Heart
A nurse is assessing patients on a medical-surgical unit. Which patient would the nurse identify as being at greatest risk for atrial fibrillation?
a. A 45-year-old who takes an aspirin daily
b. A 50-year-old who is postcoronary artery bypass graft surgery
c. A 78-year-old who had a carotid endarterectomy
d. An 80-year-old with chronic obstructive pulmonary disease
ANS: B
Atrial fibrillation occurs commonly in patients with cardiac disease and is a common occurrence after coronary artery bypass graft surgery. The other conditions do not place these patients at higher risk for atrial fibrillation.
PTS: 1 DIF: Cognitive Level: Remembering
KEY: Health screening | cardiac electrical conduction
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Reduction of Risk Potential
The nurse sees several patients with osteoporosis. For which patient would bisphosphonates not be a good option?
a. Patient with diabetes who has a serum creatinine of 0.8 mg/dL (61 mcmol/L)
b. Patient who recently fell and has vertebral compression fractures
c. Hypertensive patient who takes calcium channel blockers
d. Patient with a spinal cord injury who cannot tolerate sitting up
ANS: D
Patients on bisphosphonates must be able to sit upright for 30 to 60 minutes after taking them. The patient who cannot tolerate sitting up is not a good candidate for this class of drug. Poor renal function also makes patients bad candidates for this drug, but the patient with a creatinine of 0.8 mg/dL (61 mcmol/L) is within normal range. Diabetes and hypertension are not related unless the patient also has renal disease. The patient who recently fell and sustained fractures is a good candidate for this drug if the fractures are related to osteoporosis.
PTS: 1 DIF: Cognitive Level: Analyzing
KEY: Musculoskeletal disorders | osteoporosis | bisphosphonates | adverse effects
MSC: Integrated Process: Nursing Process/Analysis
NOT: Patient Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
A nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness. What action would the nurse take first?
a. Start fluids via a large-bore catheter.
b. Turn the client’s head to the side.
c. Administer IV push diazepam.
d. Prepare to intubate the client.
ANS: B
The nurse would turn the client’s head to the side to prevent aspiration and allow drainage of secretions. Anticonvulsants are administered on a routine basis if a seizure is sustained. If the seizure is sustained (status epilepticus), the client must be intubated and would be administered oxygen, 0.9% sodium chloride, and IV push lorazepam or diazepam.
PTS: 1 DIF: Cognitive Level: Applying KEY: Seizure | aspiration precautions
MSC: Integrated Process: Nursing Process/Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
A patient does not understand why vision loss due to glaucoma is irreversible. What explanation by the nurse is best?
a. “Because eye pressure was too high, the tissue died.”
b. “Glaucoma always leads to permanent blindness.”
c. “The traumatic damage to your eye was too great.”
d. “The infection occurs so quickly it can’t be treated.”
ANS: A
Glaucoma is caused when the intraocular pressure becomes too high and stays high long enough to cause tissue ischemia and death. At that point, vision loss is permanent. Glaucoma does not have to cause blindness. Trauma can cause glaucoma but is not the most common cause. Glaucoma is not an infection.
PTS: 1 DIF: Cognitive Level: Understanding
KEY: Visual system | visual disorders | glaucoma | patient education | pathophysiology
MSC: Integrated Process: Teaching and Learning
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
A nurse cares for a patient with right-sided heart failure. The patient asks, “Why do I need to weigh myself every day?” How would the nurse respond?
a. “Weight is the best indication that you are gaining or losing fluid.”
b. “Daily weights will help us make sure that you’re eating properly.”
c. “The hospital requires that all inpatients be weighed daily.”
d. “You need to lose weight to decrease the incidence of heart failure.”
ANS: A
Daily weights are needed to document fluid retention or fluid loss. One liter of fluid equals 2.2 lbs (1 kg). The other responses do not address the importance of monitoring fluid retention or loss.
PTS: 1 DIF: Cognitive Level: Remembering KEY: Heart failure | patient education
MSC: Integrated Process: Teaching and Learning
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
A nurse cares for a patient who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification would the nurse suggest to avoid further slowing of the heart rate?
a. “Make certain that your bath water is warm.”
b. “Avoid straining while having a bowel movement.”
c. “Limit your intake of caffeinated drinks to one a day.”
d. “Avoid strenuous exercise such as running.”
ANS: B
Bearing down strenuously during a bowel movement is one type of Valsalva maneuver, which stimulates the vagus nerve and results in slowing of the heart rate. Such a response is not desirable in a person who has bradycardia. The other instructions are not appropriate for this condition.
PTS: 1 DIF: Cognitive Level: Applying KEY: Functional ability
MSC: Integrated Process: Nursing Process/Implementation
NOT: Patient Needs Category: Physiological Integrity: Reduction of Risk Potential
A patient in a nursing home refuses to take medications. The patient is at high risk for osteomalacia. What action by the nurse is best?
a. Ensure that the patient gets at least 5 minutes of sun exposure daily.
b. Give the patient daily vitamin D injections.
c. Hide vitamin D supplements in favorite foods.
d. Plan to serve foods naturally high in vitamin D.
ANS: A
Sunlight is a good source of vitamin D, and the nursing staff can ensure some sun exposure each day. A minimum of 5 minutes is needed. Vitamin D is not given by injection. Hiding the supplement in food is unethical. Very few foods are naturally high in vitamin D, but some are supplemented.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Musculoskeletal disorders | ethics | nursing interventions
MSC: Integrated Process: Nursing Process/Implementation
NOT: Patient Needs Category: Physiological Integrity: Basic Care and Comfort
After teaching the wife of a client who has Parkinson disease, the nurse assesses the wife’s understanding. Which statement by the client’s wife indicates that she correctly understands changes associated with this disease?
a. “His masklike face makes it difficult to communicate, so I will use a white board.”
b. “He should not socialize outside of the house due to uncontrollable drooling.”
c. “This disease is associated with anxiety causing increased perspiration.”
d. “He may have trouble chewing, so I will offer bite-sized portions.”
ANS: D
Because chewing and swallowing can be problematic, small frequent meals and a supplement are better for meeting the client’s nutritional needs. A masklike face and drooling are common in clients with Parkinson disease. The client would be encouraged to continue to socialize and communicate as normally as possible. The wife should understand that the client’s masklike face can be misinterpreted and additional time may be needed for the client to communicate with her or others. Excessive perspiration is also common in clients with Parkinson disease and is associated with the autonomic nervous system’s response.
PTS: 1 DIF: Cognitive Level: Applying KEY: Parkinson disease
MSC: Integrated Process: Teaching and Learning
NOT: Client Needs Category: Psychosocial Integrity
A nurse is seeing patients in the ophthalmology clinic. Which patient would the nurse see first?
a. Patient with intraocular pressure reading of 24 mm Hg
b. Patient who has had cataract surgery and has worsening vision
c. Patient whose red reflex is absent on ophthalmologic examination
d. Patient with a tearing, reddened eye with exudate
ANS: B
After cataract surgery, worsening vision indicates an infection or other complication. The nurse would see this patient first. The intraocular pressure is slightly elevated. An absent red reflex may indicate cataracts. The patient who has the tearing eye may have an infection.
PTS: 1 DIF: Cognitive Level: Applying KEY: Visual system | visual disorders
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Safe and Effective Care Environment: Management of Care
After teaching a client who is diagnosed with new-onset status epilepticus and prescribed phenytoin (Dilantin), the nurse assesses the client’s understanding. Which statement by the client indicates a correct understanding of the teaching?
a. “To prevent complications, I will drink at least 2 L of water daily.”
b. “This medication will stop me from getting an aura before a seizure.”
c. “I will not drive a motor vehicle while taking this medication.”
d. “Even when my seizures stop, I will continue to take this drug.”
ANS: D
Discontinuing antiepileptic drugs can lead to the recurrence of seizures or status epilepticus. The client does not need to drink more water and can drive while taking this medication. The medication will not stop an aura before a seizure.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Medication safety | seizure | antiepileptic
MSC: Integrated Process: Teaching and Learning
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
After teaching a patient who has an implantable cardioverter-defibrillator (ICD), a nurse assesses the patient’s understanding. Which statement by the patient indicates a correct understanding of the teaching?
a. “I should wear a snug-fitting shirt over the ICD.”
b. “I will avoid sources of strong electromagnetic fields.”
c. “I should participate in a strenuous exercise program.”
d. “Now I can discontinue my antidysrhythmic medication.”
ANS: B
The patient being discharged with an ICD is instructed to avoid strong sources of electromagnetic fields. Patients should avoid tight clothing, which could cause irritation over the ICD generator. The patient should be encouraged to exercise but should not engage in strenuous activities that cause the heart rate to meet or exceed the ICD cutoff point because the ICD can discharge inappropriately. The patient should continue all prescribed medications.
PTS: 1 DIF: Cognitive Level: Evaluating KEY: Cardiac electrical conduction
MSC: Integrated Process: Teaching and Learning
NOT: Patient Needs Category: Health Promotion and Maintenance
What information does the nurse teach a women’s group about osteoporosis?
a. “Primary osteoporosis occurs in postmenopausal women due to lack of estrogen.”
b. “Men actually have higher rates of the disease but are underdiagnosed.”
c. “There is no way to prevent or slow osteoporosis after menopause.”
d. “Women and men have an equal chance of getting osteoporosis.”
ANS: A
Women are more at risk of developing primary osteoporosis after menopause due to the lack of estrogen. Men have a slower loss of bone after the age of 75. Many treatments are now available for women to slow osteoporosis after menopause.
PTS: 1 DIF: Cognitive Level: Remembering
KEY: Musculoskeletal disorders | osteoporosis | older adult | gender differences
MSC: Integrated Process: Teaching and Learning
NOT: Patient Needs Category: Health Promotion and Maintenance
A patient with a stroke is being evaluated for fibrinolytic therapy. What information from the patient or family is most important for the nurse to obtain?
a. Loss of bladder control
b. Other medical conditions
c. Progression of symptoms
d. Time of symptom onset
ANS: D
The time limit for initiating fibrinolytic therapy for a stroke is 3 to 4.5 hours, so the exact time of symptom onset is the most important information for this patient. The other information is not as critical.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Stroke | neurologic disorders | nursing assessment | fibrinolytic therapy
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
The patient’s chart indicates a sensorineural hearing loss. What assessment question does the nurse ask to determine the possible cause?
a. “Do you feel like something is in your ear?”
b. “Do you have frequent ear infections?”
c. “Have you been exposed to loud noises?”
d. “Have you been told your ear bones don’t move?”
ANS: C
Sensorineural hearing loss can occur from damage to the cochlea, the eighth cranial nerve, or the brain. Exposure to loud music is one etiology. The other questions relate to conductive hearing loss.
PTS: 1 DIF: Cognitive Level: Remembering
KEY: Auditory system | auditory assessment | auditory disorders
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Reduction of Risk Potential
A nurse is caring for a patient with a deep vein thrombosis (DVT). What nursing assessment indicates that a priority outcome has been met?
a. Ambulates with assistance
b. Oxygen saturation of 98%
c. Pain of 2/10 after medication
d. Verbalizing risk factors
ANS: B
A critical complication of DVT is pulmonary embolism. A normal oxygen saturation indicates that this has not occurred. The other assessments are also positive, but not the priority.
PTS: 1 DIF: Cognitive Level: Analyzing
KEY: Pulmonary embolism | deep vein thrombosis | respiratory assessment | thromboembolic event
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Reduction of Risk Potential
A nurse prepares to defibrillate a patient who is in ventricular fibrillation. Which priority intervention would the nurse perform prior to defibrillating this patient?
a. Make sure that the defibrillator is set to the synchronous mode.
b. Administer 1 mg of intravenous epinephrine.
c. Test the equipment by delivering a smaller shock at 100 J.
d. Ensure that everyone is clear of contact with the patient and the bed.
ANS: D
To avoid injury, the rescuer commands that all personnel clear contact with the patient or the bed and ensures their compliance before delivery of the shock. A precordial thump can be delivered when no defibrillator is available. Defibrillation is done in asynchronous mode. Equipment should not be tested before a patient is defibrillated because this is an emergency procedure; equipment would be checked on a routine basis. Epinephrine should be administered after defibrillation.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Cardiac electrical conduction | safety
MSC: Integrated Process: Nursing Process/Implementation
NOT: Patient Needs Category: Safe and Effective Care Environment: Safety and Infection Control
A patient had an arthroscopy 1 hour ago on the left knee. The nurse finds the left lower leg to be pale and cool, with 1+/4+ pedal pulses. What action by the nurse is best?
a. Assess the neurovascular status of the right leg.
b. Document the findings in the patient’s chart.
c. Elevate the left leg on at least two pillows.
d. Notify the provider of the findings immediately.
ANS: A
The nurse would compare findings of the two legs as these findings may be normal for the patient. If a difference is observed, the nurse notifies the provider. Documentation would occur after the nurse has all the data. Elevating the left leg will not improve perfusion if there is a problem.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Musculoskeletal system | musculoskeletal assessment | musculoskeletal disorders | nursing assessment
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Reduction of Risk Potential
A patient has a traumatic brain injury and a positive halo sign. The patient is in the intensive care unit, sedated and on a ventilator, and is in critical but stable condition. What collaborative problem takes priority at this time?
a. Inability to communicate
b. Nutritional deficit
c. Risk for acquiring an infection
d. Risk for skin breakdown
ANS: C
The positive halo sign indicates a leak of cerebrospinal fluid. This places the patient at high risk of acquiring an infection. Communication and nutrition are not priorities compared with preventing a brain infection. The patient has a definite risk for a skin breakdown, but it is not the immediate danger a brain infection would be.
PTS: 1 DIF: Cognitive Level: Analyzing
KEY: Neurologic disorders | infection control | asepsis
MSC: Integrated Process: Nursing Process/Analysis
NOT: Patient Needs Category: Physiological Integrity: Reduction of Risk Potential
A nurse is teaching a community group about noise-induced hearing loss. Which patient who does not use ear protection would the nurse refer to an audiologist as the priority?
a. Patient with an hour car commute on the freeway each day
b. Patient who rides a motorcycle to work 20 minutes each way
c. Patient who sat in the back row at a rock concert recently
d. Patient who is a tree-trimmer and uses a chainsaw 6 to 7 hours a day
ANS: D
A chainsaw becomes dangerous to hearing after 2 hours of exposure without hearing protection. This patient needs to be referred as the priority. Normal car traffic is safe for more than 8 hours. Motorcycle noise is safe for about 8 hours. The safe exposure time for a front-row rock concert seat is 3 minutes, but this patient was in the back, and so had less exposure. In addition, a one-time exposure is less damaging than chronic exposure.
PTS: 1 DIF: Cognitive Level: Remembering
KEY: Auditory system | auditory disorders | referrals
MSC: Integrated Process: Communication and Documentation
NOT: Patient Needs Category: Safe and Effective Care Environment: Management of Care
A nurse assesses a patient with early-onset multiple sclerosis (MS). Which clinical manifestation would the nurse expect to find?
a. Hyperresponsive reflexes
b. Excessive somnolence
c. Nystagmus
d. Heat intolerance
ANS: C
Early signs and symptoms of MS include changes in motor skills, vision, and sensation. Hyperresponsive reflexes, excessive somnolence, and heat intolerance are later manifestations of MS.
PTS: 1 DIF: Cognitive Level: Understanding
KEY: Multiple sclerosis | assessment/diagnostic examination
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
A nurse cares for a patient with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions would the nurse implement to address this patient’s concerns?
a. Administer oxygen therapy at 2 L per nasal cannula.
b. Provide the patient with a sleeping pill to stimulate rest.
c. Schedule periods of exercise and rest during the day.
d. Ask unlicensed assistive personnel to help bathe the patient.
ANS: C
Patients who have atrial fibrillation are at risk for decreased cardiac output and fatigue when completing activities of daily living. The nurse would schedule periods of exercise and rest during the day to decrease fatigue. The other interventions will not assist the patient with self-care activities.
PTS: 1 DIF: Cognitive Level: Applying KEY: Cardiac electrical conduction
MSC: Integrated Process: Teaching and Learning
NOT: Patient Needs Category: Physiological Integrity: Basic Care and Comfort
A patient with chronic osteomyelitis is being discharged from the hospital. What information is important for the nurse to teach this patient and family? (Select all that apply.)
a. Adherence to the antibiotic regimen
b. Correct intramuscular injection technique
c. Eating high-protein and high-carbohydrate foods
d. Keeping daily follow-up appointments
e. Proper use of the intravenous equipment
ANS: A, C, E
The patient going home with chronic osteomyelitis will need long-term antibiotic therapy—first intravenous, and then oral. The patient needs education on how to properly administer IV antibiotics, care for the IV line, adhere to the regimen, and eat a healthy diet to encourage wound healing. The antibiotics are not given by IM injection. The patient does not need daily follow-up.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Musculoskeletal disorders | patient education | medication administration
MSC: Integrated Process: Teaching and Learning
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
The student learning about neurological disorders remembers that key features of increased intracranial pressure include which of the following? (Select all that apply.)
a. Projectile vomiting
b. Hyperactivity
c. Narrowed pulse pressure
d. Decerebrate posturing
e. Aphasia
ANS: A, D, E
Some signs of increased intracranial pressure include projectile vomiting, decreased level of consciousness, widened pulse pressure, decerebrate posturing, and aphasia.
PTS: 1 DIF: Cognitive Level: Remembering
KEY: Neurologic disorders | nursing assessment
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
A patient with Ménière’s disease is in the hospital when the patient has an attack of this disorder. What action by the nurse takes priority?
a. Assess vital signs every 15 minutes.
b. Dim or turn off lights in the patient’s room.
c. Place the patient in bed with the upper side rails up.
d. Provide a cool, wet cloth for the patient’s face.
ANS: C
Patients with Ménière’s disease can have vertigo so severe that they can fall. The nurse would assist the patient into bed and put the side rails up to keep the patient from falling out of bed due to the intense whirling feeling. The other actions are not warranted for patients with Ménière’s disease.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Auditory system | auditory disorders | patient safety
MSC: Integrated Process: Nursing Process/Implementation
NOT: Patient Needs Category: Safe and Effective Care Environment: Safety and Infection Control
A nurse assesses a client who has Parkinson disease. Which manifestations would the nurse recognize as a key feature of this disease? (Select all that apply.)
a. Flexed trunk
b. Long, extended steps
c. Slow movements
d. Uncontrolled drooling
e. Tachycardia
ANS: A, C, D
Key features of Parkinson disease include a flexed trunk, slow and hesitant steps, bradykinesia, and uncontrolled drooling. Tachycardia is not a key feature of this disease.
PTS: 1 DIF: Cognitive Level: Remembering
KEY: Parkinson Disease, nursing assessment
MSC: Integrated Process: Nursing Process/Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation