Medical-Surgical Nursing- Concepts & Practice, 3rd Edition by Susan C. deWit, Candice K. Kumagai – Test Bank

MULTIPLE CHOICE

1. The nurse is caring for a pediatric patient recently diagnosed with severe combined immunodeficiency (SCID) disease. The nurse determines that teaching has been effective after the parent makes which statement?
a. “This disease is like a pediatric version of AIDS.”
b. “My child must be careful not to fall to avoid bleeding.”
c. “My child should not attend day care.”
d. “This problem happened because of chemotherapy treatments.”

ANS: C
There are two forms of immune deficiency: primary and acquired. In primary immune deficiency disorders (PIDD), the cause is an inherited genetic mutation and some of PIDD are detected during infancy or early childhood. Patients with this type of disorder experience repeated infections that clearly increase their risk of morbidity and mortality as well as the cost of health care. AIDS is an example of acquired immune deficiency and affects pediatric patients as well as adults. Hemophilia is a disorder in which patients can suffer life-threatening bleeds from a fall. Chemotherapy recipients may develop an acquired immune disorder, but chemotherapy would not cause any type of immune disorder in the child.

PTS: 1 DIF: Cognitive Level: Application REF: 217, Box 11-1
OBJ: 1 TOP: Primary Immune Deficiency
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

2. After an influenza immunization, the patient complains of shortness of breath, breaks out in hives, and begins to twitch. Which ordered medication should the nurse give first?
a. Epinephrine injection
b. Oxygen via mask at 5 L/min
c. Corticosteroid injection
d. Bronchodilators per nebulization

ANS: A
Epinephrine is the initial line of defense to reverse anaphylaxis, followed by high-flow oxygen, bronchodilators, and corticosteroid injection as necessary.

PTS: 1 DIF: Cognitive Level: Application REF: 249
OBJ: 6 (clinical) TOP: Anaphylaxis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

3. The nurse is educating a patient with systemic lupus erythematosus (SLE). Which information is most important for the nurse to include in the teaching plan?
a. Train with weights to increase strength.
b. Avoid glycerin-based soaps.
c. Use an SPF 15 sunblock when outdoors.
d. Apply fragrance-free lotions to dry areas twice daily.

ANS: D
Skin protection for patients with SLE is a top priority. The patient should be advised to liberally apply fragrance-free lotions to dry areas at least twice daily. Weight training could cause joint strain. SLE patients should choose a mild soap with a glycerin base and select sunscreen that features SPF of 30 or higher.

PTS: 1 DIF: Cognitive Level: Application REF: 233, 237, Patient Teaching
OBJ: 7 TOP: SLE Teaching
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

4. The nurse is educating a patient about his diagnosis of stage II Hodgkin disease. Which statement indicates that the nurse’s teaching has been successful?
a. “The cancer has spread throughout my entire body.”
b. “There is only one lymph node involved.”
c. “The lymph nodes in both of my arms are affected.”
d. “Two nodes in my left arm area are affected.”

ANS: D
Stage II indicates that there are two or more involved lymph nodes on the same side of the diaphragm (or body). The lymph nodes affected could be in any part of the lymphatic system. The disease spreading outside of the lymph system indicates stage IV. Single node involvement is stage I, and lymph involvement on both sides of the diaphragm or body is considered stage III.

PTS: 1 DIF: Cognitive Level: Application REF: 238, Figure 11-5
OBJ: 8 TOP: Hodgkin Disease Node Staging
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

5. MOPP and ABVD therapy for the treatment of Hodgkin disease are treatment protocols that use which combination of factors?
a. Multiple medications given concurrently
b. Heat, exercise, and chemotherapy
c. Alternating radiation and chemotherapy
d. Chemotherapy and alternative herbal remedies

ANS: A
MOPP and ABVD are chemotherapy treatment protocols using a combination of four drugs given concurrently. MOPP is the acronym for the drugs mechlorethamine, vincristine (Oncovin), procarbazine, and prednisone. ABVD is the acronym for the drugs doxorubicin (Adriamycin), bleomycin, vinblastine, and dacarbazine. This treatment protocol is usually used for stages III and IV of the disease.

PTS: 1 DIF: Cognitive Level: Application REF: 238
OBJ: 8 TOP: Treatment: Hodgkin Disease
KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance

6. The nurse caring for a patient with advanced AIDS. While collecting data, the nurse notes a weight loss of several pounds, poor food consumption, and complaint of no appetite. Based on these findings, the nurse should carefully monitor the patient for development of which problem?
a. Lymphedema
b. Hyperglycemia
c. Hypertension
d. Anasarca

ANS: D
Anasarca is generalized edema in the trunk, extremities, and around the eyes. It results in patients with advanced AIDS from a severe depletion of albumin when the patient has an insufficient nutritional intake, as is evident with this patient. Lymphedema is an abnormal collection of lymph fluid accumulated in the peripheral and periorbital areas, sometimes seen in AIDS patients. Hypoglycemia and hypotension are typically seen in patients with advanced AIDS who have poor nutritional and fluid intake.

PTS: 1 DIF: Cognitive Level: Analysis REF: 226
OBJ: 3 (clinical) TOP: Advanced AIDS: Symptoms
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

7. The nurse is caring for an immune compromised patient. The patient displays a low-grade fever and complains of a burning and shooting pain, along with itching and tingling, that progresses from the clavicle to the scapula. The nurse suspects that the patient will undergo evaluation for which infection?
a. Hepatitis C
b. Shingles
c. Candidiasis
d. Cryptococcosis

ANS: B
The immune compromised patient may experience opportunistic infections. Hepatitis C, bacterial infections, and cryptococcosis are all opportunistic infections, but the symptoms this patient is experiencing are consistent with shingles.

PTS: 1 DIF: Cognitive Level: Application REF: 226, Table 11-5
OBJ: 6 (theory) TOP: Opportunistic Infection
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

8. The patient scheduled for a computed tomography (CT) scan with contrast medium questions the nurse why the technologist asked her if she had any food allergies. Which response by the nurse is correct?
a. “The dye used for a CT scan is egg based, so egg allergies would prevent you from having the test.”
b. “People who are allergic to dairy products are likely to be allergic to CT scan dye.”
c. “Allergies to shellfish can be a problem because shellfish and CT scan dye are iodine based.”
d. “Wheat is the preservative used in CT scan dye, so allergies to wheat may cause allergies to the dye.”

ANS: C
Allergies to seafood indicate intolerance to iodine. This means there is potential for an allergic reaction to iodine-based contrast agents used in radiologic imaging studies such as CT scans with contrast medium.

PTS: 1 DIF: Cognitive Level: Application REF: 247, Clinical Cues
OBJ: 10 (theory) TOP: Allergies KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

9. The nurse is performing an assessment on a patient admitted for diagnostic testing to rule out fibromyalgia. Which assessment finding indicates that the patient actually may have the disorder?
a. A decreased response to painful stimuli
b. A pain response to nonpainful stimuli
c. Absent response to painful stimuli
d. Numbness and tingling in response to painful stimuli

ANS: B
Allodynia, pain response to nonpainful stimuli, is one of the signs typically seen in the patient with fibromyalgia. Patients with fibromyalgia often experience hyperalgesia, which is a heightened response to painful stimuli.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 240
OBJ: 9 (theory) TOP: Fibromyalgia
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Safe, Effective Care Environment: Management of Care

10. The nurse is working in a trauma unit and is accidentally stuck with an IV needle following venipuncture of the patient. What is the nurse’s first action?
a. Immediately begin taking the two- or three-drug regimen.
b. Report the stick to the charge nurse immediately so follow-up can be initiated.
c. Wash the punctured area with soap and water.
d. Complete an incident report so immediate testing of the patient and nurse can begin.

ANS: C
The area should first be cleansed in an attempt to flush any pathogenic organisms from the site, followed by reporting the incident to the charge nurse and completing an incident report. Appropriate treatment regimen will then be started.

PTS: 1 DIF: Cognitive Level: Application REF: 231, Safety Alert
OBJ: 9 (theory) TOP: HIV Exposure
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control