Final Exam Flashcards
(480 cards)
1
Q
The public health nurse is presenting a health-promotion class to a group at a local
community center. Which intervention most directly addresses the leading cause of
cancer deaths in North America?
A) Monthly self-breast exams
B) Smoking cessation
C) Annual colonoscopies
D) Monthly testicular exams
A
B) Smoking cessation
2
Q
A nurse who works in an oncology clinic is assessing a patient who has arrived for a 2-
month follow-up appointment following chemotherapy. The nurse notes that the
patient’s skin appears yellow. Which blood tests should be done to further explore this
clinical sign?
A) Liver function tests (LFTs)
B) Complete blood count (CBC)
C) Platelet count
D) Blood urea nitrogen and creatinine
A
A) Liver function tests (LFTs)
3
Q
The school nurse is teaching a nutrition class in the local high school. One student
states that he has heard that certain foods can increase the incidence of cancer. The
nurse responds, ìResearch has shown that certain foods indeed appear to increase the
risk of cancer.î Which of the following menu selections would be the best choice for
potentially reducing the risks of cancer?
A) Smoked salmon and green beans
B) Pork chops and fried green tomatoes
C) Baked apricot chicken and steamed broccoli
D) Liver, onions, and steamed peas
A
C) Baked apricot chicken and steamed broccoli
4
Q
Traditionally, nurses have been involved with tertiary cancer prevention. However, an
increasing emphasis is being placed on both primary and secondary prevention. What
would be an example of primary prevention?
A) Yearly Pap tests
B) Testicular self-examination
C) Teaching patients to wear sunscreen
D) Screening mammograms
A
C) Teaching patients to wear sunscreen
5
Q
The nurse is caring for a 39-year-old woman with a family history of breast cancer. She
requested a breast tumor marking test and the results have come back positive. As a
result, the patient is requesting a bilateral mastectomy. This surgery is an example of
what type of oncologic surgery?
A) Salvage surgery
B) Palliative surgery
C) Prophylactic surgery
D) Reconstructive surgery
A
C) Prophylactic surgery
6
Q
The nurse is caring for a patient who is to begin receiving external radiation for a
malignant tumor of the neck. While providing patient education, what potential adverse
effects should the nurse discuss with the patient?
A) Impaired nutritional status
B) Cognitive changes
C) Diarrhea
D) Alopecia
A
A) Impaired nutritional status
7
Q
While a patient is receiving IV doxorubicin hydrochloride for the treatment of cancer,
the nurse observes swelling and pain at the IV site. The nurse should prioritize what
action?
A) Stopping the administration of the drug immediately
B) Notifying the patient’s physician
C) Continuing the infusion but decreasing the rate
D) Applying a warm compress to the infusion site
A
A) Stopping the administration of the drug immediately
8
Q
A patient newly diagnosed with cancer is scheduled to begin chemotherapy treatment
and the nurse is providing anticipatory guidance about potential adverse effects. When
addressing the most common adverse effect, what should the nurse describe?
A) Pruritis (itching)
B) Nausea and vomiting
C) Altered glucose metabolism
D) Confusion
A
B) Nausea and vomiting
9
Q
A patient on the oncology unit is receiving carmustine, a chemotherapy agent, and the
nurse is aware that a significant side effect of this medication is thrombocytopenia.
Which symptom should the nurse assess for in patients at risk for thrombocytopenia?
A) Interrupted sleep pattern
B) Hot flashes
C) Epistaxis (nose bleed)
D) Increased weight
A
C) Epistaxis (nose bleed)
10
Q
The nurse is orienting a new nurse to the oncology unit. When reviewing the safe
administration of antineoplastic agents, what action should the nurse emphasize?
A) Adjust the dose to the patient’s present symptoms.
B) Wash hands with an alcohol-based cleanser following administration.
C) Use gloves and a lab coat when preparing the medication.
D) Dispose of the antineoplastic wastes in the hazardous waste receptacle.
A
D) Dispose of the antineoplastic wastes in the hazardous waste receptacle.
11
Q
A nurse provides care on a bone marrow transplant unit and is preparing a female
patient for a hematopoietic stem cell transplantation (HSCT) the following day. What
information should the nurse emphasize to the patient’s family and friends?
A) ìYour family should likely gather at the bedside in case there’s a negative
outcome.î
B) ìMake sure she doesn’t eat any food in the 24 hours before the procedure.î
C) ìWear a hospital gown when you go into the patient’s room.î
D) ìDo not visit if you’ve had a recent infection.
A
D) ìDo not visit if you’ve had a recent infection.
12
Q
A nurse is creating a plan of care for an oncology patient and one of the identified
nursing diagnoses is risk for infection related to myelosuppression. What intervention
addresses the leading cause of infection-related death in oncology patients?
A) Encourage several small meals daily.
B) Provide skin care to maintain skin integrity.
C) Assist the patient with hygiene, as needed.
D) Assess the integrity of the patient’s oral mucosa regularly.
A
B) Provide skin care to maintain skin integrity.
13
Q
You are caring for an adult patient who has developed a mild oral yeast infection
following chemotherapy. What actions should you encourage the patient to perform?
Select all that apply.
A) Use a lip lubricant.
B) Scrub the tongue with a firm-bristled toothbrush.
C) Use dental floss every 24 hours.
D) Rinse the mouth with normal saline.
E) Eat spicy food to aid in eradicating the yeast.
A
A) Use a lip lubricant.
C) Use dental floss every 24 hours.
D) Rinse the mouth with normal saline.
14
Q
The nurse on a bone marrow transplant unit is caring for a patient with cancer who is
preparing for HSCT. What is a priority nursing diagnosis for this patient?
A) Fatigue related to altered metabolic processes
B) Altered nutrition: less than body requirements related to anorexia
C) Risk for infection related to altered immunologic response
D) Body image disturbance related to weight loss and anorexia
A
C) Risk for infection related to altered immunologic response
15
Q
An oncology nurse is caring for a patient who has developed erythema following
radiation therapy. What should the nurse instruct the patient to do?
A) Periodically apply ice to the area.
B) Keep the area cleanly shaven.
C) Apply petroleum jelly to the affected area.
D) Avoid using soap on the treatment area.
A
D) Avoid using soap on the treatment area.
16
Q
The nurse is caring for a patient has just been given a 6-month prognosis following a
diagnosis of extensive stage small-cell lung cancer. The patient states that he would like
to die at home, but the team believes that the patient’s care needs are unable to be met
in a home environment. What might you suggest as an alternative?
A) Discuss a referral for rehabilitation hospital.
B) Panel the patient for a personal care home.
C) Discuss a referral for acute care.
D) Discuss a referral for hospice care.
A
D) Discuss a referral for hospice care.
17
Q
The clinic nurse is caring for a 42-year-old male oncology patient. He complains of
extreme fatigue and weakness after his first week of radiation therapy. Which response
by the nurse would best reassure this patient?
A) ìThese symptoms usually result from radiation therapy; however, we will
continue to monitor your laboratory and x-ray studies.
B) ìThese symptoms are part of your disease and are an unfortunately inevitable part
of living with cancer.î
C) ìTry not to be concerned about these symptoms. Every patient feels this way after
having radiation therapy.î
D) ìEven though it is uncomfortable, this is a good sign. It means that only the
cancer cells are dying.
A
A) ìThese symptoms usually result from radiation therapy; however, we will
continue to monitor your laboratory and x-ray studies.
18
Q
A 16-year-old female patient experiences alopecia resulting from chemotherapy,
prompting the nursing diagnoses of disturbed body image and situational low selfesteem.
What action by the patient would best indicate that she is meeting the goal of
improved body image and self-esteem?
A) The patient requests that her family bring her makeup and wig.
B) The patient begins to discuss the future with her family.
C) The patient reports less disruption from pain and discomfort.
D) The patient cries openly when discussing her disease.
A
A) The patient requests that her family bring her makeup and wig.
19
Q
A 50-year-old man diagnosed with leukemia will begin chemotherapy. What would the
nurse do to combat the most common adverse effects of chemotherapy?
A) Administer an antiemetic.
B) Administer an antimetabolite.
C) Administer a tumor antibiotic.
D) Administer an anticoagulant.
A
A) Administer an antiemetic.
20
Q
A 58-year-old male patient has been hospitalized for a wedge resection of the left lower
lung lobe after a routine chest x-ray shows carcinoma. The patient is anxious and asks
if he can smoke. Which statement by the nurse would be most therapeutic?
A) ìSmoking is the reason you are here.î
B) ìThe doctor left orders for you not to smoke.î
C) ìYou are anxious about the surgery. Do you see smoking as helping?
D) ìSmoking is OK right now, but after your surgery it is contraindicated.
A
C) ìYou are anxious about the surgery. Do you see smoking as helping?
21
Q
An oncology nurse educator is providing health education to a patient who has been
diagnosed with skin cancer. The patient’s wife has asked about the differences between
normal cells and cancer cells. What characteristic of a cancer cell should the educator
cite?
A) Malignant cells contain more fibronectin than normal body cells.
B) Malignant cells contain proteins called tumor-specific antigens.
C) Chromosomes contained in cancer cells are more durable and stable than those of
normal cells.
D) The nuclei of cancer cells are unusually large, but regularly shaped.
A
B) Malignant cells contain proteins called tumor-specific antigens.
22
Q
A patient’s most recent diagnostic imaging has revealed that his lung cancer has
metastasized to his bones and liver. What is the most likely mechanism by which the
patient’s cancer cells spread?
A) Hematologic spread
B) Lymphatic circulation
C) Invasion
D) Angiogenesis
A
B) Lymphatic circulation
23
Q
The nurse is describing some of the major characteristics of cancer to a patient who has
recently received a diagnosis of malignant melanoma. When differentiating between
benign and malignant cancer cells, the nurse should explain differences in which of the
following aspects? Select all that apply.
A) Rate of growth
B) Ability to cause death
C) Size of cells
D) Cell contents
E) Ability to spread
A
A) Rate of growth
B) Ability to cause death
E) Ability to spread
24
Q
A 54-year-old has a diagnosis of breast cancer and is tearfully discussing her diagnosis
with the nurse. The patient states, ìThey tell me my cancer is malignant, while my
coworker’s breast tumor was benign. I just don’t understand at all.î When preparing a
response to this patient, the nurse should be cognizant of what characteristic that
distinguishes malignant cells from benign cells of the same tissue type?
A) Slow rate of mitosis of cancer cells
B) Different proteins in the cell membrane
C) Differing size of the cells
D) Different molecular structure in the cells
A
B) Different proteins in the cell membrane
25
An oncology patient will begin a course of chemotherapy and radiation therapy for the
treatment of bone metastases. What is one means by which malignant disease processes
transfer cells from one place to another?
A) Adhering to primary tumor cells
B) Inducing mutation of cells of another organ
C) Phagocytizing healthy cells
D) Invading healthy host tissues
D) Invading healthy host tissues
26
The nurse is performing an initial assessment of an older adult resident who has just
relocated to the long-term care facility. During the nurse's interview with the patient,
she admits that she drinks around 20 ounces of vodka every evening. What types of
cancer does this put her at risk for? Select all that apply.
A) Malignant melanoma
B) Brain cancer
C) Breast cancer
D) Esophageal cancer
E) Liver cancer
C) Breast cancer
D) Esophageal cancer
E) Liver cancer
27
The clinic nurse is caring for a patient whose grandmother and sister have both had
breast cancer. She requested a screening test to determine her risk of developing breast
cancer and it has come back positive. The patient asks you what she can do to help
prevent breast cancer from occurring. What would be your best response?
A) ìResearch has shown that eating a healthy diet can provide all the protection you
need against breast cancer.î
B) ìResearch has shown that taking the drug tamoxifen can reduce your chance of
breast cancer.
C) ìResearch has shown that exercising at least 30 minutes every day can reduce
your chance of breast cancer.î
D) ìResearch has shown that there is little you can do to reduce your risk of breast
cancer if you have a genetic predisposition.
B) ìResearch has shown that taking the drug tamoxifen can reduce your chance of
breast cancer.
28
A public health nurse has formed an interdisciplinary team that is developing an
educational program entitled Cancer: The Risks and What You Can Do About Them.
Participants will receive information, but the major focus will be screening for relevant
cancers. This program is an example of what type of health promotion activity?
A) Disease prophylaxis
B) Risk reduction
C) Secondary prevention
D) Tertiary prevention
C) Secondary prevention
29
A 62-year-old woman diagnosed with breast cancer is scheduled for a partial
mastectomy. The oncology nurse explained that the surgeon will want to take tissue
samples to ensure the disease has not spread to adjacent axillary lymph nodes. The
patient has asked if she will have her lymph nodes dissected, like her mother did
several years ago. What alternative to lymph node dissection will this patient most
likely undergo?
A) Lymphadenectomy
B) Needle biopsy
C) Open biopsy
D) Sentinel node biopsy
D) Sentinel node biopsy
30
You are caring for a patient who has just been told that her stage IV colon cancer has
recurred and metastasized to the liver. The oncologist offers the patient the option of
surgery to treat the progression of this disease. What type of surgery does the
oncologist offer?
A) Palliative
B) Reconstructive
C) Salvage
D) Prophylactic
A) Palliative
31
The nurse is caring for a patient with an advanced stage of breast cancer and the patient
has recently learned that her cancer has metastasized. The nurse enters the room and
finds the patient struggling to breath and the nurse's rapid assessment reveals that the
patient's jugular veins are distended. The nurse should suspect the development of what
oncologic emergency?
A) Increased intracranial pressure
B) Superior vena cava syndrome (SVCS)
C) Spinal cord compression
D) Metastatic tumor of the neck
B) Superior vena cava syndrome (SVCS)
32
The hospice nurse is caring for a patient with cancer in her home. The nurse has
explained to the patient and the family that the patient is at risk for hypercalcemia and
has educated them on that signs and symptoms of this health problem. What else should
the nurse teach this patient and family to do to reduce the patient's risk of
hypercalcemia?
A) Stool softeners are contraindicated.
B) Laxatives should be taken daily.
C) Consume 2 to 4 L of fluid daily.
D) Restrict calcium intake.
C) Consume 2 to 4 L of fluid daily.
33
The home health nurse is performing a home visit for an oncology patient discharged 3
days ago after completing treatment for non-Hodgkin lymphoma. The nurse's
assessment should include examination for the signs and symptoms of what
complication?
A) Tumor lysis syndrome (TLS)
B) Syndrome of inappropriate antiduretic hormone (SIADH)
C) Disseminated intravascular coagulation (DIC)
D) Hypercalcemia
A) Tumor lysis syndrome (TLS)
34
The nurse is admitting an oncology patient to the unit prior to surgery. The nurse reads
in the electronic health record that the patient has just finished radiation therapy. With
knowledge of the consequent health risks, the nurse should prioritize assessments
related to what health problem?
A) Cognitive deficits
B) Impaired wound healing
C) Cardiac tamponade
D) Tumor lysis syndrome
B) Impaired wound healing
35
An oncology patient has just returned from the postanesthesia care unit after an open
hemicolectomy. This patient's plan of nursing care should prioritize which of the
following?
A) Assess the patient hourly for signs of compartment syndrome.
B) Assess the patient's fine motor skills once per shift.
C) Assess the patient's wound for dehiscence every 4 hours.
D) Maintain the patient's head of bed at 45 degrees or more at all times.
C) Assess the patient's wound for dehiscence every 4 hours.
36
The hospice nurse has just admitted a new patient to the program. What principle
guides hospice care?
A) Care addresses the needs of the patient as well as the needs of the family.
B) Care is focused on the patient centrally and the family peripherally.
C) The focus of all aspects of care is solely on the patient.
D) The care team prioritizes the patient's physical needs and the family is
responsible for the patient's emotional needs.
A) Care addresses the needs of the patient as well as the needs of the family.
37
A 60-year-old patient with a diagnosis of prostate cancer is scheduled to have an
interstitial implant for high-dose radiation (HDR). What safety measure should the
nurse include in this patient's subsequent plan of care?
A) Limit the time that visitors spend at the patient's bedside.
B) Teach the patient to perform all aspects of basic care independently.
C) Assign male nurses to the patient's care whenever possible.
D) Situate the patient in a shared room with other patients receiving brachytherapy.
A) Limit the time that visitors spend at the patient's bedside.
38
An oncology patient has begun to experience skin reactions to radiation therapy,
prompting the nurse to make the diagnosis Impaired Skin Integrity: erythematous
reaction to radiation therapy. What intervention best addresses this nursing diagnosis?
A) Apply an ice pack or heating pad PRN to relieve pain and pruritis
B) Avoid skin contact with water whenever possible
C) Apply phototherapy PRN
D) Avoid rubbing or scratching the affected area
D) Avoid rubbing or scratching the affected area
39
A patient with a diagnosis of gastric cancer has been unable to tolerate oral food and
fluid intake and her tumor location precludes the use of enteral feeding. What
intervention should the nurse identify as best meeting this patient's nutritional needs?
A) Administration of parenteral feeds via a peripheral IV
B) TPN administered via a peripherally inserted central catheter
C) Insertion of an NG tube for administration of feeds
D) Maintaining NPO status and IV hydration until treatment completion
B) TPN administered via a peripherally inserted central catheter
40
An oncology nurse is contributing to the care of a patient who has failed to respond
appreciably to conventional cancer treatments. As a result, the care team is considering
the possible use of biologic response modifiers (BRFs). The nurse should know that
these achieve a therapeutic effect by what means?
A) Promoting the synthesis and release of leukocytes
B) Focusing the patient's immune system exclusively on the tumor
C) Potentiating the effects of chemotherapeutic agents and radiation therapy
D) Altering the immunologic relationship between the tumor and the patient
D) Altering the immunologic relationship between the tumor and the patient
41
In the past three to four decades, nursing has moved into the forefront in providing care
for the dying. Which phenomenon has most contributed to this increased focus of care
of the dying?
A) Increased incidence of infections and acute illnesses
B) Increased focus of health care providers on disease prevention
C) Larger numbers of people dying in hospital settings
D) Demographic changes in the population
D) Demographic changes in the population
42
A nurse who works in the specialty of palliative care frequently encounters issues and
situations that constitute ethical dilemmas. What issue has most often presented
challenging ethical issues, especially in the context of palliative care?
A) The increase in cultural diversity in the United States
B) Staffing shortages in health care and questions concerning quality of care
C) Increased costs of health care coupled with inequalities in access
D) Ability of technology to prolong life beyond meaningful quality of life
D) Ability of technology to prolong life beyond meaningful quality of life
43
The nurse is caring for a patient who has been recently diagnosed with late stage
pancreatic cancer. The patient refuses to accept the diagnosis and refuses to adhere to
treatment. What is the most likely psychosocial purpose of this patient's strategy?
A) The patient may be trying to protect loved ones from the emotional effects of the
illness.
B) The patient is being noncompliant in order to assert power over caregivers.
C) The patient may be skeptical of the benefits of the Western biomedical model of
health.
D) The patient thinks that treatment does not provide him comfort.
A) The patient may be trying to protect loved ones from the emotional effects of the
illness.
44
A nurse who sits on the hospital's ethics committee is reviewing a complex case that
has many of the hallmarks of assisted suicide. Which of the following would be an
example of assisted suicide?
A) Administering a lethal dose of medication to a patient whose death is imminent
B) Administering a morphine infusion without assessing for respiratory depression
C) Granting a patient's request not to initiate enteral feeding when the patient is
unable to eat
D) Neglecting to resuscitate a patient with a ìdo not resuscitateî order
A) Administering a lethal dose of medication to a patient whose death is imminent
45
A medical nurse is providing palliative care to a patient with a diagnosis of end-stage
chronic obstructive pulmonary disease (COPD). What is the primary goal of this nurse's
care?
A) To improve the patient's and family's quality of life
B) To support aggressive and innovative treatments for cure
C) To provide physical support for the patient
D) To help the patient develop a separate plan with each discipline of the health care
team
A) To improve the patient's and family's quality of life
46
After contributing to the care of several patients who died in the hospital, the nurse has
identified some lapses in the care that many of these patients received toward the end of
their lives. What have research studies identified as a potential deficiency in the care of
the dying in hospital settings?
A) Families' needs for information and support often go unmet.
B) Patients are too sedated to achieve adequate pain control.
C) Patients are not given opportunities to communicate with caregivers.
D) Patients are ignored by the care team toward the end of life.
A) Families' needs for information and support often go unmet.
47
An adult oncology patient has a diagnosis of bladder cancer with metastasis and the
patient has asked the nurse about the possibility of hospice care. Which principle is
central to a hospice setting?
A) The patient and family should be viewed as a single unit of care.
B) Persistent symptoms of terminal illness should not be treated.
C) Each member of the interdisciplinary team should develop an individual plan of
care.
D) Terminally ill patients should die in the hospital whenever possible.
A) The patient and family should be viewed as a single unit of care.
48
A clinic nurse is providing patient education prior to a patient's scheduled palliative
radiotherapy to her spine. At the completion of the patient teaching, the patient
continues to ask the same questions that the nurse has already addressed. What is the
plausible conclusion that the nurse should draw from this?
A) The patient is not listening effectively.
B) The patient is noncompliant with the plan of care.
C) The patient may have a low intelligence quotient or a cognitive deficit.
D) The patient has not achieved the desired learning outcomes.
D) The patient has not achieved the desired learning outcomes.
49
The nurse is part of the health care team at an oncology center. A patient has been
diagnosed with leukemia and the prognosis is poor, but the patient is not yet aware of
the prognosis. How can the bad news best be conveyed to the patient?
A) Family should be given the prognosis first.
B) The prognosis should be delivered with the patient at eye level.
C) The physician should deliver the news to the patient alone.
D) The appointment should be scheduled at the end of the day.
B) The prognosis should be delivered with the patient at eye level.
50
A patient has just been told that her illness is terminal. The patient tearfully states, ìI
can't believe I am going to die. Why me?î What is your best response?
A) ìI know how you are feeling.î
B) ìYou have lived a long life.î
C) ìThis must be very difficult for you.
D) ìLife can be so unfair.î
C) ìThis must be very difficult for you.
51
The nurse has observed that an older adult patient with a diagnosis of end-stage renal
failure seems to prefer to have his eldest son make all of his health care decisions.
While the family is visiting, the patient explains to you that this is a cultural practice
and very important to him. How should you respond?
A) Privately ask the son to allow the patient to make his own health care decisions.
B) Explain to the patient that he is responsible for his own decisions.
C) Work with the team to negotiate informed consent.
D) Avoid divulging information to the eldest son.
C) Work with the team to negotiate informed consent.
52
One aspect of the nurse's comprehensive assessment when caring for the terminally ill
is the assessment of hope. The nurse is assessing a patient with liver failure for the
presence of hope. What would the nurse identify as a hope-fostering category?
A) Uplifting memories
B) Ignoring negative outcomes
C) Envisioning one specific outcome
D) Avoiding an actual or potential threat
A) Uplifting memories
53
A medical nurse is providing end-of-life care for a patient with metastatic bone cancer.
The nurse notes that the patient has been receiving oral analgesics for her pain with
adequate effect, but is now having difficulty swallowing the medication. What should
the nurse do?
A) Request the physician to order analgesics by an alternative route.
B) Crush the medication in order to aid swallowing and absorption.
C) Administer the patient's medication with the meal tray.
D) Administer the medication rectally.
A) Request the physician to order analgesics by an alternative route.
54
A 66-year-old patient is in a hospice receiving palliative care for lung cancer which has
metastasized to the patient's liver and bones. For the past several hours, the patient has
been experiencing dyspnea. What nursing action is most appropriate to help to relive
the dyspnea the patient is experiencing?
A) Administer a bolus of normal saline, as ordered.
B) Initiate high-flow oxygen therapy.
C) Administer high doses of opioids.
D) Administer bronchodilators and corticosteroids, as ordered.
D) Administer bronchodilators and corticosteroids, as ordered.
55
The nurse is caring for a patient who has terminal lung cancer and is unconscious.
Which assessment finding would most clearly indicate to the nurse that the patient's
death is imminent?
A) Mottling of the lower limbs
B) Slow, steady pulse
C) Bowel incontinence
D) Increased swallowing
A) Mottling of the lower limbs
56
A patient on the medical unit is dying and the nurse has determined that the family's
psychosocial needs during the dying process need to be addressed. What is a cause of
many patient care dilemmas at the end of life?
A) Poor communication between the family and the care team
B) Denial of imminent death on the part of the family or the patient
C) Limited visitation opportunities for friends and family
D) Conflict between family members
A) Poor communication between the family and the care team
57
The nurse is assessing a 73-year-old patient who was diagnosed with metastatic
prostate cancer. The nurse notes that the patient is exhibiting signs of loss, grief, and
intense sadness. Based on this assessment data, the nurse will document that the patient
is most likely in what stage of death and dying?
A) Depression
B) Denial
C) Anger
D) Resignation
A) Depression
58
You are caring for a 50-year-old man diagnosed with multiple myeloma; he has just
been told by the care team that his prognosis is poor. He is tearful and trying to express
his feelings, but he is having difficulty. What should you do first?
A) Ask if he would like you to sit with him while he collects his thoughts.
B) Tell him that you will leave for now but will be back shortly.
C) Offer to call pastoral care or a member of his chosen clergy.
D) Reassure him that you can understand how he is feeling.
A) Ask if he would like you to sit with him while he collects his thoughts.
59
The nurse in a pediatric ICU is caring for a child who is dying of sickle cell anemia.
The child's mother has been unable to eat or sleep and can talk only about her
impending loss and the guilt she feels about the child's pain and suffering. What
intervention has the highest priority?
A) Allowing the patient to express her feelings without judging her
B) Helping the patient to understand the phases of the grieving process
C) Reassuring the patient that the child's death is not her fault
D) Arranging for genetic counseling to inform the patient of her chances of having
another child with the disease
A) Allowing the patient to express her feelings without judging her
60
You are caring for a patient, a 42-year-old mother of two children, with a diagnosis of
ovarian cancer. She has just been told that her ovarian cancer is terminal. When you
admitted this patient, you did a spiritual assessment. What question would it have been
most important for you to evaluate during this assessment?
A) Is she able to tell her family of negative test results?
B) Does she have a sense of peace of mind and a purpose to her life?
C) Can she let go of her husband so he can make a new life?
D) Does she need time and space to bargain with God for a cure?
B) Does she have a sense of peace of mind and a purpose to her life?
61
A patient's rapid cancer metastases have prompted a shift from active treatment to
palliative care. When planning this patient's care, the nurse should identify what
primary aim?
A) To prioritize emotional needs
B) To prevent and relieve suffering
C) To bridge between curative care and hospice care
D) To provide care while there is still hope
B) To prevent and relieve suffering
62
The organization of a patient's care on the palliative care unit is based on
interdisciplinary collaboration. How does interdisciplinary collaboration differ from
multidisciplinary practice?
A) It is based on the participation of clinicians without a team leader.
B) It is based on clinicians of varied backgrounds integrating their separate plans of
care.
C) It is based on communication and cooperation between disciplines.
D) It is based on medical expertise and patient preference with the support of nursing.
C) It is based on communication and cooperation between disciplines.
63
As the American population ages, nurses expect see more patients admitted to longterm
care facilities in need of palliative care. Regulations now in place that govern how
the care in these facilities is both organized and reimbursed emphasize what aspect of
care?
A) Ongoing acute care
B) Restorative measures
C) Mobility and socialization
D) Incentives to palliative care
B) Restorative measures
64
A patient with end-stage heart failure has participated in a family meeting with the
interdisciplinary team and opted for hospice care. On what belief should the patient's
care in this setting be based?
A) Meaningful living during terminal illness requires technologic interventions.
B) Meaningful living during terminal illness is best supported in designated
facilities.
C) Meaningful living during terminal illness is best supported in the home.
D) Meaningful living during terminal illness is best achieved by prolonging
physiologic dying.
C) Meaningful living during terminal illness is best supported in the home.
65
A nurse who provides care on an acute medical unit has observed that physicians are
frequently reluctant to refer patients to hospice care. What are contributing factors that
are known to underlie this tendency? Select all that apply.
A) Financial pressures on health care providers
B) Patient reluctance to accept this type of care
C) Strong association of hospice care with prolonging death
D) Advances in ìcurativeî treatment in late-stage illness
E) Ease of making a terminal diagnosis
A) Financial pressures on health care providers
B) Patient reluctance to accept this type of care
D) Advances in curative treatment in late-stage illness
66
A nurse is caring for an 87-year-old Mexican-American female patient who is in endstage
renal disease. The physician has just been in to see the patient and her family to
tell them that nothing more can be done for the patient and that death is not far. The
physician offers to discharge the patient home to hospice care, but the patient and
family refuse. After the physician leaves, the patient's daughter approaches you and
asks what hospice care is. What would this lack of knowledge about hospice care be
perceived as?
A) Lack of an American education of the patient and her family
B) A language barrier to hospice care for this patient
C) A barrier to hospice care for this patient
D) Inability to grasp American concepts of health care
C) A barrier to hospice care for this patient
67
Patients who are enrolled in hospice care through Medicare are often felt to suffer
unnecessarily because they do not receive adequate attention for their symptoms of the
underlying illness. What factor most contributes to this phenomenon?
A) Unwillingness to overmedicate the dying patient
B) Rules concerning completion of all cure-focused medical treatment
C) Unwillingness of patients and families to acknowledge the patient is terminal
D) Lack of knowledge of patients and families regarding availability of care
B) Rules concerning completion of all cure-focused medical treatment
68
One of the functions of nursing care of the terminally ill is to support the patient and his
or her family as they come to terms with the diagnosis and progression of the disease
process. How should nurses support patients and their families during this process?
Select all that apply.
A) Describe their personal experiences in dealing with end-of-life issues.
B) Encourage the patient and family to ìkeep fightingî as a cure may come.
C) Try to appreciate and understand the illness from the patient's perspective.
D) Assist patients with performing a life review.
E) Provide interventions that facilitate end-of-life closure.
C) Try to appreciate and understand the illness from the patient's perspective.
D) Assist patients with performing a life review.
E) Provide interventions that facilitate end-of-life closure.
69
The nurse is admitting a 52-year-old father of four into hospice care. The patient has a
diagnosis of Parkinson's disease, which is progressing rapidly. The patient has made
clear his preference to receive care at home. What interventions should the nurse
prioritize in the plan of care?
A) Aggressively continuing to fight the disease process
B) Moving the patient to a long-term care facility when it becomes necessary
C) Including the children in planning their father's care
D) Supporting the patient's and family's values and choices
D) Supporting the patient's and family's values and choices
70
A patient has just died following urosepsis that progressed to septic shock. The patient's
spouse says, ìI knew this was coming, but I feel so numb and hollow inside.î The nurse
should know that these statements are characteristic of what?
A) Complicated grief and mourning
B) Uncomplicated grief and mourning
C) Depression stage of dying
D) Acceptance stage of dying
B) Uncomplicated grief and mourning
71
A 67-year-old woman experienced the death of her husband from a sudden myocardial
infarction 5 weeks ago. The nurse recognizes that the woman will be going through the
process of mourning for an extended period of time. What processes of mourning will
allow the woman to accommodate the loss in a healthy way? Select all that apply.
A) Reiterating her anger at her husband's care team
B) Reinvesting in new relationships at the appropriate time
C) Reminiscing about the relationship she had with her husband
D) Relinquishing old attachments to her husband at the appropriate time
E) Renewing her lifelong commitment to her husband
B) Reinvesting in new relationships at the appropriate time
C) Reminiscing about the relationship she had with her husband
D) Relinquishing old attachments to her husband at the appropriate time
72
A nurse has made a referral to a grief support group, knowing that many individuals
find these both comforting and beneficial after the death of a loved one. What is the
most important accomplishment available by attending a grief support group?
A) Providing a framework for incorporating the old life into the new life
B) Normalizing adaptation to a continuation of the old life
C) Aiding in adjusting to using old, familiar social skills
D) Normalization of feelings and experiences
D) Normalization of feelings and experiences
73
A patient's daughter has asked the nurse about ìhelping him end his terrible suffering.î
The nurse is aware of the ANA Position Statement on Assisted Suicide, which clearly
states that nursing participation in assisted suicide is a violation of the Code for Nurses.
What does the Position Statement further stress?
A) Educating families about the moral implications of assisted suicide
B) Identifying patient and family concerns and fears
C) Identifying resources that meet the patient's desire to die
D) Supporting effective means to honor the patient's desire to die
B) Identifying patient and family concerns and fears
74
A hospice nurse is caring for a 22-year-old with a terminal diagnosis of leukemia.
When updating this patient's plan of nursing care, what should the nurse prioritize?
A) Interventions aimed at maximizing quantity of life
B) Providing financial advice to pay for care
C) Providing realistic emotional preparation for death
D) Making suggestions to maximize family social interactions after the patient's
death
C) Providing realistic emotional preparation for death
75
A pediatric nurse is emotionally distraught by the death of a 9-year-old girl who
received care on the unit over the course of many admissions spanning several years.
What action is the most appropriate response to the nurse's own grief?
A) Take time off from work to mourn the death.
B) Post mementos of the patient on the unit.
C) Solicit emotional support from the patient's family.
D) Attend the patient's memorial service.
D) Attend the patient's memorial service.
76
As a staff member in a local hospice, a nurse deals with death and dying on a frequent
basis. Where would be the safe venue for the nurse to express her feelings of frustration
and grief about a patient who has recently died?
A) In the cafeteria
B) At a staff meeting
C) At a social gathering
D) At a memorial service
B) At a staff meeting
77
A hospice nurse is well aware of how difficult it is to deal with others' pain on a daily
basis. This nurse should put healthy practices into place to guard against what
outcome?
A) Inefficiency in the provision of care
B) Excessive weight gain
C) Emotional exhaustion
D) Social withdrawal
C) Emotional exhaustion
78
The hospice nurse is caring for a 45-year-old mother of three young children in the
patient's home. During the most recent visit, the nurse has observed that the patient has
a new onset of altered mental status, likely resulting from recently diagnosed brain
metastases. What goal of nursing interventions should the nurse identify?
A) Helping the family to understand why the patient needs to be sedated
B) Making arrangements to promptly move the patient to an acute-care facility
C) Explaining to the family that death is near and the patient needs around-the-clock
nursing care
D) Teaching family members how to interact with, and ensure safety for, the patient
with impaired cognition
D) Teaching family members how to interact with, and ensure safety for, the patient
with impaired cognition
79
You are caring for a patient who has just been told that his illness is progressing and
nothing more can be done for him. After the physician leaves, the patient asks you to
stay with him for a while. The patient becomes tearful and tries several times to say
something, but cannot get the words out. What would be an appropriate response for
you to make at this time?
A) ìCan I give you some advice?î
B) ìDo you need more time to think about this?
C) ìIs there anything you want to say?î
D) ìI have cared for lots of patients in your position. It will get easier.î
B) ìDo you need more time to think about this?
80
A patient who is receiving care for osteosarcoma has been experiencing severe pain
since being diagnosed. As a result, the patient has been receiving analgesics on both a scheduled and PRN basis. For the past several hours, however, the patient's level of
consciousness has declined and she is now unresponsive. How should the patient's pain
control regimen be affected?
A) The patient's pain control regimen should be continued.
B) The pain control regimen should be placed on hold until the patient's level of
consciousness improves.
C) IV analgesics should be withheld and replaced with transdermal analgesics.
D) The patient's analgesic dosages should be reduced by approximately one half.
A) The patient's pain control regimen should be continued.
81
A teenager is diagnosed with cellulitis of the right knee and fails to respond to oral
antibiotics. He then develops osteomyelitis of the right knee, prompting a detailed
diagnostic workup that reveals a phagocytic disorder. This patient faces an increased
risk of what complication?
A) Thrombocytopenia
B) HIV/AIDS
C) Neutropenia
D) Hemophilia
C) Neutropenia
82
A patient is admitted for the treatment of a primary immunodeficiency and intravenous
immunoglobulin (IVIG) is ordered. What should the nurse monitor for as a potential
adverse effect of IVIG administration?
A) Anaphylaxis
B) Hypertension
C) Hypothermia
D) Joint pain
A) Anaphylaxis
83
A nurse is admitting a patient with an immunodeficiency to the medical unit. In
planning the care of this patient, the nurse should assess for what common sign of
immunodeficiency?
A) Chronic diarrhea
B) Hyperglycemia
C) Rhinorrhea
D) Contact dermatitis
A) Chronic diarrhea
84
A young couple visits the nurse practitioner stating that they want to start a family. The
husband states that his brother died of a severe infection at age 6 months. He says he
never knew what was wrong but his mother had him undergo ìblood testingî as a child.
Based on these statements, what health problem should the nurse practitioner suspect?
A) Severe neutropenia
B) X-linked agammaglobulinemia
C) Drug-induced thrombocytopenia
D) Aplastic anemia
B) X-linked agammaglobulinemia
85
The parents of a 1-month-old infant bring their child to the pediatrician with symptoms
of congestive heart failure. The infant is ultimately diagnosed with DiGeorge
syndrome. What will prolong this infant's survival?
A) Stem cell transplantation
B) Long-term antibiotics
C) Chemotherapy
D) Thymus gland transplantation
D) Thymus gland transplantation
86
A patient who has received a heart transplant is taking cyclosporine, an
immunosuppressant. What should the nurse emphasize during health education about
infection prevention?
A) Eat a high-calorie, high-protein diet.
B) Limit physical activity in order to conserve energy.
C) Take prophylactic antibiotics as ordered.
D) Perform frequent handwashing.
D) Perform frequent handwashing.
87
The nurse is caring for a patient who has a diagnosis of paroxysmal nocturnal
hemoglobinuria. When planning this patient's care, the nurse should recognize the
patient's heightened risk of what complication?
A) Venous thromboembolism
B) Acute respiratory distress syndrome (ARDS)
C) Myocardial infarction
D) Hypertensive urgency
A) Venous thromboembolism
88
A patient diagnosed with common variable immune deficiency (CVID) has been
admitted to the acute medicine unit. When reviewing this patient's laboratory findings,
the nurse should prioritize what values?
A) Creatinine and blood urea nitrogen (BUN)
B) Hemoglobin and vitamin B12
C) Sodium, potassium and magnesium
D) D-dimer and c-reactive protein
B) Hemoglobin and vitamin B12
89
Patient teaching regarding infection prevention for the patient with an
immunodeficiency includes which of the following guidelines?
A) Cook all food thoroughly.
B) Refrain from using creams or emollients on skin.
C) Maintain contact only with individuals who have recently been vaccinated.
D) Take OTC vitamin supplements consistently.
A) Cook all food thoroughly.
90
A nurse has admitted a patient diagnosed with severe combined immunodeficiency
disease (SCID) to the unit. The patient's orders include IVIG. How will the patient's
dose of IVIG be determined?
A) The patient will receive 25 to 50 mg/kg of body weight.
B) The dose will be determined by the patient's response.
C) The dose will be determined by body surface area.
D) The patient will receive a one-time bolus followed by 100- to 150-mg doses.
B) The dose will be determined by the patient's response.
91
The nurse is preparing to administer IVIG to a patient who has an immunodeficiency.
What nursing guideline should the nurse apply?
A) Do not exceed an infusion rate of 300 mL/hr.
B) Slow the infusion rate if the patient exhibits signs of a transfusion reaction.
C) Weigh the patient immediately after the infusion is complete.
D) Administer pretreatment medications as ordered 30 minutes prior to infusion.
D) Administer pretreatment medications as ordered 30 minutes prior to infusion.
92
IVIG has been ordered for the treatment of a patient with an immunodeficiency. Which
of the following actions should the nurse perform before administering this blood
product?
A) Ensure that the patient has a patent central line.
B) Ensure that the IVIG is appropriately mixed with normal saline.
C) Administer furosemide before IVIG to prevent hypervolemia.
D) Weigh the patient before administration to verify the correct dose.
D) Weigh the patient before administration to verify the correct dose.
93
A patient with a diagnosis of common variable immunodeficiency begins to develop
thick, sticky, tenacious sputum. The patient has a history of episodes of pneumonia at
least one time per year for the last 10 years. What does the nurse suspect the patient is
developing?
A) Pulmonary edema
B) A pulmonary neoplasm
C) Bronchiectasis
D) Emphysema
C) Bronchiectasis
94
A nurse is admitting an adolescent patient with a diagnosis of ataxia-telangiectasis.
Which of the following nursing diagnoses should the nurse include in the patient's plan
of care?
A) Fatigue Related to Pernicious Anemia
B) Risk for Constipation Related to Decreased Gastric Motility
C) Risk for Falls Due to Loss of Muscle Coordination
D) Disturbed Kinesthetic Sensory Perception Related to Vascular Changes
C) Risk for Falls Due to Loss of Muscle Coordination
95
A 20-year-old patient with an immunodeficiency is admitted to the unit with an acute
episode of upper airway edema. This is the fifth time in the past 3 months that the
patient has had such as episode. As the nurse caring for this patient, you know that the
patient may have a deficiency of what?
A) Interferons
B) C1esterase inhibitor
C) IgG
D) IgA
B) C1esterase inhibitor
96
A patient with Wiskott-Aldrich syndrome is admitted to the medical unit. The nurse
caring for the patient should prioritize which of the following?
A) Protective isolation
B) Fresh-frozen plasma administration
C) Chest physiotherapy
D) Nutritional supplementation
A) Protective isolation
97
The nurse is admitting a patient to the unit with a diagnosis of ataxia-telangiectasia. The
nurse's assessment should reflect the patient's increased risk for what complication?
A) Peripheral edema
B) Cancer
C) Anaphylaxis
D) Gastrointestinal bleeds
B) Cancer
98
The nurse is working with the interdisciplinary team to care for a patient who has
recently been diagnosed with severe combined immunodeficiency disease (SCID).
What treatment is likely of most benefit to this patient?
A) Combined radiotherapy and chemotherapy
B) Antibiotic therapy
C) Hematopoietic stem cell transplantation (HSCT)
D) Treatment with colony-stimulating factors (CSFs)
C) Hematopoietic stem cell transplantation (HSCT)
99
A patient has been admitted with a phagocytic cell disorder and the nurse is reviewing
the most common health problems that accompany these disorders. The nurse should
identify which of the following? Select all that apply.
A) Inflammatory bowel disease
B) Chronic otitis media
C) Cutaneous abscesses
D) Pneumonia
E) Cognitive deficits
B) Chronic otitis media
C) Cutaneous abscesses
D) Pneumonia
100
A nurse is caring for a patient with a phagocytic cell disorder. The patient states, ìMy
specialist says that I will likely be cured after I get my treatment tomorrow.î To what
treatment is the patient most likely referring?
A) Treatment with granulocyte-macrophage colony-stimulating factor (GM-CSF)
B) Hematopoietic stem cell transplantation
C) Treatment with granulocyte colony-stimulating factor (G-CSF)
D) Brachytherapy
B) Hematopoietic stem cell transplantation
101
A patient's primary immunodeficiency disease is characterized by the inability of white
blood cells to initiate an inflammatory response to infectious organisms. What is this
patient's most likely diagnosis?
A) Chronic granulomatous disease
B) Wiskott-Aldrich syndrome
C) Hyperimmunoglobulinemia E syndrome
D) Common variable immunodeficiency
C) Hyperimmunoglobulinemia E syndrome
102
A nurse educator is explaining that patients with primary immunodeficiencies are living
longer than in past decades because of advances in medical treatment. This increased
longevity is associated with an increased risk of what?
A) Chronic obstructive pulmonary disease
B) Dementia
C) Pulmonary fibrosis
D) Cancer
D) Cancer
103
The nurse educator is differentiating primary immunodeficiency diseases from
secondary immunodeficiencies. What is the defining characteristic of primary
immunodeficiency diseases?
A) They require IVIG as treatment.
B) They are the result of intrauterine infection.
C) They have a genetic origin.
D) They are communicable.
C) They have a genetic origin.
104
A nurse has created a plan of care for an immunodeficient patient, specifying that care
providers take the patient's pulse and respiratory rate for a full minute. What is the
rationale for this aspect of care?
A) Respirations affect heart rate in immunodeficient patients.
B) These patients' blunted inflammatory responses can cause subtle changes in
status.
C) Hemodynamic instability is one of the main complications of immunodeficiency.
D) Immunodeficient patients are prone to ventricular tachycardia and atrial
fibrillation.
B) These patients' blunted inflammatory responses can cause subtle changes in
status.
105
A nurse is providing health education regarding self-care to a patient with an
immunodeficiency. What teaching point should the nurse emphasize?
A) The importance of aggressive treatment of acne
B) The importance of avoiding alcohol-based cleansers
C) The need to keep fingernails and toenails closely trimmed
D) The need for thorough oral hygiene
D) The need for thorough oral hygiene
106
The nurse is applying standard precautions in the care of a patient who has an
immunodeficiency. What are key elements of standard precautions? Select all that
apply.
A) Using appropriate personal protective equipment
B) Placing patients in negative-pressure isolation rooms
C) Placing patients in positive-pressure isolation rooms
D) Using safe injection practices
E) Performing hand hygiene
A) Using appropriate personal protective equipment
D) Using safe injection practices
E) Performing hand hygiene
107
The nurse is caring for a patient with an immunodeficiency who has experienced
sudden malaise. The nurse's colleague states, ìI'm pretty sure that it's not an infection,
because the most recent blood work looks fine.î What principle should guide the nurse's
response to the colleague?
A) Immunodeficient patients will usually exhibit subtle and atypical signs of
infection.
B) Infections in immunodeficient patients have a slower onset but a more severe
course.
C) Laboratory blood work is often inaccurate in immunodeficient patients.
D) Immunodeficient patients do not develop symptoms of infection.
A) Immunodeficient patients will usually exhibit subtle and atypical signs of
infection.
108
A nurse is caring for a patient who has an immunodeficiency. What assessment finding
should prompt the nurse to consider the possibility that the patient is developing an
infection?
A) Uncharacteristic aggression
B) Persistent diarrhea
C) Pruritis (itching)
D) Constipation
B) Persistent diarrhea
109
A patient with a diagnosis of primary immunodeficiency informs the nurse that he has
been experiencing a new onset of a dry cough and occasional shortness of breath. After
determining that the patient's vital signs are within reference ranges, what action should
the nurse take?
A) Administer a nebulized bronchodilator.
B) Perform oral suctioning.
C) Assess the patient for signs and symptoms of infection.
D) Teach the patient deep breathing and coughing exercises.
C) Assess the patient for signs and symptoms of infection.
110
A home health nurse is reinforcing health education with a patient who is
immunosuppressed and his family. What statement best suggests that the patient has
understood the nurse's teaching?
A) ìMy family needs to understand when I can go get the seasonal flu shot.î
B) ìI need to know how to treat my infections in a home setting.î
C) ìI need to understand how to give my platelet transfusions.î
D) ìMy family needs to understand that I'll probably need lifelong treatment.
D) ìMy family needs to understand that I'll probably need lifelong treatment.
111
A nurse is preparing to administer a scheduled dose of IVIG to a patient who has a
diagnosis of severe combined immunodeficiency disease (SCID). What medication
should the nurse administer prior to initiating the infusion?
A) Diphenhydramine
B) Ibuprofen
C) Hydromorphone
D) Fentanyl
A) Diphenhydramine
112
An immunocompromised patient is being treated in the hospital. The nurse's assessment
reveals that the patient's submandibular lymph nodes are swollen, a finding that
represents a change from the previous day. What is the nurse's most appropriate action?
A) Administer a PRN dose of acetaminophen as ordered.
B) Monitor the patient's vital signs q2h for the next 24 hours.
C) Inform the patient's primary care provider of this finding.
D) Implement standard precautions in the patient's care.
C) Inform the patient's primary care provider of this finding.
113
A nurse caring for a patient who has an immunosuppressive disorder knows that
continual monitoring of the patient is critical. What is the primary rationale behind the
need for continual monitoring?
A) So that the patient's functional needs can be met immediately
B) So that medications can be given as ordered and signs of adverse reactions noted
C) So that early signs of impending infection can be detected and treated
D) So that the nurse's documentation can be thorough and accurate
C) So that early signs of impending infection can be detected and treated
114
A nurse is planning the care of a patient who requires immunosuppression to ensure
engraftment of depleted bone marrow during a transplantation procedure. What is the
most important component of infection control in the care of this patient?
A) Administration of IVIG
B) Antibiotic administration
C) Appropriate use of gloves and goggles
D) Thorough and consistent hand hygiene
D) Thorough and consistent hand hygiene
115
A home health nurse is caring for a patient who has an immunodeficiency. What is the
nurse's priority action to help ensure successful outcomes and a favorable prognosis?
A) Encourage the patient and family to be active partners in the management of the
immunodeficiency.
B) Encourage the patient and family to manage the patient's activity level and
activities of daily living effectively.
C) Make sure that the patient and family understand the importance of monitoring
fluid balance.
D) Make sure that the patient and family know how to adjust dosages of the
medications used in treatment.
A) Encourage the patient and family to be active partners in the management of the
immunodeficiency.
116
A nurse is preparing to discharge a patient with an immunodeficiency. When preparing
the patient for self-infusion of IVIG in the home setting, what education should the
nurse prioritize?
A) Sterile technique for establishing a new IV site
B) Signs and symptoms of adverse reactions
C) Formulas for calculating daily doses
D) Technique for adding medications to the IVIG
B) Signs and symptoms of adverse reactions
117
A home health nurse will soon begin administering IVIG to a new patient on a regular
basis. What teaching should the nurse provide to the patient?
A) The need for a sterile home environment
B) Complementary alternatives to IVIG
C) Expected benefits and outcomes of the treatment
D) Technique for managing and monitoring daily fluid intake
C) Expected benefits and outcomes of the treatment
118
The home health nurse is assessing a patient who is immunosuppressed following a
liver transplant. What is the most essential teaching for this patient and the family?
A) How to promote immune function through nutrition
B) The importance of maintaining the patient's vaccination status
C) How to choose antibiotics based on the patient's symptoms
D) The need to report any slight changes in the patient's health status
D) The need to report any slight changes in the patient's health status
119
Family members of an immunocompromised patient have asked the nurse why
antibiotics are not being given to the patient in order to prevent infection. How should
the nurse best respond?
A) ìUsing antibiotics to prevent infections can cause the growth of drug-resistant
bacteria.
B) ìIf an antibiotic is given to prevent a bacterial infection, the patient is at risk of a
viral infection.î
C) ìAntibiotics can never prevent an infection; they can only cure an infection that is
fully developed.î
D) ìAntibiotics cannot resolve infections in people who are immunocompromised.î
A) ìUsing antibiotics to prevent infections can cause the growth of drug-resistant
bacteria.
120
A 6-month-old infant has been diagnosed with X-linked agammaglobulinemia and the
parents do not understand why their baby did not develop an infection during the first
months of life. The nurse should describe what phenomenon?
A) Cell-mediated immunity in infants
B) Passive acquired immunity
C) Phagocytosis
D) Opsonization
B) Passive acquired immunity
121
Since the emergence of HIV/AIDS, there have been significant changes in
epidemiologic trends. Members of what group currently have the greatest risk of
contracting HIV?
A) Gay, bisexual, and other men who have sex with men
B) Recreational drug users
C) Blood transfusion recipients
D) Health care providers
A) Gay, bisexual, and other men who have sex with men
122
A clinic nurse is caring for a patient admitted with AIDS. The nurse has assessed that
the patient is experiencing a progressive decline in cognitive, behavioral, and motor
functions. The nurse recognizes that these symptoms are most likely related to the onset
of what complication?
A) HIV encephalopathy
B) B-cell lymphoma
C) Kaposi's sarcoma
D) Wasting syndrome
A) HIV encephalopathy
123
A nurse is assessing a 28-year-old man with HIV who has been admitted with
pneumonia. In assessing the patient, which of the following observations takes
immediate priority?
A) Oral temperature of 100∞F
B) Tachypnea and restlessness
C) Frequent loose stools
D) Weight loss of 1 pound since yesterday
B) Tachypnea and restlessness
124
A patient has come into the free clinic asking to be tested for HIV infection. The patient
asks the nurse how the test works. The nurse responds that if the testing shows that
antibodies to the AIDS virus are present in the blood, this indicates what?
A) The patient is immune to HIV.
B) The patient's immune system is intact.
C) The patient has AIDS-related complications.
D) The patient has been infected with HIV.
D) The patient has been infected with HIV.
125
A hospital patient is immunocompromised because of stage 3 HIV infection and the
physician has ordered a chest radiograph. How should the nurse most safely facilitate
the test?
A) Arrange for a portable x-ray machine to be used.
B) Have the patient wear a mask to the x-ray department.
C) Ensure that the radiology department has been disinfected prior to the test.
D) Send the patient to the x-ray department, and have the staff in the department
wear masks.
A) Arrange for a portable x-ray machine to be used.
126
The mother of two young children has been diagnosed with HIV and expresses fear of
dying. How should the nurse best respond to the patient?
A) ìWould you like me to have the chaplain come speak with you?î
B) ìYou'll learn much about the promise of a cure for HIV.î
C) ìCan you tell me what concerns you most about dying?
D) ìYou need to maintain hope because you may live for several years.î
C) ìCan you tell me what concerns you most about dying?
127
The nurse is addressing condom use in the context of a health promotion workshop.
When discussing the correct use of condoms, what should the nurse tell the attendees?
A) Attach the condom prior to erection.
B) A condom may be reused with the same partner if ejaculation has not occurred.
C) Use skin lotion as a lubricant if alternatives are unavailable.
D) Hold the condom by the cuff upon withdrawal.
D) Hold the condom by the cuff upon withdrawal.
128
A nurse is planning the care of a patient with AIDS who is admitted to the unit with
Pneumocystis pneumonia (PCP). Which nursing diagnosis has the highest priority for
this patient?
A) Ineffective Airway Clearance
B) Impaired Oral Mucous Membranes
C) Imbalanced Nutrition: Less than Body Requirements
D) Activity Intolerance
A) Ineffective Airway Clearance
129
A public health nurse is preparing an educational campaign to address a recent local
increase in the incidence of HIV infection. The nurse should prioritize which of the
following interventions?
A) Lifestyle actions that improve immune function
B) Educational programs that focus on control and prevention
C) Appropriate use of standard precautions
D) Screening programs for youth and young adults
B) Educational programs that focus on control and prevention
130
A nurse is working with a patient who was diagnosed with HIV several months earlier.
The nurse should recognize that a patient with HIV is considered to have AIDS at the
point when the CD4+ T-lymphocyte cell count drops below what threshold?
A) 75 cells/mm3 of blood
B) 200 cells/mm3 of blood
C) 325 cells/mm3 of blood
D) 450 cells/mm3 of blood
B) 200 cells/mm3 of blood
131
During the admission assessment of an HIV-positive patient whose CD4+ count has
recently fallen, the nurse carefully assesses for signs and symptoms related to
opportunistic infections. What is the most common life-threatening infection?
A) Salmonella infection
B) Mycobacterium tuberculosis
C) Clostridium difficile
D) Pneumocystis pneumonia
D) Pneumocystis pneumonia
132
A patient's current antiretroviral regimen includes nucleoside reverse transcriptase
inhibitors (NRTIs). What dietary counseling will the nurse provide based on the
patient's medication regimen?
A) Avoid high-fat meals while taking this medication.
B) Limit fluid intake to 2 liters a day.
C) Limit sodium intake to 2 grams per day.
D) Take this medication without regard to meals.
D) Take this medication without regard to meals.
133
A nurse is performing an admission assessment on a patient with stage 3 HIV. After
assessing the patient's gastrointestinal system and analyzing the data, what is most
likely to be the priority nursing diagnosis?
A) Acute Abdominal Pain
B) Diarrhea
C) Bowel Incontinence
D) Constipation
B) Diarrhea
134
A patient with a recent diagnosis of HIV infection expresses an interest in exploring
alternative and complementary therapies. How should the nurse best respond?
A) ìComplementary therapies generally have not been approved, so patients are
usually discouraged from using them.î
B) ìResearchers have not looked at the benefits of alternative therapy for patients
with HIV, so we suggest that you stay away from these therapies until there is
solid research data available.î
C) ìMany patients with HIV use some type of alternative therapy and, as with most
health treatments, there are benefits and risks.
D) ìYou'll need to meet with your doctor to choose between an alternative approach
to treatment and a medical approach.î
C) ìMany patients with HIV use some type of alternative therapy and, as with most
health treatments, there are benefits and risks.
135
A patient was tested for HIV using enzyme immunoassay (EIA) and results were
positive. The nurse should expect the primary care provider to order what test to
confirm the EIA test results?
A) Another EIA test
B) Viral load test
C) Western blot test
D) CD4/CD8 ratio
C) Western blot test
136
The nurse's plan of care for a patient with stage 3 HIV addresses the diagnosis of Risk
for Impaired Skin Integrity Related to Candidiasis. What nursing intervention best
addresses this risk?
A) Providing thorough oral care before and after meals
B) Administering prophylactic antibiotics
C) Promoting nutrition and adequate fluid intake
D) Applying skin emollients as needed
A) Providing thorough oral care before and after meals
137
A patient with HIV infection has begun experiencing severe diarrhea. What is the most
appropriate nursing intervention to help alleviate the diarrhea?
A) Administer antidiarrheal medications on a scheduled basis, as ordered.
B) Encourage the patient to eat three balanced meals and a snack at bedtime.
C) Increase the patient's oral fluid intake.
D) Encourage the patient to increase his or her activity level.
A) Administer antidiarrheal medications on a scheduled basis, as ordered.
138
A nurse is caring for a patient hospitalized with AIDS. A friend comes to visit the
patient and privately asks the nurse about the risk of contracting HIV when visiting the
patient. What is the nurse's best response?
A) ìDo you think that you might already have HIV?î
B) ìDon't worry. Your immune system is likely very healthy.î
C) ìAIDS isn't transmitted by casual contact.
D) ìYou can't contract AIDS in a hospital setting.î
C) ìAIDS isn't transmitted by casual contact.
139
A patient with HIV has a nursing diagnosis of Risk for Impaired Skin Integrity. What
nursing intervention best addresses this risk?
A) Utilize a pressure-reducing mattress.
B) Limit the patient's physical activity.
C) Apply antibiotic ointment to dependent skin surfaces.
D) Avoid contact with synthetic fabrics.
A) Utilize a pressure-reducing mattress.
140
A nurse would identify that a colleague needs additional instruction on standard
precautions when the colleague exhibits which of the following behaviors?
A) The nurse wears face protection, gloves, and a gown when irrigating a wound.
B) The nurse washes the hands with a waterless antiseptic agent after removing a
pair of soiled gloves.
C) The nurse puts on a second pair of gloves over soiled gloves while performing a
bloody procedure.
D) The nurse places a used needle and syringe in the puncture-resistant container
without capping the needle.
C) The nurse puts on a second pair of gloves over soiled gloves while performing a
bloody procedure.
141
An 18-year-old pregnant female has tested positive for HIV and asks the nurse if her
baby is going to be born with HIV. What is the nurse's best response?
A) ìThere is no way to know that for certain, but we do know that your baby has a
one in four chance of being born with HIV.î
B) ìYour physician is likely the best one to ask that question.î
C) ìIf the baby is HIV positive there is nothing that can be done until it is born, so
try your best not to worry about it now.î
D) ìIt's possible that your baby could contract HIV, either before, during, or after
delivery.
D) ìIt's possible that your baby could contract HIV, either before, during, or after
delivery.
142
A nurse is addressing the incidence and prevalence of HIV infection among older
adults. What principle should guide the nurse's choice of educational interventions?
A) Many older adults do not see themselves as being at risk for HIV infection.
B) Many older adults are not aware of the difference between HIV and AIDS.
C) Older adults tend to have more sex partners than younger adults.
D) Older adults have the highest incidence of intravenous drug use.
A) Many older adults do not see themselves as being at risk for HIV infection.
143
A 16-year-old has come to the clinic and asks to talk to a nurse. The nurse asks the teen
what she needs and the teen responds that she has become sexually active and is
concerned about getting HIV. The teen asks the nurse what she can do keep from
getting HIV. What would be the nurse's best response?
A) ìThere's no way to be sure you won't get HIV except to use condoms correctly.î
B) ìOnly the correct use of a female condom protects against the transmission of
HIV.î
C) ìThere are new ways of protecting yourself from HIV that are being discovered
every day.î
D) ìOther than abstinence, only the consistent and correct use of condoms is
effective in preventing HIV.
D) ìOther than abstinence, only the consistent and correct use of condoms is
effective in preventing HIV.
144
A patient is in the primary infection stage of HIV. What is true of this patient's current
health status?
A) The patient's HIV antibodies are successfully, but temporarily, killing the virus.
B) The patient is infected with HIV but lacks HIV-specific antibodies.
C) The patient's risk for opportunistic infections is at its peak.
D) The patient may or may not develop long-standing HIV infection.
B) The patient is infected with HIV but lacks HIV-specific antibodies.
145
A patient's primary infection with HIV has subsided and an equilibrium now exists
between HIV levels and the patient's immune response. This physiologic state is known
as which of the following?
A) Static stage
B) Latent stage
C) Viral set point
D) Window period
C) Viral set point
146
A patient with HIV will be receiving care in the home setting. What aspect of self-care
should the nurse emphasize during discharge education?
A) Appropriate use of prophylactic antibiotics
B) Importance of personal hygiene
C) Signs and symptoms of wasting syndrome
D) Strategies for adjusting antiretroviral dosages
B) Importance of personal hygiene
147
A patient is beginning an antiretroviral drug regimen shortly after being diagnosed with
HIV. What nursing action is most likely to increase the likelihood of successful
therapy?
A) Promoting appropriate use of complementary therapies
B) Addressing possible barriers to adherence
C) Educating the patient about the pathophysiology of HIV
D) Teaching the patient about the need for follow-up blood work
B) Addressing possible barriers to adherence
148
The nurse is caring for a patient who has been admitted for the treatment of AIDS. In
the morning, the patient tells the nurse that he experienced night sweats and recently
ìcoughed up some blood.î What is the nurse's most appropriate action?
A) Assess the patient for additional signs and symptoms of Kaposi's sarcoma.
B) Review the patient's most recent viral load and CD4+ count.
C) Place the patient on respiratory isolation and inform the physician.
D) Perform oral suctioning to reduce the patient's risk for aspiration.
C) Place the patient on respiratory isolation and inform the physician.
149
A patient has come into contact with HIV. As a result, HIV glycoproteins have fused
with the patient's CD4+ T-cell membranes. This process characterizes what phase in the
HIV life cycle?
A) Integration
B) Attachment
C) Cleavage
D) Budding
B) Attachment
150
An HIV-infected patient presents at the clinic for a scheduled CD4+ count. The results
of the test are 45 cells/μL, and the nurse recognizes the patient's increased risk for
Mycobacterium avium complex (MAC disease). The nurse should anticipate the
administration of what drug?
A) Azithromycin
B) Vancomycin
C) Levofloxacin
D) Fluconazole
A) Azithromycin
151
A patient with HIV is admitted to the hospital because of chronic severe diarrhea. The
nurse caring for this patient should expect the physician to order what drug for the
management of the patient's diarrhea?
A) Zithromax
B) Sandostatin
C) Levaquin
D) Biaxin
B) Sandostatin
152
A patient with AIDS is admitted to the hospital with AIDS-related wasting syndrome
and AIDS-related anorexia. What drug has been found to promote significant weight
gain in AIDS patients by increasing body fat stores?
A) Advera
B) Momordicacharantia
C) Megestrol
D) Ranitidine
C) Megestrol
153
```
A nurse is completing a nutritional status of a patient who has been admitted with
AIDS-related complications. What components should the nurse include in this
assessment? Select all that apply.
A) Serum albumin level
B) Weight history
C) White blood cell count
D) Body mass index
E) Blood urea nitrogen (BUN) level
```
A) Serum albumin level
B) Weight history
D) Body mass index
E) Blood urea nitrogen (BUN) level
154
A nurse is assessing the skin integrity of a patient who has AIDS. When performing
this inspection, the nurse should prioritize assessment of what skin surfaces?
A) Perianal region and oral mucosa
B) Sacral region and lower abdomen
C) Scalp and skin over the scapulae
D) Axillae and upper thorax
A) Perianal region and oral mucosa
155
A hospital nurse has experienced percutaneous exposure to an HIV-positive patient's
blood as a result of a needlestick injury. The nurse has informed the supervisor and
identified the patient. What action should the nurse take next?
A) Flush the wound site with chlorhexidine.
B) Report to the emergency department or employee health department.
C) Apply a hydrocolloid dressing to the wound site.
D) Follow up with the nurse's primary care provider.
B) Report to the emergency department or employee health department.
156
The nurse care plan for a patient with AIDS includes the diagnosis of Risk for Impaired
Skin Integrity. What nursing intervention should be included in the plan of care?
A) Maximize the patient's fluid intake.
B) Provide total parenteral nutrition (TPN).
C) Keep the patient's bed linens free of wrinkles.
D) Provide the patient with snug clothing at all times.
C) Keep the patient's bed linens free of wrinkles.
157
A patient has been diagnosed with AIDS complicated by chronic diarrhea. What
nursing intervention would be appropriate for this patient?
A) Position the patient in the high Fowler's position whenever possible.
B) Temporarily eliminate animal protein from the patient's diet.
C) Make sure the patient eats at least two servings of raw fruit each day.
D) Obtain a stool culture to identify possible pathogens.
D) Obtain a stool culture to identify possible pathogens.
158
A patient who has AIDS is being treated in the hospital and admits to having periods of
extreme anxiety. What would be the most appropriate nursing intervention?
A) Teach the patient guided imagery.
B) Give the patient more control of her antiretroviral regimen.
C) Increase the patient's activity level.
D) Collaborate with the patient's physician to obtain an order for hydromorphone.
A) Teach the patient guided imagery.
159
A patient who has AIDS has been admitted for the treatment of Kaposi's sarcoma. What
nursing diagnosis should the nurse associate with this complication of AIDS?
A) Risk for Disuse Syndrome Related to Kaposi's Sarcoma
B) Impaired Skin Integrity Related to Kaposi's Sarcoma
C) Diarrhea Related to Kaposi's Sarcoma
D) Impaired Swallowing Related to Kaposi's Sarcoma
B) Impaired Skin Integrity Related to Kaposi's Sarcoma
160
A nurse is performing the admission assessment of a patient who has AIDS. What
components should the nurse include in this comprehensive assessment? Select all that
apply.
A) Current medication regimen
B) Identification of patient's support system
C) Immune system function
D) Genetic risk factors for HIV
E) History of sexual practices
A) Current medication regimen
B) Identification of patient's support system
C) Immune system function
E) History of sexual practices
161
A patient with a family history of allergies has suffered an allergic response based on a
genetic predisposition. This atopic response is usually mediated by what
immunoglobulin?
A) Immunoglobulin A
B) Immunoglobulin M
C) Immunoglobulin G
D) Immunoglobulin E
D) Immunoglobulin E
162
An office worker takes a cupcake that contains peanut butter. He begins wheezing, with
an inspiratory stridor and air hunger and the occupational health nurse is called to the
office. The nurse should recognize that the worker is likely suffering from which type
of hypersensitivity?
A) Anaphylactic (type 1)
B) Cytotoxic (type II)
C) Immune complex (type III)
D) Delayed-type (type IV)
A) Anaphylactic (type 1)
163
A patient is learning about his new diagnosis of asthma with the asthma nurse. What
medication has the ability to prevent the onset of acute asthma exacerbations?
A) Diphenhydramine (Benadryl)
B) Montelukast (Singulair)
C) Albuterol sulfate (Ventolin)
D) Epinephrine
B) Montelukast (Singulair)
164
A nurse is preparing a patient for allergy skin testing. Which of the following
precautionary steps is most important for the nurse to follow?
A) The patient must not have received an immunization within 7 days.
B) The nurse should administer albuterol 30 to 45 minutes prior to the test.
C) Prophylactic epinephrine should be administered before the test.
D) Emergency equipment should be readily available.
D) Emergency equipment should be readily available.
165
A patient who is scheduled for a skin test informs the nurse that he has been taking
corticosteroids to help control his allergy symptoms. What nursing intervention should
the nurse implement?
A) The patient should take his corticosteroids regularly prior to testing.
B) The patient should only be tested for grass, mold, and dust initially.
C) The nurse should have an emergency cart available in case of anaphylaxis during
the test.
D) The patient's test should be cancelled until he is off his corticosteroids.
D) The patient's test should be cancelled until he is off his corticosteroids.
166
A patient has developed severe contact dermatitis with burning, itching, cracking, and
peeling of the skin on her hands. What should the nurse teach the patient to do?
A) Wear powdered latex gloves when in public.
B) Wash her hands with antibacterial soap every few hours.
C) Maintain room temperature at 75°F to 80°F whenever possible.
D) Keep her hands well-moisturized at all times.
D) Keep her hands well-moisturized at all times.
167
A patient with severe environmental allergies is scheduled for an immunotherapy
injection. What should be included in teaching the patient about this treatment?
A) The patient will be given a low dose of epinephrine before the treatment.
B) The patient will remain in the clinic to be monitored for 30 minutes following the
injection.
C) Therapeutic failure occurs if the symptoms to the allergen do not decrease after 3
months.
D) The allergen will be administered by the peripheral intravenous route.
B) The patient will remain in the clinic to be monitored for 30 minutes following the
injection.
168
The nurse in an allergy clinic is educating a new patient about the pathology of the
patient's health problem. What response should the nurse describe as a possible
consequence of histamine release?
A) Constriction of small venules
B) Contraction of bronchial smooth muscle
C) Dilation of large blood vessels
D) Decreased secretions from gastric and mucosal cells
B) Contraction of bronchial smooth muscle
169
The nurse is providing care for a patient who has experienced a type I hypersensitivity
reaction. What condition is an example of such a reaction?
A) Anaphylactic reaction after a bee sting
B) Skin reaction resulting from adhesive tape
C) Myasthenia gravis
D) Rheumatoid arthritis
A) Anaphylactic reaction after a bee sting
170
A nurse is caring for a teenage girl who has had an anaphylactic reaction after a bee
sting. The nurse is providing patient teaching prior to the patient's discharge. In the
event of an anaphylactic reaction, the nurse informs the patient that she should selfadminister
epinephrine in what site?
A) Forearm
B) Thigh
C) Deltoid muscle
D) Abdomen
B) Thigh
171
A nurse has included the nursing diagnosis of Risk for Latex Allergy Response in a
patient's plan of care. The presence of what chronic health problem would most likely
prompt this diagnosis?
A) Herpes simplex
B) HIV
C) Spina bifida
D) Hypogammaglobulinemia
C) Spina bifida
172
A patient has a documented history of allergies presents to the clinic. She states that she
is frustrated by her chronic nasal congestion, anosmia (inability to smell) and inability
to concentrate. The nurse should identify which of the following nursing diagnoses?
A) Deficient Knowledge of Self-Care Practices Related to Allergies
B) Ineffective Individual Coping with Chronicity of Condition and Need for
Environmental Modification
C) Acute Confusion Related to Cognitive Effects of Allergic Rhinitis
D) Disturbed Body Image Related to Sequelae of Allergic Rhinitis
B) Ineffective Individual Coping with Chronicity of Condition and Need for
Environmental Modification
173
A patient's decline in respiratory and renal function has been attributed to Goodpasture
syndrome, which is a type II hypersensitivity reaction. What pathologic process
underlies the patient's health problem?
A) Antigens have bound to antibodies and formed inappropriate immune complexes.
B) The patient's body has mistakenly identified a normal constituent of the body as
foreign.
C) Sensitized T cells have caused cell and tissue damage.
D) Mast cells have released histamines that directly cause cell lysis.
B) The patient's body has mistakenly identified a normal constituent of the body as
foreign.
174
A child is undergoing testing for food allergies after experiencing unexplained signs
and symptoms of hypersensitivity. What food items would the nurse inform the parents
are common allergens?
A) Citrus fruits and rice
B) Root vegetables and tomatoes
C) Eggs and wheat
D) Hard cheeses and vegetable oils
C) Eggs and wheat
175
A patient has been admitted to the emergency department with signs of anaphylaxis
following a bee sting. The nurse knows that if this is a true allergic reaction the patient
will present with what alteration in laboratory values?
A) Increased eosinophils
B) Increased neutrophils
C) Increased serum albumin
D) Decreased blood glucose
A) Increased eosinophils
176
A nurse is aware of the need to assess patients' risks for anaphylaxis. What health care
procedure constitutes the highest risk for anaphylaxis?
A) Administration of the measles-mumps-rubella (MMR) vaccine
B) Rapid administration of intravenous fluids
C) Computed tomography with contrast solution
D) Administration of nebulized bronchodilators
C) Computed tomography with contrast solution
177
After the completion of testing, a child's allergies have been attributed to her family's
cat. When introducing the family to the principles of avoidance therapy, the nurse
should promote what action?
A) Removing the cat from the family's home
B) Administering OTC antihistamines to the child regularly
C) Keeping the cat restricted from the child's bedroom
D) Maximizing airflow in the house
A) Removing the cat from the family's home
178
The nurse is providing health education to the parents of a toddler who has been
diagnosed with food allergies. What should the nurse teach this family about the child's
health problem?
A) ìFood allergies are a life-long condition, but most families adjust quite well to the
necessary lifestyle changes.î
B) ìConsistent use of over-the-counter antihistamines can often help a child
overcome food allergies.î
C) ìMake sure that you carry a steroid inhaler with you at all times, especially when
you eat in restaurants.î
D) ìMany children outgrow their food allergies in a few years if they avoid the
offending foods.
D) ìMany children outgrow their food allergies in a few years if they avoid the
offending foods.
179
A child has been diagnosed with a severe walnut allergy after suffering an anaphylactic
reaction. What is a priority for health education?
A) The need to begin immunotherapy as soon as possible
B) The need for the parents to carry an epinephrine pen
C) The need to vigilantly maintain the child's immunization status
D) The need for the child to avoid all foods that have a high potential for allergies
B) The need for the parents to carry an epinephrine pen
180
An adolescent patient's history of skin hyperreactivity and inflammation has been
attributed to atopic dermatitis. The nurse should recognize that this patient
consequently faces an increased risk of what health problem?
A) Bronchitis
B) Systemic lupus erythematosus (SLE)
C) Rheumatoid arthritis
D) Asthma
D) Asthma
181
The nurse is planning the care of a patient who has a diagnosis of atopic dermatitis,
which commonly affects both of her hands and forearms. What risk nursing diagnosis
should the nurse include in the patient's care plan?
A) Risk for Disturbed Body Image Related to Skin Lesions
B) Risk for Disuse Syndrome Related to Dermatitis
C) Risk for Ineffective Role Performance Related to Dermatitis
D) Risk for Self-Care Deficit Related to Skin Lesions
A) Risk for Disturbed Body Image Related to Skin Lesions
182
A patient has been brought to the emergency department by EMS after being found
unresponsive. Rapid assessment reveals anaphylaxis as a potential cause of the patient's
condition. The care team should attempt to assess for what potential causes of
anaphylaxis? Select all that apply.
A) Foods
B) Medications
C) Insect stings
D) Autoimmunity
E) Environmental pollutants
A) Foods
B) Medications
C) Insect stings
183
A school nurse is caring for a child who appears to be having an allergic response.
What should be the initial action of the school nurse?
A) Assess for signs and symptoms of anaphylaxis.
B) Assess for erythema and urticaria.
C) Administer an OTC antihistamine.
D) Administer epinephrine.
A) Assess for signs and symptoms of anaphylaxis.
184
A patient is receiving a transfusion of packed red blood cells. Shortly after initiation of
the transfusion, the patient begins to exhibit signs and symptoms of a transfusion
reaction. The patient is suffering from which type of hypersensitivity?
A) Anaphylactic (type 1)
B) Cytotoxic (type II)
C) Immunecomplex (type III)
D) Delayed type (type IV)
B) Cytotoxic (type II)
185
Which of the following individuals would be the most appropriate candidate for
immunotherapy?
A) A patient who had an anaphylactic reaction to an insect sting
B) A child with allergies to eggs and dairy
C) A patient who has had a positive tuberculin skin test
D) A patient with severe allergies to grass and tree pollen
D) A patient with severe allergies to grass and tree pollen
186
A nurse has asked the nurse educator if there is any way to predict the severity of a
patient's anaphylactic reaction. What would be the nurse's best response?
A) ìThe faster the onset of symptoms, the more severe the reaction.
B) ìThe reaction will be about one-third more severe than the patient's last reaction
to the same antigen.î
C) ìThere is no way to gauge the severity of a patient's anaphylaxis, even if it has
occurred repeatedly in the past.î
D) ìThe reaction will generally be slightly less severe than the last reaction to the
same antigen.î
A) ìThe faster the onset of symptoms, the more severe the reaction.
187
A nurse knows of several patients who have achieved adequate control of their allergy
symptoms using over-the-counter antihistamines. Antihistamines would be
contraindicated in the care of which patient?
A) A patient who has previously been treated for tuberculosis
B) A pregnant woman at 30 weeks' gestation
C) A patient who is on estrogen-replacement therapy
D) A patient with a severe allergy to eggs
B) A pregnant woman at 30 weeks' gestation
188
A patient has been living with seasonal allergies for many years, but does not take
antihistamines, stating, ìWhen I was young I used to take antihistamines, but they
always put me to sleep.î How should the nurse best respond?
A) ìNewer antihistamines are combined with a stimulant that offsets drowsiness.î
B) ìMost people find that they develop a tolerance to sedation after a few months.î
C) ìThe newer antihistamines are different than in years past, and cause less
sedation.
D) ìHave you considered taking them at bedtime instead of in the morning?î
C) ìThe newer antihistamines are different than in years past, and cause less
sedation.
189
A child has been transported to the emergency department (ED) after a severe allergic
reaction. The ED nurse is evaluating the patient's respiratory status. How should the
nurse evaluate the patient's respiratory status? Select all that apply.
A) Facilitate lung function testing.
B) Assess breath sounds.
C) Measure the child's oxygen saturation by oximeter.
D) Monitor the child's respiratory pattern.
E) Assess the child's respiratory rate.
B) Assess breath sounds.
C) Measure the child's oxygen saturation by oximeter.
D) Monitor the child's respiratory pattern.
E) Assess the child's respiratory rate.
190
A patient with multiple food and environmental allergies tells the nurse that he is
frustrated and angry about having to be so watchful all the time and wonders if it is
really worth it. What would be the nurse's best response?
A) ìI can only imagine how you feel. Would you like to talk about it?
B) ìLet's find a quiet spot and I'll teach you a few coping strategies.î
C) ìThat's the same way that most patients who have a chronic illness feel.î
D) ìDo you think that maybe you could be managing things more efficiently?î
A) ìI can only imagine how you feel. Would you like to talk about it?
191
A nurse at an allergy clinic is providing education for a patient starting immunotherapy
for the treatment of allergies. What education should the nurse prioritize?
A) The importance of scheduling appointments for the same time each month
B) The importance of keeping appointments for desensitization procedures
C) The importance of avoiding antihistamines for the duration of treatment
D) The importance of keeping a diary of reactions to the immunotherapy
B) The importance of keeping appointments for desensitization procedures
192
A patient has presented with signs and symptoms that are consistent with contact
dermatitis. What aspect of care should the nurse prioritize when working with this
patient?
A) Promoting adequate perfusion in affected regions
B) Promoting safe use of topical antihistamines
C) Identifying the offending agent, if possible
D) Teaching the patient to safely use an EpiPen
C) Identifying the offending agent, if possible
193
A patient was prescribed an oral antibiotic for the treatment of sinusitis. The patient has
now stopped, stating she developed a rash shortly after taking the first dose of the drug.
What is the nurse's most appropriate response?
A) Encourage the woman to continue with the medication while monitoring her skin
condition closely.
B) Refer the woman to her primary care provider to have the medication changed.
C) Arrange for the woman to go to the nearest emergency department.
D) Encourage the woman to take an OTC antihistamine with each dose of the
antibiotic.
B) Refer the woman to her primary care provider to have the medication changed.
194
A patient has sought care, stating that she developed hives overnight. The nurse's
inspection confirms the presence of urticaria. What type of allergic hypersensitivity
reaction has the patient developed?
A) Type I
B) Type II
C) Type III
D) Type IV
A) Type I
195
The nurse is providing care for a patient who has a diagnosis of hereditary angioedema.
When planning this patient's care, what nursing diagnosis should be prioritized?
A) Risk for Infection Related to Skin Sloughing
B) Risk for Acute Pain Related to Loss of Skin Integrity
C) Risk for Impaired Skin Integrity Related to Cutaneous Lesions
D) Risk for Impaired Gas Exchange Related to Airway Obstruction
D) Risk for Impaired Gas Exchange Related to Airway Obstruction
196
A junior nursing student is having an observation day in the operating room. Early in
the day, the student tells the OR nurse that her eyes are swelling and she is having
trouble breathing. What should the nurse suspect?
A) Cytotoxic reaction due to contact with the powder in the gloves
B) Immune complex reaction due to contact with anesthetic gases
C) Anaphylaxis due to a latex allergy
D) Delayed reaction due to exposure to cleaning products
C) Anaphylaxis due to a latex allergy
197
A nurse is caring for a patient who has allergic rhinitis. What intervention would be
most likely to help the patient meet the goal of improved breathing pattern?
A) Teach the patient to take deep breaths and cough frequently.
B) Use antihistamines daily throughout the year.
C) Teach the patient to seek medical attention at the first sign of an allergic reaction.
D) Modify the environment to reduce the severity of allergic symptoms.
D) Modify the environment to reduce the severity of allergic symptoms.
198
The nurse is creating a care plan for a patient suffering from allergic rhinitis. Which of
the following outcomes should the nurse identify?
A) Appropriate use of prophylactic antibiotics
B) Safe injection of corticosteroids
C) Improved skin integrity
D) Improved coping with lifestyle modifications
D) Improved coping with lifestyle modifications
199
A 5-year-old boy has been diagnosed with a severe food allergy. What is an important
parameter to address when educating the parents of this child about his allergy and
care?
A) Wear a medical identification bracelet.
B) Know how to use the antihistamine pen.
C) Know how to give injections of lidocaine.
D) Avoid live attenuated vaccinations.
A) Wear a medical identification bracelet.
200
A patient is brought to the emergency department (ED) in a state of anaphylaxis. What
is the ED nurse's priority for care?
A) Monitor the patient's level of consciousness.
B) Protect the patient's airway.
C) Provide psychosocial support.
D) Administer medications as ordered.
B) Protect the patient's airway.
201
While taking a health history on a 20-year-old female patient, the nurse ascertains that
this patient is taking miconazole (Monistat). The nurse is justified in presuming that
this patient has what medical condition?
A) Bacterial vaginosis
B) Human papillomavirus (HPV)
C) Candidiasis
D) Toxic shock syndrome (TSS)
C) Candidiasis
202
A patient with genital herpes is having an acute exacerbation. What medication would
the nurse expect to be ordered to suppress the symptoms and shorten the course of the
infection?
A) Clotrimazole (Gyne-Lotrimin)
B) Metronidazole (Flagyl)
C) Podophyllin (Podofin)
D) Acyclovir (Zovirax)
D) Acyclovir (Zovirax)
203
A patient with trichomoniasis comes to the walk-in clinic. In developing a care plan for
this patient the nurse would know to include what as an important aspect of treating this
patient?
A) Both partners will be treated with metronidazole (Flagyl).
B) Constipation and menstrual difficulties may occur.
C) The patient should perform Kegel exercises 30 to 80 times daily.
D) Care will involve hormone therapy to control the pain.
A) Both partners will be treated with metronidazole (Flagyl).
204
A student nurse is doing clinical hours at an OB/GYN clinic. The student is helping to
develop a plan of care for a patient with gonorrhea who has presented at the clinic. The
student should include which of the following in the care plan for this patient?
A) The patient may benefit from oral contraceptives.
B) The patient must avoid use of tampons.
C) The patient is susceptible to urinary incontinence.
D) The patient should also be treated for chlamydia.
D) The patient should also be treated for chlamydia.
205
When teaching patients about the risk factors of cervical cancer, what would the nurse
identify as the most important risk factor?
A) Late childbearing
B) Human papillomavirus (HPV)
C) Postmenopausal bleeding
D) Tobacco use
B) Human papillomavirus (HPV)
206
The nurse is providing preoperative education for a patient diagnosed with
endometriosis. A hysterectomy has been scheduled. What education topic should the
nurse be sure to include for this patient?
A) Menstrual periods will continue to occur for several months, some of them heavy.
B) Normal activity will be permitted within 48 hours following surgery.
C) After a hysterectomy, hormone levels remain largely unaffected.
D) The bladder must be emptied prior to surgery and a catheter may be placed
during surgery.
D) The bladder must be emptied prior to surgery and a catheter may be placed
during surgery.
207
A patient has returned to the post-surgical unit after vulvar surgery. What intervention
should the nurse prioritize during the initial postoperative period?
A) Placing the patient in high Fowler's position
B) Administering sitz baths every 4 hours
C) Monitoring the integrity of the surgical site
D) Avoiding analgesics unless the patient's pain is unbearable
C) Monitoring the integrity of the surgical site
208
A patient comes to the free clinic complaining of a gray-white discharge that clings to
her external vulva and vaginal walls. A nurse practitioner assesses the patient and
diagnoses Gardnerella vaginalis. What would be the most appropriate nursing action at
this time?
A) Advise the patient that this is an overgrowth of normal vaginal flora.
B) Discuss the effect of this diagnosis on the patient's fertility.
C) Document the vaginal discharge as normal.
D) Administer acyclovir as ordered.
A) Advise the patient that this is an overgrowth of normal vaginal flora.
209
A female patient with HIV has just been diagnosed with condylomata acuminata
(genital warts). What information is most appropriate for the nurse to tell this patient?
A) This condition puts her at a higher risk for cervical cancer; therefore, she should
have a Papanicolaou (Pap) test annually.
B) The most common treatment is metronidazole (Flagyl), which should eradicate
the problem within 7 to 10 days.
C) The potential for transmission to her sexual partner will be eliminated if condoms
are used every time they have sexual intercourse.
D) The human papillomavirus (HPV), which causes condylomata acuminata, cannot
be transmitted during oral sex.
A) This condition puts her at a higher risk for cervical cancer; therefore, she should
have a Papanicolaou (Pap) test annually.
210
The nurse is teaching a patient preventative measures regarding vaginal infections. The
nurse should include which of the following as an important risk factor?
A) High estrogen levels
B) Late menarche
C) Nonpregnant state
D) Frequent douching
D) Frequent douching
211
A nurse is caring for a pregnant patient with active herpes. The teaching plan for this
patient should include which of the following?
A) Babies delivered vaginally may become infected with the virus.
B) Recommended treatment is excision of the herpes lesions.
C) Pain generally does not occur with a herpes outbreak during pregnancy.
D) Pregnancy may exacerbate the mother's symptoms, but poses no risk to the infant.
A) Babies delivered vaginally may become infected with the virus.
212
A patient with ovarian cancer is admitted to the hospital for surgery and the nurse is
completing the patient's health history. What clinical manifestation would the nurse
expect to assess?
A) Fish-like vaginal odor
B) Increased abdominal girth
C) Fever and chills
D) Lower abdominal pelvic pain
B) Increased abdominal girth
213
A 30-year-old patient has come to the clinic for her yearly examination. The patient
asks the nurse about ovarian cancer. What should the nurse state when describing risk
factors for ovarian cancer?
A) ìUse of oral contraceptives increases the risk of ovarian cancer.î
B) ìMost cases of ovarian cancer are attributed to tobacco use.î
C) ìMost cases of ovarian cancer are considered to be random, with no obvious
causation.
D) ìThe majority of women who get ovarian cancer have a family history of the
disease.î
C) ìMost cases of ovarian cancer are considered to be random, with no obvious
causation.
214
A student nurse is caring for a patient who has undergone a wide excision of the vulva.
The student should know that what action is contraindicated in the immediate
postoperative period?
A) Placing patient in low Fowler's position
B) Application of compression stockings
C) Ambulation to a chair
D) Provision of a low-residue diet
C) Ambulation to a chair
215
A female patient tells the nurse that she thinks she has a vaginal infection because she
has noted inflammation of her vulva and the presence of a frothy, yellow-green
discharge. The nurse recognizes that the clinical manifestations described are typical of
what vaginal infection?
A) Trichomonas vaginalis
B) Candidiasis
C) Gardnerella
D) Gonorrhea
A) Trichomonas vaginalis
216
The nurse notes that a patient has a history of ìfibroidsî and is aware that this term
refers to a benign tumor of the uterus. What is a more appropriate term for a fibroid?
A) Bartholin's cyst
B) Dermoid cyst
C) Hydatidiform mole
D) Leiomyoma
D) Leiomyoma
217
A nurse practitioner is examining a patient who presented at the free clinic with vulvar
pruritus. For which assessment finding would the practitioner look that may indicate the
patient has an infection caused by Candida albicans?
A) Cottage cheese-like discharge
B) Yellow-green discharge
C) Gray-white discharge
D) Watery discharge with a fishy odor
A) Cottage cheese-like discharge
218
The nurse is planning health education for a patient who has experienced a vaginal
infection. What guidelines should the nurse include in this program regarding
prevention?
A) Wear tight-fitting synthetic underwear.
B) Use bubble bath to eradicate perineal bacteria.
C) Avoid feminine hygiene products, such as sprays.
D) Restrict daily bathing.
C) Avoid feminine hygiene products, such as sprays
219
A patient has herpes simplex 2 viral infection (HSVñ2). The nurse recognizes that
which of the following should be included in teaching the patient?
A) The virus causes ìcold soresî of the lips.
B) The virus may be cured with antibiotics.
C) The virus, when active, may not be contracted during intercourse.
D) Treatment is aimed at relieving symptoms.
D) Treatment is aimed at relieving symptoms.
220
You are caring for a patient who has been diagnosed with genital herpes. When
preparing a teaching plan for this patient, what general guidelines should be taught?
A) Thorough handwashing is essential.
B) Sun bathing assists in eradicating the virus.
C) Lesions should be massaged with ointment.
D) Self-infection cannot occur from touching lesions during a breakout.
A) Thorough handwashing is essential.
221
A patient comes to the clinic complaining of a tender, inflamed vulva. Testing does not
reveal the presence of any known causative microorganism. What aspect of this
patient's current health status may account for the patient's symptoms of vulvitis?
A) The patient is morbidly obese.
B) The patient has type 1 diabetes.
C) The patient has chronic kidney disease.
D) The patient has numerous allergies.
B) The patient has type 1 diabetes.
222
A 14-year-old is brought to the clinic by her mother. The mother explains to the nurse
that her daughter has just started using tampons, but is not yet sexually active. The
mother states ìI am very concerned because my daughter is having a lot of stabbing
pain and burning.î What might the nurse suspect is the problem with the 14-year-old?
A) Vulvitis
B) Vulvodynia
C) Vaginitis
D) Bartholin's cyst
B) Vulvodynia
223
A patient has been diagnosed with polycystic ovary syndrome (PCOS). The nurse
should encourage what health promotion activity to address the patient's hormone
imbalance and infertility?
A) Kegel exercises
B) Increased fluid intake
C) Weight loss
D) Topical antibiotics as ordered
C) Weight loss
224
A patient has been diagnosed with endometriosis. When planning this patient's care, the
nurse should prioritize what nursing diagnosis?
A) Anxiety related to risk of transmission
B) Acute pain related to misplaced endometrial tissue
C) Ineffective tissue perfusion related to hemorrhage
D) Excess fluid volume related to abdominal distention
B) Acute pain related to misplaced endometrial tissue
225
When reviewing the electronic health record of a female patient, the nurse reads that the
patient has a history of adenomyosis. The nurse should be aware that this patient
experiences symptoms resulting from what pathophysiologic process?
A) Loss of muscle tone in the vaginal wall
B) Excessive synthesis and release of unopposed estrogen
C) Invasion of the uterine wall by endometrial tissue
D) Proliferation of tumors in the uterine wall
C) Invasion of the uterine wall by endometrial tissue
226
Following a recent history of dyspareunia and lower abdominal pain, a patient has
received a diagnosis of pelvic inflammatory disease (PID). When providing health
education related to self-care, the nurse should address which of the following topics?
Select all that apply.
A) Use of condoms to prevent infecting others
B) Appropriate use of antibiotics
C) Taking measures to prevent pregnancy
D) The need for a Pap smear every 3 months
E) The importance of weight loss in preventing symptoms
A) Use of condoms to prevent infecting others
| B) Appropriate use of antibiotics
227
A middle-aged female patient has been offered testing for HIV/AIDS upon admission
to the hospital for an unrelated health problem. The nurse observes that the patient is
visibly surprised and embarrassed by this offer. How should the nurse best respond?
A) ìMost women with HIV don't know they have the disease. If you have it, it's
important we catch it early.î
B) ìThis testing is offered to every adolescent and adult regardless of their lifestyle,
appearance or history.
C) ìThe rationale for this testing is so that you can begin treatment as soon as testing
comes back, if it's positive.î
D) ìYou're being offered this testing because you are actually in the prime
demographic for HIV infection.î
B) ìThis testing is offered to every adolescent and adult regardless of their lifestyle,
appearance or history.
228
A patient with a genital herpes exacerbation has a nursing diagnosis of ìacute pain
related to the genital lesions.î What nursing intervention best addresses this diagnosis?
A) Cover the lesions with a topical antibiotic.
B) Keep the lesions clean and dry.
C) Apply a topical NSAID to the lesions.
D) Remain on bed rest until the lesions resolve.
B) Keep the lesions clean and dry.
229
The nurse is caring for a patient who has just been told that her ovarian cancer is
terminal and that no curative options remain. What would be the priority nursing care
for this patient at this time?
A) Provide emotional support to the patient and her family.
B) Implement distraction and relaxation techniques.
C) Offer to inform the patient's family of this diagnosis.
D) Teach the patient about the importance of maintaining a positive attitude.
A) Provide emotional support to the patient and her family.
230
A public health nurse is participating in a campaign aimed at preventing cervical
cancer. What strategies should the nurse include is this campaign? Select all that apply.
A) Promotion of HPV immunization
B) Encouraging young women to delay first intercourse
C) Smoking cessation
D) Vitamin D and calcium supplementation
E) Using safer sex practices
A) Promotion of HPV immunization
B) Encouraging young women to delay first intercourse
C) Smoking cessation
E) Using safer sex practices
231
A patient is being discharged home after a hysterectomy. When providing discharge
education for this patient, the nurse has cautioned the patient against sitting for long
periods. This advice addresses the patient's risk of what surgical complication?
A) Pudendal nerve damage
B) Fatigue
C) Venous thromboembolism
D) Hemorrhage
C) Venous thromboembolism
232
A 27-year-old female patient is diagnosed with invasive cervical cancer and is told she
needs to have a hysterectomy. One of the nursing diagnoses for this patient is ìdisturbed
body image related to perception of femininity.î What intervention would be most
appropriate for this patient?
A) Reassure the patient that she will still be able to have children.
B) Reassure the patient that she does not have to have sex to be feminine.
C) Reassure the patient that you know how she is feeling and that you feel her
anxiety and pain.
D) Reassure the patient that she will still be able to have intercourse with sexual
satisfaction and orgasm.
D) Reassure the patient that she will still be able to have intercourse with sexual
satisfaction and orgasm.
233
A patient is post-operative day 1 following a vaginal hysterectomy. The nurse notes an
increase in the patient's abdominal girth and the patient complains of ìbloating.î What is
the nurse's most appropriate action?
A) Provide the patient with an unsweetened, carbonated beverage.
B) Apply warm compresses to the patient's lower abdomen.
C) Provide an ice pack to apply to the perineum and suprapubic region.
D) Assist the patient into a prone position.
B) Apply warm compresses to the patient's lower abdomen.
234
A 31-year-old patient has returned to the post-surgical unit following a hysterectomy.
The patient's care plan addresses the risk of hemorrhage. How should the nurse best
monitor the patient's postoperative blood loss?
A) Have the patient void and have bowel movements using a commode rather than
toilet.
B) Count and inspect each perineal pad that the patient uses.
C) Swab the patient's perineum for the presence of blood at least once per shift.
D) Leave the patient's perineum open to air to facilitate inspection.
B) Count and inspect each perineal pad that the patient uses.
235
A patient diagnosed with cervical cancer will soon begin a round of radiation therapy.
When planning the patient's subsequent care, the nurse should prioritize actions with
what goal?
A) Preventing hemorrhage
B) Ensuring the patient knows the treatment is palliative, not curative
C) Protecting the safety of the patient, family, and staff
D) Ensuring that the patient adheres to dietary restrictions during treatment
C) Protecting the safety of the patient, family, and staff
236
The nurse is caring for a 63-year-old patient with ovarian cancer. The patient is to
receive chemotherapy consisting of Taxol and Paraplatin. For what adverse effect of
this treatment should the nurse monitor the patient?
A) Leukopenia
B) Metabolic acidosis
C) Hyperphosphatemia
D) Respiratory alkalosis
A) Leukopenia
237
The nurse is caring for a patient with a diagnosis of vulvar cancer who has returned
from the PACU after undergoing a wide excision of the vulva. How should this
patient's analgesic regimen be best managed?
A) Analgesia should be withheld unless the patient's pain becomes unbearable.
B) Scheduled analgesia should be administered around-the-clock to prevent pain.
C) All analgesics should be given on a PRN, rather than scheduled, basis.
D) Opioid analgesics should be avoided and NSAIDs exclusively provided.
B) Scheduled analgesia should be administered around-the-clock to prevent pain.
238
A 45-year-old woman has just undergone a radical hysterectomy for invasive cervical
cancer. Prior to the surgery the physician explained to the patient that after the surgery
a source of radiation would be placed near the tumor site to aid in reducing recurrence.
What is the placement of the source of radiation called?
A) Internal beam radiation
B) Trachelectomy
C) Brachytherapy
D) External radiation
C) Brachytherapy
239
A 25-year-old patient diagnosed with invasive cervical cancer expresses a desire to
have children. What procedure might the physician offer as treatment?
A) Radical hysterectomy
B) Radical culposcopy
C) Radical trabeculectomy
D) Radical trachelectomy
D) Radical trachelectomy
240
A nurse providing prenatal care to a pregnant woman is addressing measures to reduce
her postpartum risk of cystocele, rectocele, and uterine prolapse. What action should
the nurse recommend?
A) Maintenance of good perineal hygiene
B) Prevention of constipation
C) Increased fluid intake for 2 weeks postpartum
D) Performance of pelvic muscle exercises
D) Performance of pelvic muscle exercises
241
A 45-year-old woman comes into the health clinic for her annual check-up. She
mentions to the nurse that she has noticed dimpling of the right breast that has occurred
in a few months. What assessment would be most appropriate for the nurse to make?
A) Evaluate the patient's milk production.
B) Palpate the area for a breast mass.
C) Assess the patient's knowledge of breast cancer.
D) Assure the patient that this likely an age-related change.
B) Palpate the area for a breast mass.
242
The nurse leading an educational session is describing self-examination of the breast.
The nurse tells the women's group to raise their arms and inspect their breasts in a
mirror. A member of the women's group asks the nurse why raising her arms is
necessary. What is the nurse's best response?
A) ìIt helps to spread out the fat that makes up your breast.î
B) ìIt allows you to simultaneously assess for pain.î
C) ìIt will help to observe for dimpling more closely.
D) ìThis is what the American Cancer Society recommends.î
C) ìIt will help to observe for dimpling more closely.
243
A woman aged 48 years comes to the clinic because she has discovered a lump in her
breast. After diagnostic testing, the woman receives a diagnosis of breast cancer. The
woman asks the nurse when her teenage daughters should begin mammography. What
is the nurse's best advice?
A) Age 28
B) Age 35
C) Age 38
D) Age 48
C) Age 38
244
A woman scheduled for a simple mastectomy in one week is having her preoperative
education provided by the clinic nurse. What educational intervention will be of
primary importance to prevent hemorrhage in the postoperative period?
A) Limit her intake of green leafy vegetables.
B) Increase her water intake to 8 glasses per day.
C) Stop taking aspirin.
D) Have nothing by mouth for 6 hours before surgery.
C) Stop taking aspirin.
245
The nurse is caring for a 52-year-old woman whose aunt and mother died of breast
cancer. The patient states, ìMy doctor and I talked about Tamoxifen to help prevent
breast cancer. Do you think it will work?î What would be the nurse's best response?
A) ìYes, it's known to have a slight protective effect.î
B) ìYes, but studies also show an increased risk of osteoporosis.î
C) ìYou won't need to worry about getting cancer as long as you take Tamoxifen.î
D) ìTamoxifen is known to be a highly effective protective measure.
D) ìTamoxifen is known to be a highly effective protective measure.
246
A woman is being treated for a tumor of the left breast. If the patient and her physician
opt for prophylactic treatment, the nurse should prepare the woman for what
intervention?
A) More aggressive chemotherapy
B) Left mastectomy
C) Radiation therapy
D) Bilateral mastectomy
D) Bilateral mastectomy
247
During a recent visit to the clinic a woman presents with erythema of the nipple and
areola on the right breast. She states this started several weeks ago and she was fearful
of what would be found. The nurse should promptly refer the patient to her primary
care provider because the patient's signs and symptoms are suggestive of what health
problem?
A) Peau d'orange
B) Nipple inversion
C) Paget's disease
D) Acute mastitis
C) Paget's disease
248
A patient who came to the clinic after finding a mass in her breast is scheduled for a
diagnostic breast biopsy. During the nurse's admission assessment, the nurse observes
that the patient is distracted and tense. What is it important for the nurse to do?
A) Acknowledge the fear the patient is likely experiencing.
B) Describe the support groups that exist in the community.
C) Assess the patient's stress management skills.
D) Document a nursing diagnosis of ineffective coping.
A) Acknowledge the fear the patient is likely experiencing.
249
A patient has been referred to the breast clinic after her most recent mammogram
revealed the presence of a lump. The lump is found to be a small, well-defined nodule
in the right breast. The oncology nurse should recognize the likelihood of what
treatment?
A) Lumpectomy and radiation
B) Partial mastectomy and radiation
C) Partial mastectomy and chemotherapy
D) Total mastectomy and chemotherapy
A) Lumpectomy and radiation
250
A 23-year-old woman comes to the free clinic stating ìI think I have a lump in my
breast. Do I have cancer?î The nurse instructs the patient that a diagnosis of breast
cancer is confirmed by what?
A) Supervised breast self-examination
B) Mammography
C) Fine-needle aspiration
D) Chest x-ray
C) Fine-needle aspiration
251
A 42 year-old patient tells the nurse that she has found a painless lump in her right
breast during her monthly self-examination. She says that she is afraid that she has
cancer. Which assessment finding would most strongly suggest that this patient's lump
is cancerous?
A) Eversion of the right nipple and mobile mass
B) A nonmobile mass with irregular edges
C) A mobile mass that is soft and easily delineated
D) Nonpalpable right axillary lymph nodes
B) A nonmobile mass with irregular edges
252
A patient in her 30s has two young children and has just had a modified radical
mastectomy with immediate reconstruction. The patient shares with the nurse that she is
somewhat worried about her future, but she appears to be adjusting well to her
diagnosis and surgery. What nursing intervention is most appropriate to support this
patient's coping?
A) Encourage the patient's spouse or partner to be supportive while she recovers.
B) Encourage the patient to proceed with the next phase of treatment.
C) Recommend that the patient remain optimistic for the sake of her children.
D) Arrange a referral to a community-based support program.
D) Arrange a referral to a community-based support program.
253
The nurse is caring for a patient who has just had a radical mastectomy and axillary
node dissection. When providing patient education regarding rehabilitation, what
should the nurse recommend?
A) Avoid exercise of the arm for next 2 months.
B) Keep cuticles clipped neatly.
C) Avoid lifting objects heavier than 10 pounds.
D) Use a sling until healing is complete.
C) Avoid lifting objects heavier than 10 pounds.
254
A new mother who is breastfeeding calls the clinic to speak to a nurse. The patient is
complaining of pain in her left breast and describes her breast as feeling ìdoughy.î The
nurse tells her to come into the clinic and be checked. The patient is diagnosed with
acute mastitis and placed on antibiotics. What comfort measure should the nurse
recommend?
A) Apply cold compresses as ordered.
B) Avoid wearing a bra until the infection clears.
C) Avoid washing the breasts.
D) Perform gentle massage to stimulate neutrophil migration.
A) Apply cold compresses as ordered.
255
When planning discharge teaching with a patient who has undergone a total
mastectomy with axillary dissection, the nurse knows to instruct the patient that she
should report what sign or symptom to the physician immediately?
A) Fatigue
B) Temperature greater than 98.5∫F
C) Sudden cessation of output from the drainage device
D) Gradual decline in output from the drain
C) Sudden cessation of output from the drainage device
256
A patient newly diagnosed with breast cancer states that her physician suspects regional
lymph node involvement and told her that there are signs of metastatic disease. The
nurse learns that the patient has been diagnosed with stage IV breast cancer. What is an
implication of this diagnosis?
A) The patient is not a surgical candidate.
B) The patient's breast cancer is considered highly treatable.
C) There is a 10% chance that the patient's cancer will self-resolve.
D) The patient has a 15% chance of 5-year survival.
D) The patient has a 15% chance of 5-year survival.
257
The nurse is performing a comprehensive health history of a patient who is in her 50s.
The nurse should identify what risk factor that may increase this patient's risk for breast
cancer?
A) The patient breastfed each of her children.
B) The patient gave birth to her first child at age 38.
C) The patient experienced perimenopausal symptoms starting at age 46.
D) The patient experienced menarche at age 13.
B) The patient gave birth to her first child at age 38.
258
A nurse is examining a patient who has been diagnosed with a fibroadenoma. The nurse
should recognize what implication of this patient's diagnosis?
A) The patient will be scheduled for radiation therapy.
B) The patient might be referred for a biopsy.
C) The patient's breast mass is considered an age-related change.
D) The patient's diagnosis is likely related to her use of oral contraceptives.
B) The patient might be referred for a biopsy.
259
The nurse is reviewing the physician's notes from the patient who has just left the
clinic. The nurse learns that the physician suspects a malignant breast tumor. On
palpation, the mass most likely had what characteristic?
A) Nontenderness
B) A size of ≤ 5 mm
C) Softness and a regular shape
D) Mobility
A) Nontenderness
260
A patient has presented for her annual mammogram. The patient voices concerns
related to exposure to radiation. What should the nurse teach the patient about a
mammogram?
A) It does not use radiation.
B) Radiation levels are safe as long as mammograms are performed only once per
year.
C) The negative effects of radiation do not accumulate until late in life.
D) Radiation from a mammogram is equivalent to an hour of sunlight.
D) Radiation from a mammogram is equivalent to an hour of sunlight.
261
For which of the following population groups would an annual clinical breast
examination be recommended?
A) Women over age 21
B) Women over age 25
C) Women over age 40
D) All post-pubescent females with a family history of breast cancer
C) Women over age 40
262
A 42-year-old man has come to the clinic for an annual physical. The nurse notes in the
patient's history that his father was treated for breast cancer. What should the nurse
provide to the patient before he leaves the clinic?
A) A referral for a mammogram
B) Instructions about breast self-examination (BSE)
C) A referral to a surgeon
D) A referral to a support group
B) Instructions about breast self-examination (BSE)
263
The nurse is teaching breast self-examination (BSE) to a group of women. The nurse
should recommend that the women perform BSE at what time?
A) At the time of menses
B) At any convenient time, regardless of cycles
C) Weekly
D) Between days 5 and 7 after menses
D) Between days 5 and 7 after menses
264
A nurse is teaching a group of women about the potential benefits of breast selfexamination
(BSE). The nurse should teach the women that effective BSE is dependent
on what factor?
A) Women's knowledge of how their breasts normally look and feel
B) The rapport that exists between the woman and her primary care provider
C) Synchronizing women's routines around BSE with the performance of
mammograms
D) Women's knowledge of the pathophysiology of breast cancer
A) Women's knowledge of how their breasts normally look and feel
265
A 60-year-old man presents at the clinic complaining that his breasts are tender and
enlarging. The patient is subsequently diagnosed with gynecomastia. The patient should
be assessed for the possibility of what causative factor?
A) Age-related physiologic changes
B) Medication adverse effects
C) Poor nutrition
D) Fluid overload
B) Medication adverse effects
266
A woman is considering breast reduction mammoplasty. When weighing the potential
risks and benefits of this surgical procedure, the nurse should confirm that the patient is
aware of what potential consequence?
A) Chronic breast pain
B) Unclear mammography results
C) Increased risk of breast cancer
D) Decreased nipple sensation
D) Decreased nipple sensation
267
A patient is to undergo an ultrasound-guided core biopsy. The patient tells the nurse
that a friend of hers had a stereotactic core biopsy. She wants to understand the
differences between the two procedures. What would be the nurse's best response?
A) ìAn ultrasound-guided core biopsy is faster, less expensive, and does not use
radiation.
B) ìAn ultrasound-guided core biopsy is a little more expensive, but it doesn't use
radiation and it is faster.î
C) ìAn ultrasound-guided core biopsy is a little more expensive, and it also uses
radiation but it is faster.î
D) ìAn ultrasound-guided core biopsy takes more time, and it also uses radiation, but
it is less expensive.î
A) ìAn ultrasound-guided core biopsy is faster, less expensive, and does not use
radiation.
268
A patient at high risk for breast cancer is scheduled for an incisional biopsy in the
outpatient surgery department. When the nurse is providing preoperative education, the
patient asks why an incisional biopsy is being done instead of just removing the mass.
What would be the nurse's best response?
A) ìAn incisional biopsy is performed because it's known to be less painful and more
accurate than other forms of testing.î
B) ìAn incisional biopsy is performed to confirm a diagnosis and so that special
studies can be done that will help determine the best treatment.
C) ìAn incisional biopsy is performed to assess the potential for recovery from a
mastectomy.î
D) ìAn incisional biopsy is performed on patients who are younger than the age of
40 and who are otherwise healthy.î
B) ìAn incisional biopsy is performed to confirm a diagnosis and so that special
studies can be done that will help determine the best treatment.
269
A patient is being discharged home from the ambulatory surgery center after an
incisional biopsy of a mass in her left breast. What are the criteria for discharging this
patient home? Select all that apply.
A) Patient must understand when she can begin ambulating
B) Patient must have someone to accompany her home
C) Patient must understand activity restrictions
D) Patient must understand care of the biopsy site
E) Patient must understand when she can safely remove her urinary catheter
B) Patient must have someone to accompany her home
C) Patient must understand activity restrictions
D) Patient must understand care of the biopsy site
270
A patient has just been told she needs to have an incisional biopsy of a right breast
mass. During preoperative teaching, how could the nurse best assess this patient for
specific educational, physical, or psychosocial needs she might have?
A) By encouraging her to verbalize her questions and concerns
B) By discussing the possible findings of the biopsy
C) By discussing possible treatment options if the diagnosis is cancer
D) By reviewing her medical history
A) By encouraging her to verbalize her questions and concerns
271
A patient has just returned to the postsurgical unit from post-anesthetic recovery after
breast surgery for removal of a malignancy. What is the most likely major nursing
diagnosis to include in this patient's immediate plan of care?
A) Acute pain related to tissue manipulation and incision
B) Ineffective coping related to surgery
C) Risk for trauma related to post-surgical injury
D) Chronic sorrow related to change in body image
A) Acute pain related to tissue manipulation and incision
272
A 52-year-old woman has just been told she has breast cancer and is scheduled for a
modified mastectomy the following week. The nurse caring for this patient knows that
she is anxious and fearful about the upcoming procedure and the newly diagnosed
malignancy. How can the nurse most likely alleviate this patient's fears?
A) Provide written material on the procedure that has been scheduled for the patient.
B) Provide the patient with relevant information about expected recovery.
C) Give the patient current information on breast cancer survival rates.
D) Offer the patient alternative treatment options.
B) Provide the patient with relevant information about expected recovery.
273
A nurse is explaining that each breast contains 12 to 20 cone-shaped lobes. The nurse
should explain that each lobe consists of what elements?
A) Modified tendons and ligaments
B) Connective tissue and smooth muscle
C) Lobules and ducts
D) Endocrine glands and sebaceous glands
C) Lobules and ducts
274
A nurse has assessed that a patient is not yet willing to view her mastectomy site. How
should the nurse best assist the patient is developing a positive body image?
A) Ask the woman to describe the current appearance of her breast.
B) Help the patient to understand that many women have gone through the same
unpleasant experience.
C) Explain to the patient that her body image does not have to depend on her
physical appearance.
D) Provide the patient with encouragement in an empathic and thoughtful manner.
D) Provide the patient with encouragement in an empathic and thoughtful manner.
275
A patient has had a total mastectomy with immediate reconstruction. The patient asks
the nurse when she can take a shower. What should the nurse respond?
A) ìNot until the drain is removed
B) ìOn the second postoperative dayî
C) ìNow, if you wash gently with soap and waterî
D) ìSeven days after your surgeryî
A) ìNot until the drain is removed
276
A patient has been discharged home after a total mastectomy without reconstruction.
The patient lives alone and has a home health referral. When the home care nurse
performs the first scheduled visit this patient, what should the nurse assess? Select all
that apply.
A) Adherence to the exercise plan
B) Overall psychological functioning
C) Integrity of surgical drains
D) Understanding of cancer
E) Use of the breast prosthesis
A) Adherence to the exercise plan
B) Overall psychological functioning
C) Integrity of surgical drains
277
A patient has just been diagnosed with breast cancer and the nurse is performing a
patient interview. In assessing this patient's ability to cope with this diagnosis, what
would be an appropriate question for the nurse to ask this patient?
A) ìWhat is your level of education?î
B) ìAre you feeling alright these days?
C) ìIs there someone you trust to help you make treatment choices?
D) ìAre you concerned about receiving this diagnosis?î
C) ìIs there someone you trust to help you make treatment choices?
278
A 35-year-old mother of three young children has been diagnosed with stage II breast
cancer. After discussing treatment options with her physician, the woman goes home to
talk to her husband, later calling the nurse for clarification of some points. The patient
tells the nurse that the physician has recommended breast conservation surgery
followed by radiation. The patient's husband has done some online research and is
asking why his wife does not have a modified radical mastectomy ìto be sure all the
cancer is gone.î What would be the nurse's best response?
A) ìModified radical mastectomies are very hard on a patient, both physically and
emotionally and they really aren't necessary anymore.î
B) ìAccording to current guidelines, having a modified radical mastectomy is no
longer seen as beneficial.î
C) ìModified radical mastectomies have a poor survival rate because of the risk of
cancer recurrence.î
D) ìAccording to current guidelines, breast conservation combined with radiation is
as effective as a modified radical mastectomy.
D) ìAccording to current guidelines, breast conservation combined with radiation is
as effective as a modified radical mastectomy.
279
A patient who has had a lumpectomy calls the clinic to talk to the nurse. The patient
tells the nurse that she has developed a tender area on her breast that is red and warm
and looks like someone ìdrew a line with a red marker.î What would the nurse suspect
is the woman's problem?
A) Mondor disease
B) Deep vein thrombosis (DVT) of the breast
C) Recurrent malignancy
D) An area of fat necrosis
A) Mondor disease
280
A woman calls the clinic and tells the nurse she has had bloody drainage from her right
nipple. The nurse makes an appointment for this patient, expecting the physician or
practitioner to order what diagnostic test on this patient?
A) Breast ultrasound
B) Radiography
C) Positron emission testing (PET)
D) Galactography
D) Galactography
281
An adolescent is identified as having a collection of fluid in the tunica vaginalis of his
testes. The nurse knows that this adolescent will receive what medical diagnosis?
A) Cryptorchidism
B) Orchitis
C) Hydrocele
D) Prostatism
C) Hydrocele
282
An uncircumcised 78-year-old male has presented at the clinic complaining that he
cannot retract his foreskin over his glans. On examination, it is noted that the foreskin is
very constricted. The nurse should recognize the presence of what health problem?
A) Bowen's disease
B) Peyronie's disease
C) Phimosis
D) Priapism
C) Phimosis
283
A nurse practitioner is assessing a 55-year-old male patient who is complaining of
perineal discomfort, burning, urgency, and frequency with urination. The patient states
that he has pain with ejaculation. The nurse knows that the patient is exhibiting
symptoms of what?
A) Varicocele
B) Epididymitis
C) Prostatitis
D) Hydrocele
C) Prostatitis
284
A patient has been prescribed sildenafil. What should the nurse teach the patient about
this medication?
A) Sexual stimulation is not needed to obtain an erection.
B) The drug should be taken 1 hour prior to intercourse.
C) Facial flushing or headache should be reported to the physician immediately.
D) The drug has the potential to cause permanent visual changes.
B) The drug should be taken 1 hour prior to intercourse.
285
A patient is 24 hours postoperative following prostatectomy and the urologist has
ordered continuous bladder irrigation. What color of output should the nurse expect to
find in the drainage bag?
A) Red wine colored
B) Tea colored
C) Amber
D) Light pink
D) Light pink
286
A public health nurse has been asked to provide a health promotion session for men at a
wellness center. What should the nurse inform the participants about testicular cancer?
A) It is most common among men over 55.
B) It is one of the least curable solid tumors.
C) It typically does not metastasize.
D) It is highly responsive to treatment.
D) It is highly responsive to treatment.
287
A nurse is planning the postoperative care of a patient who is scheduled for radical
prostatectomy. What intraoperative position will place the patient at particular risk for
the development of deep vein thrombosis postoperatively?
A) Fowler's position
B) Prone position
C) Supine position
D) Lithotomy position
D) Lithotomy position
288
A patient has just been diagnosed with prostate cancer and is scheduled for
brachytherapy next week. The patient and his wife are unsure of having the procedure
because their daughter is 3 months pregnant. What is the most appropriate teaching the
nurse should provide to this family?
A) The patient should not be in contact with the baby after delivery.
B) The patient's treatment poses no risk to his daughter or her infant.
C) The patient's brachytherapy may be contraindicated for safety reasons.
D) The patient should avoid close contact with his daughter for 2 months.
D) The patient should avoid close contact with his daughter for 2 months.
289
A patient has presented at the clinic with symptoms of benign prostatic hyperplasia.
What diagnostic findings would suggest that this patient has chronic urinary retention?
A) Hypertension
B) Peripheral edema
C) Tachycardia and other dysrhythmias
D) Increased blood urea nitrogen (BUN)
D) Increased blood urea nitrogen (BUN)
290
A 55-year-old man presents at the clinic complaining of erectile dysfunction. The
patient has a history of diabetes. The physician orders tadalafil (Cialis) to be taken 1
hour before sexual intercourse. The nurse reviews the patient's history prior to
instructing the patient on the use of this medication. What disorder will contraindicate
the use of tadalafil (Cialis)?
A) Cataracts
B) Retinopathy
C) Hypotension
D) Diabetic nephropathy
B) Retinopathy
291
A nurse is teaching a 53-year-old man about prostate cancer. What information should
the nurse provide to best facilitate the early identification of prostate cancer?
A) Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly.
B) Have a transrectal ultrasound every 5 years.
C) Perform monthly testicular self-examinations, especially after age 60.
D) Have a complete blood count (CBC), blood urea nitrogen (BUN) and creatinine
assessment performed annually.
A) Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly.
292
A public health nurse is teaching a health class for the male students at the local high
school. The nurse is teaching the boys to perform monthly testicular self-examinations.
What point would be appropriate to emphasize?
A) Testicular cancer is a highly curable type of cancer.
B) Testicular cancer is very difficult to diagnose.
C) Testicular cancer is the number one cause of cancer deaths in males.
D) Testicular cancer is more common in older men.
A) Testicular cancer is a highly curable type of cancer.
293
A patient has just returned to the floor following a transurethral resection of the
prostate. A triple-lumen indwelling urinary catheter has been inserted for continuous
bladder irrigation. What, in addition to balloon inflation, are the functions of the three
lumens?
A) Continuous inflow and outflow of irrigation solution
B) Intermittent inflow and continuous outflow of irrigation solution
C) Continuous inflow and intermittent outflow of irrigation solution
D) Intermittent flow of irrigation solution and prevention of hemorrhage
A) Continuous inflow and outflow of irrigation solution
294
A nurse is assessing a patient who presented to the ED with priapism. The student
nurse is aware that this condition is classified as a urologic emergency because of the
potential for what?
A) Urinary tract infection
B) Chronic pain
C) Permanent vascular damage
D) Future erectile dysfunction
C) Permanent vascular damage
295
A man comes to the clinic complaining that he is having difficulty obtaining an
erection. When reviewing the patient's history, what might the nurse note that
contributes to erectile dysfunction?
A) The patient has been treated for a UTI twice in the past year.
B) The patient has a history of hypertension.
C) The patient is 66 years old.
D) The patient leads a sedentary lifestyle.
B) The patient has a history of hypertension.
296
A 35-year-old man is seen in the clinic because he is experiencing recurring episodes of
urinary frequency, dysuria, and fever. The nurse should recognize the possibility of
what health problem?
A) Chronic bacterial prostatitis
B) Orchitis
C) Benign prostatic hyperplasia
D) Urolithiasis
A) Chronic bacterial prostatitis
297
To decrease glandular cellular activity and prostate size, an 83-year-old patient has
been prescribed finasteride (Proscar). When performing patient education with this
patient, the nurse should be sure to tell the patient what?
A) Report the planned use of dietary supplements to the physician.
B) Decrease the intake of fluids to prevent urinary retention.
C) Abstain from sexual activity for 2 weeks following the initiation of treatment.
D) Anticipate a temporary worsening of urinary retention before symptoms subside.
A) Report the planned use of dietary supplements to the physician.
298
A nurse is providing an educational event to a local men's group about prostate cancer.
The nurse should cite an increased risk of prostate cancer in what ethnic group?
A) Native Americans
B) Caucasian Americans
C) African Americans
D) Asian Americans
C) African Americans
299
A man tells the nurse that his father died of prostate cancer and he is concerned about
his own risk of developing the disease, having heard that prostate cancer has a genetic
link. What aspect of the pathophysiology of prostate cancer would underlie the nurse's
response?
A) A number of studies have identified an association of BRCA-2 mutation with an
increased risk of prostate cancer.
B) HNPCC is a mutation of two genes that causes prostate cancer in men and it is
autosomal dominant.
C) Studies have shown that the presence of the TP53 gene strongly influences the
incidence of prostate cancer.
D) Recent research has demonstrated that prostate cancer is the result of lifestyle
factors and that genetics are unrelated.
A) A number of studies have identified an association of BRCA-2 mutation with an
increased risk of prostate cancer.
300
A nurse is performing an admission assessment on a 40-year-old man who has been
admitted for outpatient surgery on his right knee. While taking the patient's family
history, he states, ìMy father died of prostate cancer at age 48.î The nurse should
instruct him on which of the following health promotion activities?
A) The patient will need PSA levels drawn starting at age 55.
B) The patient should have testing for presence of the CDH1 and STK11 genes.
C) The patient should have PSA levels drawn regularly.
D) The patient should limit alcohol use due to the risk of malignancy.
C) The patient should have PSA levels drawn regularly.
301
A 35-year-old father of three tells the nurse that he wants information on a vasectomy.
What would the nurse tell him about ejaculate after a vasectomy?
A) There will be no ejaculate after a vasectomy, though the patient's potential for
orgasm is unaffected.
B) There is no noticeable decrease in the amount of ejaculate even though it contains no sperm.
C) There is a marked decrease in the amount of ejaculate after vasectomy, though
this does not affect sexual satisfaction.
D) There is no change in the quantity of ejaculate after vasectomy, but the viscosity
is somewhat increased.
B) There is no noticeable decrease in the amount of ejaculate even though it contains no sperm.
302
A 76-year-old with a diagnosis of penile cancer has been admitted to the medical floor.
Because the incidence of penile cancer is so low, the staff educator has been asked to
teach about penile cancer. What risk factors should the educator cite in this
presentation? Select all that apply.
A) Phimosis
B) Priapism
C) Herpes simplex infection
D) Increasing age
E) Lack of circumcision
A) Phimosis
D) Increasing age
E) Lack of circumcision
303
A 75-year-old male patient is being treated for phimosis. When planning this patient's
care, what health promotion activity is most directly related to the etiology of the
patient's health problem?
A) Teaching the patient about safer sexual practices
B) Teaching the patient about the importance of hygiene
C) Teaching the patient about the safe use of PDE-5 inhibitors
D) Teaching the patient to perform testicular self-examination
B) Teaching the patient about the importance of hygiene
304
A patient who is postoperative day 12 and recovering at home following a laparoscopic
prostatectomy has reported that he is experiencing occasional ìdribblingî of urine. How
should the nurse best respond to this patient's concern?
A) Inform the patient that urinary control is likely to return gradually.
B) Arrange for the patient to be assessed by his urologist.
C) Facilitate the insertion of an indwelling urinary catheter by the home care nurse.
D) Teach the patient to perform intermittent self-catheterization.
A) Inform the patient that urinary control is likely to return gradually.
305
A physician explains to the patient that he has an inflammation of the Cowper glands.
Where are the Cowper glands located?
A) Within the epididymis
B) Below the prostate, within the posterior aspect of the urethra
C) On the inner epithelium lining the scrotum, lateral to the testes
D) Medial to the vas deferens
B) Below the prostate, within the posterior aspect of the urethra
306
A nursing student is learning how to perform sexual assessments using the PLISSIT
model. According to this model, the student should begin an assessment by doing
which of the following?
A) Briefly teaching the patient about normal sexual physiology
B) Assuring the patient that what he says will be confidential
C) Asking the patient if he is willing to discuss sexual functioning
D) Ensuring patient privacy
C) Asking the patient if he is willing to discuss sexual functioning
307
A nurse is caring for a 33-year-old male who has come to the clinic for a physical
examination. He states that he has not had a routine physical in 5 years. During the
examination, the physician finds that digital rectal examination (DRE) reveals ìstoneyî
hardening in the posterior lobe of the prostate gland that is not mobile. The nurse
recognizes that the observation typically indicates what?
A) A normal finding
B) A sign of early prostate cancer
C) Evidence of a more advanced lesion
D) Metastatic disease
C) Evidence of a more advanced lesion
308
A patient who is scheduled for an open prostatectomy is concerned about the potential
effects of the surgery on his sexual function. What aspect of prostate surgery should
inform the nurse's response?
A) Erectile dysfunction is common after prostatectomy as a result of hormonal
changes.
B) All prostatectomies carry a risk of nerve damage and consequent erectile
dysfunction.
C) Erectile dysfunction after prostatectomy is expected, but normally resolves within
several months.
D) Modern surgical techniques have eliminated the risk of erectile dysfunction
following prostatectomy.
B) All prostatectomies carry a risk of nerve damage and consequent erectile
dysfunction.
309
A patient has returned to the floor from the PACU after undergoing a suprapubic
prostatectomy. The nurse notes significant urine leakage around the suprapubic tube.
What is the nurse's most appropriate action?
A) Cleanse the skin surrounding the suprapubic tube.
B) Inform the urologist of this finding.
C) Remove the suprapubic tube and apply a wet-to-dry dressing.
D) Administer antispasmodic drugs as ordered.
B) Inform the urologist of this finding.
310
A 29-year-old patient has just been told that he has testicular cancer and needs to have
surgery. During a presurgical appointment, the patient admits to feeling devastated that
he requires surgery, stating that it will leave him ìemasculatedî and ìa shell of a man.î
The nurse should identify what nursing diagnosis when planning the patient's
subsequent care?
A) Disturbed Body Image Related to Effects of Surgery
B) Spiritual Distress Related to Effects of Cancer Surgery
C) Social Isolation Related to Effects of Surgery
D) Risk for Loneliness Related to Change in Self-Concept
A) Disturbed Body Image Related to Effects of Surgery
311
A nurse is providing care for a patient who has recently been admitted to the
postsurgical unit from PACU following a transuretheral resection of the prostate. The
nurse is aware of the nursing diagnosis of Risk for Imbalanced Fluid Volume. In order
to assess for this risk, the nurse should prioritize what action?
A) Closely monitoring the input and output of the bladder irrigation system
B) Administering parenteral nutrition and fluids as ordered
C) Monitoring the patient's level of consciousness and skin turgor
D) Scanning the patient's bladder for retention every 2 hours
A) Closely monitoring the input and output of the bladder irrigation system
312
A 22-year-old male is being discharged home after surgery for testicular cancer. The
patient is scheduled to begin chemotherapy in 2 weeks. The patient tells the nurse that
he doesn't think he can take weeks or months of chemotherapy, stating that he has
researched the adverse effects online. What is the most appropriate nursing action for
this patient at this time?
A) Provide empathy and encouragement in an effort to foster a positive outlook.
B) Tell the patient it is his decision whether to accept or reject chemotherapy.
C) Report the patient's statement to members of his support system.
D) Refer the patient to social work.
A) Provide empathy and encouragement in an effort to foster a positive outlook.
313
A 57-year-old male comes to the clinic complaining that when he has an erection his
penis curves and becomes painful. The patient's diagnosis is identified as severe
Peyronie's disease. The nurse should be aware of what likely treatment modality?
A) Physical therapy
B) Treatment with PDE-5 inhibitors
C) Intracapsular hydrocortisone injections
D) Surgery
D) Surgery
314
A patient has experienced occasional urinary incontinence in the weeks since his
prostatectomy. In order to promote continence, the nurse should encourage which of the
following?
A) Pelvic floor exercises
B) Intermittent urinary catheterization
C) Reduced physical activity
D) Active range of motion exercises
A) Pelvic floor exercises
315
A clinic nurse is providing preprocedure education for a man who will undergo a
vasectomy. Which of the following measures will enhance healing and comfort? Select
all that apply.
A) Abstaining from sexual intercourse for at least 14 days postprocedure
B) Wearing a scrotal support garment
C) Using sitz baths
D) Applying a heating pad intermittently
E) Staying on bed rest for 48 to 72 hours postprocedure
B) Wearing a scrotal support garment
| C) Using sitz baths
316
A patient has returned to the floor after undergoing a transurethral resection of the
prostate (TURP). The patient has a continuous bladder irrigation system in place. The
patient tells you he is experiencing bladder spasms and asks what you can do to relieve
his discomfort. What is the most appropriate nursing action to relieve the discomfort of
the patient?
A) Apply a cold compress to the pubic area.
B) Notify the urologist promptly.
C) Irrigate the catheter with 30 to 50 mL of normal saline as ordered.
D) Administer a smooth-muscle relaxant as ordered.
D) Administer a smooth-muscle relaxant as ordered.
317
A patient confides to the nurse that he cannot engage in sexual activity. The patient is
27 years old and has no apparent history of chronic illness that would contribute to
erectile dysfunction. What does the nurse know will be ordered for this patient to assess
his sexual functioning?
A) Sperm count
B) Ejaculation capacity tests
C) Engorgement tests
D) Nocturnal penile tumescence tests
D) Nocturnal penile tumescence tests
318
```
The nurse is leading a workshop on sexual health for men. The nurse should teach
participants that organic causes of erectile dysfunction include what? Select all that
apply.
A) Diabetes
B) Testosterone deficiency
C) Anxiety
D) Depression
E) Parkinsonism
```
A) Diabetes
B) Testosterone deficiency
E) Parkinsonism
319
A patient has been diagnosed with erectile dysfunction; the cause has been determined
to be psychogenic. The patient's interdisciplinary plan of care should prioritize which of
the following interventions?
A) Penile implant
B) PDE-5 inhibitors
C) Physical therapy
D) Psychotherapy
D) Psychotherapy
320
A patient presents to the emergency department with paraphimosis. The physician is
able to compress the glans and manually reduce the edema. Once the inflammation and
edema subside, what is usually indicated?
A) Needle aspiration of the corpus cavernosum
B) Circumcision
C) Abstinence from sexual activity for 6 weeks
D) Administration of vardenafil
B) Circumcision
321
The registered nurse taking shift report learns that an assigned patient is blind. How
should the nurse best communicate with this patient?
A) Provide instructions in simple, clear terms.
B) Introduce herself in a firm, loud voice at the doorway of the room.
C) Lightly touch the patient's arm and then introduce herself.
D) State her name and role immediately after entering the patient's room.
D) State her name and role immediately after entering the patient's room.
322
The nurse has taken shift report on her patients and has been told that one patient has an
ocular condition that has primarily affected the rods in his eyes. Considering this
information, what should the nurse do while caring for the patient?
A) Ensure adequate lighting in the patient's room.
B) Provide a dimly lit room to aid vision by limiting contrast.
C) Carefully point out color differences for the patient.
D) Carefully point out fine details for the patient.
A) Ensure adequate lighting in the patient's room.
323
A patient who presents for an eye examination is diagnosed as having a visual acuity of
20/40. The patient asks the nurse what these numbers specifically mean. What is a
correct response by the nurse?
A) ìA person whose vision is 20/40 can see an object from 40 feet away that a
person with 20/20 vision can see from 20 feet away.î
B) ìA person whose vision is 20/40 can see an object from 20 feet away that a
person with 20/20 vision can see from 40 feet away.
C) ìA person whose vision is 20/40 can see an object from 40 inches away that a
person with 20/20 vision can see from 20 inches away.î
D) ìA person whose vision is 20/40 can see an object from 20 inches away that a
person with 20/20 vision can see from 40 inches away.î
B) ìA person whose vision is 20/40 can see an object from 20 feet away that a
person with 20/20 vision can see from 40 feet away.
324
During discharge teaching the nurse realizes that the patient is not able to read
medication bottles accurately and has not been taking her medications consistently at
home. How should the nurse intervene most appropriately in this situation?
A) Ask the social worker to investigate alternative housing arrangements.
B) Ask the social worker to investigate community support agencies.
C) Encourage the patient to explore surgical corrections for the vision problem.
D) Arrange for referral to a rehabilitation facility for vision training.
B) Ask the social worker to investigate community support agencies.
325
The nurse is providing health education to a patient newly diagnosed with glaucoma.
The nurse teaches the patient that this disease has a familial tendency. The nurse should
encourage the patient's immediate family members to undergo clinical examinations
how often?
A) At least monthly
B) At least once every 2 years
C) At least once every 5 years
D) At least once every 10 years
B) At least once every 2 years
326
A patient is exploring treatment options after being diagnosed with age-related cataracts
that affect her vision. What treatment is most likely to be used in this patient's care?
A) Antioxidant supplements, vitamin C and E, beta-carotene, and selenium
B) Eyeglasses or magnifying lenses
C) Corticosteroid eye drops
D) Surgical intervention
D) Surgical intervention
327
A patient presents at the ED after receiving a chemical burn to the eye. What would be
the nurse's initial intervention for this patient?
A) Generously flush the affected eye with a dilute antibiotic solution.
B) Generously flush the affected eye with normal saline or water.
C) Apply a patch to the affected eye.
D) Apply direct pressure to the affected eye.
B) Generously flush the affected eye with normal saline or water.
328
The nurse is administering eye drops to a patient with glaucoma. After instilling the
patient's first medication, how long should the nurse wait before instilling the patient's
second medication into the same eye?
A) 30 seconds
B) 1 minute
C) 3 minutes
D) 5 minutes
D) 5 minutes
329
A patient is being discharged home from the ambulatory surgical center after cataract
surgery. In reviewing the discharge instructions with the patient, the nurse instructs the
patient to immediately call the office if the patient experiences what?
A) Slight morning discharge from the eye
B) Any appearance of redness of the eye
C) A ìscratchyî feeling in the eye
D) A new floater in vision
D) A new floater in vision
330
A patient comes to the ophthalmology clinic for an eye examination. The patient tells
the nurse that he often sees floaters in his vision. How should the nurse best interpret
this subjective assessment finding?
A) This is a normal aging process of the eye.
B) Glasses will minimize this phenomenon.
C) The patient may be exhibiting signs of glaucoma.
D) This may be a result of weakened ciliary muscles.
A) This is a normal aging process of the eye.
331
A patient's ocular tumor has necessitated enucleation and the patient will be fitted with
a prosthesis. The nurse should address what nursing diagnosis when planning the
patient's discharge education?
A) Disturbed body image
B) Chronic pain
C) Ineffective protection
D) Unilateral neglect
A) Disturbed body image
332
The nurse's assessment of a patient with significant visual losses reveals that the patient
cannot count fingers. How should the nurse proceed with assessment of the patient's
visual acuity?
A) Assess the patient's vision using a Snellen chart.
B) Determine whether the patient is able to see the nurse's hand motion.
C) Perform a detailed examination of the patient's external eye structures.
D) Palpate the patient's periocular regions.
B) Determine whether the patient is able to see the nurse's hand motion.
333
The nurse on the medicalñsurgical unit is reviewing discharge instructions with a
patient who has a history of glaucoma. The nurse should anticipate the use of what
medications?
A) Potassium-sparing diuretics
B) Cholinergics
C) Antibiotics
D) Loop diuretics
B) Cholinergics
334
A nurse is teaching a patient with glaucoma how to administer eye drops to achieve
maximum absorption. The nurse should teach the patient to perform what action?
A) Instill the medication in the conjunctival sac.
B) Maintain a supine position for 10 minutes after administration.
C) Keep the eyes closed for 1 to 2 minutes after administration.
D) Apply the medication evenly to the sclera
A) Instill the medication in the conjunctival sac.
335
A patient with chronic open-angle glaucoma is being taught to self-administer
pilocarpine. After the patient administers the pilocarpine, the patient states that her
vision is blurred. Which nursing action is most appropriate?
A) Holding the next dose and notifying the physician
B) Treating the patient for an allergic reaction
C) Suggesting that the patient put on her glasses
D) Explaining that this is an expected adverse effect
D) Explaining that this is an expected adverse effect
336
The nurse should recognize the greatest risk for the development of blindness in which
of the following patients?
A) A 58-year-old Caucasian woman with macular degeneration
B) A 28-year-old Caucasian man with astigmatism
C) A 58-year-old African American woman with hyperopia
D) A 28-year-old African American man with myopia
A) A 58-year-old Caucasian woman with macular degeneration
337
A 6-year-old child is brought to the pediatric clinic for the assessment of redness and
discharge from the eye and is diagnosed with viral conjunctivitis. What is the most
important information to discuss with the parents and child?
A) Handwashing can prevent the spread of the disease to others.
B) The importance of compliance with antibiotic therapy
C) Signs and symptoms of complications, such as meningitis and septicemia
D) The likely need for surgery to prevent scarring of the conjunctiva
A) Handwashing can prevent the spread of the disease to others.
338
The nurse is admitting a 55-year-old male patient diagnosed with a retinal detachment
in his left eye. While assessing this patient, what characteristic symptom would the
nurse expect to find?
A) Flashing lights in the visual field
B) Sudden eye pain
C) Loss of color vision
D) Colored halos around lights
A) Flashing lights in the visual field
339
Several residents of a long-term care facility have developed signs and symptoms of
viral conjunctivitis. What is the most appropriate action of the nurse who oversees care
in the facility?
A) Arrange for the administration of prophylactic antibiotics to unaffected residents.
B) Instill normal saline into the eyes of affected residents two to three times daily.
C) Swab the conjunctiva of unaffected residents for culture and sensitivity testing.
D) Isolate affected residents from residents who have not developed conjunctivitis.
D) Isolate affected residents from residents who have not developed conjunctivitis.
340
A patient has just returned to the surgical floor after undergoing a retinal detachment
repair. The postoperative orders specify that the patient should be kept in a prone
position until otherwise ordered. What should the nurse do?
A) Call the physician and ask for the order to be confirmed.
B) Follow the order because this position will help keep the retinal repair intact.
C) Instruct the patient to maintain this position to prevent bleeding.
D) Reposition the patient after the first dressing change.
B) Follow the order because this position will help keep the retinal repair intact.
341
A patient has informed the home health nurse that she has recently noticed distortions
when she looks at the Amsler grid that she has mounted on her refrigerator. What is the
nurse's most appropriate action?
A) Reassure the patient that this is an age-related change in vision.
B) Arrange for the patient to have her visual acuity assessed.
C) Arrange for the patient to be assessed for macular degeneration.
D) Facilitate tonometry testing.
C) Arrange for the patient to be assessed for macular degeneration.
342
A 56-year-old patient has come to the clinic for his routine eye examination and is told
he needs bifocals. The patient asks the nurse what change in his eyes has caused his
need for bifocals. How should the nurse respond?
A) ìYou know, you are getting older now and we change as we get older.î
B) ìThe parts of our eyes age, just like the rest of us, and this is nothing to cause you
to worry.î
C) ìThere is a gradual thickening of the lens of the eye and it can limit the eye's
ability for accommodation.
D) ìThe eye gets shorter, back to front, as we age and it changes how we see things.î
C) ìThere is a gradual thickening of the lens of the eye and it can limit the eye's
ability for accommodation.
343
The nurse is teaching a patient to care for her new ocular prosthesis. What should the
nurse emphasize during the patient's health education?
A) The need to limit exposure to bright light
B) The need to maintain a low Fowler's position when removing the prosthesis
C) The need to perform thorough hand hygiene before handling the prosthesis
D) The need to apply antiviral ointment to the prosthesis daily
C) The need to perform thorough hand hygiene before handling the prosthesis
344
Cytomegalovirus (CMV) is the most common cause of retinal inflammation in patients
with AIDS. What drug, surgically implanted, is used for the acute stage of CMV
retinitis?
A) Pilocarpine
B) Penicillin
C) Ganciclovir
D) Gentamicin
C) Ganciclovir
345
A patient got a sliver of glass in his eye when a glass container at work fell and
shattered. The glass had to be surgically removed and the patient is about to be
discharged home. The patient asks the nurse for a topical anesthetic for the pain in his
eye. What should the nurse respond?
A) ìOveruse of these drops could soften your cornea and damage your eye.
B) ìYou could lose the peripheral vision in your eye if you used these drops too
much.î
C) ìI'm sorry, this medication is considered a controlled substance and patients
cannot take it home.î
D) ìI know these drops will make your eye feel better, but I can't let you take them
home.î
A) ìOveruse of these drops could soften your cornea and damage your eye.
346
A patient has been diagnosed with glaucoma and the nurse is preparing health
education regarding the patient's medication regimen. The patient states that she is
eager to ìbeat this diseaseî and looks forward to the time that she will no longer require
medication. How should the nurse best respond?
A) ìYou have a great attitude. This will likely shorten the amount of time that you
need medications.î
B) ìIn fact, glaucoma usually requires lifelong treatment with medications.
C) ìMost people are treated until their intraocular pressure goes below 50 mm Hg.î
D) ìYou can likely expect a minimum of 6 months of treatment.î
B) ìIn fact, glaucoma usually requires lifelong treatment with medications.
347
An older adult patient has been diagnosed with macular degeneration and the nurse is
assessing him for changes in visual acuity since his last clinic visit. When assessing the
patient for recent changes in visual acuity, the patient states that he sees the lines on an
Amsler grid as being distorted. What is the nurse's most appropriate response?
A) Ask if the patient has been using OTC vasoconstrictors.
B) Instruct the patient to repeat the test at different times of the day when at home.
C) Arrange for the patient to visit his ophthalmologist.
D) Encourage the patient to adhere to his prescribed drug regimen.
C) Arrange for the patient to visit his ophthalmologist.
348
A public health nurse is teaching a health promotion workshop that focuses on vision
and eye health. What should this nurse cite as the most common causes of blindness
and visual impairment among adults over the age of 40? Select all that apply.
A) Diabetic retinopathy
B) Trauma
C) Macular degeneration
D) Cytomegalovirus
E) Glaucoma
A) Diabetic retinopathy
C) Macular degeneration
E) Glaucoma
349
The nurse is providing discharge education to an adult patient who will begin a regimen
of ocular medications for the treatment of glaucoma. How can the nurse best determine
if the patient is able to self-administer these medications safely and effectively?
A) Assess the patient for any previous inability to self-manage medications.
B) Ask the patient to demonstrate the instillation of her medications.
C) Determine whether the patient can accurately describe the appropriate method of
administering her medications.
D) Assess the patient's functional status.
B) Ask the patient to demonstrate the instillation of her medications.
350
A patient with low vision has called the clinic and asked the nurse for help with
acquiring some low-vision aids. What else can the nurse offer to help this patient
manage his low vision?
A) The patient uses OTC NSAIDs.
B) The patient has a history of stroke.
C) The patient has diabetes.
D) The patient has Asian ancestry.
C) The patient has diabetes.
351
The public health nurse is addressing eye health and vision protection during an
educational event. What statement by a participant best demonstrates an understanding
of threats to vision?
A) ìI'm planning to avoid exposure to direct sunlight on my next vacation.î
B) ìI've never exercised regularly, but I'm going to start working out at the gym
daily.î
C) ìI'm planning to talk with my pharmacist to review my current medications.î
D) ìI'm certainly going to keep a close eye on my blood pressure from now on.
D) ìI'm certainly going to keep a close eye on my blood pressure from now on.
352
A patient has had a sudden loss of vision after head trauma. How should the nurse best
describe the placement of items on the dinner tray?
A) Explain the location of items using clock cues.
B) Explain that each of the items on the tray is clearly separated.
C) Describe the location of items from the bottom of the plate to the top.
D) Ask the patient to describe the location of items before confirming their location.
A) Explain the location of items using clock cues.
353
A hospitalized patient with impaired vision must get a picture in his or her mind of the
hospital room and its contents in order to mobilize independently and safely. What
must the nurse monitor in the patient's room?
A) That a commode is always available at the bedside
B) That all furniture remains in the same position
C) That visitors do not leave items on the bedside table
D) That the patient's slippers stay under the bed
B) That all furniture remains in the same position
354
A patient has just arrived to the floor after an enucleation procedure following a
workplace accident in which his left eye was irreparably damaged. Which of the
following should the nurse prioritize during the patient's immediate postoperative
recovery?
A) Teaching the patient about options for eye prostheses
B) Teaching the patient to estimate depth and distance with the use of one eye
C) Assessing and addressing the patient's emotional needs
D) Teaching the patient about his post-discharge medication regimen
C) Assessing and addressing the patient's emotional needs
355
A patient with a diagnosis of retinal detachment has undergone a vitreoretinal
procedure on an outpatient basis. What subject should the nurse prioritize during
discharge education?
A) Risk factors for postoperative cytomegalovirus (CMV)
B) Compensating for vision loss for the next several weeks
C) Non-pharmacologic pain management strategies
D) Signs and symptoms of increased intraocular pressure
D) Signs and symptoms of increased intraocular pressure
356
A patient is ready to be discharged home after a cataract extraction with intraocular lens
implant and the nurse is reviewing signs and symptoms that need to be reported to the
ophthalmologist immediately. Which of the patient's statements best demonstrates an
adequate understanding?
A) ìI need to call the doctor if I get nauseated.î
B) ìI need to call the doctor if I have a light morning discharge.î
C) ìI need to call the doctor if I get a scratchy feeling.î
D) ìI need to call the doctor if I see flashing lights.
D) ìI need to call the doctor if I see flashing lights.
357
A patient has lost most of her vision as a result of macular degeneration. When
attempting to meet this patient's psychosocial needs, what nursing action is most
appropriate?
A) Encourage the patient to focus on her use of her other senses.
B) Assess and promote the patient's coping skills during interactions with the
patient.
C) Emphasize that her lifestyle will be unchanged once she adapts to her vision loss.
D) Promote the patient's hope for recovery.
B) Assess and promote the patient's coping skills during interactions with the
patient.
358
When administering a patient's eye drops, the nurse recognizes the need to prevent
absorption by the nasolacrimal duct. How can the nurse best achieve this goal?
A) Ensure that the patient is well hydrated at all times.
B) Encourage self-administration of eye drops.
C) Occlude the puncta after applying the medication.
D) Position the patient supine before administering eye drops.
C) Occlude the puncta after applying the medication.
359
A patient with glaucoma has presented for a scheduled clinic visit and tells the nurse
that she has begun taking an herbal remedy for her condition that was recommended by
a work colleague. What instruction should the nurse provide to the patient?
A) The patient should discuss this new remedy with her ophthalmologist promptly.
B) The patient should monitor her IOP closely for the next several weeks.
C) The patient should do further research on the herbal remedy.
D) The patient should report any adverse effects to her pharmacist.
A) The patient should discuss this new remedy with her ophthalmologist promptly.
360
A patient is scheduled for enucleation and the nurse is providing anticipatory guidance
about postoperative care. What aspects of care should the nurse describe to the patient?
Select all that apply.
A) Application of topical antibiotic ointment
B) Maintenance of a supine position for the first 48 hours postoperative
C) Fluid restriction to prevent orbital edema
D) Administration of loop diuretics to prevent orbital edema
E) Use of an ocular pressure dressing
A) Application of topical antibiotic ointment
| E) Use of an ocular pressure dressing
361
The clinic nurse is assessing a child who has been brought to the clinic with signs and
symptoms that are suggestive of otitis externa. What assessment finding is
characteristic of otitis externa?
A) Tophi on the pinna and ear lobe
B) Dark yellow cerumen in the external auditory canal
C) Pain on manipulation of the auricle
D) Air bubbles visible in the middle ear
C) Pain on manipulation of the auricle
362
While reviewing the health history of an older adult experiencing hearing loss the nurse
notes the patient has had no trauma or loss of balance. What aspect of this patient's
health history is most likely to be linked to the patient's hearing deficit?
A) Recent completion of radiation therapy for treatment of thyroid cancer
B) Routine use of quinine for management of leg cramps
C) Allergy to hair coloring and hair spray
D) Previous perforation of the eardrum
B) Routine use of quinine for management of leg cramps
363
A nurse is planning preoperative teaching for a patient with hearing loss due to
otosclerosis. The patient is scheduled for a stapedectomy with insertion of a prosthesis.
What information is most crucial to include in the patient's preoperative teaching?
A) The procedure is an effective, time-tested treatment for sensory hearing loss.
B) The patient is likely to experience resolution of conductive hearing loss after the
procedure.
C) Several months of post-procedure rehabilitation will be needed to maximize
benefits.
D) The procedure is experimental, but early indications suggest great therapeutic
benefits.
B) The patient is likely to experience resolution of conductive hearing loss after the
procedure.
364
Which of the following nursing interventions would most likely facilitate effective
communication with a hearing-impaired patient?
A) Ask the patient to repeat what was said in order to evaluate understanding.
B) Stand directly in front of the patient to facilitate lip reading.
C) Reduce environmental noise and distractions before communicating.
D) Raise the voice to project sound at a higher frequency.
C) Reduce environmental noise and distractions before communicating.
365
The nurse is providing discharge education for a patient with a new diagnosis of
MÈniËre's disease. What food should the patient be instructed to limit or avoid?
A) Sweet pickles
B) Frozen yogurt
C) Shellfish
D) Red meat
A) Sweet pickles
366
Following a motorcycle accident, a 17-year-old man is brought to the ED. What
physical assessment findings related to the ear should be reported by the nurse
immediately?
A) The malleus can be visualized during otoscopic examination.
B) The tympanic membrane is pearly gray.
C) Tenderness is reported by the patient when the mastoid area is palpated.
D) Clear, watery fluid is draining from the patient's ear.
D) Clear, watery fluid is draining from the patient's ear.
367
A patient has been diagnosed with hearing loss related to damage of the end organ for
hearing or cranial nerve VIII. What term is used to describe this condition?
A) Exostoses
B) Otalgia
C) Sensorineural hearing loss
D) Presbycusis
C) Sensorineural hearing loss
368
A group of high school students is attending a concert, which will be at a volume of 80
to 90 dB. What is a health consequence of this sound level?
A) Hearing will not be affected by a decibel level in this range.
B) Hearing loss may occur with a decibel level in this range.
C) Sounds in this decibel level are not perceived to be harsh to the ear.
D) Ear plugs will have no effect on these decibel levels.
B) Hearing loss may occur with a decibel level in this range.
369
A patient has undergone diagnostic testing and has been diagnosed with otosclerosis?
What ear structure is primarily affected by this diagnosis?
A) Malleus
B) Stapes
C) Incus
D) Tympanic membrane
B) Stapes
370
A patient with otosclerosis has significant hearing loss. What should the nurse do to
best facilitate communication with the patient?
A) Sit or stand in front of the patient when speaking.
B) Use exaggerated lip and mouth movements when talking.
C) Stand in front of a light or window when speaking.
D) Say the patient's name loudly before starting to talk.
A) Sit or stand in front of the patient when speaking.
371
The nurse in the ED is caring for a 4 year-old brought in by his parents who state that
the child will not stop crying and pulling at his ear. Based on information collected by
the nurse, which of the following statements applies to a diagnosis of external otitis?
A) External otitis is characterized by aural tenderness.
B) External otitis is usually accompanied by a high fever.
C) External otitis is usually related to an upper respiratory infection.
D) External otitis can be prevented by using cotton-tipped applicators to clean the
ear.
A) External otitis is characterized by aural tenderness.
372
A patient diagnosed with arthritis has been taking aspirin and now reports experiencing
tinnitus and hearing loss. What should the nurse teach this patient?
A) The hearing loss will likely resolve with time after the drug is discontinued.
B) The patient's hearing loss and tinnitus are irreversible at this point.
C) The patient's tinnitus is likely multifactorial, and not directly related to aspirin
use.
D) The patient's tinnitus will abate as tolerance to aspirin develops.
A) The hearing loss will likely resolve with time after the drug is discontinued.
373
A patient is postoperative day 6 following tympanoplasty and mastoidectomy. The
patient has phoned the surgical unit and states that she is experiencing occasional sharp,
shooting pains in her affected ear. How should the nurse best interpret this patient's
complaint?
A) These pains are an expected finding during the first few weeks of recovery.
B) The patient's complaints are suggestive of a postoperative infection.
C) The patient may have experienced a spontaneous rupture of the tympanic
membrane.
D) The patient's surgery may have been unsuccessful.
A) These pains are an expected finding during the first few weeks of recovery.
374
The nurse is discussing the results of a patient's diagnostic testing with the nurse
practitioner. What Weber test result would indicate the presence of a sensorineural
loss?
A) The sound is heard better in the ear in which hearing is better.
B) The sound is heard equally in both ears.
C) The sound is heard better in the ear in which hearing is poorer.
D) The sound is heard longer in the ear in which hearing is better.
A) The sound is heard better in the ear in which hearing is better.
375
The advanced practice nurse is attempting to examine the patient's ear with an
otoscope. Because of impacted cerumen, the tympanic membrane cannot be visualized.
The nurse irrigates the patient's ear with a solution of hydrogen peroxide and water to
remove the impacted cerumen. What nursing intervention is most important to
minimize nausea and vertigo during the procedure?
A) Maintain the irrigation fluid at a warm temperature.
B) Instill short, sharp bursts of fluid into the ear canal.
C) Follow the procedure with insertion of a cerumen curette to extract missed ear
wax.
D) Have the patient stand during the procedure.
A) Maintain the irrigation fluid at a warm temperature.
376
A patient is scheduled to have an electronystagmography as part of a diagnostic workup
for MÈniËre's disease. What question is it most important for the nurse to ask the
patient in preparation for this test?
A) Have you ever experienced claustrophobia or feelings of anxiety while in
enclosed spaces?
B) Do you currently take any tranquilizers or stimulants on a regular basis?
C) Do you have a history of falls or problems with loss of balance?
D) Do you have a history of either high or low blood pressure?
B) Do you currently take any tranquilizers or stimulants on a regular basis?
377
The nurse is planning the care of a patient who is adapting to the use of a hearing aid
for the first time. What is the most significant challenge experienced by a patient with
hearing loss who is adapting to using a hearing aid for the first time?
A) Regulating the tone and volume
B) Learning to cope with amplification of background noise
C) Constant irritation of the external auditory canal
D) Challenges in keeping the hearing aid clean while minimizing exposure to
moisture
B) Learning to cope with amplification of background noise
378
A patient with mastoiditis is admitted to the post-surgical unit after undergoing a
radical mastoidectomy. The nurse should identify what priority of postoperative care?
A) Assessing for mouth droop and decreased lateral eye gaze
B) Assessing for increased middle ear pressure and perforated ear drum
C) Assessing for gradual onset of conductive hearing loss and nystagmus
D) Assessing for scar tissue and cerumen obstructing the auditory canal
A) Assessing for mouth droop and decreased lateral eye gaze
379
The nurse is assessing a patient with multiple sclerosis who is demonstrating
involuntary, rhythmic eye movements. What term will the nurse use when documenting
these eye movements?
A) Vertigo
B) Tinnitus
C) Nystagmus
D) Astigmatism
C) Nystagmus
380
The nurse is planning the care of a patient with a diagnosis of vertigo. What nursing
diagnosis risk should the nurse prioritize in this patient's care?
A) Risk for disturbed sensory perception
B) Risk for unilateral neglect
C) Risk for falls
D) Risk for ineffective health maintenance
C) Risk for falls
381
A patient has been diagnosed with serous otitis media for the third time in the past year.
How should the nurse best interpret this patient's health status?
A) For some patients, these recurrent infections constitute an age-related physiologic
change.
B) The patient would benefit from a temporary mobility restriction to facilitate
healing.
C) The patient needs to be assessed for nasopharyngeal cancer.
D) Blood cultures should be drawn to rule out a systemic infection.
C) The patient needs to be assessed for nasopharyngeal cancer.
382
A patient with a sudden onset of hearing loss tells the nurse that he would like to begin
using hearing aids. The nurse understands that the health professional dispensing
hearing aids would have what responsibility?
A) Test the patient's hearing promptly.
B) Perform an otoscopy.
C) Measure the width of the patient's ear canal.
D) Refer the patient to his primary care physician.
D) Refer the patient to his primary care physician.
383
The nurse is providing care for a patient who has benefited from a cochlear implant.
The nurse should understand that this patient's health history likely includes which of
the following? Select all that apply.
A) The patient was diagnosed with sensorineural hearing loss.
B) The patient's hearing did not improve appreciably with the use of hearing aids.
C) The patient has deficits in peripheral nervous function.
D) The patient's hearing deficit is likely accompanied by a cognitive deficit.
E) The patient is unable to lip-read.
A) The patient was diagnosed with sensorineural hearing loss.
B) The patient's hearing did not improve appreciably with the use of hearing aids.
384
A patient presents to the ED complaining of a sudden onset of incapacitating vertigo,
with nausea and vomiting and tinnitus. The patient mentions to the nurse that she
suddenly cannot hear very well. What would the nurse suspect the patient's diagnosis
will be?
A) Ossiculitis
B) MÈniËre's disease
C) Ototoxicity
D) Labyrinthitis
D) Labyrinthitis
385
Which of the following nurse's actions carries the greatest potential to prevent hearing
loss due to ototoxicity?
A) Ensure that patients understand the differences between sensory hearing loss and
conductive hearing loss.
B) Educate patients about expected age-related changes in hearing perception.
C) Educate patients about the risks associated with prolonged exposure to
environmental noise.
D) Be aware of patients' medication regimens and collaborate with other
professionals accordingly.
D) Be aware of patients' medication regimens and collaborate with other
professionals accordingly.
386
A child goes to the school nurse and complains of not being able to hear the teacher.
What test could the school nurse perform that would preliminarily indicate hearing
loss?
A) Audiometry
B) Rinne test
C) Whisper test
D) Weber test
C) Whisper test
387
A nurse is teaching preventative measures for otitis externa to a group of older adults.
What action should the nurse encourage?
A) Rinsing the ears with normal saline after swimming
B) Avoiding loud environmental noises
C) Instilling antibiotic ointments on a regular basis
D) Avoiding the use of cotton swabs
D) Avoiding the use of cotton swabs
388
The nurse is reviewing the health history of a newly admitted patient and reads that the
patient has been previously diagnosed with exostoses. How should the nurse
accommodate this fact into the patient's plan of care?
A) The nurse should perform the Rinne and Weber tests.
B) The nurse should arrange for audiometry testing as soon as possible.
C) The nurse should collaborate with the pharmacist to assess for potential ototoxic
medications.
D) No specific assessments or interventions are necessary to addressing exostoses.
D) No specific assessments or interventions are necessary to addressing exostoses.
389
The nurse is caring for a patient who has undergone a mastoidectomy. In an effort to
prevent postoperative infection, what intervention should the nurse implement?
A) Teach the patient about the risks of ototoxic medications.
B) Instruct the patient to protect the ear from water for several weeks.
C) Teach the patient to remove cerumen safely at least once per week.
D) Instruct the patient to protect the ear from temperature extremes until healing is
complete.
B) Instruct the patient to protect the ear from water for several weeks.
390
A patient is being discharged home after mastoid surgery. What topic should the nurse
address in the patient's discharge education?
A) Expected changes in facial nerve function
B) The need for audiometry testing every 6 months following recovery
C) Safe use of analgesics and antivertiginous agents
D) Appropriate use of OTC ear drops
C) Safe use of analgesics and antivertiginous agents
391
After mastoid surgery, an 81-year-old patient has been identified as needing assistance
in her home. What would be a primary focus of this patient's home care?
A) Preparation of nutritious meals and avoidance of contraindicated foods
B) Ensuring the patient receives adequate rest each day
C) Helping the patient adapt to temporary hearing loss
D) Assisting the patient with ambulation as needed to avoid falling
D) Assisting the patient with ambulation as needed to avoid falling
392
A hearing-impaired patient is scheduled to have an MRI. What would be important for
the nurse to remember when caring for this patient?
A) Patient is likely unable to hear the nurse during test.
B) A person adept in sign language must be present during test.
C) Lip reading will be the method of communication that is necessary.
D) The nurse should interact with the patient like any other patient.
A) Patient is likely unable to hear the nurse during test.
393
The nurse and a colleague are performing the Epley maneuver with a patient who has a
diagnosis of benign paroxysmal positional vertigo. The nurses should begin this
maneuver by performing what action?
A) Placing the patient in a prone position
B) Assisting the patient into a sitting position
C) Instilling 15 mL of warm normal saline into one of the patient's ears
D) Assessing the patient's baseline hearing by performing the whisper test
B) Assisting the patient into a sitting position
394
A 6-month-old infant is brought to the ED by his parents for inconsolable crying and
pulling at his right ear. When assessing this infant, the advanced practice nurse is aware
that the tympanic membrane should be what color in a healthy ear?
A) Yellowish-white
B) Pink
C) Gray
D) Bluish-white
C) Gray
395
A child has been experiencing recurrent episodes of acute otitis media (AOM). The
nurse should anticipate that what intervention is likely to be ordered?
A) Ossiculoplasty
B) Insertion of a cochlear implant
C) Stapedectomy
D) Insertion of a ventilation tube
D) Insertion of a ventilation tube
396
An older adult with a recent history of mixed hearing loss has been diagnosed with a
cholesteatoma. What should this patient be taught about this diagnosis? Select all that
apply
A) Cholesteatomas are benign and self-limiting, and hearing loss will resolve
spontaneously.
B) Cholesteatomas are usually the result of metastasis from a distant tumor site.
C) Cholesteatomas are often the result of chronic otitis media.
D) Cholesteatomas, if left untreated, result in intractable neuropathic pain.
E) Cholesteatomas usually must be removed surgically.
C) Cholesteatomas are often the result of chronic otitis media.
E) Cholesteatomas usually must be removed surgically.
397
The nurse is admitting a patient to the unit who is scheduled to have an ossiculoplasty.
What postoperative assessment will best determine whether the procedure has been
successful?
A) Otoscopy
B) Audiometry
C) Balance testing
D) Culture and sensitivity testing of ear discharge
B) Audiometry
398
```
On otoscopy, a red blemish behind the tympanic membrane is suggestive of what
diagnosis?
A) Acoustic tumor
B) Cholesteatoma
C) Facial nerve neuroma
D) Glomus tympanicum
```
D) Glomus tympanicum
399
The nurse is discharging a patient home after mastoid surgery. What should the nurse
include in discharge teaching?
A) ìTry to induce a sneeze every 4 hours to equalize pressure.î
B) ìBe sure to exercise to reduce fatigue.î
C) ìAvoid sleeping in a side-lying position.î
D) ìDon't blow your nose for 2 to 3 weeks.
D) ìDon't blow your nose for 2 to 3 weeks.
400
An advanced practice nurse has performed a Rinne test on a new patient. During the
test, the patient reports that air-conducted sound is louder than bone-conducted sound.
How should the nurse best interpret this assessment finding?
A) The patient's hearing is likely normal.
B) The patient is at risk for tinnitus.
C) The patient likely has otosclerosis.
D) The patient likely has sensorineural hearing loss.
A) The patient's hearing is likely normal.
401
A patient with possible bacterial meningitis is admitted to the ICU. What assessment
finding would the nurse expect for a patient with this diagnosis?
A) Pain upon ankle dorsiflexion of the foot
B) Neck flexion produces flexion of knees and hips
C) Inability to stand with eyes closed and arms extended without swaying
D) Numbness and tingling in the lower extremities
B) Neck flexion produces flexion of knees and hips
402
The nurse is planning discharge education for a patient with trigeminal neuralgia. The
nurse knows to include information about factors that precipitate an attack. What would
the nurse be correct in teaching the patient to avoid?
A) Washing his face
B) Exposing his skin to sunlight
C) Using artificial tears
D) Drinking large amounts of fluids
A) Washing his face
403
The nurse is caring for a patient with multiple sclerosis (MS). The patient tells the nurse
the hardest thing to deal with is the fatigue. When teaching the patient how to reduce
fatigue, what action should the nurse suggest?
A) Taking a hot bath at least once daily
B) Resting in an air-conditioned room whenever possible
C) Increasing the dose of muscle relaxants
D) Avoiding naps during the day
B) Resting in an air-conditioned room whenever possible
404
A patient with Guillain-BarrÈ syndrome has experienced a sharp decline in vital
capacity. What is the nurse's most appropriate action?
A) Administer bronchodilators as ordered.
B) Remind the patient of the importance of deep breathing and coughing exercises.
C) Prepare to assist with intubation.
D) Administer supplementary oxygen by nasal cannula.
C) Prepare to assist with intubation.
405
A patient diagnosed with Bell's palsy is being cared for on an outpatient basis. During
health education, the nurse should promote which of the following actions?
A) Applying a protective eye shield at night
B) Chewing on the affected side to prevent unilateral neglect
C) Avoiding the use of analgesics whenever possible
D) Avoiding brushing the teeth
A) Applying a protective eye shield at night
406
The nurse is working with a patient who is newly diagnosed with MS. What basic
information should the nurse provide to the patient?
A) MS is a progressive demyelinating disease of the nervous system.
B) MS usually occurs more frequently in men.
C) MS typically has an acute onset.
D) MS is sometimes caused by a bacterial infection.
A) MS is a progressive demyelinating disease of the nervous system.
407
The nurse is creating a plan of care for a patient who has a recent diagnosis of MS.
Which of the following should the nurse include in the patient's care plan?
A) Encourage patient to void every hour.
B) Order a low-residue diet.
C) Provide total assistance with all ADLs.
D) Instruct the patient on daily muscle stretching.
D) Instruct the patient on daily muscle stretching.
408
A patient with metastatic cancer has developed trigeminal neuralgia and is taking
carbamazepine (Tegretol) for pain relief. What principle applies to the administration of
this medication?
A) Tegretol is not known to have serious adverse effects.
B) The patient should be monitored for bone marrow depression.
C) Side effects of the medication include renal dysfunction.
D) The medication should be first taken in the maximum dosage form to be
effective.
B) The patient should be monitored for bone marrow depression.
409
A male patient presents to the clinic complaining of a headache. The nurse notes that
the patient is guarding his neck and tells the nurse that he has stiffness in the neck area.
The nurse suspects the patient may have meningitis. What is another well-recognized
sign of this infection?
A) Negative Brudzinski's sign
B) Positive Kernig's sign
C) Hyperpatellar reflex
D) Sluggish pupil reaction
B) Positive Kernig's sign
410
The nurse is developing a plan of care for a patient newly diagnosed with Bell's palsy.
The nurse's plan of care should address what characteristic manifestation of this
disease?
A) Tinnitus
B) Facial paralysis
C) Pain at the base of the tongue
D) Diplopia
B) Facial paralysis
411
The nurse caring for a patient diagnosed with Guillain-BarrÈ syndrome is planning care
with regard to the clinical manifestations associated this syndrome. The nurse's
communication with the patient should reflect the possibility of what sign or symptom
of the disease?
A) Intermittent hearing loss
B) Tinnitus
C) Tongue enlargement
D) Vocal paralysis
D) Vocal paralysis
412
The nurse is preparing to provide care for a patient diagnosed with myasthenia gravis.
The nurse should know that the signs and symptoms of the disease are the result of
what?
A) Genetic dysfunction
B) Upper and lower motor neuron lesions
C) Decreased conduction of impulses in an upper motor neuron lesion
D) A lower motor neuron lesion
D) A lower motor neuron lesion
413
A patient with suspected Creutzfeldt-Jakob disease (CJD) is being admitted to the unit.
The nurse would expect what diagnostic test to be ordered for this patient?
A) Cerebral angiography
B) ABG analysis
C) CT
D) EEG
D) EEG
414
To alleviate pain associated with trigeminal neuralgia, a patient is taking Tegretol
(carbamazepine). What health education should the nurse provide to the patient before
initiating this treatment?
A) Concurrent use of calcium supplements is contraindicated.
B) Blood levels of the drug must be monitored.
C) The drug is likely to cause hyperactivity and agitation.
D) Tegretol can cause tinnitus during the first few days of treatment.
B) Blood levels of the drug must be monitored.
415
A patient with herpes simplex virus encephalitis (HSV) has been admitted to the ICU.
What medication would the nurse expect the physician to order for the treatment of this
disease process?
A) Cyclosporine (Neoral)
B) Acyclovir (Zovirax)
C) Cyclobenzaprine (Flexeril)
D) Ampicillin (Prinicpen)
B) Acyclovir (Zovirax)
416
A middle-aged woman has sought care from her primary care provider and undergone
diagnostic testing that has resulted in a diagnosis of MS. What sign or symptom is most
likely to have prompted the woman to seek care?
A) Cognitive declines
B) Personality changes
C) Contractures
D) Difficulty in coordination
D) Difficulty in coordination
417
A nurse is planning the care of a 28-year-old woman hospitalized with a diagnosis of
myasthenia gravis. What approach would be most appropriate for the care and
scheduling of diagnostic procedures for this patient?
A) All at one time, to provide a longer rest period
B) Before meals, to stimulate her appetite
C) In the morning, with frequent rest periods
D) Before bedtime, to promote rest
C) In the morning, with frequent rest periods
418
The nurse is caring for a patient who is hospitalized with an exacerbation of MS. To
ensure the patient's safety, what nursing action should be performed?
A) Ensure that suction apparatus is set up at the bedside.
B) Pad the patient's bed rails.
C) Maintain bed rest whenever possible.
D) Provide several small meals each day.
A) Ensure that suction apparatus is set up at the bedside.
419
A 33-year-old patient presents at the clinic with complaints of weakness,
incoordination, dizziness, and loss of balance. The patient is hospitalized and diagnosed
with MS. What sign or symptom, revealed during the initial assessment, is typical of
MS?
A) Diplopia, history of increased fatigue, and decreased or absent deep tendon
reflexes
B) Flexor spasm, clonus, and negative Babinski's reflex
C) Blurred vision, intention tremor, and urinary hesitancy
D) Hyperactive abdominal reflexes and history of unsteady gait and episodic
paresthesia in both legs
C) Blurred vision, intention tremor, and urinary hesitancy
420
The nurse is developing a plan of care for a patient with Guillain-BarrÈ syndrome.
Which of the following interventions should the nurse prioritize for this patient?
A) Using the incentive spirometer as prescribed
B) Maintaining the patient on bed rest
C) Providing aids to compensate for loss of vision
D) Assessing frequently for loss of cognitive function
A) Using the incentive spirometer as prescribed
421
A 69-year-old patient is brought to the ED by ambulance because a family member
found him lying on the floor disoriented and lethargic. The physician suspects bacterial
meningitis and admits the patient to the ICU. The nurse knows that risk factors for an
unfavorable outcome include what? Select all that apply.
A) Blood pressure greater than 140/90 mm Hg
B) Heart rate greater than 120 bpm
C) Older age
D) Low Glasgow Coma Scale
E) Lack of previous immunizations
B) Heart rate greater than 120 bpm
C) Older age
D) Low Glasgow Coma Scale
422
The critical care nurse is caring for 25-year-old man admitted to the ICU with a brain
abscess. What is a priority nursing responsibility in the care of this patient?
A) Maintaining the patient's functional independence
B) Providing health education
C) Monitoring neurologic status closely
D) Promoting mobility
C) Monitoring neurologic status closely
423
A patient is being admitted to the neurologic ICU with suspected herpes simplex virus
encephalitis. What nursing action best addresses the patient's complaints of headache?
A) Initiating a patient-controlled analgesia (PCA) of morphine sulfate
B) Administering hydromorphone (Dilaudid) IV as needed
C) Dimming the lights and reducing stimulation
D) Distracting the patient with activity
C) Dimming the lights and reducing stimulation
424
A patient is admitted through the ED with suspected St. Louis encephalitis. The unique
clinical feature of St. Louis encephalitis will make what nursing action a priority?
A) Serial assessments of hemoglobin levels
B) Blood glucose monitoring
C) Close monitoring of fluid balance
D) Assessment of pain along dermatomes
C) Close monitoring of fluid balance
425
The nurse is caring for a 77-year-old woman with MS. She states that she is very
concerned about the progress of her disease and what the future holds. The nurse should
know that elderly patients with MS are known to be particularly concerned about what
variables? Select all that apply.
A) Possible nursing home placement
B) Pain associated with physical therapy
C) Increasing disability
D) Becoming a burden on the family
E) Loss of appetite
A) Possible nursing home placement
C) Increasing disability
D) Becoming a burden on the family
426
You are the clinic nurse caring for a patient with a recent diagnosis of myasthenia
gravis. The patient has begun treatment with pyridostigmine bromide (Mestinon). What
change in status would most clearly suggest a therapeutic benefit of this medication?
A) Increased muscle strength
B) Decreased pain
C) Improved GI function
D) Improved cognition
A) Increased muscle strength
427
The critical care nurse is admitting a patient in myasthenic crisis to the ICU. The nurse
should prioritize what nursing action in the immediate care of this patient?
A) Suctioning secretions
B) Facilitating ABG analysis
C) Providing ventilatory assistance
D) Administering tube feedings
C) Providing ventilatory assistance
428
The nurse caring for a patient in ICU diagnosed with Guillain-BarrÈ syndrome should
prioritize monitoring for what potential complication?
A) Impaired skin integrity
B) Cognitive deficits
C) Hemorrhage
D) Autonomic dysfunction
D) Autonomic dysfunction
429
The nurse is teaching a patient with Guillain-BarrÈ syndrome about the disease. The
patient asks how he can ever recover if demyelination of his nerves is occurring. What
would be the nurse's best response?
A) ìGuillain-BarrÈ spares the Schwann cell, which allows for remyelination in the
recovery phase of the disease.
B) ìIn Guillain-BarrÈ, Schwann cells replicate themselves before the disease
destroys them, so remyelination is possible.î
C) ìI know you understand that nerve cells do not remyelinate, so the physician is
the best one to answer your question.î
D) ìFor some reason, in Guillain-BarrÈ, Schwann cells become activated and take
over the remyelination process.î
A) ìGuillain-BarrÈ spares the Schwann cell, which allows for remyelination in the
recovery phase of the disease.
430
A patient diagnosed with myasthenia gravis has been hospitalized to receive
plasmapheresis for a myasthenic exacerbation. The nurse knows that the course of
treatment for plasmapheresis in a patient with myasthenia gravis is what?
A) Every day for 1 week
B) Determined by the patient's response
C) Alternate days for 10 days
D) Determined by the patient's weight
B) Determined by the patient's response
431
The nurse is discharging a patient home after surgery for trigeminal neuralgia. What
advice should the nurse provide to this patient in order to reduce the risk of injury?
A) Avoid watching television or using a computer for more than 1 hour at a time.
B) Use OTC antibiotic eye drops for at least 14 days.
C) Avoid rubbing the eye on the affected side of the face.
D) Rinse the eye on the affected side with normal saline daily for 1 week.
C) Avoid rubbing the eye on the affected side of the face.
432
A patient diagnosed with Bell's palsy is having decreased sensitivity to touch of the
involved nerve. What should the nurse recommend to prevent atrophy of the muscles?
A) Blowing up balloons
B) Deliberately frowning
C) Smiling repeatedly
D) Whistling
D) Whistling
433
A patient with diabetes presents to the clinic and is diagnosed with a mononeuropathy.
This patient's nursing care should involve which of the following?
A) Protection of the affected limb from injury
B) Passive and active ROM exercises for the affected limb
C) Education about improvements to glycemic control
D) Interventions to prevent contractures
A) Protection of the affected limb from injury
434
A patient diagnosed with MS has been admitted to the medical unit for treatment of an
MS exacerbation. Included in the admission orders is baclofen (Lioresal). What should
the nurse identify as an expected outcome of this treatment?
A) Reduction in the appearance of new lesions on the MRI
B) Decreased muscle spasms in the lower extremities
C) Increased muscle strength in the upper extremities
D) Decreased severity and duration of exacerbations
B) Decreased muscle spasms in the lower extremities
435
A 35-year-old woman is diagnosed with a peripheral neuropathy. When making her
plan of care, the nurse knows to include what in patient teaching? Select all that apply.
A) Inspect the lower extremities for skin breakdown.
B) Footwear needs to be accurately sized.
C) Immediate family members should be screened for the disease.
D) Assistive devices may be needed to reduce the risk of falls.
E) Dietary modifications are likely necessary.
A) Inspect the lower extremities for skin breakdown.
B) Footwear needs to be accurately sized.
D) Assistive devices may be needed to reduce the risk of falls.
436
A 73-year-old man comes to the clinic complaining of weakness and loss of sensation
in his feet and legs. Assessment of the patient shows decreased reflexes bilaterally.
Why would it be a challenge to diagnose a peripheral neuropathy in this patient?
A) Older adults are often vague historians.
B) The elderly have fewer peripheral nerves than younger adults.
C) Many older adults are hesitant to admit that their body is changing.
D) Many symptoms can be the result of normal aging process.
D) Many symptoms can be the result of normal aging process.
437
A patient with MS has been admitted to the hospital following an acute exacerbation.
When planning the patient's care, the nurse addresses the need to enhance the patient's
bladder control. What aspect of nursing care is most likely to meet this goal?
A) Establish a timed voiding schedule.
B) Avoid foods that change the pH of urine.
C) Perform intermittent catheterization q6h.
D) Administer anticholinergic drugs as ordered.
A) Establish a timed voiding schedule.
438
A patient with MS has developed dysphagia as a result of cranial nerve dysfunction.
What nursing action should the nurse consequently perform?
A) Arrange for the patient to receive a low residue diet.
B) Position the patient upright during feeding.
C) Suction the patient following each meal.
D) Withhold liquids until the patient has finished eating.
B) Position the patient upright during feeding.
439
A 48-year-old patient has been diagnosed with trigeminal neuralgia following recent
episodes of unilateral face pain. The nurse should recognize what implication of this
diagnosis?
A) The patient will likely require lifelong treatment with anticholinergic
medications.
B) The patient has a disproportionate risk of developing myasthenia gravis later in
life.
C) The patient needs to be assessed for MS.
D) The disease is self-limiting and the patient will achieve pain relief over time.
C) The patient needs to be assessed for MS.
440
A patient presents at the clinic complaining of pain and weakness in her hands. On
assessment, the nurse notes diminished reflexes in the upper extremities bilaterally and
bilateral loss of sensation. The nurse knows that these findings are indicative of what?
A) Guillain-BarrÈ syndrome
B) Myasthenia gravis
C) Trigeminal neuralgia
D) Peripheral nerve disorder
D) Peripheral nerve disorder
441
A nurse is assessing a patient with an acoustic neuroma who has been recently admitted
to an oncology unit. What symptoms is the nurse likely to find during the initial
assessment?
A) Loss of hearing, tinnitus, and vertigo
B) Loss of vision, change in mental status, and hyperthermia
C) Loss of hearing, increased sodium retention, and hypertension
D) Loss of vision, headache, and tachycardia
A) Loss of hearing, tinnitus, and vertigo
442
A 25-year-old female patient with brain metastases is considering her life expectancy
after her most recent meeting with her oncologist. Based on the fact that the patient is
not receiving treatment for her brain metastases, what is the nurse's most appropriate
action?
A) Promoting the patient's functional status and ADLs
B) Ensuring that the patient receives adequate palliative care
C) Ensuring that the family does not tell the patient that her condition is terminal
D) Promoting adherence to the prescribed medication regimen
B) Ensuring that the patient receives adequate palliative care
443
The nurse is writing a care plan for a patient with brain metastases. The nurse decides
that an appropriate nursing diagnosis is ìanxiety related to lack of control over the
health circumstances.î In establishing this plan of care for the patient, the nurse should
include what intervention?
A) The patient will receive antianxiety medications every 4 hours.
B) The patient's family will be instructed on planning the patient's care.
C) The patient will be encouraged to verbalize concerns related to the disease and its
treatment.
D) The patient will begin intensive therapy with the goal of distraction.
C) The patient will be encouraged to verbalize concerns related to the disease and its
treatment.
444
A patient with suspected Parkinson's disease is initially being assessed by the nurse.
When is the best time to assess for the presence of a tremor?
A) When the patient is resting
B) When the patient is ambulating
C) When the patient is preparing his or her meal tray to eat
D) When the patient is participating in occupational therapy
A) When the patient is resting
445
The clinic nurse caring for a patient with Parkinson's disease notes that the patient has
been taking levodopa and carbidopa (Sinemet) for 7 years. For what common side
effect of Sinemet would the nurse assesses this patient?
A) Pruritus
B) Dyskinesia
C) Lactose intolerance
D) Diarrhea
B) Dyskinesia
446
The nurse is caring for a boy who has muscular dystrophy. When planning assistance
with the patient's ADLs, what goal should the nurse prioritize?
A) Promoting the patient's recovery from the disease
B) Maximizing the patient's level of function
C) Ensuring the patient's adherence to treatment
D) Fostering the family's participation in care
B) Maximizing the patient's level of function
447
A 37-year-old man is brought to the clinic by his wife because he is experiencing loss
of motor function and sensation. The physician suspects the patient has a spinal cord
tumor and hospitalizes him for diagnostic testing. In light of the need to diagnose
spinal cord compression from a tumor, the nurse will most likely prepare the patient for
what test?
A) Anterior-posterior x-ray
B) Ultrasound
C) Lumbar puncture
D) MRI
D) MRI
448
A patient with Parkinson's disease is undergoing a swallowing assessment because she
has recently developed adventitious lung sounds. The patient's nutritional needs should
be met by what method?
A) Total parenteral nutrition (TPN)
B) Provision of a low-residue diet
C) Semisolid food with thick liquids
D) Minced foods and a fluid restriction
C) Semisolid food with thick liquids
449
While assessing the patient at the beginning of the shift, the nurse inspects a surgical
dressing covering the operative site after the patients' cervical diskectomy. The nurse
notes that the drainage is 75% saturated with serosanguineous discharge. What is the
nurse's most appropriate action?
A) Page the physician and report this sign of infection.
B) Reinforce the dressing and reassess in 1 to 2 hours.
C) Reposition the patient to prevent further hemorrhage.
D) Inform the surgeon of the possibility of a dural leak.
D) Inform the surgeon of the possibility of a dural leak.
450
A patient, diagnosed with cancer of the lung, has just been told he has metastases to the
brain. What change in health status would the nurse attribute to the patient's metastatic
brain disease?
A) Chronic pain
B) Respiratory distress
C) Fixed pupils
D) Personality changes
D) Personality changes
451
A patient has just been diagnosed with Parkinson's disease and the nurse is planning the
patient's subsequent care for the home setting. What nursing diagnosis should the nurse
address when educating the patient's family?
A) Risk for infection
B) Impaired spontaneous ventilation
C) Unilateral neglect
D) Risk for injury
D) Risk for injury
452
The nurse is caring for a patient with Huntington disease who has been admitted to the
hospital for treatment of malnutrition. What independent nursing action should be
implemented in the patient's plan of care?
A) Firmly redirect the patient's head when feeding.
B) Administer phenothiazines after each meal as ordered.
C) Encourage the patient to keep his or her feeding area clean.
D) Apply deep, gentle pressure around the patient's mouth to aid swallowing.
D) Apply deep, gentle pressure around the patient's mouth to aid swallowing.
453
A patient has been admitted to the neurologic unit for the treatment of a newly
diagnosed brain tumor. The patient has just exhibited seizure activity for the first time.
What is the nurse's priority response to this event?
A) Identify the triggers that precipitated the seizure.
B) Implement precautions to ensure the patient's safety.
C) Teach the patient's family about the relationship between brain tumors and
seizure activity.
D) Ensure that the patient is housed in a private room.
B) Implement precautions to ensure the patient's safety.
454
A patient diagnosed with a pituitary adenoma has arrived on the neurologic unit. When
planning the patient's care, the nurse should be aware that the effects of the tumor will
primarily depend on what variable?
A) Whether the tumor utilizes aerobic or anaerobic respiration
B) The specific hormones secreted by the tumor
C) The patient's pre-existing health status
D) Whether the tumor is primary or the result of metastasis
B) The specific hormones secreted by the tumor
455
A male patient with a metastatic brain tumor is having a generalized seizure and begins
vomiting. What should the nurse do first?
A) Perform oral suctioning.
B) Page the physician.
C) Insert a tongue depressor into the patient's mouth.
D) Turn the patient on his side.
D) Turn the patient on his side.
456
The nurse in an extended care facility is planning the daily activities of a patient with
postpolio syndrome. The nurse recognizes the patient will best benefit from physical
therapy when it is scheduled at what time?
A) Immediately after meals
B) In the morning
C) Before bedtime
D) In the early evening
B) In the morning
457
A patient newly diagnosed with a cervical disk herniation is receiving health education
from the clinic nurse. What conservative management measures should the nurse teach
the patient to implement?
A) Perform active ROM exercises three times daily.
B) Sleep on a firm mattress.
C) Apply cool compresses to the back of the neck daily.
D) Wear the cervical collar for at least 2 hours at a time.
B) Sleep on a firm mattress.
458
A patient has just returned to the unit from the PACU after surgery for a tumor within
the spine. The patient complains of pain. When positioning the patient for comfort and
to reduce injury to the surgical site, the nurse will position to patient in what position?
A) In the high Fowler's position
B) In a flat side-lying position
C) In the Trendelenberg position
D) In the reverse Trendelenberg position
B) In a flat side-lying position
459
A patient with Huntington disease has just been admitted to a long-term care facility.
The charge nurse is creating a care plan for this patient. Nutritional management for a
patient with Huntington disease should be informed by what principle?
A) The patient is likely to have an increased appetite.
B) The patient is likely to required enzyme supplements.
C) The patient will likely require a clear liquid diet.
D) The patient will benefit from a low-protein diet.
A) The patient is likely to have an increased appetite.
460
A patient with amyotrophic lateral sclerosis (ALS) is being visited by the home health
nurse who is creating a care plan. What nursing diagnosis is most likely for a patient
with this condition?
A) Chronic confusion
B) Impaired urinary elimination
C) Impaired verbal communication
D) Bowel incontinence
C) Impaired verbal communication
461
The nurse educator is discussing neoplasms with a group of recent graduates. The
educator explains that the effects of neoplasms are caused by the compression and
infiltration of normal tissue. The physiologic changes that result can cause what
pathophysiologic events? Select all that apply.
A) Intracranial hemorrhage
B) Infection of cerebrospinal fluid
C) Increased ICP
D) Focal neurologic signs
E) Altered pituitary function
C) Increased ICP
D) Focal neurologic signs
E) Altered pituitary function
462
The nurse is caring for a patient newly diagnosed with a primary brain tumor. The
patient asks the nurse where his tumor came from. What would be the nurse's best
response?
A) ìYour tumor originated from somewhere outside the CNS.î
B) ìYour tumor likely started out in one of your glands.î
C) ìYour tumor originated from cells within your brain itself.
D) ìYour tumor is from nerve tissue somewhere in your body.î
C) ìYour tumor originated from cells within your brain itself.
463
A gerontologic nurse is advocating for diagnostic testing of an 81-year-old patient who
is experiencing personality changes. The nurse is aware of what factor that is known to
affect the diagnosis and treatment of brain tumors in older adults?
A) The effects of brain tumors are often attributed to the cognitive effects of aging.
B) Brain tumors in older adults do not normally produce focal effects.
C) Older adults typically have numerous benign brain tumors by the eighth decade
of life.
D) Brain tumors cannot normally be treated in patient over age 75.
A) The effects of brain tumors are often attributed to the cognitive effects of aging.
464
A patient who has been experiencing numerous episodes of unexplained headaches and
vomiting has subsequently been referred for testing to rule out a brain tumor. What
characteristic of the patient's vomiting is most consistent with a brain tumor?
A) The patient's vomiting is accompanied by epistaxis.
B) The patient's vomiting does not relieve his nausea.
C) The patient's vomiting is unrelated to food intake.
D) The patient's emesis is blood-tinged.
C) The patient's vomiting is unrelated to food intake.
465
A male patient presents at the free clinic with complaints of impotency. Upon physical
examination, the nurse practitioner notes the presence of hypogonadism. What
diagnosis should the nurse suspect?
A) Prolactinoma
B) Angioma
C) Glioma
D) Adrenocorticotropic hormone (ACTH)ñproducing adenoma
A) Prolactinoma
466
The nurse is planning the care of a patient who has been recently diagnosed with a
cerebellar tumor. Due to the location of this patient's tumor, the nurse should
implement measures to prevent what complication?
A) Falls
B) Audio hallucinations
C) Respiratory depression
D) Labile BP
A) Falls
467
A patient has been admitted to the neurologic ICU with a diagnosis of a brain tumor.
The patient is scheduled to have a tumor resection/removal in the morning. Which of
the following assessment parameters should the nurse include in the initial assessment?
A) Gag reflex
B) Deep tendon reflexes
C) Abdominal girth
D) Hearing acuity
A) Gag reflex
468
A patient with a brain tumor has begun to exhibit signs of cachexia. What subsequent
assessment should the nurse prioritize?
A) Assessment of peripheral nervous function
B) Assessment of cranial nerve function
C) Assessment of nutritional status
D) Assessment of respiratory status
C) Assessment of nutritional status
469
```
A patient with an inoperable brain tumor has been told that he has a short life
expectancy. On what aspects of assessment and care should the home health nurse
focus? Select all that apply.
A) Pain control
B) Management of treatment complications
C) Interpretation of diagnostic tests
D) Assistance with self-care
E) Administration of treatments
```
A) Pain control
B) Management of treatment complications
D) Assistance with self-care
E) Administration of treatments
470
An older adult has encouraged her husband to visit their primary care provider, stating
that she is concerned that he may have Parkinson's disease. Which of the wife's
descriptions of her husband's health and function is most suggestive of Parkinson's
disease?
A) ìLately he seems to move far more slowly than he ever has in the past.
B) ìHe often complains that his joints are terribly stiff when he wakes up in the
morning.î
C) ìHe's forgotten the names of some people that we've known for years.î
D) ìHe's losing weight even though he has a ravenous appetite.î
A) ìLately he seems to move far more slowly than he ever has in the past.
471
A patient, brought to the clinic by his wife and son, is diagnosed with Huntington
disease. When providing anticipatory guidance, the nurse should address the future
possibility of what effect of Huntington disease?
A) Metastasis
B) Risk for stroke
C) Emotional and personality changes
D) Pathologic bone fractures
C) Emotional and personality changes
472
A patient who was diagnosed with Parkinson's disease several months ago recently
began treatment with levodopa-carbidopa. The patient and his family are excited that he
has experienced significant symptom relief. The nurse should be aware of what
implication of the patient's medication regimen?
A) The patient is in a ìhoneymoon periodî when adverse effects of levodopacarbidopa
are not yet evident.
B) Benefits of levodopa-carbidopa do not peak until 6 to 9 months after the initiation
of treatment.
C) The patient's temporary improvement in status is likely unrelated to levodopacarbidopa.
D) Benefits of levodopa-carbidopa often diminish after 1 or 2 years of treatment.
D) Benefits of levodopa-carbidopa often diminish after 1 or 2 years of treatment.
473
```
The nurse caring for a patient diagnosed with Parkinson's disease has prepared a plan of
care that would include what goal?
A) Promoting effective communication
B) Controlling diarrhea
C) Preventing cognitive decline
D) Managing choreiform movements
```
A) Promoting effective communication
474
The nurse is caring for a patient diagnosed with Parkinson's disease. The patient is
having increasing problems with rising from the sitting to the standing position. What
should the nurse suggest to the patient to use that will aid in getting from the sitting to
the standing position as well as aid in improving bowel elimination?
A) Use of a bedpan
B) Use of a raised toilet seat
C) Sitting quietly on the toilet every 2 hours
D) Following the outlined bowel program
B) Use of a raised toilet seat
475
A patient with Parkinson's disease is experiencing episodes of constipation that are
becoming increasingly frequent and severe. The patient states that he has been
achieving relief for the past few weeks by using OTC laxatives. How should the nurse
respond?
A) ìIt's important to drink plenty of fluids while you're taking laxatives.î
B) ìMake sure that you supplement your laxatives with a nutritious diet.î
C) ìLet's explore other options, because laxatives can have side effects and create dependency.
D) ìYou should ideally be using herbal remedies rather than medications to promote
bowel function.î
C) ìLet's explore other options, because laxatives can have side effects and create dependency.
476
A family member of a patient diagnosed with Huntington disease calls you at the clinic.
She is requesting help from the Huntington's Disease Society of America. What kind of
help can this patient and family receive from this organization? Select all that apply.
A) Information about this disease
B) Referrals
C) Public education
D) Individual assessments
E) Appraisals of research studies
A) Information about this disease
B) Referrals
C) Public education
477
A patient with a new diagnosis of amyotrophic lateral sclerosis (ALS) is overwhelmed
by his diagnosis and the known complications of the disease. How can the patient best
make known his wishes for care as his disease progresses?
A) Prepare an advance directive.
B) Designate a most responsible physician (MRP) early in the course of the disease.
C) Collaborate with representatives from the Amyotrophic Lateral Sclerosis
Association.
D) Ensure that witnesses are present when he provides instruction.
A) Prepare an advance directive.
478
The nurse is caring for a patient who is scheduled for a cervical discectomy the
following day. During health education, the patient should be made aware of what
potential complications?
A) Vertebral fracture
B) Hematoma at the surgical site
C) Scoliosis
D) Renal trauma
B) Hematoma at the surgical site
479
The nurse responds to the call light of a patient who has had a cervical diskectomy
earlier in the day. The patient states that she is having severe pain that had a sudden
onset. What is the nurse's most appropriate action?
A) Palpate the surgical site.
B) Remove the dressing to assess the surgical site.
C) Call the surgeon to report the patient's pain.
D) Administer a dose of an NSAID.
C) Call the surgeon to report the patient's pain.
480
A nurse is planning discharge education for a patient who underwent a cervical
diskectomy. What strategies would the nurse assess that would aid in planning
discharge teaching?
A) Care of the cervical collar
B) Technique for performing neck ROM exercises
C) Home assessment of ABGs
D) Techniques for restoring nerve function
A) Care of the cervical collar
