n. 2. slides. 3. programmed instruction. 4. discussion. 2.The nurse is instructing a client regarding food safety, injury prevention, and occupational health. Which of the following Healthy People 2010 objectives is the nurse instructing the client? 1. Promote healthy behaviors 2. Promote healthy and safe communities 3. Improve systems for personal health and public health 4. Prevent and reduce diseases and disorders 3.A client has inadequate resources and impairment of personal support systems. Which nursing diagnosis would apply to this patient? 1. Noncompliance 2. Deficient knowledge 3. Ineffective health maintenance 4. Health-seeking behavior 4.While planning care for a client, the nurse identifies content that would address the clients diagnosis of Deficient Knowledge. The nurse will ensure time is allocated for client instruction because: 1. the client cannot be discharged without it. 2. it is a legal component of the nursing process. 3. it is a nice thing to do for a client. 4. the physician has written an order for instruction. 5.The nurse is engaged in an information teaching session with a client. Which of the following would be appropriate to instruct during an informal teaching session? 1 . Expected effects of a new medication 2 . Instruction on leg exercises to be used after surgery 3 . How to use an incentive spirometer 4 . Diet and medications to manage a new diagnosis of diabetes mellitus 6.The nurse is planning a presentation to a group of senior citizens as part of a wellness program. Which of the following topics would be appropriate for the nurse to instruct this client population? 1. Importance of taking medications as prescribed 2. Ways to follow a physicians treatment plan 3. Ease of changing an abdominal dressing 4. Strategies to reduce salt in the diet and increase activity 7.A client is considering several changes in personal habits to improve his health. Which of the following critical thinking strategies can the nurse use to help this client? 1 . Ask the client to identify his goals to improve his health. 2 . Remind the client that the physician has to approve all changes in his health improvement plan. 3 . Suggest the client wait until he is discharged before planning to make personal habit changes. 4 . Recommend that immediate changes are made to confuse the bodys responses. 8.A client has several identified learning needs. Which of the following should the nurse assess prior to planning instruction for this client? 1. Home address 2. Clients learning style 3. Living arrangements 4. Financial resources 9.Which of the following teaching strategy would best support a client who needs to learn how to self-administer insulin injections? 1. Discussion 2. Role-playing 3. Demonstration 4. Programmed instruction 10.A client tells the nurse that she uses audio CDs in her vehicle when driving to and from work to keep current with educational requirements for her job. The nurse would assess this client as preferring which type of learning style? 1. Auditory 2. Visual 3. Kinesthetic 4. Anesthetic 11.The nurse is attempting to instruct a client on ways to eliminate smoking. The client tells the nurse that he has no health problems because of smoking and does not understand why he needs to quit. Which of the following is interfering with the nurses ability to instruct the client in health promotion behaviors? 1. Motivation 2. Perception 3. Self-image 4. Maintenance 12.The nurse is planning instruction to support health promotion behaviors. Which of the following clients would benefit the most from these instructions? 1. 60-year-old client diagnosed with type 2 diabetes mellitus 2. 83-year-old client with hypertension 3. 75-year-old client recovering from a total hip replacement 4. 35-year-old client desiring to begin an exercise program 13.The nurse and client have determined that goals established for health maintenance behaviors have not been achieved. In which step of the nursing process are the nurse and client working at this time? 1. Evaluation 2. Assessment 3. Planning 4. Implementation 1. Evaluation 2. Assessment 3. Planning 4. Implementation MULTIPLE RESPONSE 1.A client is demonstrating behaviors consistent with normal health maintenance. Which of the following has this client demonstrated? (Select all that apply.) 1. Motivation 2. Health encouragement 3. Readiness 4. Maintenance 5. Health activities 6. Perception 2.The nurse is planning an instructional session with a client. When planning this session, the nurse should incorporate which teaching/learning principles? (Select all that apply.) 1. Assessment of how the client organizes knowledge 2. Motivation and self-efficacy 3. Setting goals 4. Developmental level of the client 5. Time management 6. Self-engagement 3.The nurse is planning client instruction interventions to support critical thinking. Which of the following are characteristics of critical thinking in the client education process? (Select all that apply.) 1. Organized 2. Clearly explained with examples 3. Vague 4. Task-oriented 5. Knowledge-oriented 6. Moral and ethically focused 4.The nurse is utilizing the technique of motivational interviewing to instruct a client on ways to limit alcohol intake. Which of the following are techniques used when implementing motivational interviewing? (Select all that apply.) 1. Express empathy 2. Develop discrepancy 3. Avoid arguing 4. Roll with resistance 5. Support self-efficacy 6. Contract for goal achievement 5.Which of the following self-examination techniques is a health maintenance behavior for the nurse to instruct a client? (Select all that apply.) 1. Breast self-examination 2. Capillary blood glucose testing 3. Testicular self-examination 4. Skin examination 5. Application of hydrocortisone cream for a skin disorder 6. Elevating edematous lower extremities 3. Testicular self-examination 4. Skin examination 5. Application of hydrocortisone cream for a skin disorder 6. Elevating edematous lower extremities Chapter 2 General MULTIPLE CHOICE 1.The nurse ensures that a clients bedspace is neat and clean with the call light within easy reach. The nurse is focusing on which nursing theorist who realized the importance of the environment for care? 1. Florence Nightingale 2. Sister Callista Roy 3. Dorothea Orem 4. Martha Rogers 2.The nurse is instructing a client on self-administration of insulin so that the client will not need a health care provider to do this activity. The nurse is implementing which of the following aspects of Virginia Hendersons theory of nursing? 1 . A caring relationship 2 . Helping the client achieve independence from the nurses assistance as quickly as possible 3 . Integration of objective and subjective data 4 . Application of critical thinking 3.A client tells the nurse that he has an HMO for his health insurance. The nurse understands that the purpose of this type of health plan is to: 1. ensure payment is made to Medicare for services rendered. 2. maximize the utilization of health care resources. 3. efficiently manage costs while providing quality care. 4. focus on the illness when providing care. 4.A client tells the nurse that he does not have a primary care physician but rather makes an appointment with a doctor who specializes in the area in which he is experiencing a problem. The nurse realizes this client is at risk for which of the following? 1. Fragmented care 2. Overpayment of services 3. Inability to sustain health 4. Finding an appropriate general practitioner 5.The nurse is attending a masters degree program in efforts to be educationally prepared to serve as a hospital leader. The nurse realizes that this educational preparation will: 1 . hinder the nurses ability to work with physicians. 2 . be viewed as not supporting the profession of nursing by other nurses. 3 . ensure the nurse is biased towards clinicians interests. 4 . prepare the nurse to serve as strong clinical support with the ability to integrate business and caring. 1 . hinder the nurses ability to work with physicians. 2 . be viewed as not supporting the profession of nursing by other nurses. 3 . ensure the nurse is biased towards clinicians interests. 4 . prepare the nurse to serve as strong clinical support with the ability to integrate business and caring. 6.A client tells the nurse that all hospitals care about is doing the minimum for a client regardless of the outcome. Which of the following should the nurse respond to this client? 1 . It does feel like that sometimes. 2 . Health insurance companies have caused this problem. 3 . The doctors will get paid regardless of the clients outcomes. 4 . There are quality programs in place to make sure clients receive the best quality of care regardless of the cost. 7.The nurse is providing care at a time that is the most beneficial to the client. The nurse is implementing which of the following Joint Commission Dimensions of Quality Performance? 1. Safety 2. Timeliness 3. Efficiency 4. Availability 8.The nurse is providing care while adhering to safety as a Joint Commission Dimension of Quality Performance. Which of the following did the nurse provide to the client? 1 . Using a needleless device when providing intravenous medications 2 . Keeping the siderails of the bed in the down position after providing a pain medication to a client 3 . Having the client sit in a wheelchair with the wheels in the unlocked position 4 . Placing cloth towels over a spill in the room of an ambulatory client 2 . Keeping the siderails of the bed in the down position after providing a pain medication to a client 3 . Having the client sit in a wheelchair with the wheels in the unlocked position 4 . Placing cloth towels over a spill in the room of an ambulatory client 9.The nurse is planning and providing care while adhering to the American Nurses Association definition of professional nursing. Which of the following does the nurse include when implementing client care? 1. Follows the NANDA nursing diagnoses process 2. Integrates objective and subjective data 3. Respects cultural diversity of peers 4. Acknowledges the experience and training of physicians 10.The nurse has shifted her practice from an illness focus to a health focus. Which of the following has this nurse implemented? 1. Standardized care plans 2. Critical pathways 3. Instructing a client on relaxation techniques to aid with sleep 4. Holding around-the-clock medication when a client is asleep 11.A client is admitted with a highly communicable disease. The nurses do not want to participate in the care of this client. Which of the following should be done to ensure the client receives the highest quality of care? 1 . Adhere to strict standard precautions. 2 . Plan to have the client transferred to another health care organization. 3 . Ask the physician if the client can be cared for in the home. 4 . Suspend the nurses without pay who refuse to care for the client. 12.The nurse has been an employee of an organization for 2 years and is considering a job change. Which of the following does this nurses plan suggest to any future employers? 1 . The nurse moves to other jobs too frequently. 2 . The nurse is inflexible. 3 . The nurse is searching for a more challenging environment with career opportunities. 4 . The nurse is willing to sacrifice home and personal life for a job. 13.The nurse is experiencing pain and fatigue in both arms when using the computer to document client care. Which of the following can the nurse do to reduce these symptoms? 1 . Refuse to use the computer and document using a pen and paper. 2 . Stand up when using the computer. 3 . Adjust the keyboard and chair to reduce the pressure on the wrists and arms. 4 . Ask another nurse to input the information for client care activities. MULTIPLE RESPONSE 1.The nurse is planning care for a client and reviewing appropriate educational materials to use for discharge instructions. Which domains of nursing is this nurse implementing? (Select all that apply.) 1. Nursing process 2. Clinical practice 3. Education 4. Literature 5. Administration 6. Research 2.The nurse suspects that another health care colleague may be chemically dependent when which of the following is assessed? (Select all that apply.) 1. Prolonged work breaks 2. Clinical care omissions 3. Mood stability 4. Extraordinary accomplishments 5. Heavy use of fragrances 6. Inability to recall recent events 3.The nurse is a member of a health care team that includes a physician and other health care providers. These providers work together to ensure the client is relieved of suffering, has diseases cured, and experiences enhanced health and performance. Which of the following are the levels of care represented by this team of health care providers? (Select all that apply.) 1. Sustain life 2. Maintain health 3. Regain health 4. Minimize injury 5. Maximize cost 6. Attain enhanced health 4.A client tells the nurse that she is disappointed that her employer is offering a health maintenance organization for a health care benefit. Which of the following can the nurse use as responses to the client as advantages of this type of health plan? (Select all that apply.) 1 . Since there is a nursing shortage, clients need to stay out of the hospital. 2 . This type of plan provides wellness care at a minimal cost to keep people healthy. 3 . This type of plan helps clients avoid illnesses with high costs. 4 . An HMO standardizes diagnostic and treatment decisions across the nation. 5 . This type of plan ensures coordinated services from wellness to death. 6 . This type of plan costs as much as the traditional plans, but the insurance companies get the extra money from premiums. 3 . This type of plan helps clients avoid illnesses with high costs. 4 . An HMO standardizes diagnostic and treatment decisions across the nation. 5 . This type of plan ensures coordinated services from wellness to death. 6 . This type of plan costs as much as the traditional plans, but the insurance companies get the extra money from premiums. 5.The nurse has incorporated several criteria that are essential for being a member of a profession. Which of the following has this nurse done? (Select all that apply.) 1 . Has passed the licensure examination 2 . Works regularly scheduled shifts 3 . Completed a bachelors degree in nursing 4 . Limits absences from work 5 . Joined the American Nurses Association 6 . Reads evidenced-based information to incorporate into planning client care 5 . Joined the American Nurses Association 6 . Reads evidenced-based information to incorporate into planning client care Chapter 3 Behavioral problems & Chapter 4 Mental health Multiple Choice Identify the choice that best completes the statement or answers the question. ____ 1. A patient with a suspected mental health disorder having blood drawn to check electrolyte levels asks what blood work have to do with mental health. Which response by the nurse is correct? a. Electrolyte imbalances are the cause of certain mental health disorders. b. Some mental health disorders cause the electrolytes to be out of balance. c. The doctor wants to make sure your symptoms are not caused by a physical problem. d. People with mental illnesses frequently take illicit drugs that can cause electrolyte imbalances. ____ 2. The nurse is assisting a patient identify coping mechanisms. What general definition of coping is the nurse most likely using with this patient? a. The way one adapts to a stressor b. The adaptation to mental health problems c. The use of specific mechanisms to reduce anxiety d. The development of unconscious behaviors to reduce psychological distress ____ 3. A student feels anxious about being unprepared for an upcoming test. Which action is a positive response to this anxiety? a. Canceling nonessential activities for 3 days to study b. Staying up all night the night before the test to study c. Borrowing notes from another student who has had the class in the past d. Choosing not to worry about studying because grades have been good so far ____ 4. A patient who has been diagnosed with a mental illness tells the nurse about plans to find a voodoo doctor. How should the nurse respond? a. You know voodoo doctors cant really help you. Dont waste your money. b. Be sure to mention your plan to your psychiatrist. It is important to follow up with that treatment plan also. c. Research has shown that voodoo can effectively treat many mental health disorders. That decision is up to you. d. I do not think using voodoo is safe. I would recommend you think about it carefully before contacting a voodoo doctor. ____ 5. After being admitted for a surgical procedure a patient with a history of schizophrenia becomes extremely agitated when other patients are around and believes that others want to cause the patient harm. Which intervention should the nurse use to provide a therapeutic milieu for the patient? a. Place the patient in a private room. b. Request an order for antipsychotic medications. c. Help the patient clarify the meaning of the feelings. d. Suggest the patient be scheduled for a psychotherapy session. ____ 6. A patient recovering from electroconvulsive therapy (ECT) for severe depression is confused and wants to know what has been done. What action by the nurse is best? a. Administer a sedative to help calm the patient. b. Call the physician and report the patients response. c. Explain that the patient is in the hospital and has just had ECT. d. Encourage the patient to go back to sleep until the pre-procedure medication has worn off. ____ 7. A student is angry about failing a test at school and accuses the teacher of trying to fail everyone. What type of response is the student demonstrating? a. Anger b. Denial c. Projection d. Repression ____ 8. After talking with a patient being evaluated for a mental health disorder, the nurse says, It sounds as if you are feeling angry. Which therapeutic communication technique is the nurse employing? a. Restating b. Reflecting c. Giving recognition d. Offering a general lead ____ 9. During initial assessment of mental health status, the nurse asks a patient to interpret a familiar proverb and explain what it means. Which area/aspect of the patients mental status is the nurse assessing? a. Memory b. Judgment c. Mood and affect d. Level of awareness and orientation ____ 10. A young mother is angry with the mess her son has made in his room. She yells at him and tells him to stay in his room until it is cleaned up. About 20 minutes later, the mother enters the boys room offering him milk and cookies. Which ego defense mechanism is the mother using? a. Restitution b. Regression c. Reaction formation d. Conversion reaction ____ 11. A patient with schizophrenia states, Im going to the fribity to see a megnat. What term should the nurse use to describe this language? a. Imagery b. Soliloquy c. Neologisms d. Conversions ____ 12. While providing care a teenage mother expresses ambivalence about her new role as a parent. Which response by the nurse is best? a. Ill call the social worker so you can discuss adoption. b. Tell me more about how you feel when you hold the baby. c. Parenthood is certainly not for everyone, you shouldnt feel guilty about that. d. Im sure your own parents felt the same way when you were small, you should talk to your mom. ____ 13. During a mental status assessment a patient cannot remember the name of a childhood neighborhood. In which aspect of the assessment is the patient demonstrating an alteration? a. Speech b. Memory c. Orientation d. Mood and affect ____ 14. Staff on a mental health unit routinely uses positive and negative reinforcement when caring for patients with mental health disorders. What needs to be done before the staff can implement these approaches? a. Have a health care provider order to use the approaches. b. Ensure all patients have medication orders for sedatives. c. Place a set of 4 point restraints within each patients room. d. Have the patient sign a consent form agreeing to this approach. Multiple Response Identify one or more choices that best complete the statement or answer the question. ____ 15. The nurse is preparing to establish a relationship with a newly admitted patient. On which qualities should the nurse focus when creating this nursepatient relationship? (Select all that apply.) a. Humor b. Respect c. Honesty d. Empathy e. Sympathy f. Friendship ____ 16. The nurse is caring for a patient experiencing anxiety. Which techniques should the nurse use when instructing on progressive muscle relaxation therapy? (Select all that apply.) a. Start at the head and neck. b. End with the lower extremities. c. Play soft music to aid with relaxation. d. Systematically tense and relax muscle groups. e. Imaging a pleasurable experience from the past. ____ 17. The nurse is caring for a patient who is verbalizing concerns related to a difficult relationship. Which responses by the nurse will block communication and should be avoided? (Select all that apply.) a. Using silence b. Asking why c. Changing the subject d. Agreeing or disagreeing e. Verbalizing the implied ____ 18. The nurse is caring for a patient experiencing depression. Which neurotransmitters should the nurse consider being decreased in this patient? (Select all that apply.) a. Serotonin b. Dopamine c. Substance P d. Acetylcholine e. Norepinephrine ____ 19. After collecting data the nurse is concerned that a patient is at risk for developing a mental illness. What findings caused the nurse to come to this conclusion? (Select all that apply.) a. Difficulty thinking b. Discussed the use of daily exercise to deal with stress c. Made statements indicating being out of touch with reality d. Expressed remorse in having to leave a pet dog with a neighbor e. Explaining a lack of friends because everyone is jealous of the patient ____ 20. A patient diagnosed with a mental illness is being considered for psychotherapy. What should the nurse realize are the goals for this treatment? (Select all that apply.) a. Relaxing the body b. Improve social interactions c. Clarify the meaning of events d. Reduce emotional discomfort e. Enhance performance in situations ____ 21. The nurse is visiting the home of a patient with a mental health disorder. What should the nurse ensure during this home visit? (Select all that apply.) a. Status of suicide ideation b. Ability to provide self-care safely c. Patients risk of falling in the home d. Number of family members who visit e. Compliance with prescribed medications Chapter 56. Mental Health Function, Assessment, and Therapeutic Measures Chapter 5 Infectious diseases MULTIPLE CHOICE 1.The nurse, assessing a clients leukocyte level, determines the amount to be within normal limits. Which of the following would indicate a normal level of leukocytes in the clients blood? 1. 14 to 18 g/dL 2. 4.6 to 6.2 million/mm3 3. 4500 to 11,000 mm3 4. 50 to 60 percent 1. 14 to 18 g/dL 2. 4.6 to 6.2 million/mm3 3. 4500 to 11,000 mm3 4. 50 to 60 percent 2.A clients complete blood count reveals a large amount of phagocytic cells present. The nurse realizes that this type of cell is most likely: 1. basophils. 2. eosinophils. 3. monocytes. 4. neutrophils. 3.According to assessment findings, the nurse determines that a client is experiencing an inflammatory process. Which of the following did the nurse assess in this client? 1. Redness, swelling, heat, and pain 2. Reduced urine output 3. Thirst 4. Elevated blood pressure and slow heart rate 1. Redness, swelling, heat, and pain 2. Reduced urine output 3. Thirst 4. Elevated blood pressure and slow heart rate ion 4.A client is diagnosed with a bacterial infection. Which of the following is an example of this type of infection? 1. Malaria 2. Gastroenteritis 3. Urinary tract infection 4. Typhus 5.A client is diagnosed with gastroenteritis. The nurse realizes that this illness occurs from which type of disease-causing organism? 1. Bacteria 2. Fungi 3. Protozoa 4. Viruses 1. Bacteria 2. Fungi 3. Protozoa 4. Viruses 6.A client has been diagnosed with Rocky Mountain spotted fever. The causative organism for this disease process is: 1. bacteria. 2. helminth. 3. mycoplasma. 4. rickettsia. 7.Which of the following will the nurse most likely assess in a client diagnosed with asthma? 1. Wheezing and anxiety 2. Barking cough and increased blood pressure 3. Bradycardia and restlessness 4. Anemia and hypoxia 8.The nurse would expect that a client diagnosed with arthritis will be prescribed which of the following medications? 1. Albuterol 2. Furosemide 3. Ibuprofen 4. Nortriptyline 9.A client is being admitted to a health care facility. Which type of precautions will the nurse implement at this time? 1. Airborne 2. Contact 3. Droplet 4. Standard 10.A client diagnosed with tuberculosis is scheduled for a chest x-ray to be completed in the radiology department. Which of the following devices should be utilized when transporting this client? 1. Face shield with mask and gown 2. N-95 mask 3. Surgical mask 4. Patient does not need to wear a device 11.The nurse is preparing to administer medications to a client diagnosed with varicella. Which of the following personal protective equipment should the nurse use when entering the clients room? 1. Face shield with mask and gown 2. Gloves and gown 3. A high-efficiency particulate air filter mask 4. Surgical mask 12.A client is diagnosed with venous leg ulcers. The nurse would expect that these wounds will heal by which of the following types of intention? 1. Primary 2. Secondary 3. Tertiary 4. Quaternary 13.The nurse is using the Braden Scale to determine a clients risk for developing a pressure ulcer. Which of the following areas are assessed with this scale? 1. Home environment 2. Finances 3. Medications 4. Friction and shear MULTIPLE RESPONSE 1.The nurse is identifying nursing diagnoses for a client experiencing inflammation. Which of the following diagnoses would be appropriate for this client? (Select all that apply.) 1. Risk for infection 2. Thermoregulation: Ineffective 3. Ineffective coping 4. Pain: Acute 5. Nutrition: Imbalanced, less than body requirements 6. Anxiety 2.The nurse is determining the route of transmission for an infectious organism. Which of the following are types of transmission routes? (Select all that apply.) 1. Ingestion 2. Vector-borne 3. Common vehicle 4. Airborne 5. Droplet 6. Contact 1. Ingestion 2. Vector-borne 3. Common vehicle 4. Airborne 5. Droplet 6. Contact 3.The nurse is determining when gloves should be worn when providing client care. Which of the following situations would necessitate the wearing of gloves? (Select all that apply.) 1. In contact with blood 2. In contact with mucous membranes 3. Delivering a meal tray 4. Providing medications 5. Measuring urine output 6. Suctioning oral secretions 4.The nurse is concerned that a client will experience delayed wound healing when which of the following is assessed? (Select all that apply.) 1. Prescribed a beta-blocker medication 2. Poor appetite 3. Ambulating in the room several times a day 4. Age 85 5. Prescribed steroids 6. Skin warm and dry 5.The nurse is planning care for a client with a chronic wound. Which of the following principles should be reflected in this clients care? 1. Debridement 2. Restrict fluids 3. Provide moist environment 4. Prevent further injury 5. Maintain on bed rest 6. Nutrition Chapter 6 Skin problems in children and adults MULTIPLE CHOICE 1.A clients wound is being debrided by letting a wet-to-dry dressing that is packed into the wound dry. This type of debridement is called: 1 autolytic debridement. 2 enzymatic debridement. 3 mechanical debridement. 4 sharp debridement. 2.A client is experiencing a circular lesion with an advancing, red, scaly border on the abdomen. The nurse recognizes this lesion as being: 1 tinea capitis. 2 tinea corporis. 3 tinea cruris. 4 tinea pedis. 3.A client is complaining of pain and drainage coming from an area on his back. The nurse assesses the area and finds a large erythematous, swollen mass with multiple areas of purulent drainage. The nurse suspects the client has a(n): 1 abscess. 2 carbuncle. 3 furuncle. 4 papule. 4.A client has what appears to be a bacterial infection or warts on her fingertips. This can be a sign of: 1 herpes gladiatorum. 2 herpes simplex. 3 herpes zoster. 4 herpetic whitlow. 5.A school-age child is experiencing pruritic vesicles around the mouth. The lesions have a honey-colored crust. The nurse realizes that the child is most likely experiencing: 1 candidiasis. 2 herpes simplex. 3 impetigo. 4 tinea corporis. 6.A client is being treated for lice. Which of the following medications would the nurse expect to see prescribed for this client? 1 Acyclovir 2 Diphenhydramine 3 Mupirocin 4 Permethrin 7.A client is diagnosed with genital herpes simplex virus. The nurse know that symptoms of the primary infection occur: 1 1 to 4 days after exposure. 2 3 to 7 days after exposure. 3 5 to 9 days after exposure. 4 7 to 11 days after exposure. 8.A client is demonstrating patches of thick, red skin with silvery scales on the elbows and knees. The nurse suspects that this client is experiencing: 1 psoriasis. 2 rosacea. 3 scabies. 4 stasis dermatitis. 9.A middle-aged construction worker has a raised lesion with a pearly border on his arm that bleeds easily. The nurse realizes that this client most likely is experiencing a(n): 1 actinic keratosis. 2 basal cell carcinoma. 3 malignant melanoma. 4 melanoma in situ. 10.A client periodically experiences pseudofolliculitis barbae. Which of the following should the nurse instruct this client? 1 Avoid close shaving. 2 Avoid washing the hair prior to shaving. 3 Apply a topical antibiotic. 4 Contact the physician since the client needs a prescription for an oral antibiotic. 11.A client is diagnosed with tinea versicolor. Which of the following should the nurse instruct this client regarding the care for this skin condition? 1 Do nothing since there is no treatment. 2 Utilize shampoo with selenium. 3 Utilize an oral antifungal preparation as prescribed. 4 Apply warm compresses to the affected areas. 12.Which of the following should the nurse instruct a client who is prescribed a topical medication for a skin condition? 1 Apply directly to broken or irritated skin. 2 Apply before bathing. 3 Apply after bathing. 4 Cover the area with an occlusive dressing. 13.A client is diagnosed with a dermatologic condition causing pruritis and inflammation. Which of the following should the nurse instruct this client? 1 Use regular perfumed lotion to moisturize the skin. 2 Use scented soap to bathe the skin daily. 3 Apply skin oil daily. 4 Apply a body moisturizer to the skin within 3 to 5 minutes after bathing. MULTIPLE RESPONSE 1.The nurse is assessing a clients skin for signs of normal aging. Which of the following are skin changes seen with aging? (Select all that apply.) 1 Lentigo 2 Loss of subcutaneous tissue 3 Telangiectasias 4 Thickened, wrinkled, yellowish skin 5 Thin, fragile, and inelastic skin 1 Lentigo 2 Loss of subcutaneous tissue 3 Telangiectasias 4 Thickened, wrinkled, yellowish skin 5 Thin, fragile, and inelastic skin 6 Seborrheic keratosis 2.A client is diagnosed with severe nodulocystic acne. The nurse should instruct the client on which of the following types of treatments? (Select all that apply.) 1 Oral antibiotics 2 Benzoyl peroxide 3 Sulfur 4 Intralesional injections 5 Soap and water 6 Topical therapy 3.A client is diagnosed with cellulitis. Which of the following will the nurse most likely assess in this client? (Select all that apply.) 1 Heat 2 Redness 3 Swelling 4 Pain 5 Glossy, stretched skin appearance 6 Thirst 4.A client is diagnosed with rosacea. Which of the following should the nurse instruct the client regarding this condition? (Select all that apply.) 1 Avoid sunlight. 2 Avoid alcohol. 3 Avoid spicy food. 4 Wash the face five times a day. 5 Wash the face with a clean washcloth. 6 Apply medication to affected areas immediately after washing the face. 5.A client is diagnosed with a viral skin infection. The nurse realizes that which of the following medications may be prescribed for this client? (Select all that apply.) 1 Nystatin (Mycostatin) 2 Docosanol (Abreva) 3 Boric acid 4 Penciclovir (Denavir) 5 Hydrogen peroxide 6 Acyclovir (Zovirax) Chapter 7 Problems of the eyes MULTIPLE CHOICE 1.A client is diagnosed with strabismus. Which of the following will the client most likely experience with this disorder? 1. Nystagmus 2. Diplopia 3. Aphakic vision 4. Ptosis 2.A client is experiencing a gradual blurring of vision in both eyes not associated with any pain. The nurse suspects the client is experiencing: 1. glaucoma. 2. cataracts. 3. macular degeneration. 4. retinal detachment. 3.The nurse should instruct a client, diagnosed with glaucoma, that the purpose of medication is to: 1. help dry up excess secretions. 2. lower the intraocular pressure. 3. strengthen the muscles of the eye. 4. improve the vision in the eye. 4.After surgery to remove a cataract, which of the following should the nurse instruct the client? 1 . Be sure to follow the schedule for the prescribed eyedrop medication. 2 . Sleep on the right side to promote drainage. 3 . It is okay to rub the eye because the surgery was on the inside. 4 . This is an outpatient procedure, and there are no instructions for the patient. 5.A tonometry test has been performed with a client and the results are 25 mmHg. The nurse know that: 1 . the reading is low and there is no problem. 2 . the reading is normal and nothing needs to be done at this time. 3 . the results are high and follow-up readings and tests are needed. 4 . the results are high and there is no cure to bring the pressure down. 6.A client has been diagnosed with cataracts. The nurse realizes that the only treatment for this disorder is? 1. Medical management with eyedrops 2. Surgical removal of the lens 3. Cryopexy 4. Phototherapy 7.Which of the following should the nurse assess in a client diagnosed with open-angle glaucoma? 1. Degree of lost vision 2. Severity of headaches 3. Amount of blurred vision 4. Date of onset 8.A client is experiencing little flashes of lights and things floating in the visual field. The nurse suspects: 1. cataracts. 2. glaucoma. 3. conjunctivitis. 4. retinal detachment. 9.A client tells the nurse that she sees a shadow that is slowing getting worse in her left eye. Which of the following should the nurse do? 1. Instruct the client to return home to rest in bed. 2. Encourage the client to continue with normal daily activities. 3. Notify an ophthalmologist. 4. Encourage fluids and normal saline eyedrops. 10.A client is experiencing a loss of central vision but not a loss of peripheral vision. The nurse realizes the client should be evaluated for: 1. detached retina syndrome. 2. nystagmus. 3. macular degeneration. 4. conjunctivitis. 11.A client is experiencing redness, burning, itching, and pain of the eyes. The nurse suspects the client is experiencing: 1. blepharitis. 2. conjunctivitis. 3. keratitis. 4. iritis. 12.A client has been diagnosed as being legally blind. The nurse realizes this clients vision is: 1. 20/200 or less in the better eye with correction. 2. 20/200 or less in the worse eye without correction. 3. 20/100 or less in the better eye without correction. 4. 20/100 or less in the worse eye with correction. 13.The nurse realizes that the best medication treatment for open-angle glaucoma would be: 1. timolol (Timoptic) eyedrops. 2. latanoprost (Xalatan) eyedrops. 3. timolol (Timoptic) and Latanoprost (Xalatan) eyedrops. 4. metoprolol oral medication. MULTIPLE RESPONSE 1.A client tells the nurse that he does not want to develop macular degeneration like his mother. Which of the following should the nurse instruct the client as being risk factors for the development of this disorder? (Select all that apply.) 1. There is greater risk as people age. 2. Women are at greater risk than men. 3. African Americans are at greater risk than Caucasians. 4. Family history of macular degeneration increases risk. 5. Smoking does not increase risk. 6. Alcohol prevents the onset of this disorder. 2.A client is receiving tests to diagnose glaucoma. Which of the following diagnostic tests will be used to identify this disorder in the client? (Select all that apply.) 1. Visual acuity 2. Visual field test 3. Tonometry 4. Weber test 5. Rinne test 6. Electroencephalogram 1. Visual acuity 2. Visual field test 3. Tonometry 4. Weber test 5. Rinne test 6. Electroencephalogram 3.A client is diagnosed with ocular cancer. The nurse realizes this client could be treated with: (Select all that apply.) 1. Enucleation 2. Laser surgery 3. Plaque brachytherapy 4. Block incision 5. Trabeculoplasty 6. Trabeculectomy 4.A client, diagnosed with keratoconus, asks the nurse what caused the disorder to develop. The nurse should instruct the client on which of the following as risk factors for the development of this disorder? (Select all that apply.) 1. Sun exposure 2. Ocular allergies 3. Wearing rigid contact lenses 4. Vigorous eye rubbing 5. Herpes simplex virus 6. Dry eyes 5.The nurse is planning instruction for a client experiencing dry eyes. Which of the following should be included in these instructions? (Select all that apply.) 1. Drink 8 to 10 glasses of water each day. 2. Apply petroleum jelly to the eyelids. 3. Blink more frequently. 4. Avoid sun exposure. 5. Avoid rubbing the eyes. 6. Avoid dry air. 6.Which of the following should the nurse instruct a client diagnosed with type 2 diabetes mellitus regarding vision care? (Select all that apply.) 1. Maintain good glucose control. 2. Stop smoking. 3. Limit exercise. 4. Reduce reading. 5. Frequently rest the eyes. 6. Rub eyes daily. Chapter 8 Problems of the ears, nose, sinuses, throat, mouth, and neck MULTIPLE CHOICE 1.A client is not able to successfully pass the whisper test. Which of the following would be indicated for this client? 1. Head CT scan 2. Audiometry 3. MRI of the brain 4. Electroencephalogram 1. Head CT scan 2. Audiometry 3. MRI of the brain 4. Electroencephalogram 2.A client is prescribed a medication that is ototoxic. The nurse realizes that this medication may cause: 1. permanent or temporary vision loss. 2. permanent or temporary hearing loss. 3. nausea and vomiting. 4. central nervous system (CNS) depression. 3.The nurse is trying to communicate with a hearing-impaired client. The best way to do this is to: 1. write down all of the message. 2. shout in the impaired ear. 3. speak slowly and clearly while facing the client. 4. talk in a regular voice in the good ear. 1. write down all of the message. 2. shout in the impaired ear. 3. speak slowly and clearly while facing the client. 4. talk in a regular voice in the good ear. 4.A client is diagnosed with a conductive hearing loss. The nurse realizes type of hearing loss is not associated with: 1. cerumen. 2. brain damage. 3. otitis media. 4. otosclerosis. 5.A client is complaining of dizziness, unilateral ringing in the ear, feeling of pressure or fullness in the ear, and unilateral hearing loss. The nurse would suspect the client is experiencing: 1. Mnires disease. 2. osteosclerosis. 3. otitis media. 4. mastoiditis. 6.A client complains of a slight itching, slight pain, and a scratching sound in the ear. The nurse suspects that an insect may have entered the ear. Which of the following should not be done? 1. Add water to flush out the insect. 2. Add mineral oil to kill the insect. 3. Add lidocaine to kill the insect. 4. Call an otologist for a referral. 7.The hearing of an unresponsive client needs to be assessed. Which of the following will be used to assess the hearing of this client? 1. Audiometer 2. Brainstem auditory evoked responses (BAER) test 3. Rinne test 4. Weber test 1. Audiometer 2. Brainstem auditory evoked responses (BAER) test 3. Rinne test 4. Weber test 8.The nurse is planning to assess a client diagnosed with conductive hearing loss. When performing the Weber test, the nurse would expect which of the following findings? 1. The sound will be louder in the affected ear. 2. The sound will be louder in the good ear. 3. Air conduction is shorter than bone conduction. 4. No sounds will be heard. 9.The nurse is performing postoperative teaching with a client recovering from a stapedectomy. Which of the following instructions would the nurse want to include in the teaching? 1. It is okay to resume exercise the next day. 2. It is okay to resume work the same day. 3. It is okay to shower and shampoo the next day. 4. It is okay to blow the nose gently one side at a time. 1. It is okay to resume exercise the next day. 2. It is okay to resume work the same day. 3. It is okay to shower and shampoo the next day. 4. It is okay to blow the nose gently one side at a time. 10.After a mastoidectomy, the most important complication for the nurse to assess for is: 1. vomiting. 2. headache. 3. fever. 4. stiff neck. 11.When instructing a client on cleaning the ear, the nurse should instruct the client to clean: 1. only the outer ear. 2. all the way to the middle ear. 3. all parts of the ear outer, middle, and inner ear. 4. just the tympanic membrane. 12.Which of the following would prohibit an elderly client from wanting to obtain and use a hearing aid? 1. Fears sounds will be too loud 2. Thinks not necessary for a temporary problem 3. Fears the cost 4. Prefers silence 13.Which of the following should the nurse instruct a client who is being fitted for a hearing aid? 1. Keep the appliance turned on at all times. 2. Store the hearing aid in a warm, moist place. 3. Batteries last for at least 1 month. 4. Clean ear molds at least once a week. MULTIPLE RESPONSE 1.The nurse is instructing a client diagnosed with otitis media on management during the acute phase. Which of the following should the nurse include in the teaching? (Select all that apply.) 1 . Take the antibiotics as ordered. 2 . Take over-the-counter analgesics for mild pain as recommended. 3 . It is okay to go swimming. 4 . It is okay to go on vacation and trips that require flying. 5 . If excruciating pain develops, seek medical care. 6 . Limit fluids. 2.When caring for a client with total hearing loss, the nurse is instructing the client about the many options that are available to function in a hearing world. Which of the following should the nurse include? (Select all that apply.) 1. Flashing lights for alarms 2. TV with closed captions 3. Talking computer 4. Lip reading and sign language 5. Cell phones with headsets 6. Loud ringers on telephones 3.A client is diagnosed with a congenital hearing loss. Which causes does the nurse realize are reasons for this type of hearing loss? (Select all that apply.) 1. Genetics 2. Natal infections 3. Physical deformities 4. Noise levels 5. Maternal ototoxic drugs 6. Maternal TORCH infections 4.A client with a family history of hearing loss asks the nurse what he can do to prevent this disorder as he ages. Which of the following should the nurse instruct this client? (Select all that apply.) 1. Turn down radio and television volume. 2. Avoid noisy areas such as rock concerts. 3. Wear protective devices. 4. Use plain cotton balls in the ears. 5. Avoid sun exposure. 6. Flush the ears daily with mineral oil. 5.Which of the following are indications that a client has been exposed to excessive noise? (Select all that apply.) 1. Raising the voice to talk in normal conversation 2. Clear drainage from the ears 3. Inability to hear a conversation 2 feet away 4. Sounds are muffled 5. Ringing of the ears 6. Short periods of pain in the ears 1. Raising the voice to talk in normal conversation 2. Clear drainage from the ears 3. Inability to hear a conversation 2 feet away 4. Sounds are muffled 5. Ringing of the ears 6. Short periods of pain in the ears Chapter 9 Problems of the upper airways and lower respiratory system MULTIPLE CHOICE 1.A child is diagnosed with severe allergic rhinitis. Which of the following manifestations would the nurse most likely assess in this client? 1. Edematous neck glands 2. Reduced hearing 3. Pruritis 4. Frequent wiping of the nose with the palm of the hand 2.A client tells the nurse that she experiences a stuffy nose, nasal pain, and postnasal drip every time she works in her companys office. Which of the following types of allergic rhinitis is this client most likely experiencing? 1. Infectious 2. Perennial 3. Occupational 4. Seasonal 3.A client asks the nurse if there is an antihistamine that does not cause drowsiness. Which of the following medications would this client most likely prefer to treat allergic rhinitis? 1. Diphenhydramine 2. Chlorpheniramine maleate 3. Clemastine 4. Fexofenadine 4.A client diagnosed with hypertension is experiencing allergic rhinitis. The nurse realizes that the medication that would not be indicated for this client would be: 1. loratadine. 2. montelukast. 3. pseudoephedrine. 4. zafirlukast. 5.A 16-year-old client is being prescribed a medication to treat acute sinusitis. The nurse realizes that this client should not be prescribed: 1. amoxicillin. 2. cefuroxime. 3. ciprofloxacin. 4. erythromycin. 6.The nurse is caring for a client diagnosed with acute sinusitis. Which of the following symptoms is the client most likely experiencing? 1. Anosmia 2. Fever 3. Halitosis 4. Metallic taste 1. Anosmia 2. Fever 3. Halitosis 4. Metallic taste 7.The nurse is planning care for the client diagnosed with viral rhinitis. Which of the following would be the best goal of care for this client? 1. Prevent secondary bacterial infection. 2. Prevent rhinitis medicamentosa. 3. Refrain from use of analgesics. 4. Encourage complete participation in activities. 8.The nurse is instructing the mother of a client recovering from a tonsillectomy. Which of the following should the nurse instruct the mother to report? 1. Difficulty swallowing 2. Difficulty talking 3. Excessive swallowing 4. Pain 9.Which of the following should the nurse instruct a client recovering from a tonsillectomy? 1. Drink milk to promote healing. 2. Gargle with salt water. 3. Maintain good hydration. 4. Use a straw to drink. 10.A client is experiencing epistaxis. Which of the following interventions would the nurse complete? 1. Call the doctor. 2. Check laboratory test results. 3. Obtain an emesis basin. 4. Show the patient how to pinch the nose. 11.A client is diagnosed with fractured ribs. Which of the following should the nurse instruct this client? 1 . Engage in routine activities of daily living after taking pain medication. 2 . Splint the rib cage when deep breathing and coughing. 3 . Restrict fluids. 4 . Stay on bed rest until the ribs heal. 12.A client is prescribed a diuretic for treatment of pulmonary hypertension. Which of the following should the nurse instruct the client regarding this medication? 1 . This medication expands the blood vessels. 2 . This medication causes smooth muscle relaxation to reduce pulmonary engorgement. 3 . This medication reduces the amount of water in the body. 4 . This medication keeps the blood from clotting. 13.The nurse is assessing a client experiencing manifestations of cor pulmonale. Which of the following will the nurse most likely assess in this client? 1. Low blood pressure 2. Low heart rate 3. Hoarseness 4. Lumbar pain MULTIPLE RESPONSE 14.The nurse is caring for a client diagnosed with pneumonia. Which of the following signs and symptoms would the nurse most likely assess in this client? (Select all that apply.) 1. Abdominal pain 2. Anorexia 3. Cough 4. Dyspnea 5. Fever 6. Frequent wiping of the nose ANS: 1, 2, 3, 4, 5 15.The nurse is planning to administer the pneumococcus vaccination to a client. Which of the following would indicate that a client is a candidate for this vaccination? (Select all that apply.) 1. Age 70 2. Age 55 3. Diagnosis of heart failure 4. Recovering from knee replacement surgery 5. Diagnosis of asthma 6. Recovering from an appendectomy 1. Age 70 2. Age 55 3. Diagnosis of heart failure 4. Recovering from knee replacement surgery 5. Diagnosis of asthma 6. Recovering from an appendectomy 16.The nurse is planning care for a client diagnosed with bronchiolectasis. Which of the following would be goals for this clients care? (Select all that apply.) 1. Treat the infection. 2. Reduce the heart rate. 3. Minimize further damage. 4. Improve urine output. 5. Promote breathing. 6. Remove secretions. 17.The nurse, planning care for a client diagnosed with a pneumothorax, identifies which types of pneumothorax? (Select all that apply.) 1. Spontaneous 2. Radical 3. Traumatic 4. Incomplete 5. Iatrogenic 6. Tension 18.Which of these instructions are for a client diagnosed with a pneumothorax? (Select all that apply.) 1. Remove air from the pleural space. 2. Correct acid-base imbalances. 3. Treat infection. 4. Minimize damage. 5. Reexpand the lung. 6. Improve fluid balance. 19.A client states, I dont know why I should quit smoking. It cant improve anything. The nurse responds by informing the client about the decrease in lung cancer rates over time after a person quits smoking. Which of the following is correct? 1 . The lung cancer rate corresponds to that of nonsmokers 1 year after quitting smoking. 2 . The lung cancer rate corresponds to that of nonsmokers 2 years after quitting smoking. 3 . The lung cancer rate corresponds to that of nonsmokers 5 years after quitting smoking. 4 . The lung cancer rate corresponds to that of nonsmokers 10 years after quitting smoking. 20.A client has been smoking for the last 40 years and has a history of emphysema. Which of the following findings would the nurse not expect to find? 1. Decreased forced vital capacity (FVC) 2. Increased anterior-posterior chest diameter 3. Increased forced expiratory volume (FEV1) 4. Pursed lip breathing Chapter 10 Cardiovascular problems MULTIPLE CHOICE 1.A client is learning about cholesterol. The nurse explains that the good cholesterol transports plasma cholesterol away from plaques and to the liver for metabolism. This type of cholesterol is called: 1. high-density lipoprotein. 2. low-density lipoprotein. 3. very-high-density lipoprotein. 4. very-low-density lipoprotein. 2.A client has a blood pressure of 124/78 mmHg and a triglyceride level of 160 mg/dL. Based on these results, the nurse knows that the client has: 1 . an optimal blood pressure and triglyceride level. 2 . a prehypertensive blood pressure and an optimal triglyceride level. 3 . a prehypertensive blood pressure and a borderline high triglyceride level. 4 . stage I hypertension and a high triglyceride level. 2 . a prehypertensive blood pressure and an optimal triglyceride level. 3 . a prehypertensive blood pressure and a borderline high triglyceride level. 4 . stage I hypertension and a high triglyceride level. 3.The nurse measures a clients blood pressure to be 158/92 mmHg. The nurse recognizes that this blood pressure is classified as: 1. normal. 2. prehypertension. 3. stage I hypertension. 4. stage II hypertension. 4.A client is complaining of chest pain that occurs during exercise. This pain is relieved when the client rests. The nurse realizes that this client is experiencing which type of angina? 1. Prinzmetals variant angina 2. Silent angina 3. Stable angina 4. Unstable angina 5.A client diagnosed with stable angina is undergoing a 12-lead electrocardiogram. Which of the following results is not expected? 1. ST segment depression 2. ST segment elevation 3. T-wave flattening 4. T-wave inversion 6.A client is scheduled for a cardiac angiogram. Which of the following should the nurse instruct the client about this diagnostic test? 1. It is noninvasive. 2. Contrast dye is injected. 3. Clients can move about after the procedure. 4. General anesthesia is used. 7.When planning the care of a client diagnosed with stable angina, which of the following would be considered a goal of treatment? 1. Decrease in ischemia and episodes of angina 2. Prevent myocardial infection 3. Reduction of risk factors 4. Reduction of stress by education 8.Which of the following would the nurse most likely assess in a client diagnosed with rightsided heart failure? 1. Distended neck veins 2. Oliguria 3. Cough with frothy blood-tinged sputum 4. Syncope 9.Which of the following diagnostic tests is useful to diagnose mitral valve prolapse? 1. Electrocardiogram 2. Echocardiogram 3. Cardiac angiography 4. Transesophageal echocardiography 10.A client diagnosed with mitral valve prolapse is experiencing palpitations. Which of the following should the nurse instruct this client? 1. Avoid tobacco 2. Ingest alcohol in moderation 3. Avoid weight loss 4. Limit caffeine intake 1. Avoid tobacco 2. Ingest alcohol in moderation 3. Avoid weight loss 4. Limit caffeine intake 11.A client tells the nurse that she had rheumatic heart disease as a child. For which of the following valvular disorders should this client be assessed? 1. Mitral valve prolapse 2. Mitral stenosis 3. Aortic regurgitation 4. Aortic stenosis 12.A client, recovering from surgery to replace a calcified aortic valve with a mechanical valve, should be instructed that which of the following medications will be needed long term? 1. ACE inhibitor 2. Beta-blocker 3. Antibiotic 4. Anticoagulant 1. ACE inhibitor 2. Beta-blocker 3. Antibiotic 4. Anticoagulant 13.A client is scheduled for annuloplasty surgery to the aortic valve. Which of the following will most likely occur during this clients procedure? 1. A catheter will be inserted through the femoral vein. 2. A heart bypass machine will be used. 3. Local anesthesia will be provided. 4. A balloon will inflate and stretch the valve open. MULTIPLE RESPONSE 1.A client with a heart rate of 40 who is experiencing shortness of breath and nausea is diagnosed with second-degree AV block type II. Which of the following will be included in this clients treatment? (Select all that apply.) 1. Administer digoxin 2. Administer antiemetic 3. Administer atropine sulfate 4. Insert external pacemaker 5. Decrease intravenous fluids 1. Administer digoxin 2. Administer antiemetic 3. Administer atropine sulfate 4. Insert external pacemaker 5. Decrease intravenous fluids 6. Lower the head of the bed 2.A clients electrocardiogram rhythm strip is a straight line. Which of the following should the nurse do to help this client? (Select all that apply.) 1 . Assess for loose leads. 2 . Assess for power to the monitor. 3 . Assess the strip for possible fine ventricular fibrillation. 4 . Begin cardiopulmonary resuscitation once verified the client has no pulse. 5 . Raise the head of the bed. 6 . Stop intravenous fluid infusion. 5 . Raise the head of the bed. 6 . Stop intravenous fluid infusion. 3.The nurse is assessing a client who is diagnosed with pulseless electrical activity. Which of the following will the nurse include in this assessment? (Select all that apply.) 1. Hypovolemia 2. Hypoxia 3. Hypothermia 4. Tamponade 5. Thrombosis 6. Throat pain 4.Which of the following should be implemented to ensure the safe use of a defibrillator? (Select all that apply.) 1 . Do not place over monitoring electrodes. 2 . Do not place over an implanted pacemaker. 3 . Place the paddles at inch from the implanted pacemaker site. 4 . Apply transdermal medication to the chest before using the paddles. 5 . Insert an oral airway before using the paddles. 6 . Have another person hold the clients airway open while using the paddles. 5.Which of the following interventions would be appropriate for a client recovering from a pacemaker insertion? (Select all that apply.) 1. Monitor vital signs every 15 minutes until stable. 2. Assess for chest pain. 3. Restrict movement of affected extremity. 4. Monitor electrocardiogram every 8 hours. 5. Begin intravenous fluid infusion at 150 mL/hr. 6. Reinforce dressing with excessive bleeding. 3. Restrict movement of affected extremity. 4. Monitor electrocardiogram every 8 hours. 5. Begin intravenous fluid infusion at 150 mL/hr. 6. Reinforce dressing with excessive bleeding. Chapter 11 Peripheral vascular disease MULTIPLE CHOICE 1.Which of the following should the nurse instruct a client in order to reduce the risk factors for developing arteriosclerosis? 1. Limit diet to contain less than 40% fat 2. Restrict exercise 3. Stop smoking 4. Avoid prescription medications 2.The nurse is concerned that an elderly client has evidence of arteriosclerosis since the clients capillary refill is greater than: 1. 3 seconds. 2. 4 seconds. 3. 5 seconds. 4. 6 seconds. s 3.When instructing a client on ways to lower his cholesterol levels, which of the following should the nurse include? 1. Eat more meat and eggs. 2. Consume less meat and eggs. 3. Incorporate more vegetables. 4. Limit fruits. 4.A client diagnosed with arteriosclerosis is prescribed an anticoagulant. For which of the following should the nurse assess in this client? 1. Respiratory distress 2. Skin breakdown 3. Decreased urine output 4. Bruising and bleeding 5.The nurse is assessing a client diagnosed with an abdominal aortic aneurysm. Which of the following sounds did the nurse auscultate during the assessment? 1. Pleural rub 2. Hyperactive bowel sounds 3. Crackles 4. Bruit 6.A client is admitted with abdominal aortic aneurysm. For which of the following complications should the nurse be concerned? 1. Hypotension 2. Cardiac arrhythmias 3. Aneurysm rupture 4. Loss of bowel sounds 7.A client who has experienced signs of Virchows triad has developed a deep vein thrombosis. Which of the following is not a part of this triad? 1. Venous stasis 2. Vessel wall injury 3. Alteration in blood clotting 4. Pregnancy 8.A client is diagnosed with Buergers disease. Which of the following should the nurse instruct the client regarding this disorder? 1. It is a common disorder. 2. It appears in women more than in men. 3. Smoking exacerbates the disease. 4. It is more common in African Americans. 9.A client is diagnosed with Raynauds disease. Which of the following will the nurse most likely assess in this client? 1. Elevated blood pressure 2. Pain, cyanosis, and numb, cold extremities 3. Absent peripheral pulses 4. Increase in varicose veins 10.A client is diagnosed with acute peripheral arterial occlusion. The nurse should prepare to provide which of the following interventions for this client? 1. Administer oxygen. 2. Assist with ambulation. 3. Administer heparin as prescribed. 4. Restrict fluids. 11.A client receiving a heparin infusion is demonstrating signs of acute bleeding. Which of the following should the nurse prepare to administer to this client? 1. Aspirin 2. Vitamin K 3. Protamine sulfate 4. Narcan 12.A clients blood pressure measurements have a 20 mmHg difference between the upper extremity readings. Which of the following does this assessment finding suggest to the nurse? 1. Arteriosclerosis 2. Aortic aneurysm 3. Deep vein thrombosis 4. Subclavian steal syndrome 13.The nurse is assessing a client for risks in the development of varicose veins. Which of the following findings would increase this clients risk? 1. Normal weight 2. Prolonged standing 3. Engages in golf three times a week 4. Eats several servings of fruits and vegetables each day MULTIPLE RESPONSE 1.A client is having laboratory tests conducted to confirm a diagnosis of arteriosclerosis. Which of the following laboratory values would support this clients medical diagnosis? (Select all that apply.) 1. Serum cholesterol 300 mg/dL 2. LDL 125 mg/dL 3. Blood glucose 90 mg/dL 4. HDL 45 mg/dL 5. Triglycerides 400 mg/dL 6. Serum potassium 4.0 mEq/L 2.The nurse is assessing a client diagnosed with a peripheral arterial occlusion. Which of the following will the nurse assess in this client? (Select all that apply.) 1. Pulselessness 2. Pain 3. Pallor 4. Paresthesia 5. Paralysis 1. Pulselessness 2. Pain 3. Pallor 4. Paresthesia 5. Paralysis 6. Petechiae 3.The nurse is instructing a client recovering from arterial aneurysm repair. Which of the following should be included in these instructions? (Select all that apply.) 1 . Do not lift anything heavier than 15 to 20 lbs. 2 . Limit activity for up to 8 weeks after the surgery. 3 . Use a pillow to splint when coughing. 4 . Driving is permitted 1 week after surgery. 5 . Notify the physician for pain, redness, or swelling around the incision. 6 . Avoid pain medication. 4.The nurse is utilizing the Wells Scale to assess a client for deep vein thrombosis. Which of the following is assessed when using this scale? (Select all that apply.) 1 . Treatment for cancer 2 . Recent immobility for greater than 3 days 3 . Recovery from surgery with general anesthesia within 12 weeks 4 . Entire leg edematous 5 . Pitting edema of the symptomatic leg 6 . Blood pressure 130/86 mmHg 5.A client is diagnosed with a venous stasis ulcer on the foot. Which of the following will be included in this clients plan of care? (Select all that apply.) 1. Administer oral antibiotics if infection is present. 2. Keep the foot open to the air. 3. Cover the foot with a hydrocolloidal dressing. 4. Provide pain medication with debridement. 5. Restrict fluids. 6. Instruct the client to ambulate without shoes. MULTIPLE CHOICE 1.Which of the following should the nurse instruct a client in order to reduce the risk factors for developing arteriosclerosis? 1. Limit diet to contain less than 40% fat 2. Restrict exercise 3. Stop smoking 4. Avoid prescription medications 2.The nurse is concerned that an elderly client has evidence of arteriosclerosis since the clients capillary refill is greater than: 1. 3 seconds. 2. 4 seconds. 3. 5 seconds. 4. 6 seconds. REF: Arteriosclerosis and Atherosclerosis: Assessment with Clinical Manifestations 3.When instructing a client on ways to lower his cholesterol levels, which of the following should the nurse include? 1. Eat more meat and eggs. 2. Consume less meat and eggs. 3. Incorporate more vegetables. 4. Limit fruits. 4.A client diagnosed with arteriosclerosis is prescribed an anticoagulant. For which of the following should the nurse assess in this client? 1. Respiratory distress 2. Skin breakdown 3. Decreased urine output 4. Bruising and bleeding 5.The nurse is assessing a client diagnosed with an abdominal aortic aneurysm. Which of the following sounds did the nurse auscultate during the assessment? 1. Pleural rub 2. Hyperactive bowel sounds 3. Crackles 4. Bruit 1. Pleural rub 2. Hyperactive bowel sounds 3. Crackles 4. Bruit 6.A client is admitted with abdominal aortic aneurysm. For which of the following complications should the nurse be concerned? 1. Hypotension 2. Cardiac arrhythmias 3. Aneurysm rupture 4. Loss of bowel sounds 7.A client who has experienced signs of Virchows triad has developed a deep vein thrombosis. Which of the following is not a part of this triad? 1. Venous stasis 2. Vessel wall injury 3. Alteration in blood clotting 4. Pregnancy 1. Venous stasis 2.