that is 293.Which of the following substances may
thought to be protozoan but believed to be a be used to lubricate a condom?
fungus based on its structure.
K-Y jelly
K-Y jelly is water-based and will provide
291.Of the following blood tests, which lubrication while not damaging the condom.
confirms the presence of antibodies to HIV?
Skin lotion
Enzyme-linked immunoabsorbant assay The oil in skin lotion will cause the condom to
(ELISA) break.
ELISA, as well as Western blot assay,
identifies and confirms the presence of Baby oil
antibodies to HIV. Baby oil will cause the condom to break.
p24 antigen
The p24 antigen is a blood test that 294.More than 500 CD4+ T
measures viral core protein. lymphocytes/mm3 indicates which stage of
HIV infection?
Reverse transcriptase
Reverse transcriptase is not a blood test. CDC category A - HIV asymptomatic
Rather, it is an enzyme that transforms More than 500 CD4+ T lymphocytes/mm3
single-stranded RNA into a double-stranded indicates CDC category A - HIV
DNA. asymptomatic.
Wearing of medical alert bracelet 303.The nurse teaches the patient with
The medical alert bracelet will assist those allergies about anaphylaxis including which
rendering aid to the patient who has of the following statements?
experienced an anaphylactic reaction.
The most common cause of anaphylaxis
is penicillin.
301.When the nurse observes diffuse The most common cause of anaphylaxis,
swelling involving the deeper skin layers in accounting for about 75% of fatal
the patient who has experienced an allergic anaphylactic reactions in the U.S., is
reaction, the nurse records the finding as penicillin.
Remission
305.Which of the following terms refers to Active range of motion and isometrics are
fixation or immobility of a joint? recommended during the remission stage of
rheumatic diseases.
Ankylosis
Ankylosis may result from disease or scarring
due to trauma. 308.Which of the following connective tissue
disorders is characterized by insoluble
Hemarthrosis collagen being formed and accumulating
Hemarthrosis refers to bleeding into the joint. excessively in the tissues?
Diarthrodial Scleroderma
Diarthrodial refers to a joint with two freely Scleroderma occurs initially in the skin but
moveable parts. also occurs in blood vessels, major organs,
and body systems, potentially resulting in
Arthroplasty death.
Arthroplasty refers to replacement of a joint.
Rheumatoid arthritis
Rheumatoid arthritis results from an
306.Accumulation of crystalline depositions autoimmune response in the synovial tissue
in articular surfaces, bones, soft tissue, and with damage taking place in body joints.
cartilage is referred to as
Systemic lupus erythematosus
tophi. SLE is an immunoregulatory disturbance that
Tophi, when problematic, are surgically results in increased autoantibody production.
excised.
Polymyalgia rheumatic
In polymyalgia rheumatic, immunoglobulin is
deposited in the walls of inflamed temporal 311.Which of the following statements reflect
arteries. nursing interventions in the care of the
patient with osteoarthritis?
Vitiligo syphilis.
Vitiligo results in the development of white A painless chancre or ulcerated lesion is a
patches that may be localized or widespread. typical finding in the patient with syphilis.
Hirsutism
Hirsutism is the condition of having excessive 316.The nurse reading the physician's report
hair growth. of an elderly patient’s physical examination
knows a notation that the patient
Lichenification demonstrates xanthelasma refers to
Lichenification refers to a leathery thickening
of the skin. yellowish waxy deposits on upper
eyelids.
Telangiectases The change is a common, benign
Telangiectases refers to red marks on the manifestation of aging skin or it can
skin caused by stretching of the superficial sometimes signal hyperlipidemia.
blood vessels.
liver spots.
Solar lentigo is the term that refers to liver
314.Of the following types of cells, which are spots.
believed to play a significant role in
cutaneous immune system reactions? dark discoloration of the skin.
Melasma is the term that refers to dark
Langerhans' cells discoloration of the skin.
Langerhans' cells are common to the
epidermis and are accessory cells of the bright red moles.
afferent immune system process. Cherry angioma is the term that is used to
describe a bright red mole.
Merkel's cells
Merkel's cells are the receptor cells in the
epidermis that transmit stimuli to the axon 317.The nurse notes that the patient
via a chemical response. demonstrates generalized pallor and
recognizes that this finding may be indicative
Melanocytes of
Melanocytes are special cells of the
epidermis that are primarily involved in anemia.
producing melanin, which colors the hair and In the light-skinned individual, generalized
skin. pallor is a manifestation of anemia. In brown-
and black-skinned individuals, anemia is
Phagocytes demonstrated as a dull skin appearance.
Phagocytes are white blood cells that engulf
and destroy foreign materials. albinism.
Albinism is a condition of total absence of
pigment in which the skin appears whitish
315.When the nurse assesses the patient pink.
and observes blue-red and dark brown
plaques and nodules, she recognizes that vitiligo.
these manifestations are associated with Vitiligo is a condition characterized by the
destruction of the melanocytes in
Kaposi's sarcoma. circumscribed areas of skin, resulting in
Kaposi's sarcoma is a frequent comorbidity of patchy, milky white spots.
the patient with AIDS.
local arterial insufficiency. absorb and retain moisture from the air and
Local arterial insufficiency is characterized by to reduce friction between surfaces.
marked localized pallor.
Paste
A paste is a mixture of powder and ointment.
318.Which of the following terms refers most
precisely to a localized skin infection of a Linament
single hair follicle? A linament is a lotion with oil added to
prevent crusting.
Furuncle
Furuncles occur anywhere on the body, but
are most prevalent in areas subjected to 321.Which of the following skin conditions is
irritation, pressure friction, and excessive caused by staphylococci, streptococci, or
perspiration, such as the back of the neck, multiple bacteria?
the axillae, or the buttocks.
Impetigo
Carbuncle Impetigo is seen at all ages, but is
A carbuncle is a localized skin infection particularly common among children living
involving several hair follicles. under poor hygienic conditions.
Chelitis. Scabies
Chelitis refers to dry cracking at the corners Scabies is caused by the itch mite.
of the mouth.
Pediculosis capitis
Comedone. Pediculosis capitis is caused by head lice.
Comedones are the primary lesions of acne,
caused by sebum blockage in the hair follicle. Poison ivy
Poison ivy is a contact dermatitis caused by
the oleoresin given off by a particular form of
319.The nurse recommends which of the ivy.
following types of therapeutic baths for its
antipruritic action?
322.The nurse teaches the patient who
Colloidal (Aveeno, oatmeal) demonstrates herpes zoster (shingles) that
Aveeno or oatmeal baths are recommended
to decrease itching associated with a the infection results from reactivation
dermatologic disorder. of the chickenpox virus.
It is assumed that herpes zoster represents a
Sodium bicarbonate (baking soda) reactivation of latent varicella (chickenpox)
Baking soda baths are cooling but dangerous. virus and reflects lowered immunity.
The tub gets very slippery and a bath mat
must be used in the tub. once a patient has had shingles, they will not
have it a second time.
Water It is believed that the varicella zoster virus
Water baths have the same effect as wet lies dormant inside nerve cells near the brain
dressings, not known to counteract itching. and spinal cord and is reactivated with
weakened immune systems and cancers.
Saline
Saline baths have the same effects as saline a person who has had chickenpox can
dressings, not known to counteract itching. contract it again upon exposure to a person
with shingles.
A person who has had chickenpox is immune
320.Which of the following materials consists and, therefore, not at risk of infection after
of a powder in water? exposure to patients with herpes zoster.
Tinnitus Tympanotomy
Tinnitus refers to a subjective perception of A tympanotomy is an incision into the
sound with internal origin. tympanic membrane.
Nystagmus Myringotomy
Nystagmus refers to involuntary rhythmic A myringotomy is an incision into the
eye movement. tympanic membrane.
Ossiculoplasty
347.Of the following terms, which describes a An ossiculoplasty is a surgical reconstruction
condition characterized by abnormal spongy of the middle ear bones to restore hearing.
bone formation around the stapes?
Paraparesis occipital
Paraparesis is a frequent manifestation of The occipital lobe is responsible for visual
degenerative neurologic disorders. interpretation.
Hemiplegia
Hemiplegia refers to paralysis of one side of 359.The lobe of the brain that is the largest
the body or a part of it due to an injury to the and controls abstract thought is the
motor areas of the brain. ____________ lobe.
Quadriparesis frontal
Quadriparesis refers to weakness that The frontal lobe also controls information
involves all four extremities. storage or memory and motor function.
Paraplegia temporal
Paraplegia refers to paralysis of both legs The temporal lobe contains the auditory
and the lower trunk. receptive area.
parietal
357.Of the following neurotransmitters, The parietal lobe contains the primary
which demonstrates inhibitory action, helps sensory cortex, which analyzes sensory
control mood and sleep, and inhibits pain information and relays interpretation to the
pathways? thalamus and other cortical areas.
Serotonin occipital
The sources of serotonin are the brain stem, The occipital lobe is responsible for visual
hypothalamus, and dorsal horn of the spinal interpretation.
cord.
Norepinephrine Meninges
Norepinephrine is usually excitatory and The meninges have three layers, the dura
affects mood and overall activity. mater, arachnoid mater, and pia mater.
Arachnoid mater
358.The lobe of the brain that contains the The arachnoid is the middle membrane of the
auditory receptive areas is the ____________ protective covering of the brain and spinal
lobe. cord.
Electrocardiography
368.What safety actions does the nurse need Electrocardiography is performed to assess
to take for a patient on oxygen therapy who the electrical activity of the heart.
is undergoing magnetic resonance imaging
(MRI)? Electrogastrography
Electrogastrography is an electrophysiologic
Ensure that no patient care equipment study performed to assess gastric motility
containing metal enters the room where disturbances.
the MRI is located.
For patient safety the nurse must make sure
no patient care equipment (e.g., portable 370.Which of the following are sympathetic
oxygen tanks) that contains metal or metal effects of the nervous system?
parts enters the room where the MRI is
located. The magnetic field generated by the Dilated pupils
unit is so strong that any metal-containing Dilated pupils are a sympathetic effect of the
items will be strongly attracted and can nervous system. Constricted pupils are a
literally be pulled away with such great force parasympathetic effect.
that they can fly like projectiles towards the
magnet. Decreased blood pressure
Decreased blood pressure is a
Securely fasten the patient's portable oxygen parasympathetic effect. Increased blood
tank to the bottom of the MRI table after the pressure is a sympathetic effect.
patient has been positioned on the top of the
Increased peristalsis the dynamic equilibrium of cranial
Increased peristalsis is a parasympathetic contents.
effect. Decreased peristalsis is a sympathetic The hypothesis states that because of the
effect. limited space for expansion within the skull,
an increase in any one of the cranial contents
Decreased respiratory rate (brain tissue, blood, or cerebrospinal fluid)
Decreased respiratory rate is a causes a change in the volume of the others.
parasympathetic effect. Increased respiratory
rate is a sympathetic effect. unresponsiveness to the environment.
Akinetic mutism is the phrase used to refer to
unresponsiveness to the environment.
371.Lesions in the temporal lobe may result
in which of the following types of agnosia? the brain's attempt to restore blood flow by
increasing arterial pressure to overcome the
Auditory increased intracranial pressure.
Lesions in the temporal lobe (lateral and Cushing's response is the phrase used to
superior portions) may result in auditory refer to the brain's attempt to restore blood
agnosia. flow by increasing arterial pressure to
overcome the increased intracranial
Visual pressure.
Lesions in the occipital lobe may result in
visual agnosia. a condition in which the patient is wakeful
but devoid of conscious content, without
Tactile cognitive or affective mental function.
Lesions in the parietal lobe may result in Persistent vegetative state is the phrase used
tactile agnosia. to describe a condition in which the patient is
wakeful but devoid of conscious content,
Relationship without cognitive or affective mental
Lesions in the parietal lobe (posteroinferior function.
regions) may result in relationship and body
part agnosia.
374.A patient who demonstrates an
obtunded level of consciousness
372.When the nurse observes that the
patient has extension and external rotation sleeps almost constantly but can be
of the arms and wrists and extension, plantar aroused and can follow simple
flexion, and internal rotation of the feet, she commands.
records the patient's posturing as An obtunded patient stays awake only with
persistent stimulation.
decerebrate.
Decerebrate posturing is the result of lesions has difficulty following commands, and may
at the midbrain and is more ominous than be agitated or irritable.
decorticate posturing. A confused patient has difficulty following
commands, and may be agitated or irritable.
normal.
The described posturing results from cerebral sleeps often and shows slowed speech and
trauma and is not normal. thought processes.
A patient who sleeps often and shows slowed
flaccid. speech and thought processes is described
The patient has no motor function, is limp, as lethargic.
and lacks motor tone with flaccid posturing.
does not respond to environmental stimuli.
decorticate. A comatose patient does not respond to
In decorticate posturing, the patient has environmental stimuli.
flexion and internal rotation of the arms and
wrists and extension, internal rotation, and
plantar flexion of the feet. 375.An osmotic diuretic, such as Mannitol, is
given to the patient with increased
intracranial pressure (IICP) in order to
373.Monro-Kellie hypothesis refers to
dehydrate the brain and reduce cerebral
edema.
Osmotic diuretics draw water across intact Trauma
membranes, thereby reducing the volume of Trauma is associated with hemorrhagic
brain and extracellular fluid. strokes.
control shivering.
Chloropromazine (Thorazine) may be 378.When the patient is diagnosed as having
prescribed to control shivering in the patient global aphasia, the nurse recognizes that the
with IICP. patient will
Agnosia
Auditory agnosia is failure to recognize 383.A patient has had neurologic deficits
significance of sounds. lasting for more than 24 hours, and now the
symptoms are resolving. The nurse
Agraphia concludes that the patient has had which
Agraphia refers to disturbances in writing type of stroke?
intelligible words.
Reversible ischemic neurologic deficit
Apraxia With a reversible ischemic neurologic deficit,
Apraxia refers to inability to perform the patient has more pronounced signs and
previously learned purposeful motor acts on symptoms that last more than 24 hours;
a voluntary basis. symptoms resolve in a matter of days
without any permanent neurologic deficit.
Perseveration
Perseveration is the continued and automatic Transient ischemic attack (TIA)
repetition of an activity, word, or phrase that With a TIA, the patient has a temporary
is no longer appropriate. episode of neurologic dysfunction that may
last a few seconds or minutes but not longer
than 24 hours.
381.Which of the following terms related to
aphasia refers to difficulty reading? Stroke in evolution
With a stroke in evolution the patient
Alexia experiences a worsening of neurological
Alexia or dyslexia may occur in the absence signs and symptoms over several minutes or
of aphasia. hours; it is a progressing stroke.
Paraphasia
Paraphasia refers to using wrong words, word 385.A patient who has had a previous stroke
and is taking warfarin tells the nurse that he Intracerebral hemorrhage is bleeding in the
started taking garlic to help reduce his blood brain or the cerebral tissue with
pressure. The nurse knows that garlic when displacement of surrounding structures.
taken together with warfarin
epidural hematoma.
can greatly increase the international An epidural hematoma is bleeding between
normalization ratio (INR) and therefore the inner skull and the dura, compressing the
increase the risk of bleeding. brain underneath.
Garlic and warfarin taken together can
greatly increase the INR, increasing the risk extradural hematoma.
of bleeding. An extradural hematoma is another name for
an epidural hematoma.
Spondylosis
399.Which of the following terms refers to Spondylosis refers to degenerative arthritis of
muscular hypertonicity with increased the cervical or lumbar vertebrae.
resistance to stretch?
Ataxia Prodrome
Ataxia refers to impaired ability to coordinate The prodrome phase occurs hours to days
movement. before a migraine headache.
Myclonus Headache
Myoclonus refers to spasm of a single muscle The headache phase lasts from 4 to 72 hours.
or group of muscles.
Recovery
During the post-headache phase, patients
400.Of the following terms, which refers to may sleep for extended periods.
blindness in the right or left halves of the
visual fields of both eyes?
403.The most common type of brain
Homonymous hemianopsia neoplasm is the
Homonymous hemianopsia occurs with
occipital lobe tumors. glioma.
Gliomas are the most common brain
Scotoma neoplasms, accounting for about 45% of all
Scotoma refers to a defect in vision in a brain tumors.
specific area in one or both eyes.
angioma.
Diplopia Angiomas account for approximately 4% of
Diplopia refers to double vision or the brain tumors.
awareness of two images of the same object
occurring in one or both eyes. meningioma.
Meningiomas account for 15-20% of all brain
Nystagmus tumors.
Nystagmus refers to rhythmic, involuntary
movements or oscillations of the eyes. neuroma.
Neuromas account for 7% of all brain tumors. Creutzfeldt-Jakob's disease is a rare,
transmissible, progressive fatal disease of
the central nervous system characterized by
404.Which of the following diseases is a spongiform degeneration of the gray matter
chronic, degenerative, progressive of the brain.
disease of the central nervous system
characterized by the occurrence of
small patches of demyelination in the 406.Which of the following diseases is a
brain and spinal cord? chronic, progressive, hereditary disease of
the nervous system that results in
Multiple sclerosis progressive involuntary dance-like movement
The cause of MS is not known and the and dementia?
disease affects twice as many women as
men. Huntington's disease
Because it is transmitted as an autosomal
Parkinson's disease dominant genetic disorder, each child of a
Parkinson's disease is associated with parent with HD has a 50% risk of inheriting
decreased levels of dopamine caused by the illness.
destruction of pigmented neuronal cells in
the substantia nigra in the basal ganglia of Multiple sclerosis
the brain. Multiple sclerosis is a chronic, degenerative,
progressive disease of the CNS characterized
Huntington's disease by the occurrence of small patches of
Huntington's disease is a chronic, demyelination in the brain and spinal cord.
progressive, hereditary disease of the
nervous system that results in progressive Parkinson's disease
involuntary dance-like movement and Parkinson's disease is associated with
dementia. decreased levels of dopamine due to
destruction of pigmented neuronal cells in
Creutzfeldt-Jakob's disease the substantia nigra in the basal ganglia of
Creutzfeldt-Jakob's disease is a rare, the brain.
transmissible, progressive fatal disease of
the central nervous system characterized by Creutzfeldt-Jakob's disease
spongiform degeneration of the gray matter Creutzfeldt-Jakob's disease is a rare,
of the brain. transmissible, progressive fatal disease of
the central nervous system characterized by
spongiform degeneration of the gray matter
405.Which of the following diseases is of the brain.
associated with decreased levels of
dopamine due to destruction of pigmented
neuronal cells in the substantia nigra in the 407.Which of the following diseases is a rare,
basal ganglia of the brain? transmissible, progressive fatal disease of
the central nervous system characterized by
Parkinson's disease spongiform degeneration of the gray matter
In some patients, Parkinson's disease can be of the brain?
controlled; however, it cannot be cured.
Creutzfeldt-Jakob's disease
Multiple sclerosis The disease causes severe dementia and
Multiple sclerosis is a chronic, degenerative, myoclonus.
progressive disease of the CNS characterized
by the occurrence of small patches of Multiple sclerosis
demyelination in the brain and spinal cord. Multiple sclerosis is a chronic, degenerative,
progressive disease of the CNS characterized
Huntington's disease by the occurrence of small patches of
Huntington's disease is a chronic, demyelination in the brain and spinal cord.
progressive, hereditary disease of the
nervous system that results in progressive Parkinson's disease
involuntary dance-like movement and Parkinson's disease is associated with
dementia. decreased levels of dopamine due to
destruction of pigmented neuronal cells in
Creutzfeldt-Jakob's disease the substantia nigra in the basal ganglia of
the brain. Providing comfort measures directed at the
headache, include dimmed lights, limited
Huntington's disease noise, and analgesics are the basic nursing
Huntington's disease is a chronic, measures in the care of the patient with a
progressive, hereditary disease of the viral encephalitis.
nervous system that results in progressive
involuntary dance-like movement and Administering narcotic analgesics
dementia. Narcotic analgesics may mask neurologic
symptoms; therefore, they are used
cautiously.
408.Bell's palsy is a disorder of which cranial
nerve? Administering amphotericin B.
With viral encephalitis, acyclovir therapy is
Facial (VII) commonly prescribed; Amphotericin B is
Bell's palsy is characterized by facial used in the treatment of fungal encephalitis.
dysfunction, weakness, and paralysis
Monitoring cardiac output
Trigeminal (V) Nursing management of the patient with viral
Trigeminal neuralgia is a disorder of the encephalitis includes monitoring of blood
trigeminal nerve and causes facial pain. chemistry test results and urinary output to
alert the nurse to the presence of renal
Vestibulocochlear (VIII) complications related to acyclovir therapy.
Meniere's syndrome is a disorder of the
vestibulocochlear nerve.
411.Nursing management of the patient with
Vagus (X) new variant Creutzfeldt-Jakob Disease
Guillain-Barre syndrome is a disorder of the (nvCJD) includes
vagus nerve.
providing supportive care.
The nvCJD is a progressive fatal disease with
409.The most common cause of acute no treatment available. Due to the fatal
encephalitis in the United States is outcome of nvCJD, nursing care is primarily
supportive.
Herpes Simplex Virus (HSV).
Viral infection is the most common cause of initiating isolation procedures.
encephalitis. HSV is the most common cause Prevention of disease transmission is an
of acute encephalitis in the U.S. important part of providing nursing care.
Although patient isolation is not necessary,
Cryptococcus neoformans. use of standard precautions is important.
C. neoformans is one of several fungi that Institutional protocols are followed for blood
may cause fungal encephalitis. Fungal and body fluid exposure and
infections of the central nervous system decontamination of equipment.
occur rarely in healthy people.
preparing for organ donation.
Western equine bacteria. Organ donation is not an option because of
The Western equine encephalitis virus is one the risk for disease transmission.
of four types of arboviral encephalitis that
occur in North America. administering amphotericin B.
Amphotericin B is used in the treatment of
Candida albicans. fungal encephalitis; no treatment is available
C. albicans is one of several fungi that may for nvCJD.
cause fungal encephalitis. Fungal infections
of the central nervous system occur rarely in
healthy people. 412.Three medications referred to as the
'ABC drugs' are currently the main
pharmacological therapy for multiple
410.Which of the following reflects basic sclerosis. Which of the following statements
nursing measures in the care of the patient reflects information to be included in patient
with viral encephalitis? teaching?
414.The primary North American vector indicate renal toxicity and a worsening of the
transmitting arthropod-borne virus patient's condition.
encephalitis is the Renal toxicity due to amphotericin B is dose
limiting. Monitoring the serum creatinine and
mosquito blood urea nitrogen levels may alert the
Arthropod vectors transmit several types of nurse to the development of renal
viruses that cause encephalitis. The primary insufficiency and the need to address the
vector in North America is the mosquito. patients’ renal status.
signs and symptoms of cardiac insufficiency. mood changes and fluid and electrolyte
Monitoring of blood chemistry test results alterations.
and urinary output will alert the nurse to the Patients receiving corticosteroids are
presence of renal complications related to monitored for side effects related to
acyclovir therapy. corticosteroids such as mood changes and
fluid and electrolyte alterations.
signs of relapse.
Monitoring of blood chemistry test results renal insufficiency.
and urinary output will alert the nurse to the Patients receiving mitoxantrone are closely
presence of renal complications related to monitored for leukopenia and cardiac
acyclovir therapy. To prevent relapse toxicity.
treatment with acyclovir should continue for
up to 3 weeks. hypoxia.
Patients receiving mitoxantrone are closely
signs of improvement in the patient's monitored for leukopenia and cardiac
condition. toxicity.
Monitoring of blood chemistry test results
and urinary output will alert the nurse to the
presence of renal complications related to 420.What percentage of patients who
acyclovir therapy. survived the polio epidemic of the 1950s are
now estimated to have developed post-polio
syndrome?
418.Medical management of arthropod-borne
virus (arboviral) encephalitis is aimed at 60-80%
Patients who survived the polio epidemic of
controlling seizures and increased the 1950s, many now elderly, are developing
intracranical pressure. new symptoms of weakness, fatigue and
There is no specific medication for musculoskeletal pain. It is estimated that
arboviral encephalitis. Medical between 60% and 80% of the 640,000 polio
management is aimed at controlling survivors are experiencing the phenomenon
seizures and increased intracranial known as post-polio syndrome.
pressure.
50%
preventing renal insufficiency. It is estimated that between 60 and 80% of
Medical management is aimed at controlling patients who survived the polio epidemic of
seizures and increased intracranial pressure. the 1950s are now experiencing post-polio
syndrome.
maintaining hemodynamic stability and
25-30% Administering antiretroviral agents.
It is estimated that between 60 and 80% of No specific medical or surgical treatment is
patients who survived the polio epidemic of available for this syndrome.
the 1950s are now experiencing post-polio
syndrome. Planning activities for evening hours rather
then morning hours.
10% Patients need to plan and coordinate
It is estimated that between 60 and 80% of activities to conserve energy and reduce
patients who survived the polio epidemic of fatigue. Important activities should be
the 1950s are now experiencing post-polio planned for the morning as fatigue often
syndrome. increases in the afternoon and evening.
Trabecula
Trabecula refers to lattice-like bone 430.Which of the following terms refers to a
structure. grating or crackling sound or sensation?
Callus
427.An osteon is defined as a Callus is fibrous tissue that forms at the
fracture site.
microscopic functional bone unit.
The center of an osteon contains a capillary. Clonus
Clonus refers to rhythmic contraction of
bone-forming cell. muscle.
An osteoblast is a bone-forming cell.
Fasciculation
Fasciculation refers to involuntary twitch of and debride the fracture area.
muscle fibers.
Revascularization
Revascularization occurs within about 5 days
431.Which of the following terms refers to after the fracture.
muscle tension being unchanged with muscle
shortening and joint motion? Reparative
Callus formation occurs during the reparative
Isotonic contraction stage but is disrupted by excessive motion at
Exercises such as swimming and bicycling the fracture site.
are isotonic.
All fracture healing takes place at the same external soft tissue.
rate no matter the type of bone fractured. Fracture healing occurs in four areas,
The type of bone fractured, the adequacy of including the bone marrow, bone cortex,
blood supply, the surface contact of the periosteum, and the external soft tissue,
fragments, and the general health of the where a bridging callus (fibrous tissue)
person influence the rate of fracture healing. stabilizes the fracture.
fascia.
437.Diminished range of motion, loss of Fracture healing occurs in four areas,
flexibility, stiffness, and loss of height are including the bone marrow, bone cortex,
history and physical findings associated with periosteum, and the external soft tissue.
age-related changes of the Fascia is fibrous tissue that covers, supports,
and separates muscles.
joints.
History and physical findings associated
with age-related changes of the joints 439.Which of the following is an indicator of
include diminished range of motion, loss neurovascular compromise?
of flexibility, stiffness, and loss of
height. Capillary refill more than 3 seconds
Capillary refill more than 3 seconds is an
bones. indicator of neurovascular compromise.
History and physical findings associated with Other indicators include cool skin
age-related changes of bones include loss of temperature, pale or cyanotic color,
height, posture changes, kyphosis, flexion of weakness, paralysis, paresthesia, unrelenting
hips and knees, back pain, osteoporosis, and pain, pain on passive stretch, and absence of
fracture. feeling.
Continuous passive motion (CPM) device Keep the knees together at all times.
A CPM device is an instrument that moves a The patient should be taught to keep the
body part to promote healing and circulation. knees apart at all times.
Achilles
Injury to the peroneal nerve as a result of 449.Which of the following terms refers to
pressure is a cause of footdrop. disease of a nerve root?
Radiculopathy
447.The nurse teaching the patient with a When the patient reports radiating pain down
cast about home care includes which of the the leg, he is describing radiculopathy.
following instructions?
Involucrum
Dry a wet fiberglass cast thoroughly using a Involucrum refers to new bone growth
hair dryer on a cool setting to avoid skin around the sequestrum.
problems.
Instruct the patient to keep the cast dry and Sequestrum
to dry a wet fiberglass cast thoroughly using Sequestrum refers to dead bone in an
a hair dryer on a cool setting to avoid skin abscess cavity.
problems; do not cover it with plastic or
rubber. Contracture
Contracture refers to abnormal shortening of
Cover the cast with plastic or rubber. muscle or fibrosis of joint structures.
A cast should be kept dry; do not cover it
with plastic or rubber because this causes
condensation, which dampens the cast and 450.Of the following common problems of
skin. the upper extremities, which results from
entrapment of the median nerve at the
Keep the cast below heart level. wrist?
A casted extremitiy should be elevated
frequently to heart level to prevent swelling. Carpal tunnel syndrome
Carpal tunnel syndrome is commonly due to
Fix a broken cast by applying tape. repetitive hand activities.
A broken cast should be reported to the
physician; the patient should not attempt to Ganglion
fix it. A ganglion, a collection of gelatinous material
near the tendon sheaths and joints, appears
as a round, firm, cystic swelling, usually on
448.A continuous passive motion (CPM) the dorsum of the wrist.
device applied after knee surgery
Dupuytren's contracture
promotes healing by increasing Dupuytren's contracture is a slowly
circulation and movement of the knee progressive contracture of the palmar fascia.
Staphylococcus aureus causes 70-80% of
Impingement syndrome bone infections.
Impingement syndrome is associated with
the shoulder and may progress to a rotator Proteus species
cuff tear. While Proteus species are frequently found in
osteomyelitis, they do not cause the majority
of bone infections.
451.When the nurse notes that the patient's
left great toe deviates laterally, she Pseudomonas species
recognizes that the patient has a While Pseudomonas species are frequently
found in osteomyelitis, they do not cause the
hallux valgus. majority of bone infections.
Hallux valgus is commonly referred to as a
bunion. Escherichia coli
While E. coli is frequently found in
hammertoe. osteomyelitis, it does not cause the majority
Hammertoes are usually pulled upward. of bone infections
pes cavus.
Pes cavus refers to a foot with an abnormally 454.Which of the following statements
high arch and a fixed equinus deformity of reflects information to be included when
the forefoot. teaching the patient about plantar fasciitis?
Staphylococcus
455.Lifestyle risk factors for osteoporosis and caffeine consumption in moderation, and
include performing a regular weight-bearing exercise
regimen.
lack of exposure to sunshine.
Lifestyle risk factors for osteoporosis include Decrease the intake of vitamin A and D.
lack of exposure to sunshine, low calcium Risk-lowering strategies for osteoporosis
and vitamin D diet, cigarette smoking, use of include increasing dietary calcium and
alcohol and/or caffeine, and lack of weight- vitamin D intake,
bearing exercise. walking or exercising out of doors, smoking
cessation, consuming alcohol and caffeine
lack of aerobic exercise. consumption in moderation, and performing
Lack of weight-bearing exercise, not aerobic a regular weight-bearing exercise regimen.
exercise, is a lifestyle risk factor for
osteoporosis.
457.Instructions for the patient with low back
a low protein, high fat diet. pain include which of the following?
A low calcium and vitamin D diet, not a low
protein, high fat diet, is a lifestyle risk factor When lifting, avoid overreaching.
for osteoporosis. Instructions for the patient with low back pain
should include that when lifting, the patient
an estrogen deficiency or menopause. should avoid overreaching. The patient
An estrogen deficiency or menopause is an should also keep the load close to the body,
individual, not lifestyle risk factor for bend the knees and tighten the abdominal
osteoporosis. Other individual risk factors muscles, use a wide base of support, and use
include female gender, white non-Hispanic or a back brace to protect the back.
Asian race, increased age, low weight and
body mass index, family history of When lifting, place the load away from the
osteoporosis, low initial bone mass, and body.
contributing co-existing medical conditions When lifting, the patient with low back pain
and medications. should keep the load close to the body.
45-160 days.
Hepatitis B is responsible for more than 200 478.Which of the following statements
deaths of healthcare workers annually. reflects the nursing management of the
patient with West Nile Virus infection?
15-50 days.
The incubation period for hepatitis B is 45- There is no treatment for West Nile
160 days. Virus infection.
Patients are supported by fluid replacement,
6-9 months. airway management, and standard nursing
The incubation period for hepatitis B is care support during the time that the patient
shorter than 6-9 months. has meningitis symptoms.
476.Which of the following terms refers to a Patients with West Nile virus present with
state of microorganisms being present within gastrointestinal complaints, such as nausea,
a host without causing host interference or vomiting, diarrhea, and abdominal pain.
interaction? Most human infections are asymptomatic.
When symptoms are present, headache and
Colonization fever are most frequently reported. Less than
Understanding the principle of colonization one percent of those infected develop more
facilitates interpretation of microbiologic severe illness, including meningitis.
reports.
Transmission of West Nile virus occurs from
Susceptible human-to-human.
A susceptible host is a host who does not Birds are the natural reservoir for the virus.
possess immunity to a particular pathogen. Mosquitoes become infected when feeding
on birds and can transmit the virus to
Immune animals and humans. There is no human-to-
human transmission of virus. establish isolation with positive pressure.
Isolation with negative pressure should be
established.
479.Prophylaxis antibiotic for anthrax is
given to people with symptoms who have Assess the patient for signs of a rash similar
been in a defined "hot zone" for a period of to chickenpox in appearance and
progression.
60 days. The lesions associated with smallpox may
Those with symptoms who have been in the appear similar in appearance, but the
hot zone should be given 60 days of progression is very different from that of
prophylactic antibiotic. The aim of chickenpox. Smallpox lesions will appear to
prophylaxis is to assure that if spores were be at the same stage of development as the
inhaled, bacteria will be killed immediately rash progresses from macules to papules to
upon release from spores. Those who have pustules to scabs. This progression is very
symptoms of fever, cough, headache, chills, different from that of chickenpox. With
and especially evidence of mediastinal lymph chickenpox, lesions appear at different
node involvement should be treated with developmental stages.
intravenous antibiotics and respiratory
support, if needed.
481.The six elements necessary for infection
30 days. are a causative organism, a reservoir of
Those with symptoms who have been in the available organisms, a portal or mode of exit
hot zone should be given 60 days of from the reservoir, a mode of transmission
prophylactic antibiotic from reservoir to host, a susceptible host,
and a
14 days.
Those with symptoms who have been in the mode of entry to host.
hot zone should be given 60 days of The six elements necessary for infection
prophylactic antibiotic are a causative organism, a reservoir of
available organisms, a portal or mode of
10 days. exit from the reservoir, a mode of
Those with symptoms who have been in the transmission from reservoir to host, a
hot zone should be given 60 days of susceptible host, and a mode of entry to
prophylactic antibiotic host.
appears intoxicated.
491.Which of the following statements reflect A person suffering from carbon monoxide
the nursing management of pulmonary poisoning appears intoxicated (from cerebral
anthrax (B. anthracis)? hypoxia). Other signs and symptoms include
headache, muscular weakness, palpitation,
Prophylaxis with fluoroquinone is dizziness, and mental confusion.
suggested after exposure.
Treatment is with ciprofloxacin or presents with severe hypertension.
doxycycline. A person suffering from carbon monoxide
poisoning appears intoxicated (from cerebral
Airborne person-to-person transmission hypoxia). Other signs and symptoms include
occurs. headache, muscular weakness, palpitation,
Anthracis is a spore forming bacteria dizziness, and mental confusion.
resulting in gastrointestinal, pulmonary, and
skin symptoms. Symptoms are dependent appears hyperactive.
upon contact, ingestion, or inhalation of the A person suffering from carbon monoxide
spores. Routine universal precautions are poisoning appears intoxicated (from cerebral
effective. Anthrax survives in the spore form hypoxia). Other signs and symptoms include
for long periods making the body a potential headache, muscular weakness, palpitation,
source of infection for morticians. dizziness, and mental confusion.
Diagnosis is by pulmonary function testing will always present with a cherry red skin
and chest x-ray. coloring.
Blood cultures are required to confirm the The skin coloring in the patient with carbon
bacteria's presence and diagnosis. monoxide poisoning can range from pink to
cherry red to cynanotic and pale and is not a
Pulmonary effects include respiratory failure, reliable diagnostic sign.
shock, and death within five to seven days
after exposure.
The pulmonary effects include respiratory 494.Treatment of an acetaminophen
failure, shock, and death within 24-36 hours overdose includes the administration of
after exposure.
N-acetylcysteine (Mucomyst).
Treatment of acetaminophen overdose
492.Which of the following terms refers to includes administration of N-acetylcysteine
injuries that occur when a person is caught (Mucomyst).
between objects, run over by a moving
vehicle, or compressed by machinery? flumazenil (Romazicon).
Flumazenil is administered in the treatment
Crush injuries of nonbarbituate sedative overdoses.
Crush injuries are those that occur when a
person is caught between objects, run over naloxone (Narcan).
by a moving vehicle, or compressed by Naloxone (Narcan) is administered in the
machinery. treatment of narcotic overdoses.
Do not apply water to the burn. 497.If a person has been exposed to
Water should not be applied to burns from radiation, presenting symptoms, such as
lye or white phosphorus because of the nausea, vomiting, loss of appetite, diarrhea,
potential for an explosion or deepening of the or fatigue can be expected to occur within
burn. _______ hours after exposure?
injuries that are minor and treatment 498.Which of the following refers to a
can be delayed hours to days. management tool for organizing personnel,
A green triage tag (priority 3 or minimal) facilities, equipment, and communication for
indicates injuries that are minor and any emergency situation?
treatment can be delayed hours to days.
The Incident Command System
injuries that are life-threatening but The Incident Command System (ICS) is a
survivable with minimal intervention. management tool for organizing personnel,
A red triage tag (priority 1 or immediate) facilities, equipment and communication for
indicates injuries that are life-threatening but any emergency situation. The federal
survivable with minimal intervention. government mandates that the ICS be used
during emergencies. Under this structure,
injuries that are significant and require one person is designated as incident
medical care, but can wait hours without commander. This person must be
threat to life or limb. continuously informed of all activities and
A yellow triage tag (priority 2 or delayed) informed about any deviation from the
indicates injuries that are significant and established plan. While the ICS is primarily a
require medical care, but can wait hours field structure and process, aspects of it are
without threat to life or limb. used at the level of an individual hospital’s
emergency response plan as well.
indicates injuries that are extensive and
chances of survival are unlikely even with Office of Emergency Management
definitive care. Office of Emergency Management (OEM)
A black triage tag (priority 4 or expectant) coordinates the disaster relief efforts at the
indicates injuries that are extensive and state and local levels. The OEM is responsible
chances of survival are unlikely even with for providing interagency coordination during
an emergency. It maintains a corps of 500.The first step in decontamination is
emergency management personnel,
including responders, planners, and removal of the patient's clothing and
administrative and support staff. jewelry and then rinsing the patient
with water.
National Disaster Medical System To be effective, decontamination must
National Disaster Medical System (NDMS). include a minimum of two steps. The first
The NDMS has many medical support teams step is removal of the patient’s clothing and
such as Disaster Medical Assistance Teams jewelry and then rinsing the patient with
(DMATs) that provide medical personnel to water. The second step consists of a
set up and staff a field hospital. thorough soap and water wash and rinse.
The Hospital Emergency Preparedness Plan a thorough soap and water wash and rinse of
The Hospital Emergency Preparedness Plan is the patient.
a facility-specific plan for emergency A thorough soap and water wash and rinse of
preparedness required by the Joint the patient is the second step in the
Commission on Accreditation of Healthcare decontamination process. The first is to
Organizations (JCAHO). remove the patient's clothing and jewelry
and then rinsing the patient with water.
Follow-up
In follow-up, members of the critical incident
stress management (CISM) team contact the
participants of a debriefing and schedule a
follow-up meeting if necessary. People with
ongoing stress reactions are referred to
mental health specialists.