FIFTH EDITION

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4069_FM_i-viii 25/11/14 3:15 PM Page i

STUDENT WORKBOOK FOR

UNDERSTANDING

Medical
Surgical
Nursing
FIFTH EDITION
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STUDENT WORKBOOK FOR

UNDERSTANDING

Medical
Surgical
Nursing FIFTH EDITION

Paula D. Hopper, MSN, RN, CNE

Professor of Nursing
Jackson College
Jackson, Michigan

Linda S. Williams, MSN, RN

Professor of Nursing
Jackson College
Jackson, Michigan
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F.A. Davis Company

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Philadelphia, PA 19103
www.fadavis.com

Copyright © 2015 by F.A. Davis Company

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4069_FM_i-viii 25/11/14 3:15 PM Page v

Preface

NOTE TO THE STUDENT

The Student Workbook for Understanding Medical Surgical Nursing has been written and
edited by the authors to accompany the fifth edition of Understanding Medical Surgical
Nursing. We have included exercises that not only help you review content, but also will
help you develop your critical thinking abilities. It is essential for you to be able to think
critically about the content as you prepare for the NCLEX-PN. We hope you will use this
resource as well as your electronic study guide and the great resources on DavisPlus.

SUGGESTIONS FOR USING THE STUDY GUIDE

Checklists for Learning Success are provided at the beginning of each unit. You can use
these checklists to track your study of the major topics.
Each chapter includes:
• An exercise to help you practice chapter vocabulary items. It is important to understand
the underlying vocabulary before attempting to apply the terms to understand the re-
mainder of the information in each chapter.
• Basic matching, true/false, word scramble, and other exercises to allow you to practice
and understand medical-surgical nursing information. These exercises are most helpful
for developing knowledge and recall of material.
• Critical thinking exercises to help you practice your new knowledge in patient situations
and make good clinical judgments. We feel strongly that you must learn to think criti-
cally, rather than just memorize facts. The answers we provide for the critical thinking
exercises are just some of the possibilities. You will come up with additional answers of
your own as your knowledge base expands.
• NCLEX-PN style questions to provide practice in applying your new knowledge.
Rationale for why an answer is correct or incorrect has been included to strengthen
your critical thinking and test-taking abilities.
• Function and Assessment chapters also include a labeling exercise to help you review
basic anatomy.

STUDY GUIDE ANSWERS

• To students: Study Guide answers are posted on the instructor’s DavisPlus site. Ask
your instructor about accessing answers.
• To instructors: Study Guide answers are posted on the instructor’s DavisPlus site. Stu-
dents do not have access to Study Guide answers. Please provide answers to students
according to your needs.
We hope you find this study guide useful. Happy studying!

PAULA D. HOPPER AND LINDA S. WILLIAMS

v
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Contents

UNIT ONE UNIT FIVE

Understanding Health Care Issues 1 Understanding the Cardiovascular
1 Critical Thinking and the Nursing Process 2 System 77
2 Evidence-Based Practice 5 21 Cardiovascular System Function,
3 Issues in Nursing Practice 8 Assessment, and Therapeutic Measures 78
4 Cultural Influences on Nursing Care 12 22 Nursing Care of Patients With Hypertension 82
5 Complementary and Alternative Modalities 16 23 Nursing Care of Patients With Valvular,
Inflammatory, and Infectious Cardiac or
UNIT TWO Venous Disorders 86
Understanding Health and Illness 19 24 Nursing Care of Patients With Occlusive
Cardiovascular Disorders 92
6 Nursing Care of Patients With Fluid,
25 Nursing Care of Patients With Cardiac
Electrolyte, and Acid-Base Imbalances 20
Dysrhythmias 96
7 Nursing Care of Patients Receiving
26 Nursing Care of Patients With Heart Failure 102
Intravenous Therapy 23
8 Nursing Care of Patients With Infections 26 UNIT SIX
9 Nursing Care of Patients in Shock 30
10 Nursing Care of Patients in Pain 34 Understanding the Hematologic
11 Nursing Care of Patients With Cancer 37 and Lymphatic Systems 107
12 Nursing Care of Patients Having Surgery 40
27 Hematologic and Lymphatic System
13 Nursing Care of Patients With Emergent
Function, Assessment, and Therapeutic
Conditions and Disaster/Bioterrorism
Measures 108
Response 45
28 Nursing Care of Patients With Hematologic
UNIT THREE and Lymphatic Disorders 112

Understanding Life Span Influences on UNIT SEVEN

Health and Illness 49 Understanding the Respiratory System 117
14 Developmental Considerations in the 29 Respiratory System Function, Assessment,
Nursing Care of Adults 50 and Therapeutic Measures 118
15 Nursing Care of Older Adult Patients 53 30 Nursing Care of Patients With Upper
16 Nursing Care of Patients at Home 57 Respiratory Tract Disorders 123
17 Nursing Care of Patients at the End of Life 60 31 Nursing Care of Patients With Lower
Respiratory Tract Disorders 126
UNIT FOUR
Understanding the Immune System 63 UNIT EIGHT
18 Immune System Function, Assessment, Understanding the Gastrointestinal,
and Therapeutic Measures 64 Hepatic, and Pancreatic Systems 131
19 Nursing Care of Patients With Immune
32 Gastrointestinal, Hepatobiliary, and
Disorders 68
Pancreatic Systems Function, Assessment,
20 Nursing Care of Patients With HIV
and Therapeutic Measures 132
Disease and AIDS 74

vii
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viii Contents

33 Nursing Care of Patients With Upper UNIT THIRTEEN

Gastrointestinal Disorders 137
34 Nursing Care of Patients With Lower Understanding the Neurologic System 197
Gastrointestinal Disorders 141 47 Neurologic System Function, Assessment,
35 Nursing Care of Patients With Liver, and Therapeutic Measures 198
Pancreatic, and Gallbladder Disorders 144 48 Nursing Care of Patients With Central
Nervous System Disorders 203
UNIT NINE 49 Nursing Care of Patients With
Understanding the Urinary System 149 Cerebrovascular Disorders 207
50 Nursing Care of Patients With Peripheral
36 Urinary System Function, Assessment, Nervous System Disorders 211
and Therapeutic Measures 150
37 Nursing Care of Patients With Disorders UNIT FOURTEEN
of the Urinary System 154
Understanding the Sensory System 215
UNIT TEN 51 Sensory System Function, Assessment, and
Understanding the Endocrine System 159 Therapeutic Measures: Vision and Hearing 216
52 Nursing Care of Patients With Sensory
38 Endocrine System Function and Assessment 160 Disorders: Vision and Hearing 221
39 Nursing Care of Patients With Endocrine
Disorders 163 UNIT FIFTEEN
40 Nursing Care of Patients With Disorders
of the Endocrine Pancreas 167 Understanding the Integumentary
System 225
UNIT ELEVEN
53 Integumentary System Function, Assessment,
Understanding the Genitourinary and Therapeutic Measures 226
and Reproductive System 171 54 Nursing Care of Patients With Skin
Disorders 229
41 Genitourinary and Reproductive System 55 Nursing Care of Patients With Burns 232
Function and Assessment 172
42 Nursing Care of Women With Reproductive UNIT SIXTEEN
System Disorders 177
43 Nursing Care of Male Patients With Understanding Mental Health Care 235
Genitourinary Disorders 180 56 Mental Health Function, Assessment,
44 Nursing Care of Patients With Sexually and Therapeutic Measures 236
Transmitted Infections 183 57 Nursing Care of Patients With Mental
Health Disorders 239
UNIT TWELVE
Understanding the Musculoskeletal
System 187
45 Musculoskeletal Function and Assessment 188
46 Nursing Care of Patients With
Musculoskeletal and Connective Tissue
Disorders 192
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unit ONE

Understanding
Health Care Issues
CHECKLIST FOR LEARNING SUCCESS
Critical Thinking Evidence-Based Practice Issues Cultural Influences Alternative/Complementary
❑ Critical thinking traits ❑ Evidence-based practice ❑ Health care delivery ❑ Cultural diversity ❑ Alternative versus
❑ Knowledge base ❑ Use of evidence-based ❑ Economic issues ❑ Communication complementary therapies
❑ Critical thinking skills practice ❑ Nursing/health team ❑ Space ❑ Allopathic/Western medicine
❑ Problem solving ❑ Identifying evidence ❑ Leadership in nursing ❑ Time orientation ❑ Ayurveda
❑ Role of the LPN/LVN ❑ Evidence-based practice practice ❑ Social organization ❑ Chinese medicine
❑ Nursing process process ❑ Career opportunities ❑ Environmental control ❑ Chiropractic
❑ Data collection ❑ Six steps of evidence- ❑ Ethics and values ❑ Health care providers ❑ Homeopathy
❑ Documentation of data based practice ❑ Ethical obligations and ❑ Biological variations ❑ Naturopathy
❑ Nursing diagnosis ❑ Evidence-based practice, nursing ❑ Death and dying ❑ American Indian medicine
❑ Planning care quality and safety ❑ Nursing code of ethics ❑ Cultural groups ❑ Osteopathy
❑ Prioritizing care ❑ Quality and Safety ❑ Building blocks of ethics ❑ Culturally competent care ❑ Herbal therapy
❑ Identifying interventions Education for Nurses ❑ Ethical theories ❑ Relaxation therapies
❑ Implementation (QSEN) project ❑ Ethical decision making ❑ Massage therapy
❑ Evaluation ❑ Joint Commission’s 2014 ❑ Legal concepts ❑ Aquatherapy
National Patient Safety ❑ HIPAA ❑ Heat and cold
Goals ❑ Nursing liability and the law ❑ Safety/effectiveness
❑ Role of LPN/LVN
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Critical Thinking
1 and the Nursing
Process
VOCABULARY
Define the following terms and use them in sentences.
Nursing process
Definition:
Sentence:
Critical thinking
Definition:
Sentence:
Assessment
Definition:
Sentence:
Objective data
Definition:
Sentence:
Subjective data
Definition:
Sentence:
Nursing diagnosis
Definition:
Sentence:
Evaluation
Definition:
Sentence:
Vigilance
Definition:
Sentence:

2
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Chapter 1 Critical Thinking and the Nursing Process 3

SUBJECTIVE AND OBJECTIVE DATA 12. Serum potassium 3.6 mEq/L

13. Palpitations (feeling of racing heart)
Identify the following data as subjective (symptom) or
objective (sign). 14. Blood pressure 130/82 mm Hg
15. White blood cell count 7000/mm3
1. Pain
2. Shortness of breath CRITICAL THINKING
3. Edema (swelling) Sometimes cognitive maps are used to organize thinking. Look
4. Capillary refill 2 seconds at samples in any of the Function and Assessment chapters
under Aging Changes. Some of the workbook chapters will ask
5. Nausea
you to make a cognitive map, so here is an opportunity to prac-
6. Vomiting tice. Consider a time when you have had a headache or other
7. Dizziness discomfort. Fill in the spaces with information related to the
8. Cyanosis WHAT’S UP? questions. See Chapter 1 Answers for one pa-
tient’s responses. Once you have the questions answered, you
9. Numbness
could go even further and make links with possible interven-
10. Indigestion tions. There is no one right way to make a cognitive map—use
11. Pale your imagination!

Patient's Where is it? Quality Aggravating and

perception alleviating factors

Headache

Useful other Severity Timing

data

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 3. An LPN wishes to learn why a patient’s lung sounds
have crackles and questions the physician during morn-
1. Which one of the following is a nursing diagnosis?
ing rounds. Which critical thinking attitude is the nurse
1. Peptic ulcer
exhibiting?
2. Pneumonia
1. Intellectual humility
3. Ineffective airway clearance
2. Intellectual sense of justice
4. Myocardial infarction
3. Intellectual empathy
4. Intellectual integrity
2. Which one of the following is a medical diagnosis?
1. Hiatal hernia
2. Impaired mobility
3. Powerlessness
4. Anxiety
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4 UNIT ONE Understanding Health Care Issues

4. The LVN is caring for a patient with diabetes. In what 5. Which of the following statements best defines critical
order should the nurse carry out the nursing process? thinking?
Place all steps in correct sequential order. 1. Orderly, goal-directed thinking
1. Implement plan of care 2. Clear thinking during critical situations
2. Assist with evaluation 3. Constructive feedback about nursing actions
3. Collect data 4. Critical evaluation of patient responses to care
4. Assist with development of nursing diagnoses
5. Assist with planning of outcomes and interventions

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 10. A patient has a nursing diagnosis of impaired swallow-
ing related to muscle weakness as evidenced by drool-
6. The LPN is reviewing the nursing care plan for a patient
ing, coughing, and choking. Which of the following
with acute pain related to a fractured ankle. Which of
outcomes is appropriate for this patient’s nursing
the following would determine whether the care plan is
diagnosis?
effective?
1. Improved airway clearance within 8 hours as evi-
1. Assessment of the patient’s ability to walk
denced by clear lung sounds and productive cough
2. Evaluation of the patient’s fracture on X-ray
2. Baseline body weight maintained as evidenced by
3. Elevating the patient’s foot on two pillows
no weight loss
4. Evaluation of the patient’s pain rating on a
3. Improved muscle strength as evidenced by ability to
10-point scale.
sit up while eating
4. Improved swallowing within 48 hours as evidenced
7. A patient with a history of cardiac disease reports a feel-
by no coughing or choking
ing of tightness in the chest that radiates down the left
arm. Which of the following actions by the LPN should
11. The LPN is providing care for a patient with a medical
be carried out immediately?
diagnosis of congestive heart failure who is very short
1. Check the patient’s vital signs.
of breath. Which of the following is a nursing diagno-
2. Formulate nursing diagnoses related to an acute
sis that is correctly stated in the PES (problem, etiology,
myocardial infarction.
and signs and symptoms) format?
3. Determine the patient’s outcome after nitroglycerin
1. Deficient knowledge related to disease process and
has been administered.
self-care for shortness of breath
4. Plan interventions to reduce long-term cardiac
2. Impaired gas exchange related to excess interstitial
damage.
fluid as evidenced by respiratory rate of 32 per
minute and patient stating he feels short of breath
8. The LPN is documenting patient data. Which of the fol-
3. Congestive heart failure related to decreased cardiac
lowing should the nurse document under objective data?
output as evidenced by abnormal arterial blood
1. Denies nausea
gasses
2. Shortness of breath
4. Acute dyspnea related to congestive heart failure
3. Heart rate 72 beats per minute
as evidenced by swollen lower extremities and
4. Midsternal chest pain
confusion.
9. A patient is admitted with chest pain, which has re-
solved. The patient states, “I hope I can live a normal
life.” According to Maslow’s hierarchy of needs,
which of the following levels is best reflected by
this statement?
1. Physiological needs
2. Safety and security
3. Love and belonging
4. Self-esteem
4069_Ch02_005-007 24/11/14 3:45 PM Page 5

Evidence-Based Practice 2
VOCABULARY
Define the following terms.
1. Evidence-based practice

2. Randomized controlled trials

3. Research

4. Systematic review

EVIDENCE-BASED PRACTICE 9. Patient-centered care meets the needs and

preferred schedules.
1. Evidence is the of effectiveness behind
10. Evidence is the core that directs safe,
nursing practice.
quality-driven, excellent patient care.
2. It is important for the in which the evidence
will be used to be considered. CRITICAL THINKING
3. Evidence-based practice (EBP) is a complex but impor- Read the following case study and answer the questions.
tant, necessary process to facilitate care
Nurses on a surgical unit were interested in knowing if music
and optimal patient outcomes. would reduce the preoperative anxiety of patients on their unit.
4. Evidence-based practice is used by nurses to give the
best possible. 1. How are these nurses contributing to quality care?
5. Level I is the evidence and is an analysis
of many controlled trials.
6. Nurses will know from measured that they
are giving the best care possible. 2. What should the nurses do to begin the process?
7. Evidence-based practice is considered the
standard of health care.
8. The Quality and Safety Education for Nurses (QSEN)
3. What are some examples of resources that can be used
project focuses on education that promotes
to find evidence?
the continual improvement of quality and safety in
patient care.

5
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6 UNIT ONE Understanding Health Care Issues

4. The nurses found Level I research studies that showed 5. The planned intervention was implemented, data were
music therapy could be beneficial in reducing anxiety. collected during the implementation, and now the pilot
What step should the nurses take next? study has ended. What step should the nurses take next?

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 4. Which of the following best describes a randomized
clinical trial (RCT)?
1. Which of the following is considered significant
1. An observational study designed to collect subjective
evidence to guide nursing care?
data
1. Research studies that are quasi-experimental
2. An experimental study in which multiple factors
2. Cochrane Reviews
affecting the results are controlled
3. Nursing information from the Internet
3. A specific design categorizing modifiable and
4. The opinion of a nationally known nursing expert
nonmodifiable risk factors
4. Tracking of disease occurrence over a set period
2. A nurse would like to find other studies on wound
of time
care that might be relevant to how wound care is done.
Which of the following would be the best for searching
5. Evidence-based practice most often begins with which
for nursing articles on wound care?
of the following?
1. CINAHL
1. Asking how to solve a clinical problem
2. Medline
2. Initiating a literature search
3. Cochrane Review
3. Analyzing available evidence
4. PubMed
4. Measuring baseline outcomes
3. A nurse on the safety committee is assigned to review
the current National Patient Safety Goals. In which
of these ways will the nurse find the goals?
1. Review Joanna Briggs Best Practices.
2. Review a fundamentals nursing textbook.
3. Go to www.jointcommission.org.
4. Search Cochrane Reviews.

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 7. A nurse on the research committee is assigned to review
the best evidence on patient centered bathing. Which of
6. The nurse is reviewing the patient’s plan of care and
the following kinds of evidence would the nurse select
ordered treatments. Which of the following is an inde-
for Level I research? Select all that apply.
pendent nursing intervention? Select all that apply.
1. A Cochrane review
1. Giving Tylenol 650 milligrams orally every 4 hours
2. One RCT
as needed (prn)
3. Four quasi-experimental studies that show similar
2. Assisting patient to position of comfort
results
3. Giving hand massage daily
4. The opinion of a national nursing expert on the
4. Initiating high-risk fall protocol
subject
5. Placing call button within reach at all times
5. A Joanna Briggs Best Practice Review
6. Teaching deep breathing and relaxation techniques
as needed
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Chapter 2 Evidence-Based Practice 7

8. The nurse will include which of the following in apply- 10. A nurse investigating the effect of 12-hour shifts on
ing the process of evidence-based practice to patient medication errors identifies 962 articles published on
centered care? Select all that apply. the topic of 12-hour shifts in the past 5 years. Which
1. Evaluate the change. action should the nurse take next?
2. Determine current practice. 1. Find out how many of the articles can be found
3. Ask a burning question. at the institution.
4. Know how to conduct an RCT. 2. Request all 962 articles and determine their validity.
5. Search for the best available evidence. 3. Limit the request to articles published in the past
6. Make it happen. 3 years.
4. Narrow the search to identify which articles discuss
9. The nurse provides care for residents on an Alzheimer’s medication errors.
unit and is working with family members of a 67-year-old
patient who was recently admitted. Which of the following
statements reveals the nurse’s awareness of evidence-based
reality orientation practice?
1. “Patients on this unit are generally very sweet, so
your loved one will quickly fit right in.”
2. “Our dietician provides high-protein snacks twice
daily to help prevent brain degeneration.”
3. “You’ll notice clocks, calendars, and the use of
patient pictures in the hallways to help residents
stay oriented.”
4. “Alzheimer’s is a devastating disease, so it is manda-
tory that family members participate in our weekly
support groups.”
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Issues in
3 Nursing Practice

VOCABULARY
Match the term with the appropriate definition or statement.
1. Assault 1. Unlawful touching of another
2. Battery 2. Unlawful conduct that places another in the
3. Defamation immediate fear of unlawful touching or battery;
4. False imprisonment the real threat of bodily harm
5. Outrage 3. Unlawful restriction of a person’s freedom
6. Invasion of privacy and wrongful dis- 4. Extreme and outrageous conduct by a defendant
closure of confidential information relating to the care of the patient or the body of a
deceased individual
5. Wrongful injury to another’s reputation or
standing in a community; may be written (libel)
or spoken (slander)
6. Liability when a patient’s privacy is invaded phys-
ically or if records are released without authority

NURSING PRACTICE AND ETHICAL AND VALUES CLARIFICATION

LEGAL PRINCIPLES Complete the following sentences.
1. The health–illness continuum represents the potential
1. The one thing I have always wanted to do is
shifting between health and poor health
.
throughout the span.
2. If I inherited 5 million dollars, I would
2. Nurses must be licensed to practice to
.
the public and maintain the
3. As president of the United States, I would
of health care services.
.
3. is a central virtue in nursing.
4. If I died today, I would like my obituary to say
4. Nursing care uses the following principles: ensuring
.
and respect, confidentiality,
5. If I could control the world and its destiny, I would
respecting the patient’s right to make care choices, and
.
maintaining a professional relationship with the patient.
5. Effective leaders are about the manage-
ment process, , positive thinkers, and use
to earn the of their coworkers.

8
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Chapter 3 Issues in Nursing Practice 9

Complete this list of things people value with any other perhaps sepsis. In her already weakened condition, an in-
items you believe should be included, then rank the value fection or sepsis would most likely be fatal. Betsy, who had
you believe each item has, with 1 being the highest value. been a licensed practical nurse for some 15 years, disagreed
Rank Valued Item Rank Valued Item with the manager. Her feeling was that causing this obvi-
ously terminal patient so much pain by turning her was
Family Professionalism
cruel and violated her dignity as a human being. She stated
Career that she could not stand to hear Mrs. Reo yell anymore and
Religion refused to take care of her until some other decision was
Honor made about her nursing care. Sally, a new graduate nurse,
felt that the patient should have some say in her own care
Material possessions
and that perhaps some type of compromise could be reached
Health about turning her, perhaps turning her less frequently or pro-
Recreation viding more pain relief medication. Monica, a registered
nurse who had worked on the unit for 2 years, felt that the
What have you learned about yourself by doing this exer-
physician should make the decision about turning this
cise? What do the rankings signify? Can you identify your-
patient, and then the nurses should follow the order. This
self as more utilitarian or more deontological? (There are
last suggestion was met with strong negative comments by
no answers to this section because this is an exercise requir-
the other nurses present. They felt that patient comfort and
ing personal responses.)
turning were nursing measures.
CRITICAL THINKING
1. What are the important ethical principles in this dilemma?
Read the following case study and answer the questions.
Mrs. Reo, a 5 foot, 3 inch, 105-lb, 86-year-old retired clean-
ing lady, was admitted to a general medical-surgical unit in a
small rural hospital. She was diagnosed 3 months ago with
2. How does the Code of Ethics apply to this situation?
metastatic cancer that had spread from her liver to her lungs
and bone marrow. She received chemotherapy and radiation
therapy for several weeks, but the treatment was not effective.
She was admitted to the hospital because she became too
weak to walk or care for herself at home. The cancer returned, 3. What are the legal issues?
and the large doses of oral narcotic medications taken at
home were having little effect on her pain while increasing
her confusion and weakness.
Her oncologist decided that further chemotherapy or ra-
diation therapy would not be effective, and she ordered 4. Are there ever any situations when a nurse might legally
Mrs. Reo to be kept comfortable with medications. A con- and ethically violate a standard of care?
tinuous morphine intravenous (IV) drip was started to help
control the pain. Even with this medication, Mrs. Reo cried
out in pain, particularly when morning care was given, and
begged the nurses not to move her. Because she was se-
verely underweight, the skin over her bony prominences 5. What are some other possible solutions to this dilemma?
quickly became reddened and showed the beginning signs What types of consequences might they have?
of breakdown.
The hospital standards of care for immobile patients
require that they be repositioned at least every 2 hours.
Mrs. Reo yelled so loudly when she was turned that the
nursing staff wondered if they were really helping her or (There are no correct answers to this section because this is
hurting her. an ethical exercise that has many choices to be considered
To help decide what should be done, the nurses who
for the best outcome for the patient. Discuss your options
gave care to Mrs. Reo called a patient care conference. The
manager of the unit stated clearly that the hospital stan- with classmates.)
dards of care required Mrs. Reo be repositioned at least
every 2 hours to prevent skin breakdown, infections, and
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10 UNIT ONE Understanding Health Care Issues

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 5. Ethical dilemmas most often involve which of the
following situations?
1. The ethical principle that the primary goal of health care
1. A conflict of basic human rights
and nursing is to do good for others is called which of
2. Violations of the Nurses’ Code of Ethics
the following?
3. Nurses who do not understand the ethical code
1. Autonomy
4. Patients who wish to die
2. Fidelity
3. Beneficence
6. When applying the ethical principle of autonomy to
4. Veracity
patient care, the nurse should understand that which of
the following is applicable to autonomy?
2. The ethical principle of nonmaleficence is defined as
1. Autonomy is an absolute principle that has no
which of the following?
exceptions.
1. Health care workers avoiding harm to patients
2. Only patients who are awake and oriented have the
2. Telling the truth to patients in all matters
right to autonomy.
3. Being faithful to commitments made to patients
3. Under certain conditions, autonomy can be limited.
4. The right of self-determination of patients
4. Autonomy is the same as the principle of
nonmaleficence.
3. Which of the following is the term used to describe an
ethical situation that arises in which there is a choice
7. Which of the following punishments distinguishes crim-
between two equally unfavorable alternatives?
inal liability from civil liability?
1. Tort
1. Personal liability
2. Ethical antagonism
2. Financial recovery
3. Contraindication
3. Loss of license
4. Ethical dilemma
4. Potential loss of freedom
4. Which of the following is the first step in the ethical
8. Which of the following is an unintentional tort?
decision-making process?
1. Negligence
1. Analyze the alternatives.
2. Outrage
2. Identify the ethical dilemma.
3. Assault
3. Consider the consequences of the actions.
4. Privacy invasion
4. Make a decision.

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 10. A Nurses’ Code of Ethics states, “The nurse safeguards
the patient’s right to privacy by judiciously protecting
9. A patient with emphysema is being seen by the home
information of a confidential nature.” This statement is
health nurse. The patient is on oxygen, lives alone, and
based on which of the following principles?
is able to perform activities of daily living, prepare
1. The right to privacy is an inalienable right of all
meals, and do light household tasks with rest periods.
persons.
The patient is unable to perform yard work, which was a
2. The nurse–patient relationship is based on trust.
favorite hobby. Which of the following would describe
3. A breach of confidentiality may expose the nurse to
the patient’s location on the health–illness continuum?
liability.
1. Near death
4. Nurses know what is best for patients’ health care.
2. High-level wellness
3. Poor health
4. Moderate-level wellness
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Chapter 3 Issues in Nursing Practice 11

11. A patient asks the nurse what is the purpose of a new 13. The LVN is considering whether the task of taking a
medication. The nurse responds, “The medication will blood pressure on a 78-year-old resident with hyperten-
help you feel better, and not to worry about it.” The sion can be delegated to a nursing assistant. Which of
nurse’s response demonstrates which of the following the following steps should the nurse consider in this
conditions? decision-making process for delegation? Select all that
1. Therapeutic communication apply.
2. Paternalism 1. Right task
3. Lack of knowledge 2. Right circumstances
4. Legal obligations 3. Right patient
4. Right communication
12. The nurse attempts to apply the standard of best inter- 5. Right supervision
est to a patient who has had a cardiac arrest and is now 6. Right route
unconscious. Which of the following conditions is the
most important factor for the nurse to consider?
1. The patient’s wishes as expressed before becoming
unconscious
2. The family’s wishes now that the patient can no
longer communicate
3. The patient’s chances for survival after the cardiac
arrest
4. The physician’s orders regarding future arrest
situations
4069_Ch04_012-015 24/11/14 3:47 PM Page 12

Cultural Influences
4 on Nursing Care

VOCABULARY
Match the term with the appropriate definition or statement.
1. Belief 1. A usual way of acting in a given situation
2. Cultural awareness 2. Accepted as true, need not be proven
3. Cultural competence 3. Focuses on knowledge and appreciation of
4. Ethnic history and ancestry of other cultures
5. Ethnocentrism 4. Avoiding actions that may offend another
6. Generalization person’s cultural beliefs
7. Stereotype 5. Belief that “my way is the only right way”
8. Value 6. An assumption that needs validation
9. Worldview 7. An opinion or belief about someone because of
10. Custom ethnic background
11. Cultural sensitivity 8. Belonging to a subgroup of a larger cultural
12. Assimilation group
9. Way a person perceives the world
10. The process of taking on a dominant culture’s
values, sometimes with risk of losing one’s own
cultural heritage
11. Using knowledge and skills about another
culture to provide care
12. A principle or belief that has worth to an
individual or group

CULTURAL CHARACTERISTICS 2. What are some examples of secondary characteristics of

culture?
Answer the following questions. Discuss with a classmate.

1. What are some examples of primary characteristics of

culture?

12
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Chapter 4 Cultural Influences on Nursing Care 13

3. What is meant by traditional health care practitioners? 3. What significance does food have to you besides satis-
Give an example. fying hunger?

4. What are some characteristics of people who are primarily

present oriented? Past oriented? Future oriented? 4. Are you usually on time for social events? For appoint-
ments? Why or why not?

CRITICAL THINKING: IMMIGRANTS

There are no correct or incorrect answers to the following (There are no answers to this section because this is an
questions. Share your thoughts with your classmates. exercise requiring personal responses.)
1. Are immigrants taking away from the United States, or
CRITICAL THINKING: BATHING
are they adding to its richness? Give specific examples,
and share your reasons for your position. Read the following case study and answer the questions.
An older adult male Arab American patient refuses to be
bathed by a female nurse’s aide. He has not been bathed for
3 days, and today he really needs a bath. His family is at his
bedside.

2. Identify health care difficulties that new immigrants 1. Why do you think he is refusing his bath?
must overcome in the United States. How might you, as
a nurse, help them overcome these difficulties?

2. What alternatives do you have?

(There are no answers to this section because this is an
exercise requiring personal responses.)

CRITICAL THINKING: PERSONAL INSIGHTS

Answer the following questions. Consider how people from 3. What is the best solution to the problem?
other cultures might answer differently.

1. What do you personally do to prevent illness?

2. What home remedies do you use when you have a

minor illness such as a cold or flu? Do you use over-
the-counter medications to treat yourself? How might
these over-the-counter medicines cause a problem with
prescription medications?
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14 UNIT ONE Understanding Health Care Issues

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 2. A patient states, “I don’t know why that foreign doctor
needs to be here. I only want to see American doctors.”
1. Patients of Eastern European Jewish heritage who are
This is an example of which of the following principles?
getting married should be provided information on
1. Cultural sensitivity
which disorder?
2. Cultural diversity
1. Sickle cell anemia
3. Ethnocentrism
2. Thalassemia
4. Acculturation
3. Lactose intolerance
4. Tay-Sachs disease
3. Hispanic Americans and American Indians generally have
a _______ (higher or lower) glucose level than whites.

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 6. A Laotian child is brought to the emergency department
by the school nurse. She wants the child examined for
4. A 26-year-old Pueblo American Indian mother arrives at
the possibility of child abuse because he has several cir-
the health clinic to receive treatment for a laceration on
cular ecchymotic areas 2 inches in diameter on his back.
her leg. Accompanying her are her two children, who
What action should the intake nurse perform?
missed their immunization appointments last month
1. Call the child welfare authorities to intervene.
because she did not have transportation. As the clinic
2. Explain to the school nurse that the bruised areas
nurse, what is the best approach to ensure that the chil-
may be caused by the traditional Chinese practice of
dren get their immunizations?
cupping.
1. Give the immunizations today.
3. Inform the child’s mother that he is in the emergency
2. Reschedule the appointment for next month at the
department.
regular hours for the immunization clinic.
4. Report the school nurse for not getting consent from
3. Reschedule the immunizations for when she returns
the mother to bring the child to the emergency
to have her stitches removed.
department.
4. Ask the community health nurse to go to the home to
give the immunizations.
7. A 42-year-old Arab American patient has chronic renal
failure. He asks the nurse where he can purchase a
5. A Guatemalan patient died after a cardiac arrest. His
kidney for transplantation. Which response is best?
wife is uncontrollably wailing and shouting “Vaya con
1. Organs cannot be purchased in the United States.
dios!” and lying on the floor shaking. What action
2. Explain the ethical dilemma in purchasing organs.
should the nurse take?
3. Call the unit supervisor.
1. Call a cardiac arrest team.
4. Give him the area organ procurement telephone
2. Immediately call for a stretcher and get her off the
number.
floor.
3. Calmly remain beside her and talk to her.
4. Call the house physician to order a tranquilizer.
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Chapter 4 Cultural Influences on Nursing Care 15

8. A 12-year-old child from a traditional Korean American 11. A 42-year-old African American patient is 40 pounds
family is newly diagnosed with diabetes mellitus. His overweight. She admits to baking pies with lard and
home health nurse is to teach the patient and family dia- frying food in bacon grease, practices she does not
betes care. Both parents and the child can administer wish to stop. To reduce fat and calories, what can the
his insulin and recite the signs and symptoms of hypo- home health nurse encourage her to do?
glycemia and hyperglycemia. They are highly educated 1. Do not purchase lard.
and read and speak English well. Which is the best 2. Reduce the portion size when she cuts her pies.
first step in teaching them about nutrition therapy for 3. Bake two separate pies, one for her and one for her
diabetes? family.
1. Give them a food exchange list for a diabetic diet. 4. Continue baking with lard, but reduce calories she
2. Determine whether they can calculate calories in a receives from other foods in her diet.
sample meal.
3. Assess current dietary food practices. 12. A 41-year-old Hispanic woman has had a mastectomy
4. Have them make an appointment with a consulting for cancer of the breast. Her physician recommends
dietitian. radiation therapy. She says, “What is the use? My life
is in God’s hands anyway.” Which of the following
9. A 46-year-old Cuban American high school teacher has responses is appropriate?
been admitted for cancer of the breast. She wants her 1. Agree with her, but tell her she must accept the
religious counselor, a santero, to visit. Which action radiation or she will die.
should the nurse take? 2. Ensure that she understands all of the implications
1. Ask the nursing supervisor to see if a visit from a of her decision before accepting it.
santero is permitted. 3. Keep encouraging her to think about the radiation,
2. Tell her that santeros are not permitted in the hospital. and ask all of the other staff to do the same.
3. Suggest that she see a hospital priest instead. 4. Have her ask her physician to prescribe chemother-
4. Tell her a visit is fine, but for safety reasons she apy instead of radiation therapy.
should tell the nurse or physician before accepting
any treatments. 13. A 72-year-old Iranian patient says he will not be able
to take his morning antibiotic, which is scheduled
10. A 62-year-old Hispanic Peruvian woman is in the oper- every 8 hours, because he is celebrating Ramadan and
ating room having bypass surgery. Eighteen family has to fast from sunup to sundown. Which of the
members arrive on the unit and wait in her room, following actions should the nurse take?
which is shared by two other patients. Which is the 1. Explain that the medicine must be taken now to
best solution to this problem? maintain the blood level of the drug.
1. Allow two family members to wait in the room and 2. Rearrange his medication schedule so he can take
send the rest of them to the cafeteria. all his medicines between sundown and sunup.
2. Send all of them to the lobby and tell them they will 3. Omit the medicine and record his refusal on the
be notified when the patient returns to her room. medication administration record.
3. Allow only her husband and mother to visit. 4. Ask his family to encourage him to take the
4. Assign the patient to a private room and allow the medicine.
family to wait there.
4069_Ch05_016-018 24/11/14 3:48 PM Page 16

Complementary and
5 Alternative Modalities

VOCABULARY
Match the term with the appropriate definition or statement.
1. Alternative modality 1. Illness is a result of falling out of balance with
2. Complementary modality nature
3. Homeopathy 2. Uses nutrition, herbs, and hydrotherapy
4. Naturopathy 3. Illness is a result of nerve dysfunction
5. Ayurvedic 4. Added to a conventional therapy
6. Chiropractic 5. Unconventional therapy
6. “Like cures like”

COMPLEMENTARY MODALITY: GUIDED 1. What is feverfew used for?

IMAGERY
Describe the purpose of guided imagery. Write a teaching
plan on how to do guided imagery. Try teaching it to a 2. What is capsaicin used for?
family member or friend.

Purpose:

3. What is St. John’s wort used for?

Teaching Plan:

4. Where can you get information about the safety of tak-

ing these herbs with heart failure or with heart failure
CRITICAL THINKING medications?
Read the following case study and answer the questions.
Mrs. Lawless is admitted to your unit with heart failure and
fluid overload. As you collect admission data, you find that 5. What should you tell Mrs. Lawless?
she is taking feverfew, capsaicin, and St. John’s Wort reg-
ularly in addition to her prescribed medications for heart
failure. When you question her, she says that the salesper-
son at the health food store told her these herbs were safe
to use with her other medications.

16
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Chapter 5 Complementary and Alternative Modalities 17

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 3. Which of the following terms describes traditional
Western medicine?
1. Which of the following therapies would be considered a
1. Homeopathy
complementary modality?
2. Naturopathy
1. Using inhalers in addition to oral medications for
3. Allopathy
asthma
4. Ayurveda
2. Participating in a cardiac rehabilitation program after
having a heart attack
4. Which of the following herbal remedies is possibly
3. Using echinacea instead of antibiotics for an upper
effective against viruses and colds?
respiratory infection
1. Echinacea
4. Using progressive muscle relaxation in addition to
2. Feverfew
muscle relaxants for back pain
3. Chamomile
4. Ginger
2. Which of the following therapies would be considered
an alternative modality?
5. The nurse recognizes which of the following as comple-
1. Using hydrotherapy in place of nonsteroidal anti-
mentary or alternative therapies aimed at altering the
inflammatory drugs for arthritis
body’s energy? Select all that apply.
2. Visiting a spiritual healer in addition to chemother-
1. Reiki
apy for cancer treatment
2. Magnet therapy
3. Using antibiotics and bronchodilators for acute
3. Music therapy
bronchitis
4. Hydrotherapy
4. Using aspirin for a headache
5. Yoga
6. Therapeutic touch

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 7. A patient tells a nurse that a chiropractor is going to do
minor surgery to remove a small superficial lump on her
6. The nurse has provided instruction to a patient on how
neck. Which response by the nurse is best?
to use guided imagery. Which of the following state-
1. “The lump is likely pressing against a nerve; that is
ments by the patient would indicate to the nurse that fur-
why it needs to be removed.”
ther teaching is required?
2. “You need to question your chiropractor’s qualifica-
1. “I will focus on my breathing.”
tions. Chiropractors do not perform surgery.”
2. “I imagine the ocean, including the smell, the sound,
3. “Chiropractors specialize in nerve function; remov-
and the feel of the air.”
ing the lump will restore normal nerve function.”
3. “I will relax all parts of my body.”
4. “Surgery might not be necessary; usually a simple
4. “I will keep my eyes open until the exercise is
chiropractic adjustment will relieve pressure on a
complete.”
nerve.”
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18 UNIT ONE Understanding Health Care Issues

8. A patient admitted with chronic pain says he is inter- 10. A patient is preparing to go home from the hospital
ested in pursuing an alternative modality for his pain, after an anterior wall myocardial infarction. He has
but he is unsure how to determine whether it is safe. new prescriptions for isosorbide (Imdur), warfarin
Which of the following responses by the nurse is best? (Coumadin), atorvastatin (Lipitor), and aspirin. He also
1. “As long as the therapy does not include medication, takes metformin (Glucophage) and glipizide (Glucotrol
it should be safe.” XL) for type 2 diabetes and takes self-prescribed gin-
2. “You should talk with your primary care practitioner seng daily. Which initial response by the nurse is best?
before trying anything new.” 1. “Ginseng can effectively lower blood glucose in pa-
3. “Be careful, because many alternative therapies have tients with diabetes. It is a good choice for you.”
dangerous side effects.” 2. “Ginseng is a relatively safe herbal agent. Be sure
4. “Traditional analgesics are always the safest treat- to check out a reliable website for interactions be-
ment for chronic pain.” fore continuing to take it at home.”
3. “Ginseng, like other herbal agents, is unsafe to take
9. A nurse is interested in providing therapeutic touch ther- with your prescribed medications.”
apy for her home care patient with severe pain. This will 4. “I am concerned that ginseng could interact with
be her first experience with therapeutic touch. Which of your prescribed medications and affect your blood
the following steps is least appropriate before beginning glucose and your blood clotting.”
to provide this new service?
1. Obtain permission from the patient’s physician and
home care agency.
2. Take classes on how to administer therapeutic touch.
3. Tell the patient he will be able to reduce the number
of medications he takes.
4. Read current research on the use of therapeutic touch.
4069_Ch06_019-022 24/11/14 3:49 PM Page 19

unit TWO

Understanding
Health and Illness
CHECKLIST FOR LEARNING SUCCESS
Nursing Care of
Patients With
Emergent
Fluid, Electrolyte, Nursing Care of Conditions and
and Acid–Base Patients Receiving Nursing Care of Nursing Care of Nursing Care of Disaster/
Balance and Intravenous (IV) Patients With Nursing Care of Nursing Care of Patients With Patients Having Bioterrorism
Imbalance Therapy Infections Patients in Shock Patients in Pain Cancer Surgery Response
❑ Fluid balance ❑ Indications ❑ Infectious ❑ Pathophysiology ❑ Definitions of ❑ Review of ❑ Surgery urgency/ ❑ Primary survey
❑ Dehydration for IV therapy process of shock pain normal purpose ❑ Secondary survey
❑ Fluid excess ❑ Types of ❑ Body’s ❑ Complications ❑ Mechanism of anatomy and ❑ Preoperative ❑ Shock
❑ Electrolyte infusions defense from shock pain physiology phase ❑ Anaphylaxis
balance ❑ Methods of mechanisms ❑ Hypovolemic transmission ❑ Pathophysiology ❑ Preoperative ❑ Major trauma
❑ Sodium infusion ❑ Infectious shock ❑ Types of pain and etiology assessment/ ❑ Hypothermia
imbalances ❑ Types of Fluids disease ❑ Cardiogenic ❑ Nonopioid ❑ Risk factors admission ❑ Frostbite
❑ Potassium (tonicity) ❑ Community shock analgesics for cancer ❑ Nursing process: ❑ Hyperthermia
imbalances ❑ IV access infection ❑ Obstructive ❑ Opioid ❑ Cancer ❑ Preoperative ❑ Poisoning and
❑ Calcium ❑ Peripheral IV control shock analgesics classification ❑ Intraoperative drug overdose
imbalances therapy ❑ Health care ❑ Distributive ❑ Opioid ❑ Early detection/ phase ❑ Near-drowning
❑ Magnesium ❑ Venipuncture agency shock antagonists prevention ❑ Postoperative ❑ Psychiatric
imbalances steps infection ❑ Shock ❑ Adjuvants ❑ Diagnostic phase emergencies
❑ Acid–base ❑ Nursing control therapeutic ❑ WHO ladder tests ❑ Perianesthesia ❑ Disaster response
balance process ❑ Antibiotic- interventions ❑ Routes for ❑ Staging and care unit ❑ Bioterrorism
❑ Respiratory ❑ Complications resistant ❑ Nursing analgesic grading ❑ Postoperative
acidosis of IV therapy infections process administration ❑ Surgery nursing care:
❑ Metabolic ❑ Central ❑ Infectious ❑ Nondrug ❑ Radiation ❑ Respiratory
acidosis venous access disease therapies therapy ❑ Circulatory
❑ Respiratory devices interventions ❑ Nursing ❑ Chemo-therapy ❑ Pain
alkalosis ❑ Nutrition ❑ Nursing process ❑ Side effects of ❑ Urinary
❑ Metabolic support process ❑ Pain therapies ❑ Wound care
alkalosis ❑ Home IV assessment ❑ Nursing process ❑ Gastrointestinal
therapy ❑ Patient ❑ Hospice care ❑ Mobility
education ❑ Oncological ❑ Patient discharge
emergencies ❑ Home health care
4069_Ch06_019-022 24/11/14 3:49 PM Page 20

Nursing Care of Patients

6 With Fluid, Electrolyte,
and Acid–Base Imbalances
VOCABULARY
Fill in the blanks with key terms from the chapter.
1. The process through which a solute moves from an area of higher to an area of lower concentration is
.

2. A fluid that has the same osmolarity as blood is said to be .

3. A fluid that has a higher osmolarity than blood is said to be .

4. A decrease in blood volume is called .

5. Electrolytes in the blood that have a positive charge are called .

6. The patient with an excess of sodium in the blood has .

7. The patient with not enough potassium in the blood has .

8. The patient with not enough calcium in the blood has .

9. occurs when the serum pH falls below 7.35.

10. If the serum pH is too high, the condition is called .

DEHYDRATION ELECTROLYTE IMBALANCES

Circle the errors in the following paragraph and write in Match the electrolyte imbalance with its signs and symptoms.
the correct information.
1. Hyponatremia 1. Osteoporosis, hyperac-
Mrs. White is a 78-year-old woman admitted to the hospital
2. Hyperkalemia tive reflexes
with a diagnosis of severe dehydration. The licensed practical
nurse/licensed vocational nurse (LPN/LVN) assigned to Mrs. 3. Hypokalemia 2. Muscle weakness,
White is asked to collect data related to fluid status. The LPN 4. Hypercalcemia weak pulse
expects Mrs. White’s blood pressure to be elevated because 5. Hypocalcemia 3. Muscle weakness,
of the shift of fluid from tissues to her bloodstream. The nurse
kidney stones
also finds Mrs. White’s skin to be taut and firm and notes that
the urine is copious and dark amber. The nurse asks Mrs. 4. Fluid balance and
White if she knows where she is and what day it is because mental status changes
severe dehydration may cause confusion. In addition, the 5. Muscle cramps,
nurse initiates intake and output measurements because this
irregular heart rate
is the most accurate way to monitor fluid balance.

20
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Chapter 6 Nursing Care of Patients With Fluid, Electrolyte, and Acid–Base Imbalances 21

CRITICAL THINKING 3. The RN pages the physician while you return to check
on the patient. What nursing interventions can help until
Read the following case study and answer the questions.
orders are received?
Mr. James is an 89-year-old man admitted to your unit with
worsening chronic bronchitis. On admission he is short of
breath, but he is able to walk to the bathroom without difficulty.
The physician orders bronchodilators, antibiotics, and an intra-
venous (IV) infusion of normal saline at 150 mL per hour. The
next day when you return to work, you find Mr. James gasping
for breath, coughing, and panicky. You quickly listen to his
4. How will you know when the problem has been resolved?
lungs and hear an increase in moist crackles since yesterday.

1. What additional data do you collect to confirm your

suspicion of fluid overload?

2. You report your findings to the registered nurse (RN) and

collaborate on quickly developing a nursing diagnosis of
fluid overload. What factors contributed to this problem?

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 4. Which food is recommended for the patient who must
increase intake of potassium?
1. Which of the following IV solutions is hypotonic?
1. Bread
1. Normal saline
2. Egg
2. 0.45% saline
3. Potato
3. Ringer’s lactate
4. Cereal
4. 5% dextrose in normal saline
5. Which is the most reliable method for monitoring fluid
2. Which of the following hormones retains sodium
balance?
in the body?
1. Daily intake and output
1. Antidiuretic hormone
2. Daily weight
2. Thyroid hormone
3. Vital signs
3. Aldosterone
4. Skin turgor
4. Insulin
6. An older adult patient presents to the emergency depart-
3. Which food should be avoided by the patient on a
ment reporting severe vomiting and diarrhea, sweating,
low-sodium diet?
and rapid heartbeat but has a normal temperature. In
1. Apples
continuing the assessment of the patient, what should
2. Cheese
the nurse first suspect?
3. Chicken
1. Hypervolemia
4. Broccoli
2. Dehydration
3. Edema
4. Hyponatremia
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22 UNIT TWO Understanding Health and Illness

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 11. A 19-year-old student develops symptoms of respira-
tory alkalosis related to an anxiety attack. Which nurs-
7. Which patient is most at risk for fluid volume
ing intervention is most appropriate?
overload?
1. Make sure his oxygen is being administered as
1. The 40-year-old with meningitis
ordered.
2. The 35-year-old with kidney failure
2. Have him breathe into a paper bag.
3. The 60-year-old with psoriasis
3. Place him in a semi-Fowler’s position.
4. The 2-year-old with influenza
4. Have him do coughing and deep-breathing
exercises.
8. Which patients should be monitored closely for dehy-
dration? Select all that apply.
12. A patient has chronic respiratory acidosis related to
1. A 50-year-old with an ileostomy
long-standing lung disease. Which of the following
2. A 19-year-old with chronic asthma
problems is the cause?
3. A 22-year-old with diabetes mellitus
1. Hyperventilation
4. A 45-year-old with a temperature of 102.3°F
2. Hypoventilation
5. A 28-year-old with a broken femur
3. Loss of acid by kidneys
6. A 36-year-old taking diuretic therapy
4. Loss of base by kidneys
9. An older-adult nursing home resident who has always
13. The nurse is providing discharge instructions for a pa-
been alert and oriented is now showing signs of dehy-
tient taking Slow-K®, an oral potassium chloride sup-
dration and has become confused. Which electrolyte
plement. Which of the following statements by the
imbalance is most likely involved?
patient indicates that more teaching is needed? Select
1. Hyponatremia
all that apply.
2. Hyperkalemia
1. “I won’t use salt substitutes that have potassium.”
3. Hypercalcemia
2. “I need to have my blood checked routinely.”
4. Hypomagnesemia
3. “I should take my supplement first thing in the
morning and then wait 30 minutes before eating.”
10. The LPN/LVN is caring for a patient with osteoporosis
4. “If the pill is too big to swallow, I can crush it.”
who appears weak and frail. Which of the following
5. “I should call the doctor if I have nausea, vomiting,
nursing interventions is best?
or abdominal cramps.”
1. Maintain bed rest
6. “I can expect some diarrhea with this medication.”
2. Encourage fluids
3. Ambulate with assistance
4. Provide a high-protein diet
4069_Ch07_023-025 24/11/14 3:49 PM Page 23

Nursing Care of Patients

Receiving Intravenous
Therapy
7
VOCABULARY
Match the term with the appropriate definition or statement.
1. Intravenous (IV) 1. Inside a vein
2. Cannula 2. Seepage of IV fluid into tissues
3. Distal 3. Nearest the point of attachment
4. Infiltration 4. Inflammation of a vein
5. Peripherally inserted central catheter 5. Access device inserted into a superficial periph-
(PICC) eral vein and advanced into the central system to
6. Hematoma the superior vena cava.
7. Phlebitis 6. An IV needle or catheter with a stylet.
8. Proximal 7. Farthest from the center or from the trunk
8. A localized collection of extravasated blood in
the subcutaneous tissue, from a break in a blood
vessel

PERIPHERAL VEINS
Label the veins that can be used for IV therapy.

23
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24 UNIT TWO Understanding Health and Illness

COMPLICATIONS OF IV THERAPY of the problem? What is the role of the licensed practical
nurse (LPN)? When must the registered nurse (RN) be
Fill in the blank with the correct complication. consulted?
1. Pain and inflammation at the IV insertion site is called
.

2. Redness and exudate at the IV insertion site indicate the

presence of . CALCULATION PRACTICE
Calculate the answers to the following problems. Round
3. Infiltration into tissue by an IV fluid or drug is called each answer to the nearest whole number.
. 1. June has an IV of 5% dextrose in water ordered to infuse
at 83 mL/hr. How many drops per minute should be set if
4. Dyspnea and crackles can be a sign of the tubing delivers 15 drops per milliliter?
.

2. Frank has a piggyback antibiotic of 500 mg in 50 mL of

5. A cool, puffy insertion site indicates .
5% dextrose in water. The medication must infuse over
20 minutes. The tubing drip factor is 10. How many
6. Fever, chills, and tachycardia indicate a systemic infec- drops per minute?
tion called .

7. Sharp pain at the IV site during infusion of a cold fluid 3. Dave has an IV of normal saline ordered at 1 L over
12 hours. How many milliliters per hour should he receive?
indicates a .

8. If the patient develops cyanosis, hypotension, and loss 4. Lucy has an order to administer 800 units of heparin per
of consciousness, the nurse should suspect hour. The registered nurse hangs heparin 50,000 units in
. 500 mL of 5% dextrose in water. It will run on an elec-
tronic infusion device. How many milliliters should be
CRITICAL THINKING administered per hour?

Read the following case study and answer the questions.

Mr. Livesay is admitted with cellulitis and is receiving IV flu- 5. Jack has an order for 1000 mL of normal saline over
ids by gravity drip. When you check his IV, you find it is not 24 hours. How many drops should be administered per
dripping. What data can you collect to determine the cause minute, using microdrop tubing?

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 3. Which of the following complications can occur if a
clotted cannula is aggressively flushed?
1. Which vein should be used first when initiating IV
1. A clot can enter the circulation.
therapy?
2. An air embolism can enter the circulation.
1. Jugular
3. A painful arterial spasm can occur.
2. Basilic
4. The patient can experience speed shock.
3. Brachiocephalic
4. Axillary
4. Which of the following symptoms most likely indicates
that an infusion is infiltrated?
2. When preparing a site for venipuncture with chlorhexi-
1. Redness at the site
dine gluconate, how long must the area be cleaned?
2. Pain at the site
1. 5 seconds
3. Puffiness at the site
2. 10 seconds
4. Exudate at the site
3. 30 seconds
4. 60 seconds
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Chapter 7 Nursing Care of Patients Receiving Intravenous Therapy 25

5. An 87-year-old patient recovering from abdominal sur-

gery has a continuous IV infusion to supply nutrients
and antibiotics. What complication should the LPN sus-
pect when signs and symptoms of redness, warmth, and
pain at the infusion site are reported?
1. Phlebitis
2. Thrombosis
3. Hematoma
4. Infiltration

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 9. A patient is receiving an IV piggyback antibiotic in
50 mL of 5% dextrose in water to run over 1 hour.
6. Which patient would benefit most from a capped IV ac- The tubing has a drop factor of 60. How many drops
cess that is used intermittently rather than continuously? per minute should be delivered?
1. The patient with pneumonia who needs fluids and 1. 6
antibiotics 2. 17
2. The patient who has had major blood loss after a 3. 50
motor vehicle accident 4. 100
3. The young child who is dehydrated
4. The older patient who is receiving a diuretic for fluid 10. The nurse is caring for a patient who is to receive IV
overload fluids at 100 mL per hour with IV antibiotic therapy
scheduled every 4 hours. Which of the following sites
7. The physician orders furosemide (Lasix) 40 mg IV push for the IV placement is best?
(IVP) STAT for a patient in acute fluid overload. Why 1. Large vein on the dorsal side of the patient’s non-
was the IV route likely chosen? dominant arm
1. Furosemide can be administered only by the IV route. 2. Small vein on the surface of the patient’s dominant
2. IVP is the route of choice for rapid action. hand
3. IVP dosing is more accurate. 3. Small vein on the surface of the patient’s nondomi-
4. IVP furosemide has fewer side effects than oral. nant hand
4. Large vein in the nondominant antecubital space
8. A patient has orders to receive 1 L (1000 mL) of 5% dex-
trose and lactated Ringer’s solution to be infused over 8
hours. How many milliliters will be infused per hour?
1. 80
2. 100
3. 125
4. 150
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Nursing Care of Patients

8 With Infections

VOCABULARY
Define the following terms and use them in a sentence.
Antigen
Definition:
Sentence:
Asepsis
Definition:
Sentence:
Bacteria
Definition:
Sentence:
Clostridium difficile (C. diff)
Definition:
Sentence:
Hand hygiene
Definition:
Sentence:
Pathogens
Definition:
Sentence:
Personal protective equipment
Definition:
Sentence:
Phagocytosis
Definition:
Sentence:
Sepsis
Definition:
Sentence:
Virulence
Definition:
Sentence:

26
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Chapter 8 Nursing Care of Patients With Infections 27

Viruses
Definition:
Sentence:

PATHOGEN TRANSMISSION CRITICAL THINKING

Match the pathogen with its mode of transmission. Read the following case study and answer the questions.
1. Chickenpox 1. Common vehicle A 72-year-old patient is admitted to a private room with an
2. Malaria 2. Droplet antibiotic-resistant respiratory tract infection.
3. Airborne
3. Tuberculosis
4. Vectorborne 1. What equipment is needed for isolation?
4. Rocky Mountain
spotted fever
5. Meningitis
6. Pneumonia
7. Measles 2. What type of equipment would be used to do assess-
8. Influenza ments and nursing interventions?
9. Pneumonic
plague
10. Hepatitis A

PATHOGENS AND INFECTIOUS DISEASE 3. Describe the psychosocial effects on a patient in isolation.
Fill in the blanks with the appropriate pathogen or infec-
tious disease name.

1. Gram-positive bacteria clusters

that can cause pneumonia, cellulitis, peritonitis, and
4. What can the nurse include in the plan of care for a pa-
toxic shock.
tient in isolation to reduce social isolation?
2. Group of plantlike organisms
that includes yeast, molds, and mushrooms; rarely path-
ogenic.
3. A fungi that can cause thrush.
4. The virus that causes infectious
5. What condition is the patient at risk of developing dur-
mononucleosis.
ing antibiotic treatment for this infection?
5. A systemic fungal respiratory
disease caused by Histoplasma capsulatum.
6. A disease caused by infection
with the protozoan Toxoplasma gondii.
7. Single-celled parasitic organ- 6. What intervention can be used to reduce this risk during
isms that move and live mainly in the soil. antibiotic treatment?
8. Small intracellular parasites that
can only live inside cells; may produce disease when
they enter a cell.
9. A bacterium that must be inside
living cells to reproduce and cause disease and causes
Rocky Mountain spotted fever.
10. Bleach is used to kill its spores.
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28 UNIT TWO Understanding Health and Illness

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 4. Which of the following antibiotics would the nurse an-
ticipate would be used to treat methicillin-resistant
1. Which of the following would the nurse recognize as a
Staphylococcus aureus (MRSA)?
sign of a local infection during data collection?
1. Gentamicin
1. Warm skin
2. Tobramycin
2. Clammy skin
3. Penicillin
3. Anorexia
4. Vancomycin
4. Paleness
5. A nurse should wear a fit-tested high-efficiency particu-
2. Which of the following does the nurse understand is a
late air filter (HEPA) mask when entering the room of a
sterile technique method?
patient with which disease?
1. Use of antiseptics
1. Influenza
2. Use of autoclaves
2. Scabies
3. Frequent hand washing
3. HIV infection
4. Use of gloves when coming in contact with body fluids
4. Tuberculosis
3. Which of the following infections would the nurse rec-
ognize as being a health care–acquired infection?
1. Chronic urinary tract infection for a homebound
person
2. A sexually transmitted infection in a healthy young
adult
3. Pneumonia in a hospitalized postoperative patient
4. Hospitalization for cellulitis

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 9. A patient is to have a sterile urine specimen collected.
Which of the following techniques is used to collect
6. Which of the following actions would be MOST appro-
this specimen? Select all that apply.
priate for the nurse to take while providing patient care
1. Cleansing the patient’s external genitalia before the
to help prevent the spread of infection?
patient voids
1. Sterilizing hands with a germicide once a day
2. Having the patient void into a sterile container
2. Washing hands at the beginning of patient rounds
3. Straight catheterizing the patient
3. Performing hand hygiene before and after each pa-
4. Obtaining a midstream voided specimen
tient contact
5. Obtaining a second voiding specimen
4. Wearing gloves for all patient care
6. Placing urine specimen from catheter in a sterile
container
7. In planning care for a patient, the nurse understands
that surgical asepsis is based on which of the following
10. Which of the following actions can the nurse take to
principles?
help prevent a health care–acquired infection in an in-
1. Destroying organisms before they enter the body
continent patient?
2. Isolating all patients who have infectious diseases
1. Avoiding use of a urinary catheter
3. Destroying bacteria as they leave the body
2. Applying absorbent briefs
4. Maintaining basic cleanliness
3. Toileting patient every 4 hours
4. Restricting fluids
8. Which of the following does the nurse understand is
needed by all pathogenic organisms to multiply? Select
all that apply.
1. Moisture
2. Light
3. A host
4. Oxygen
5. Warmth
6. Food
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Chapter 8 Nursing Care of Patients With Infections 29

11. A patient has been diagnosed recently as having an 13. Which of the following data collection findings should
upper respiratory infection. Which of the following the nurse recognize and report as a possible sign of in-
symptoms would indicate to the nurse that the patient fection in the older adult? Select all that apply.
is developing a complication? 1. Poor skin turgor
1. Scratchy throat 2. Irritability
2. Clear, watery drainage from the nose 3. Hypertension
3. Dry cough 4. Bradycardia
4. High fever 5. Pacing behavior
6. Hunger
12. The nurse is collecting a culture of wound drainage,
and the patient asks what a culture is. Which of the fol- 14. The nurse observes a nursing assistant providing oral
lowing is the best response by the nurse to explain care to an immunocompromised patient. The use of
what a culture is? which of the following by the nursing assistant would
1. A culture identifies the presence of pathogens. require further instruction for patient safety?
2. A culture measures antibiotic levels. 1. Sterile water
3. A culture identifies an antibiotic’s effect on a 2. Tap water
pathogen. 3. Fluoride toothpaste
4. A culture determines the appropriate medication 4. Soft toothbrush
dosage.
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Nursing Care
9 of Patients in Shock

VOCABULARY
Fill in the blank with the word formed by word building.
1. acid—sour + osis—condition
2. an—without + aerobic—presence of oxygen
3. an—without + phylaxis—protection
4. dys—difficult + rhythmia—rhythm
5. kardia—heart + genesis—beginning
6. cyan—blue coloring + osis—condition
7. tachy—fast + pnea—breathing
8. olig—few + uria—urine condition
9. tachy—fast + cardia—heart condition
10. hypo-low + perfuser—to pour over or through

MATCHING
Match the area of the cardiovascular system that contributes to the development of shock with each type of shock.
1. Hypovolemic shock 1. Heart
2. Cardiogenic shock 2. Blood vessels
3. Anaphylactic shock 3. Fluid volume
4. Septic shock
5. Neurogenic shock
6. Obstructive shock

30
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Chapter 9 Nursing Care of Patients in Shock 31

SIGNS AND SYMPTOMS OF SHOCK PHASES

Complete the table.

Signs/Symptoms Phases
Compensating Progressive Irreversible
Heart rate Elevated Slowing
Pulses Weaker, thready
Systolic Blood pressure Normal <90 mm Hg
*In hypertensive, 25%
below baseline
Diastolic Blood pressure Decreasing to 0
Respirations Tachypnea
Depth
Temperature Varies Decreased
*May elevate in septic
shock
Level of consciousness Confused, lethargy Unconscious, comatose
Skin/mucous membranes Cool, pale Cold, moist, clammy, pale
Urine output 15 mL/hr decreasing to
anuria
Bowel sounds Decreasing

CRITICAL THINKING 3. A 50-year-old patient who is hypotensive is receiving a

fluid challenge of 1000 mL 0.9% normal saline over 4
Identify the stage of shock, category of shock, and initial
hours. Her lung sounds are now full of crackles. Her
action to take for the following patients.
heart rhythm is irregular. Jugular vein distention and
1. An 80-year-old woman admitted with a bowel obstruc- ankle edema are present. Blood pressure has dropped
tion has minimal urine output. A nasogastric tube has from 96/50 to 80/40 mm Hg in 1 hour, pulse 108 beats
1500 mL of bloody aspirate returned on insertion. She per minute, respirations 24 per minute, and temperature
becomes comatose. Vital signs are as follows: blood 95°F (35°C). She is confused.
pressure 78 mm Hg with Doppler stethoscope, pulse Stage:
140 beats per minute and thready, respirations Category of Shock:
8 per minute, and temperature 94°F (34°C). Initial Action:
Stage:
Category of Shock:
Initial Action:

2. A 56-year-old patient with chronic renal failure is agi-

tated. Her blood pressure is 100/92 mm Hg, pulse 110
beats per minute, respirations 18 per minute, and tem-
perature 102°˚F (39°C).
Stage:
Category of Shock:
Initial Action:

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 2. Which of the following does the nurse understand is the
primary reason that respirations increase in compensated
1. Which of the following nursing interventions would the
shock?
nurse use to collect data to determine status of periph-
1. Anxiety causes hyperventilation.
eral tissue perfusion in a 48-year-old patient in shock?
2. Retention of carbon dioxide is decreased.
1. Obtain apical pulse.
3. Normal oxygen levels are maintained.
2. Check capillary refill.
4. Cardiac output is increased.
3. Check for sacral edema.
4. Monitor level of consciousness.
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32 UNIT TWO Understanding Health and Illness

3. With which of the following types of shock would the 5. Which of the following outcomes for the nursing diag-
nurse anticipate the skin to be cold and moist during nosis Deficient Knowledge is appropriate for the patient
data collection? recovering from shock?
1. Compensating 1. Accepts responsibility for shock
2. Progressive 2. States understanding of shock
3. Irreversible 3. Interacts with others
4. Verbalizes fears
4. The nurse is caring for a hypertensive patient whose
blood pressure is usually 156/86. Which of the follow-
ing blood pressures is considered a progressive shock
blood pressure finding for this patient?
1. 90/44
2. 140/80
3. 114/64
4. 130/72

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 8. The nurse is caring for a patient with a bowel obstruc-
tion. Which of the following is the earliest indication
6. The nurse monitors a patient with chronic kidney dis-
that the patient is developing symptoms of shock?
ease who has just returned from completing a hemodial-
1. Blood pressure 88/50 mm Hg
ysis session. The patient’s data before dialysis is as
2. Pulse 110 beats per minute
follows: blood pressure 150/88 mm Hg, pulse 90 beats
3. Lethargy
per minute, respirations 18 per minute, temperature
4. Urine 18 mL/hr
98.9°F (37°C), and weight 168 lb. Patient data obtained
after dialysis is as follows: blood pressure 98/50 mm Hg,
9. The nurse is caring for a postoperative patient follow-
pulse 110 beats per minute, respirations 18 per minute,
ing a splenectomy. Which of the following symptoms
temperature 99°F (37°C), and weight 165 lb. Which of
is of highest priority for the nurse to report?
the following actions should the nurse take after com-
1. Blood pressure 86/52 mm Hg
paring the data?
2. Pulse 100 beats per minute
1. Reweigh the patient.
3. Cool, pale skin
2. Provide a quiet environment so patient may rest.
4. Urine 40 mL/hr
3. Have the health care provider notified of the post-
dialysis data.
10. The nurse is caring for a patient with gastrointestinal
4. Check on the patient in 10 minutes.
bleeding who has an intravenous (IV) infusion of 0.9%
normal saline at 50 mL/hr. The patient has a large, red,
7. A 47-year-old patient is admitted with hypovolemic
bloody stool and reports dizziness. The nurse assists
shock from trauma injuries resulting from an automobile
the patient back to bed and obtains vital signs of blood
accident. The patient remains oliguric 2 days later.
pressure 90/52 mm Hg, pulse 118 beats per minute,
Which of the following assessments of the patient indi-
and respirations 22 per minute. Which of the following
cates to the nurse that the patient is experiencing a com-
actions should the nurse take?
plication of shock that requires follow-up treatment?
1. Continue monitoring vital signs.
1. Hematocrit 42% (normal = 38%–47%)
2. Inform the registered nurse now.
2. Creatinine 2.2 mg/dL (normal = 0.6–1.3 mg/dL)
3. Decrease the IV flow rate.
3. Blood urea nitrogen 24 mg/dL (normal =
4. Elevate the head of the bed.
6–25 mg/dL)
4. Hemoglobin 13.4 g/dL (normal = 13.5–18 g/dL)
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Chapter 9 Nursing Care of Patients in Shock 33

11. Which of the following medications would the nurse 13. The nurse is providing care for a patient with pericar-
anticipate the health care provider may order to in- dial effusion who is at risk for pericardial tamponade.
crease blood pressure for a patient with septic shock? Which of the following symptoms would indicate the
1. Atropine patient was developing obstructive shock? Select all
2. Dopamine that apply.
3. Digoxin (Lanoxin) 1. BP 88/56 mm Hg
4. Nitroglycerin 2. Urine output 100 mL over 6 hours
3. Pulse 66 beats per minute
12. For the patient in hypovolemic shock, place the follow- 4. Respirations 12 per minute
ing interventions in the order of priority in which the 5. Jugular vein distension
nurse should perform them. 6. Confusion and lethargy
1. Record hourly urine output.
2. Apply oxygen.
3. Provide restful environment.
4. Ensure patent airway.
5. Obtain vital signs.
6. Monitor IV fluids.
4069_Ch10_034-036 24/11/14 3:51 PM Page 34

Nursing Care
10 of Patients in Pain

VOCABULARY
Match the term with the appropriate definition or statement.
1. Addiction 1. Whatever the experiencing person says it is
2. Tolerance 2. Endogenous chemicals that act like opioids
3. Ceiling effect 3. Larger dose of analgesic required to relieve
4. Pain same pain
5. Prostaglandin 4. Psychological dependence
6. Adjuvants 5. Self-administered analgesics
7. Opioid 6. Dose of analgesic limited by side effects
8. Patient-controlled anesthesia (PCA) 7. Medications that relieve pain
9. Endorphins 8. Drugs that are used to potentiate analgesics
10. Analgesics 9. Neurotransmitter released during pain
10. A morphine-like drug

CULTURAL COMPETENCE find orders for morphine 5 to 10 mg intravenous push (IVP)

You are working on a medical unit in a large metropolitan every 4 hours as needed (prn) for pain.
area. Your patients come from varied cultural backgrounds. 1. List at least seven areas you will assess related to her
What differences in pain expressions might you expect to see
pain.
in patients from the following cultures?
Native American
European American
African American
Hispanic American 2. Based on your assessment, you discuss administering
Asian American 10 mg of morphine with the registered nurse (RN), who
Arab American will give the intravenous (IV) medication. What class of
drugs does morphine belong to? What is its mechanism
CRITICAL THINKING
of action? Why is it important for you to be aware of
Read the following case study and answer the questions.
these things when the RN is administering the drug?
Ms. Murphy is a 32-year-old woman admitted to your unit
following an emergency appendectomy at 0800. When you
enter her room at 1400, she is sitting up in bed smiling and
visiting with her family. She tells you she is hurting and asks
for her pain medication. You check her medication record and

34
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Chapter 10 Nursing Care of Patients in Pain 35

3. What is the most effective medication schedule that can 6. The next morning you decide to administer Tylenol #3
be implemented today? (acetaminophen 300 mg with codeine 30 mg) for
Ms. Murphy’s pain, but it is not effective. Why do you
think it did not help?

4. What side effects will you watch for?

7. What nondrug therapies might be appropriate for

Ms. Murphy? What technique has already been effective
for her?
5. How will you know if the medication has been effective?

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 4. Which is the most accurate way to assess the severity of
a patient’s pain?
1. Which of the following definitions of pain is most
1. Observe for moaning or other physical signs.
appropriate to use when planning nursing care?
2. Watch for elevated blood pressure and pulse.
1. Knifelike sensation along a nerve pathway
3. Have the patient rate pain on a standard pain scale.
2. Burning sensation that accompanies severe injury or
4. Monitor the frequency with which the patient re-
trauma
quests pain medication.
3. Injured tissues responding with release of neurotrans-
mitters that cause a sensation of pressure or discomfort
5. Which of the following statements best explains why a
4. Whatever the experiencing person says it is, occur-
patient can be laughing and talking and yet still be in
ring whenever the person experiencing it says it does
pain?
1. Most patients try to deny their pain because pain is
2. Which of the following terms describes a feeling of
socially unacceptable.
threat to one’s self-image or life that may accompany
2. Distraction can help relieve pain when used in com-
pain?
bination with analgesics.
1. Fear
3. Most patients who are laughing and talking are not in
2. Anxiety
pain.
3. Suffering
4. Laughing prolongs the effects of opioids in the body.
4. Panic

3. Which of the following is a common side effect of opioid

administration?
1. Constipation
2. Respiratory depression
3. Tachycardia
4. Addiction
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36 UNIT TWO Understanding Health and Illness

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise.
10. A patient has a PCA pump after surgery on his spine.
6. An 82-year-old patient in an extended care facility has He appears to be in pain but is too drowsy to push the
been receiving intramuscular (IM) meperidine (De- button on the pump. Which response by the nurse is
merol) for chronic back pain. After several weeks, the correct?
patient becomes irritable, which is a change from nor- 1. Push the button for the patient.
mal behavior. Which response by the nurse is best? 2. Instruct the patient’s wife to push the button, not to
1. Understand that chronic pain can cause a patient to exceed every 10 minutes.
become irritable. 3. Assess the patient’s vital signs.
2. Obtain an order for an adjuvant sedative to adminis- 4. Increase the dose of medication delivered in each
ter with the meperidine. injection.
3. Request a psychiatric referral to evaluate the
patient’s mental status. 11. A patient with a known history of cocaine abuse is ad-
4. Consult with the RN or health care provider about mitted after a motorcycle accident. He calls you into
changing to a different analgesic. his room and says, “I need something for this pain.
Now.” Which assumption by the nurse is best?
7. A nurse is caring for a patient who reports being in 1. The patient is withdrawing from cocaine and needs
severe pain. The patient has an order for hydrocodone/ an opioid to prevent withdrawal symptoms.
acetaminophen (Vicodin) 2 tabs every 6 hours prn for 2. The patient is in pain and needs an analgesic.
pain. Before providing the medication, which of the 3. The patient is trying to establish control over his
following actions should the nurse take? situation.
1. Verify the patient’s liver and kidney function studies 4. The patient is faking pain to gain access to opioids.
are within normal limits.
2. Determine the patient’s current pulse rate and blood 12. The nurse is providing care for a patient in the emer-
glucose level. gency department who is experiencing a migraine
3. Assess the patient’s pain level and respiratory rate. headache. The patient reports taking two extra-strength
4. Identify the emotional or physical cause of the acetaminophen (Tylenol 500 mg tablets) every 6 hours
patient’s pain. for the past few days. The nurse would be most con-
cerned by which of the following statements by the
8. A patient with severe pain is receiving narcotic pain patient?
medication through the use of a patient-controlled anal- 1. “I usually drink three or four beers a day.”
gesia IV pump. The licensed practical nurse/licensed 2. “My headache pain is six out of ten.”
vocational nurse (LPN/LVN) notes that the patient is 3. “I’m having difficulty sleeping.”
lethargic and difficult to arouse with a respiratory rate 4. “It hurts even worse with these bright lights.”
of seven breaths per minute. After informing the RN,
which of the following drugs does the nurse anticipate
will be ordered?
1. Naloxone (Narcan)
2. Methadone (Dolophine)
3. Hydrocodone with acetaminophen (Vicodin)
4. Phenytoin (Dilantin)

9. A 42-year-old woman has chronic pain for which no

cause can be found. Her physician orders a placebo.
Which response by the nurse to the physician is best?
1. “I will give the placebo and document her response.”
2. “I know if the placebo helps her pain, then her pain is
not real.”
3. “I am not comfortable administering this placebo
without the patient’s consent.”
4. “May we alternate the placebo with her opioid
order?”
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Nursing Care of Patients

With Cancer 11
VOCABULARY
Fill in the blank.
1. Loss of hair is called .
2. Loss of appetite is called .
3. places the patient at risk of infection.
4. Dry mouth is called .
5. Treatment aimed at maintaining comfort is called therapy.
6. is the use of drugs to combat cancer.
7. Substances that poison cells are described as .
8. is the term used to describe new growth.
9. When cancer , it travels to a new site.
10. A tumor that is not cancerous is called .
11. A is done to obtain a tissue sample to detect cancer cells.
12. Agents that prevent damage to healthy cells from chemotherapy or radiation are called
agents.

CELLS
Label each statement as true or false and correct the false statement.

1. Chromosomes are made of DNA and protein.

2. A gene is the code for one DNA molecule.
3. Messenger RNA carries the genetic code to the cell membrane.
4. A genetic change in a cell is called a mutation.
5. Transfer RNA brings amino acids to the proper sites on the DNA.
6. Cells become malignant by mutating.
7. In any human cell, most of the genes are always active.
8. The chromosome number for a human cell is 48.
9. The process of mitosis produces two identical cells with 23 chromosomes each.
10. Mitosis is necessary only for growth of the body.

37
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38 UNIT TWO Understanding Health and Illness

BENIGN VERSUS MALIGNANT TUMORS

Compare the characteristics of benign and malignant tumors. List as many characteristics as you can remember.

CRITICAL THINKING
Delmae is a 48-year-old restaurant worker undergoing chemotherapy following a right modified mastectomy. List two or three
nursing interventions for each of the side effects she can expect to experience.
1. Leukopenia:

2. Thrombocytopenia:

3. Anemia:

4. Stomatitis:

5. Nausea and vomiting:

6. Alopecia:

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 3. Which of the following foods can increase cancer risk?
1. Broccoli, cauliflower
1. Genes are made of which of the following?
2. Butter, ice cream
1. Chromosomes
3. Chicken, fish
2. DNA
4. Cakes, breads
3. RNA
4. Protein
4. A nurse is caring for a patient with a radioactive implant.
How can the nurse avoid unnecessary radiation exposure?
2. Which is the correct term used for a group of similar
1. Avoid entering the patient’s room more than once
cells found on an external or internal body surface?
each 24 hours.
1. Skin
2. Limit the amount of time spent with the patient.
2. Mucous membrane
3. Avoid touching the patient.
3. Epithelial tissue
4. Place a “contaminated” sign on the patient’s bed.
4. Connective tissue
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Chapter 11 Nursing Care of Patients With Cancer 39

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 10. A patient with terminal cancer is referred to hospice for
support. How can hospice help the patient and family?
5. A patient is admitted with suspected lung cancer and
Select all that apply.
asks, “How will my physician know for sure if I have
1. Hospice nurses can help administer curative
cancer?” Which of the following responses is correct?
chemotherapy.
1. “Your physician will do cultures of your sputum.”
2. Hospice supports research efforts in finding cancer
2. “An X-ray examination will be done to confirm the
cures.
diagnosis.”
3. Hospice can help the patient’s family keep the patient
3. “A biopsy is the only way to know for sure.”
comfortable until death.
4. “Your physician will do a bronchoscopy to view the
4. Hospice can help the patient find financial resources
cancer.”
for cancer treatment.
5. Hospice can provide follow-up counseling after the
6. Which of the following nursing interventions will help re-
patient’s death.
lieve symptoms of mucositis related to radiation therapy?
6. Hospice can provide respite care for family mem-
1. Provide frequent mouth care.
bers or caregivers.
2. Offer cold liquids often.
3. Provide high-carbohydrate foods.
11. The nurse is providing care for a patient in an out-
4. Offer juices frequently.
patient surgical center anticipating a needle biopsy of
suspicious nodules in the left lung. The patient asks, “If
7. A patient is receiving chemotherapy after surgery for
they think this might be cancer, why don’t they just cut
prostate cancer. Which of the following signs or symp-
it all out?” Which of the following responses by the
toms indicates that he is experiencing thrombocytopenia?
nurse is best?
1. Fever
1. “Most patients who have lung biopsies don’t end up
2. Petechiae
having cancer.”
3. Pain
2. “Why do they think you have cancer?”
4. Vomiting
3. “The biopsy will determine if you have cancer and,
if so, what treatment is best.”
8. How can the nurse best prevent complications in the pa-
4. “It does seem odd that the doctor didn’t simply
tient with leukopenia? Select all that apply.
schedule surgery.”
1. Wash hands frequently.
2. Avoid injections.
3. Allow no visitors.
4. Provide colony stimulating factors as ordered.
5. Monitor temperature every 4 hours.
6. Offer fresh fruits and vegetables.

9. A patient has severe pain related to bone cancer. The

nurse notes that the patient does not ask for pain med-
ication while watching television. Which of the follow-
ing statements best explains this?
1. Distraction is a good pain relief method and can pre-
vent the need for analgesics.
2. The patient may ask for pain medication when the
television is not on because of boredom.
3. The pain must be psychosomatic because it is re-
lieved by television.
4. Distraction can be a helpful intervention when used
in addition to analgesics.
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Nursing Care of Patients

12 Having Surgery

VOCABULARY
Fill in the blank.
1. are physicians who perform surgical procedures.
2. The three surgical phases are referred to collectively by the term .
3. The phase begins with the admission of the patient to the perianesthesia
care unit (PACU) and continues until the patient’s recovery is completed.
4. is the period when an anesthetic is first given until full anesthesia is reached.
5. The phase begins with the decision to have surgery and ends with transfer
of the patient to the operating room.
6. The phase begins when the patient is transferred to the operating room and
ends when the patient is admitted to the PACU.
7. An agent is medication (such as narcotics, muscle relaxants, or antiemetics)
used with the primary anesthetic agents.
8. The sudden bursting open of a wound’s edges that may be preceded by an increase in serosanguineous
drainage is referred to as .
9. are physicians who administer anesthesia.
10. causes a loss of sensation and allows the surgical procedure to be done safely.
11. occurs from hypoventilation or mucous obstruction that prevents some
alveoli from opening and being fully ventilated.
12. is the removal of necrotic and infected tissue.
13. is a body temperature that is below normal range.
14. is the viscera spilling out of the abdomen.

40
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Chapter 12 Nursing Care of Patients Having Surgery 41

SURGERY URGENCY LEVELS

Match the surgery urgency level to the appropriate definition or example. The level may be used more than once.
1. Surgery needed when any delay jeopardizes the patient’s life or limb 1. Optional surgery
2. Fracture repair 2. Elective surgery
3. Surgery needed within 24 to 30 hours 3. Urgent surgery
4. Extremity emboli 4. Emergency surgery
5. Surgery planned and scheduled without immediate time constraints
6. Surgery done at request of patient
7. Hernia repair
8. Rhinoplasty
9. Infected gallbladder
10. Cosmetic surgery

NOURISHING THE SURGICAL PATIENT INTRAOPERATIVE NURSING DIAGNOSES

AND OUTCOMES
Find the seven errors and insert the correct information.
Write a patient objective (goal) for each nursing diagnosis.
Healing requires increased vitamin A for collagen formation,
1. Risk for Injury related to pressure points from position-
vitamin B12 for blood clotting, and magnesium for tissue
growth, skin integrity, and cell-mediated immunity. Carbohy- ing, chemicals, electrical equipment, and effect of being
drates are essential for controlling fluid balance and manufac- anesthetized
turing antibodies and white blood cells. Hypoalbuminemia,
low urine albumin, impedes the return of interstitial fluid to
the venous return system, decreasing the risk of shock. A
2. Risk for Impaired Skin Integrity related to chemicals,
serum zinc level is a useful measure of protein status.
pressure points from positioning, and immobility
MEDICATIONS
Indicate whether the statement is true or false and correct
the false statement.
3. Risk for Deficient Fluid Volume related to being NPO
1. All medications that patients are taking must be
and blood loss
reviewed preoperatively.
2. Most anticoagulants, such as warfarin
(Coumadin), do not need to be stopped before surgery.
4. Risk for Infection related to incision and invasive
3. Diabetic patients on insulin are told to increase
procedures
their normal insulin dose the day of surgery.
4. Blood glucose monitoring for diabetic patients
is ordered on admission. 5. Pain related to pressure points from positioning, inci-
5. _______ If a patient is on chronic oral steroid therapy, it sion, and surgical procedure
cannot be abruptly stopped when nil per os (NPO).
6. Surgery is not a serious stressor for the body.
7. Chronic oral steroid therapy should be contin-
ued via the parenteral route if the patient is NPO.
8. Circulatory collapse can develop if steroids are
not stopped abruptly.
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42 UNIT TWO Understanding Health and Illness

WOUND HEALING PHASES

Complete the table.

Phase Time Frame Wound Healing Patient Effect

Phase I Fever, malaise
Phase II Granulation tissue forms
Phase III Collagen deposited
Phase IV Months to 1 year

CRITICAL THINKING 5. What is the role of the holding area nurse?

Read the case study and answer the questions.
Mrs. Vell, 74, is scheduled for a total hip replacement because
of osteoarthritis. She is seen in the preadmission testing de-
partment 1 week before surgery.
1. Why is Mrs. Vell being seen in preadmission testing? 6. What is a role of the licensed practical nurse/licensed
vocational nurse (LPN/LVN) in the operating room?

2. What preadmission testing may be done?

7. What are the two prioritized primary responsibilities of
the perianesthesia care nurse?

3. What teaching should the nurse do in preadmission testing?

8. Explain why postoperative care for this patient includes

pain control, deep breathing and coughing, leg exer-
cises, activity, leg abduction, and drain care.
4. What are the responsibilities of the admitting nurse to
prepare Mrs. Vell for surgery?

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 2. When the patient’s signature is witnessed by the nurse
on the surgical consent, which of the following does the
1. Which of the following is an LPN/LVN patient care role
nurse’s signature indicate?
in the preoperative phase?
1. The nurse obtained informed consent.
1. Obtaining preoperative orders
2. The nurse provided informed consent.
2. Explaining the surgical procedure
3. The nurse answered all surgical procedure questions.
3. Offering emotional support
4. The nurse verified that the patient signed the consent.
4. Providing informed consent
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Chapter 12 Nursing Care of Patients Having Surgery 43

3. Which of the following is an intraoperative outcome for 5. Which of the following is one of the discharge criteria
a patient undergoing an inguinal hernia repair? from ambulatory surgery for patients following surgery?
1. Verbalizes fears. 1. Able to drive self home.
2. Maintains skin integrity. 2. Has home telephone.
3. Demonstrates leg exercises. 3. Understands discharge instructions.
4. Explains deep-breathing exercises. 4. IV narcotics given less than 30 minutes before
discharge.
4. Which of the following is a discharge criterion from the
PACU for a patient after surgery?
1. Oxygen saturation above 90%
2. Oxygen saturation below 90%
3. Intravenous (IV) narcotics given less than 15 minutes
earlier
4. IV narcotics given less than 30 minutes earlier

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 10. Which of the following actions should the nurse take to
maintain patient safety when ambulating a patient for
6. The LPN/LVN is caring for a patient in the preoperative
the first time postoperatively?
period who, even after verbalizing concerns and having
1. Use one person to assist patient.
questions answered, states, “I know I am not going to
2. Use two people to assist patient.
wake up after surgery.” Which of the following actions
3. Encourage patient to “dangle” self 1 hour before
should the LPN/LVN take?
ambulation.
1. Reassure patient everything will be all right.
4. Give narcotic 15 minutes before ambulation.
2. Inform the registered nurse.
3. Explain national surgery death rate.
11. The nurse is caring for a patient with a bowel resection.
4. Ask family to comfort the patient.
Which of the following would indicate that the patient’s
gastrointestinal tract is resuming normal function?
7. The nurse understands that which of the following is the
1. Firm abdomen
reason that long-term steroid therapy cannot be abruptly
2. Excessive thirst
stopped?
3. Presence of flatus
1. Higher steroid levels are needed during stress.
4. Absent bowel sounds
2. Malignant hyperthermia will result.
3. Malignant hypertension will occur.
12. The patient is dangling at the bedside and states, “Oh,
4. Respiratory failure will result.
my stomach is tearing open.” Which of the following
actions should the nurse immediately take when dehis-
8. The nurse is to provide preoperative teaching for a 74-year-
cence occurs?
old patient. Which of the following actions should the
1. Have patient sit upright in a chair.
nurse take to improve learning?
2. Slow IV fluids.
1. Sit in front of window in bright sunlight.
3. Have patient lie down.
2. Use small, white-on-black printed materials.
4. Obtain a sterile suture set.
3. Speak in a high tone.
4. Eliminate background noise.
13. When the nurse is assisting the patient to use an incen-
tive spirometer, which of the following actions by the
9. The nurse is caring for a postoperative patient. Which of
patient indicates that the patient needs further teaching
the following complications would the nurse explain to
on how to use the spirometer?
the patient can be prevented with early postoperative
1. Taking two normal breaths before use
ambulation?
2. Inhaling deeply to reach target
1. Increased peristalsis
3. Sitting upright before use
2. Coughing
4. Exhaling deeply to reach target
3. Pneumonia
4. Wound healing
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44 UNIT TWO Understanding Health and Illness

14. After surgery, the nurse notes that the patient’s urine is 15. The patient develops a low-grade fever 18 hours post-
dark amber and concentrated. Which of the following operatively and has diminished breath sounds. Which
does the nurse understand may be the reason for this? of the following actions is most appropriate for the
1. The sympathetic nervous system saves fluid in re- nurse to take to prevent complications? Select all that
sponse to stress of surgery. apply.
2. The sympathetic nervous system diureses fluid in 1. Administer antibiotics.
response to stress of surgery. 2. Encourage coughing and deep breathing.
3. The parasympathetic nervous system saves fluid in 3. Administer acetaminophen (Tylenol).
response to stress of surgery. 4. Decrease fluid intake.
4. The parasympathetic nervous system diureses fluid 5. Ambulate patient as ordered.
in response to stress of surgery. 6. Monitor intake and output.
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Nursing Care of Patients

With Emergent Conditions
and Disaster/Bioterrorism
13
Response
VOCABULARY
Match the word with its definition.
1. Skin scraped away because of injury. 1. Asphyxia
2. Disease caused by organism entering body through an open 2. Tetanus
3. Abrasion
wound resulting in convulsions, muscle spasms, stiffness of the
4. Laceration
jaw, coma, and death. 5. Shock
3. Insufficient intake of oxygen. 6. Amputation
4. Inadequate and progressively failing tissue perfusion that can 7. Heat exhaustion
8. Frostbite
result in cellular death.
9. Anthrax
5. Irregular tear of the skin. 10. Plague
6. Loss of water and electrolytes through heavy sweating, causing
hypovolemia.
7. Tearing away or crushing of body limbs.
8. Frozen body parts that are white or yellow-white.
9. A biological weapon that may occur in three forms: inhala-
tional, cutaneous, and gastrointestinal.
10. A biological weapon that can result in a severe febrile illness
with hemoptysis as a classic sign.

PRINCIPLES FOR TREATING SHOCK

Indicate whether the statement is true or false and correct the false statement.

1. Maintain an open airway and give oxygen as ordered.

2. Control external bleeding by indirect pressure.
3. Apply cooling blanket to cool patient.
4. As possible, keep the patient supine.
5. Take hourly vital signs.
6. Give the patient oral fluids.
7. Administer intravenous (IV) fluids as ordered.

45
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46 UNIT TWO Understanding Health and Illness

SIGNS AND SYMPTOMS OF INCREASED INTRACRANIAL PRESSURE

Indicate whether the sign is an early sign or a late sign of increased intracranial pressure.

1. Abnormal posturing 1. Early sign

2. Altered level of consciousness 2. Late sign
3. Amnesia
4. Changes in respiratory pattern
5. Changes in speech
6. Decreased pulse rate
7. Dilated nonreactive pupils
8. Drowsiness
9. Headache
10. Nausea and vomiting
11. Unresponsiveness
12. Widening pulse pressure

ASSESSMENT OF MOTOR FUNCTION

Complete the table.

If the Patient Is Unable to: The Lesion Is Above the Level of:
C-5 to C-7
Extend and flex legs
Flex foot, extend toes
S-3 to S-5

HYPERTHERMIA
Indicate whether the sign is an early sign or a late sign of hyperthermia caused by exposure to a hot environment.

1. Core body temperature of 100.4° to 102.2°F (38°–39°C) 1. Early sign

2. Diaphoresis 2. Late sign
3. Hot, dry, flushed skin
4. Hypotension
5. Pulse rate more than 100
6. Increasing body core temperature of 106°F (41°C) or more
7. Cool, clammy skin
8. Altered mental status
9. Coma or seizures
10. Dizziness

PRINCIPLES FOR DISASTER 4. The emergency department serves as the

OR BIOTERRORISM RESPONSE and area.
Fill in the blank. 5. Those treated first are the most injured but
who have the greatest chance for recovery.
1. A disaster existing personnel, facilities, and
6. Disaster are conducted on a regular basis.
equipment.
7. You should be with your
2. Hospitals activate in a disaster.
in a disaster.
3. In a disaster, off-duty staff members are ,
8. Clinical illness from a biological weapon may differ
and noncritical patients are .
from infections.
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Chapter 13 Nursing Care of Patients With Emergent Conditions and Disaster/Bioterrorism Response 47

CRITICAL THINKING 3. Why should Mr. Harvey be referred for treatment?

Read the case study and answer the questions.

Mr. Harvey, age 66, retired 1 year ago and made plans to
travel with his wife. His wife unexpectedly died from a my-
ocardial infarction 2 months ago. Mr. Harvey now lives
alone. He has been withdrawn and rarely leaves the house
since his wife’s funeral. His son, Ted, who lives in another 4. What nursing diagnoses apply to Mr. Harvey?
state, arrives for a weekend visit and is concerned about his
father’s behavior. Mr. Harvey has not bathed and is wearing
soiled clothing. The refrigerator is bare, and he keeps the cur-
tains drawn. He continually paces and says, “I want to die.”
Ted takes his father to the local emergency room.
5. What nursing interventions are appropriate for Mr. Harvey
1. Why might Mr. Harvey be exhibiting this behavior initially?
change?

2. What symptoms of an acute psychiatric episode is

Mr. Harvey exhibiting?

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 3. During data collection, which of the following findings
1. For a patient who experiences anaphylactic shock after would indicate to the nurse that severe blood loss has
receiving a medication, which one of the following occurred?
symptoms would the nurse anticipate? 1. Normal, bounding pulse
1. Chest pain 2. Slow, strong pulse
2. Hot, dry skin 3. Rapid, thready pulse
3. Difficulty breathing 4. Slow, bounding pulse
4. Fever

2. The nurse is assessing a patient’s extremity, which may

be fractured. Which of the following is the nurse’s pur-
pose in checking capillary refill during the assessment?
1. To evaluate arterial blood flow in an extremity
2. To assess venous blood flow in an extremity
3. To measure oxygen saturation of the blood
4. To assess peripheral edema
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48 UNIT TWO Understanding Health and Illness

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 9. The nurse is admitting a trauma patient to the emer-
gency department. Place in order of priority the areas
4. Which of the following monitoring is a priority for the
on which data are collected as the nurse performs the
nurse when caring for a patient with botulism exposure?
primary survey. Use all options.
1. Gag reflex
1. Circulation
2. Pupil response
2. Breathing
3. Corneal reflex
3. Airway
4. Babinski’s response
4. Disability
5. The nurse anticipates that treatment for an unconscious
10. The nurse is caring for a patient who is bleeding from
patient who has ingested 50 tablets of alprazolam
the radial artery. The nurse is applying direct pressure
(Xanax), a noncaustic substance, might include which
to the radial artery and has elevated the arm, but the
of the following?
wound continues to bleed. Which of the following
1. Administering an antiemetic
actions should the nurse take now?
2. Administering activated charcoal
1. Apply pressure to the carotid artery.
3. Forced vomiting
2. Apply pressure to the brachial artery.
4. Forcing fluids
3. Apply pressure to the femoral artery.
4. Apply pressure to the temporal artery.
6. The nurse is planning care for a patient who has hyper-
thermia. Which of the following indicates that treatment
11. The nurse is caring for a patient with a painful rash on
is effective?
the face and forearms who is febrile. Which of the fol-
1. Core body temperature less than 94°F (34.4°C)
lowing items is important for the nurse who is unvacci-
2. Patient alert and oriented
nated to use while providing care to the patient? Select
3. Skin cool and moist to touch
all that apply.
4. Core body temperature greater than 101°F (38.3°C)
1. Mask
2. Gown
7. The health care provider orders haloperidol (Haldol)
3. Gloves
3 mg intramuscularly for a patient who is experiencing
4. Fit-tested N95 respirator
a psychiatric crisis. Haloperidol 5 mg/mL is available.
5. Shoe covers
How many milliliters should the nurse give?
6. Hair net
1. 0.3 mL
2. 0.5 mL
3. 0.6 mL
4. 1.3 mL

8. The nurse is collecting data on a patient with a large

bleeding laceration. Which of the following requires
immediate intervention by the nurse?
1. Thready pulse at 116
2. Strong pulse at 84
3. Weak pulse at 56
4. Bounding pulse at 66
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unit THREE

Understanding Life
Span Influences on
Health and Illness
CHECKLIST FOR LEARNING SUCCESS
Influences on Health Nursing Care of Older Nursing Care of Patients Nursing Care of Patients
and Illness Adult Patients at Home at the End of Life
❑ Health, wellness, illness ❑ Physiological aging ❑ Introduction to home health ❑ Identifying impending
❑ Nurse’s role in supporting changes nursing death
and promoting wellness ❑ Cognitive and psychological ❑ History of home health ❑ Advance directive
❑ Young adult aging changes nursing ❑ Living wills
❑ Middle-aged adult ❑ Health promotion for ❑ Home health eligibility ❑ Durable medical power
❑ Older adult older patients ❑ Home health care team of attorney
❑ Chronic illness ❑ Nursing implications ❑ Transition from hospital- ❑ End-of-life choices
❑ Nursing care for older patients based nursing to home ❑ Communicating with
health care dying patients
❑ The role of the LPN/LVN ❑ The dying process
in home health ❑ Grieving
❑ Steps in the home health visit
❑ Nursing process: the home
health patient
❑ Other forms of home health
nursing
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Developmental
14 Considerations in the
Nursing Care of Adults
VOCABULARY
Unscramble the word that fits the definition.
1. Short-term intermittent rest provided to caregivers—serptei crea
2. Perception that one’s own actions will not affect an outcome—wporelsesesns
3. Condition of long duration—rhcnoic
4. Life principles that pervade one’s being—sitrpiauilty
5. State in which person sees no alternatives or choices—pohelesnsses
6. A certain time frame during one’s life containing tasks an individual needs to accomplish for high-level
wellness—evdlepoemnatl taseg

CHRONIC ILLNESS AND THE OLDER ADULT CRITICAL THINKING

Find and correct the eight errors. Read the case study and answer the questions.
Mrs. Martin is hospitalized for an exacerbation of her multi-
Older adults constitute one of the smallest age groups living
ple sclerosis. She tells the nurse she is tired of being ill and
with chronic illness. Older adult spouses or older family
is not getting any better. She says, “When I am in the hospital,
members rarely have to care for a chronically ill family mem-
I cannot attend church, which is my only enjoyment.” Later
ber. Children of older adults who themselves are reaching
in the day, Mrs. Martin is tearful and withdrawn when the
their 40s are being expected to care for their parents. These
nurse makes rounds.
older adult caregivers do not experience chronic illness them-
selves. For older adult spouses, it is usually the less ill spouse 1. What further data collection should the nurse obtain to
who provides care to the other spouse. The older adult family identify Mrs. Martin’s patient-centered needs?
unit is at great risk for ineffective coping or further develop-
ment of health problems. Nurses should assess ill members
of the older adult family to ensure that their health needs are
being met. 2. What possible nursing diagnoses would be appropriate
Older adults are not concerned about becoming dependent for Mrs. Martin?
and a burden to others. They may become depressed and give
up hope if they feel that they are a burden. Establishing long-
term goals or self-care activities that allow them to participate
or have small successes are important nursing actions that
can decrease their self-esteem.

50
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Chapter 14 Developmental Considerations in the Nursing Care of Adults 51

3. What patient-centered care interventions could the nurse 4. How would the nurse know that Mrs. Martin’s goal has
use to assist Mrs. Martin in meeting her wish to attend been met?
church?

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 4. The nurse is assigned to care for a group of patients with
the following conditions. Which of these does the nurse
1. The nurse is caring for a 72-year-old patient. As the
understand is an example of a chronic illness to plan
nurse identifies the patient’s developmental stage, which
patient-centered care?
of the following of Erikson’s developmental stages
1. Arthritis
would the nurse expect the patient to be in?
2. Bowel obstruction
1. Generativity versus self-absorption
3. Cellulitis
2. Identity versus role confusion
4. Peritonitis
3. Intimacy versus isolation
4. Integrity versus despair
5. The nurse is caring for a patient with a chronic illness.
The nurse would evaluate the patient as fulfilling a pri-
2. The nurse is assessing the family of a patient with
mary task that patients who are chronically ill need to
dementia. Which of the following findings would the
perform if the patient reported doing which of these
nurse anticipate finding for caregivers of patients who
actions?
are chronically ill when respite care is not available?
1. Being willing and able to carry out the medical
1. Personal time increases.
regimen
2. Rest time increases.
2. Reducing social activities to compensate for
3. Financial costs increase.
limitations
4. Stress levels increase.
3. Learning how to play the sick role
4. Refusing to accept negative changes
3. The nurse is planning care for a patient with heart fail-
ure. Which of the following is a health promotion
method for the nurse to use that is helpful for the patient
who is chronically ill?
1. Making the choices for the patient
2. Setting the goals for the family
3. Setting the goals for the patient
4. Allowing the patient to make informed decisions

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 7. The nurse is developing a plan of care for a patient,
age 68, focusing on preventive health care. While
6. The nurse is assigned to care for a group of patients.
planning this care, the nurse understands that aging
Which of these does the nurse understand is an example
processes are most affected by which of the following
of a congenital chronic illness to plan patient-centered
factors?
care? Select all that apply.
1. Stress management
1. Head injury
2. Financial issues
2. Malabsorption syndrome
3. Age at retirement
3. Chronic obstructive pulmonary disease
4. Hobbies
4. Arthritis
5. Cystic fibrosis
6. Spina bifida
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52 UNIT THREE Understanding Life Span Influences on Health and Illness

8. A patient, age 64, is active and wants to learn health 11. The nurse is caring for a patient who is secluded and
promotion interventions. Which of the following ac- sad. Which of the following nursing actions might be
tions by the nurse supports the patient’s desire for self- MOST helpful for psychosocial intervention for the
health promotion? patient who is withdrawn, depressed, or tense because
1. Assign responsibilities for the patient’s care to fam- of isolation resulting from a chronic illness?
ily members. 1. Avoiding the use of humor
2. Select a family physician for the patient. 2. Reading comics or jokes from magazines
3. List health care activities for the patient to carry out. 3. Maintaining a serious demeanor
4. Ask the patient to select desired health care activities. 4. Limiting conversation to a minimum

9. The home care nurse is caring for a patient with em- 12. The nurse is caring for a patient who is chronically ill.
physema who seems depressed. Which of the follow- In contributing to the plan of care for the patient who is
ing nursing interventions increases the patient’s chronically ill, which of the following is an appropriate
participation in self-care and assists with improving the nursing intervention designed to empower the patient?
patient’s depression? 1. Provide educational information.
1. Being a caretaker instead of a partner 2. Limit visiting hours for family members.
2. Assisting the patient rather than doing everything 3. Ask family members to provide care.
for the patient 4. Set goals for the patient and family.
3. Performing activities of daily living for the patient
instead of empowering the patient 13. The nurse is caring for a patient with Huntington’s
4. Doing everything for the patient instead of assisting disease. The family asks what the cause of the illness
the patient is. Which of the following responses is most appropri-
ate by the nurse?
10. The nurse is caring for a patient who is recovering 1. “Huntington’s disease is a genetic disorder; the
from a stroke. Which of the following nursing inter- family may want to consider genetic testing.”
ventions during rehabilitation will MOST increase the 2. “Huntington’s disease is a congenital disorder that
patient’s self-esteem? developed in the womb.”
1. Offering praise for small patient efforts 3. “Huntington’s disease is an acquired disorder
2. Offering praise for major patient efforts caused by smoking.”
3. Performing activities of daily living for the patient 4. “Huntington’s disease is common among people
4. Assisting patient at first sign of difficulty with ac- over age 65, but the cause is unknown.”
tivities of daily living
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Nursing Care of Older

Adult Patients 15
VOCABULARY
Fill in the blank with the word for the definition.
1. Behaviors that are performed in the care and maintenance of
self and surroundings
2. Irregular heart rhythm
3. Opacity of the lens of the eye, its capsule, or both
4. State of feeling or mind
5. Accidental drawing of foreign substances into the airway
6. Collection of excess fluid in body tissues
7. A group of eye diseases characterized by increased intraocular pressure
8. The act or process of coughing up materials from the air passageways
leading to the lungs
9. A condition of sluggish or difficult bowel action/evacuation
10. The body’s attempts to maintain a balance whenever a change occurs
11. Abnormal accumulation of fibrosis connective tissue in skin, muscle, or
joint capsule that prevents normal mobility
12. An open sore or lesion of the skin that develops because of prolonged
pressure against an area
13. Excessive urination at night
14. External variables that determine the occurrence and rate of structural
and functional declines in the human body over time
15. Age-related breakdown of the macular area of the retina of the eye, dis-
rupting central vision
16. A condition in which there is a reduction in the mass of bone per unit volume
17. None or minimal stimulation of senses that creates potential for mal-
adaptive coping
18. Highest level of patient activity considering the patient’s condition
19. A process to orient a person to names, dates, time, and other pertinent in-
formation through use of repeating messages
20. Excessive stimulation of the senses that creates the potential for maladap-
tive coping

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54 UNIT THREE Understanding Life Span Influences on Health and Illness

AGING CHANGES
Match the aging change with the effect of the change.

1. Increased conduction time 1. Heart rate slows, unable to increase quickly

2. Decreased blood vessel elasticity 2. Less oxygen delivered to tissues
3. Leg veins dilate, valves become less efficient 3. Increased blood pressure and cardiac workload
4. Basal metabolic rate slows 4. Poor heart oxygenation
5. Decreased cardiac output 5. Varicose veins, fluid accumulation in tissues
6. Decreased insulin release 6. Possible weight gain
7. Irregular heartbeats 7. Decreased ability to respond to stress
8. Altered adrenal hormone production 8. Hyperglycemia
9. Decreased gag reflex 9. Appetite may be reduced
10. Decreased peristalsis 10. Dry mouth, altered taste
11. Reduced liver enzymes 11. Increased aspiration risk
12. Decreased saliva 12. Frequency of urination
13. Delayed gastric emptying 13. Reduced drug metabolism/detoxification
14. Decreased bladder size and tone, changes 14. Reduced appetite, constipation
from pear to funnel shaped
15. Decreased kidney concentrating ability 15. Nocturia
16. Less sodium saved 16. Risk of dehydration
17. Reduced renal blood flow 17. Decreased renal clearance of all medications
18. Decreased immune function 18. Greater infection and cancer risk
19. Body content water loss 19. Slower healing process
20. Decreased sebaceous/sweat gland 20. Dryness of the skin
21. Reduced cell replacement 21. Decreased temperature regulation
22. Muscle responses slowed 22. Response time increased
23. Decreased brain blood flow 23. Short-term memory loss
24. Less vaginal lubrication 24. Risk of injury, burns
25. Decreased sensation 25. Dyspnea with activity
26. Decreased lung capacity 26. Painful intercourse

COMMUNICATING WITH PEOPLE WHO HAVE MEDICATIONS

HEARING IMPAIRMENTS Find the six errors and correct them.
Indicate whether the statement is true or false and correct
false statements. Older patients are less susceptible to drug-induced illness and
adverse medication side effects for various reasons. They take
1. Ensure that hearing aids are turned on and
few medicines for the one chronic illness that they have. Dif-
have working batteries.
ferent medications interact and produce side effects that can
2. The speaker should turn to the side so the
be dangerous. Over-the-counter medicines that older patients
speaker’s profile is visible to patient.
take, as well as the self-prescribed extracts, elixirs, herbal
3. Speak toward the patient’s impaired side of
teas, cultural healing substances, and other home remedies
hearing.
commonly used by individuals of their age cohort do not in-
4. Speak in a clear, moderate-volume, low-
fluence other medications.
pitched tone.
If an older patient crushes a large enteric-coated pill so it
5. Do not shout because doing so distorts sounds.
can be taken in food and is easily swallowed, it enhances the
6. Recognize that high-frequency tones and con-
enteric protection and can inadvertently cause damage to the
sonant sounds are lost last—s, z, sh, ch, d, g.
stomach and intestinal system. Some patients unintentionally
7. Eliminate background noise because it dis-
skip prescribed doses in an effort to save money. When pre-
torts sounds.
scribed doses are not being taken as expected, problems do
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Chapter 15 Nursing Care of Older Adult Patients 55

not clear up as quickly, and new problems may result. The 2. What influences your feelings?
nurse should educate the older patient and the patient’s fam-
ily. Patients need to know what each prescribed pill is for,
when it is prescribed to be taken, and how it should be taken.

CRITICAL THINKING 3. What is the first thing that you would do after this
discovery?
Read the following case study and answer the questions.
This is a values clarification exercise.
While making 2200 rounds in the extended care facility, the
nurse looks into Mr. B’s room to find Mr. B and a female res-
ident from down the hall together, sleeping soundly in 4. What issues should you consider before making a
Mr. B’s bed with the side rails up. Mr. B and the female res- decision?
ident are both 63 years of age. Mr. S, who is Mr. B’s room-
mate, is sound asleep alone in his own bed.

1. What are your initial feelings about this situation?

5. How will you interact with these patients in the future?

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 3. Which of the following actions should be taken to help
1. The nurse understands that wax buildup in an older an older person prevent osteoporosis?
patient’s ears can cause which type of hearing loss? 1. Decrease dietary intake of calcium.
1. Sensorineural 2. Encourage regular exercise.
2. Bone conduction 3. Increase dietary intake of salt.
3. Perceptive 4. Increase dietary protein intake.
4. Neural

2. The nurse understands that which of the following fac-

tors is most often the cause of sexual dysfunction for
older people?
1. Physical factors
2. Psychological factors
3. Social factors
4. Environmental factors

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 5. As the nurse performs an oral assessment on an 84-year-
old patient, which of the following is an expected find-
4. A 72-year-old patient has been seeing a doctor for treat-
ing within the patient’s mouth caused by advancing age?
ment of glaucoma for the past 5 years. Which of the fol-
1. Loss of teeth
lowing symptoms does the nurse expect the patient to
2. Hardness of the gums
relate when discussing the symptoms?
3. Increased production of saliva
1. Headaches more severe in the evening
4. Decreased taste sensitivity for salt
2. Blurred vision when attempting to focus
3. Morning headaches that disappear after rising
4. Increased sensitivity to light in the early morning
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56 UNIT THREE Understanding Life Span Influences on Health and Illness

6. As the nurse collects data on a 79-year-old patient, 10. A nurse is working in an extended care facility. Which
which of the following does the nurse recognize as an of the following nursing behaviors demonstrates the
aging change in the cardiovascular system? nurse’s respect for the older patient’s sexuality?
1. Increased cardiac output 1. Providing privacy time for a patient by enclosing
2. Increased peripheral vascular resistance the bed with the curtain and ensuring that the pa-
3. Increased resting heart rate tient is undisturbed for an hour
4. Increased cardiac reserve 2. Entering a patient’s room without knocking when a
visitor is present
7. Which of the following does the nurse understand is the 3. Walking in on a patient and visitor during an em-
rationale for dangling a 70-year-old patient at the bed- brace to prepare medications
side before helping the patient to stand upright? 4. Changing the subject when a patient expresses feel-
1. To provide a heightened awareness of body position ings toward a friend
2. To accommodate a less efficient circulatory system
3. To strengthen legs 11. A nurse caring for a number of older clients on a med-
4. To reduce anxiety about getting up ical unit recognizes that which of the following indi-
viduals would be at highest risk for using a prescription
8. As the nurse provides care to an 80-year-old patient with medication considered inappropriate?
an intravenous (IV) infusion, the nurse understands that 1. A 60-year-old college professor recently diagnosed
it is essential for older patients who are receiving IV with diabetes admitted with cellulitis.
fluids to be monitored closely to prevent which of the 2. A 72-year-old high school dropout who suffered
following? double below-the-knee amputations in the Korean
1. Circulatory distress War admitted with a decubitus ulcer.
2. Dislodging of the IV 3. A 76-year-old retired lawyer with a history of hy-
3. Venous distention pertension and chronic renal failure admitted for
4. Increased urinary output dehydration.
4. An 81-year-old retired teacher with a history of
9. The nurse is talking with a patient who is hard of hear- colorectal cancer admitted for a colonoscopy.
ing and is having the most difficulty with high-pitched
tones. To increase the patient’s hearing, which of the
following should the nurse do when speaking with the
patient?
1. Speak slowly with emphasis on important words.
2. Double the voice volume.
3. Whisper responses in proximity to the patient’s ear.
4. Use a modulated voice and talk normally in either ear.
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Nursing Care of Patients

at Home 16
VOCABULARY
Match the term to the correct definition.
1. Autonomous 1. Care that can only be delivered by a licensed
2. Case management professional nurse
3. Certified 2. Occurs when a patient is unable to leave his or
4. Collaborative care her home to obtain necessary health services
5. Community resources 3. To work together to achieve a goal
6. Homebound 4. Coordinates care among patient, health care
7. Private duty provider, and caregivers
8. Respite care 5. A health care provider’s order that allows home
9. Skilled nursing health services to care for a patient for 60 days
10. Start of care 6. To work independently
7. Available to a home health patient to improve
his or her quality of care; usually coordinated by
a social service worker
8. Scheduled care to assist the patient with personnel
and homemaking needs
9. Begins on the first day of nursing services
10. Provides family members and caregivers time
to take care of themselves

HOME HEALTH SERVICES

Match the home health services/role to the appropriate
definition.

1. Social services 1. Assists the patient with activities of daily living (ADLs)
2. Physical therapy 2. Develops the plan of care and manages the care of the
patient during home health services
3. Occupational therapy
3. Assists the patient with developing independence with
4. Registered nurse ADLs
5. Certified nursing assistant 4. Assists the patient with access to community resources
6. Licensed practical nurse/licensed vocational 5. Assists the patient with strength and gait training
6. Works with language, speech, swallowing
nurse (LPN/LVN)
7. Team leader
7. Speech therapist 8. Makes home visits and performs skilled nursing care.
8. Health care provider
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58 UNIT THREE Understanding Life Span Influences on Health and Illness

CRITICAL THINKING 2. What services will the home health nurse be performing?

Read the following case study and answer the questions.

Mrs. Thompson was just discharged from the hospital after
an exacerbation of her respiratory disease. Her health history
includes chronic obstructive pulmonary disease (COPD),
type 2 diabetes, and coronary artery disease (CAD). She is 3. What are some safety considerations for Mrs. Thompson?
receiving O2 therapy at 2 L/minute via nasal cannula. She has
a skin tear on her right lower extremity requiring dressing
changes every other day for 4 weeks. The physician increased
her heart medications to include a beta blocker for heart rate
4. Would Mrs. Thompson benefit from any other home
control.
Mrs. Thompson lives alone and has verbalized to the health services?
registered nurse (RN), on admission, that it is difficult for her
to prepare meals and “get around the house.” She has one
married daughter who lives locally and works full time.

1. How often will Mrs. Thompson require skilled nursing

services?

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 3. When providing care to a patient in the patient’s home,
1. Which of the following nursing leaders demonstrated the the nurse understands that which of the following
impact nurses can have with the care and improvement persons is in control of the home care environment?
of patients in the home? 1. Family
1. Florence Nightingale 2. Health care provider
2. Clara Barton 3. Nurse
3. Lillian Wald 4. Patient
4. Jean Watson

2. A patient has just been discharged from the hospital

after open heart surgery. The patient’s spouse is the
primary caregiver and confides that handling all of the
finances, the patient’s complex medication regime,
assistance with ADLs, and general household manage-
ment is a concern. Which of the following would be an
appropriate nursing diagnosis for the patient’s spouse?
1. Ineffective Coping
2. Powerlessness
3. Ineffective Health Maintenance
4. Risk for Caregiver Role Strain
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Chapter 16 Nursing Care of Patients at Home 59

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 9. The LPN is visiting a patient to check blood glucose
and administer insulin. As the LPN obtains the insulin
4. The nurse is making a first-time visit to a patient at
from the refrigerator where the patient stores it, the
home. Which of the following techniques could the
LPN observes that dirty dishes are stacked in the
home health nurse use to develop trust with the patient?
kitchen sink, and there is only a moldy opened can
1. Review patient’s history to plan patient needs before
of soup, a sandwich, and cat food in the refrigerator.
visit.
Which of the following actions should the LPN take
2. Call the night before the visit to set a time for the
regarding the visit findings?
visit.
1. Inform the RN of the moldy and sparse food.
3. Acknowledge patient’s fears that are expressed.
2. Tell the patient to wash the dishes.
4. Discuss treatment plans with the patient only.
3. Notify the RN that the patient is eating cat food.
4. Wash the dirty dishes.
5. The nurse collects safety data on an initial visit to the
home of a patient who has returned home from the hos-
10. Which of the following could the nurse do to prepare
pital and has an infected abdominal wound requiring
for a home health visit and ensure that it is a safe and
dressing changes. Which of the following interventions
effective visit? Select all that apply.
should the nurse include in the plan of care to promote
1. Give the patient a time range for arrival.
safety in the home? Select all that apply.
2. Provide an exact time for arrival.
1. Explain to the patient never to get out of bed without
3. Obtain driving directions to the patient’s home.
assistance.
4. Park in the patient’s driveway.
2. Instruct a family member to be available at all times
5. Keep gas tank filled.
to assist with ambulation.
6. Carry a whistle.
3. Clean the patient’s home each visit to maintain asepsis.
4. Instruct the family to remove all scatter rugs.
11. The nurse is visiting an 89-year-old woman in the
5. Ask family to install handrails in the hallway for
home to assess the need for skilled nursing care after
ambulation.
a fall resulting in a broken collarbone. Which of the
6. Clear walkways of all clutter.
following should be included in the nurse’s initial
visit? Select all that apply.
6. The nurse arrives at a patient’s home. Which of the
1. Identify fall risks in the home environment.
following interventions performed by the nurse would
2. Observe the patient perform activities of daily
demonstrate understanding of the importance of
living.
following infection control principles in the home?
3. Collect baseline vital signs.
1. Setting the nurse’s home health bag on the floor
4. Obtain a urine sample for culture and sensitivity.
2. Cleaning supplies after each home health visit
5. Review patient medications and schedule.
3. Hand washing in the patient’s kitchen sink
4. Using dressing supplies sitting opened on a table

7. The nurse is to give a patient morphine 8 mg intra-

muscular for pain. The nurse has available 10 mg of
morphine/mL. How many mL will the nurse give?
mL

8. The nurse is making a home visit to a 68-year-old

patient and is reinforcing medication teaching that was
done in the hospital setting. The nurse understands that
the teaching will be more effective with which of the
following techniques? Select all that apply.
1. Provide a long teaching session.
2. Include a support person.
3. Make instructions simple.
4. Provide demonstration.
5. Repeat instructions often.
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Nursing Care of Patients

17 at the End of Life

VOCABULARY
Fill in the blank.
1. Part of an advance directive is a document instructing caregivers in patients’ medical preferences at end
of life, called a .
2. A document specifies who can make decisions for a patient
when the patient can no longer make decisions.
3. Patients qualify for care when their prognosis is 6 months or less.
4. Care of the body after death is called .
5. The nurse who communicates patients’ and families’ wishes to the health team is acting as a patient
.

TRUE OR FALSE?
Indicate whether the statement is true or false and correct false statements.

1. Older adult patients usually gain weight while undergoing treatment in a hospital.
2. Only a few health insurance companies provide a hospice benefit.
3. Insomnia, headaches, and fatigue can be a sign of grief in nurses.
4. Dehydration in dying patients causes endorphins to be released that will enhance comfort.
5. Patients who live longer than 6 months while on hospice will be discharged from the hospice program.
6. Terminal illness is experienced by the whole family.
7. To improve the chance of success for patients receiving cardiopulmonary resuscitation (CPR) at the time of
cardiac arrest, CPR must be started within 8 minutes.
8. One benefit of withholding artificial fluids in patients who are actively dying is fewer pharyngeal and lung
secretions.
9. Eighty percent of communication with terminal patients and their families is nonverbal.
10. Confusion and agitation are two common indicators that older adult patients are approaching the end of life.

60
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Chapter 17 Nursing Care of Patients at the End of Life 61

CRITICAL THINKING 3. Copious oral secretions

Read the following case study and answer the questions.

Your patient, Mrs. Brown, is actively dying from end-stage

lung cancer. List at least two nursing interventions that may 4. Body temperature changes
be helpful to treat each symptom she is experiencing:
1. Dyspnea

5. Restlessness

2. Bowel and bladder incontinence

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 3. A dying patient’s family members are upset and crying.
Which action by the nurse will best help the family?
1. Research on patients with dementia who received
1. Sustain eye contact and encourage them to talk about
tube feedings revealed which of the following risks?
their concerns.
1. The risk of aspiration was decreased.
2. Ask them to speak quietly so as not to disturb the
2. The risk of aspiration was increased.
other patients.
3. The patients gained excess weight.
3. Tell them for the sake of their loved one, they need to
4. Pressure ulcers healed more quickly.
compose themselves.
4. Move them to another room away from the patient.
2. What question can be most effective in finding out the
patient’s understanding of the severity of the illness
he or she is experiencing?
1. “How do you feel about your illness?”
2. “How is your family coping with your illness?”
3. “What has the doctor told you about your illness?”
4. “What would you like to do about your illness?”

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 5. A patient has just been pronounced dead. What is the first
action the nurse should take?
4. A family member asks why a dying patient is receiving
1. Contact the nursing supervisor.
morphine when the patient doesn’t appear to be in any
2. Remove the patient’s tubes and create a clean, peaceful
pain. Which response by the nurse is best?
impression for the family.
1. “Morphine helps make patients less aware of their
3. Make sure the patient gets to the funeral home within
surroundings.”
12 hours for embalming.
2. “Morphine helps patients breathe more comfortably.”
4. Move the patient out of the hospital room to the
3. “Morphine helps keep body temperature under
morgue.
control.”
4. “Morphine helps patients sleep.”
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62 UNIT THREE Understanding Life Span Influences on Health and Illness

6. A dying patient appears confused and keeps saying he sees 9. The family of a patient who is terminally ill asks a
his wife who died 10 years earlier. The family appears nurse if they may bathe their loved one after death,
upset by this. What teaching should the nurse provide? in keeping with their cultural traditions. Which
1. Teach them to redirect the patient and gently remind response is best?
him that his wife died long ago. 1. “You should concentrate on the time you have left
2. Explain that this happens because of the medications together.”
that the patient is receiving. 2. “Your cultural traditions are important and will be
3. Explain that this is a common occurrence and encour- supported by our staff.”
age them to allow him to talk about his experience. 3. “Our staff will make sure the patient is clean and
4. Explain that this can occur when the brain is deprived bathed.”
of oxygen and then get an order for oxygen if the 4. “That won’t be necessary, because the funeral home
patient does not already have it. takes care of bathing the patient.”

7. An older patient with chronic disease is very weak and 10. The family members of a patient with terminal cancer
chokes when attempting to eat. The patient’s daughter have agreed to stop aggressive treatment and begin
is upset and wants a feeding tube inserted. The physi- comfort measures only. Which of the following state-
cian has told her that the patient is dying and that a tube ments would the nurse include in a discussion of
will not prolong life. The daughter is now crying in the specific decisions? Select all that apply.
hallway. Which response by the nurse is best? 1. “Withholding artificial hydration can make breathing
1. Reiterate what the doctor said about the patient not more comfortable.”
living any longer with a tube. 2. “Pain may be reduced if artificial hydration is
2. Tell the daughter that a tube is uncomfortable for the stopped because tumor swelling is decreased.”
patient. 3. “If the intravenous fluids are stopped, the patient’s
3. Tell the daughter the staff will feed him more slowly body will stop making endorphins.”
to prevent choking. 4. “Research indicates that tube feeding in people
4. Acknowledge how hard this is for her, as she has dying of cancer is not beneficial.”
taken such good care of feeding the patient throughout 5. “Patients who are not fed often say they are hungry
the illness. as they are dying.”

8. A patient being discharged from the hospital has decided

she does not want to be resuscitated should she experi-
ence a cardiopulmonary arrest. Which of the following
documents should the nurse assist the patient to
complete?
1. Living will
2. Advance medical directive
3. Durable power of attorney
4. Physician orders for life-sustaining treatments
(POLST)
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unit FOUR

Understanding the
Immune System
CHECKLIST FOR LEARNING SUCCESS
Review of Anatomy
and Physiology
and Aging Changes Major Disorders Nursing Assessment Diagnostic Tests Interventions Common Medications
❑ Immune: ❑ Immune: ❑ Medical history ❑ Blood studies ❑ Immunotherapy ❑ Antihistamines
❑ Antigens ❑ Allergic rhinitis ❑ Physical examination ❑ Radiographic tests ❑ Medications ❑ Antiretrovirals
❑ Lymphocytes ❑ Atopic dermatitis ❑ Biopsies ❑ Surgical management ❑ Corticosteroids
❑ Antibodies ❑ Anaphylaxis ❑ Skin tests ❑ Monoclonal Antibodies ❑ Epinephrine
❑ Mechanisms of ❑ Urticaria ❑ Gene testing ❑ Recombinant DNA ❑ Fusion inhibitors
immunity ❑ Angioedema technology ❑ Immunosuppressives
❑ Types of immunity ❑ Hemolytic transfusion ❑ Immunoglobulin
❑ Aging effects reaction ❑ Integrase inhibitors
❑ Serum sickness ❑ Nonnucleoside analogue
❑ Contact dermatitis reverse transcriptase
❑ Transplant rejection inhibitors
❑ Pernicious anemia ❑ Nucleoside analogue
❑ Idiopathic autoimmune reverse transcriptase
hemolytic anemia inhibitors
❑ Hashimoto’s thyroiditis ❑ Nucleotide analogue
❑ Ankylosing spondylitis reverse transcriptase
❑ Lupus erythematosus inhibitors
❑ Hypogammaglobulinemia ❑ Protease inhibitors
❑ Human ❑ Ribonucleotide reductase
immunodeficiency virus inhibitors
(HIV) ❑ Rho (D) immune
❑ Acquired immune globulin (RhoGAM)
deficiency syndrome ❑ Thyroxine
(AIDS) ❑ Vitamin B12
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Immune System Function,

18 Assessment, and
Therapeutic Measures
STRUCTURES OF THE IMMUNE SYSTEM
Label the following structures.

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Chapter 18 Immune System Function, Assessment, and Therapeutic Measures 65

IMMUNE SYSTEM CELLS

Match each cell of the immune system with the correct
description.

1. Memory cells 1. Phagocytize pathogens labeled with antibodies

2. Helper T cells 2. Produce antibodies
3. Cytotoxic T cells 3. Limit the immune response once the pathogen has been destroyed
4. Plasma cells 4. Initiate a rapid immune response if the pathogen reenters the body
5. Suppressor T cells 5. Destroy cells directly by lysing their membranes
6. Macrophages 6. May become plasma cells or memory cells
7. B cells 7. Participate in antigen recognition and activate B cells

ANTIBODIES IMMUNE SYSTEM

Name the proper class of antibodies for each of these Match the word with the definition.
functions.
1. Allergy shots 1. Periorbital edema
1. Found in mucous membrane secretions: 2. Tests for 2. Biopsies
2. Provides long-term immunity: antibodies to 3. Pruritus
3. Form the receptors on B cells: human immuno- 4. Enzyme-linked
4. Important in allergic reactions: deficiency virus immunosorbent assay
5. Cross the placenta to fetal circulation: (HIV), used as a 5. IgE
6. Found in breast milk: screening test 6. C-reactive protein
7. The first antibody produced in an infection: 3. Important in 7. Immunotherapy
allergic reactions 8. IgA
VOCABULARY
and attaches to
Fill in the blank.
mast cells
1. are chemical markers that identify cells or 4. Swelling around
molecules. the eyes
2. is the ability to destroy pathogens or other 5. A test done to
foreign material and to prevent further cases of certain confirm a diagno-
infectious diseases. sis, determine a
3. , , and are the three types prognosis, or
of lymphocytes. evaluate effec-
4. mature in the thymus gland. tiveness of
5. Antibodies are also called . treatment
6. immunity is the type of immunity that in- 6. Found in secre-
volves only T cells. tions of all mu-
7. immunity is the type cous membranes
of immunity in which a person has recovered from a 7. Itching
disease and now has antibodies and memory cells 8. An abnormal
specific for that pathogen. protein found in
8. The immunoglobulin provides long-term plasma during an
immunity following recovery from an illness. acute inflamma-
9. Lymph node enlargement with tenderness is usually tory process
indicative of .
10. The of a white blood cell differential are
increased in bacterial infections.
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66 UNIT FOUR Understanding the Immune System

DATA COLLECTION—HISTORY system. Stress (environmental, physical, and psychological)

can enhance immune system function.
Find and correct the 12 errors.
CRITICAL THINKING
Demographic Data Read the following case study and answer the questions.

The patient’s age, gender, race, and ethnic background are David Case, age 29, is visiting his health care provider
important. Systemic lupus erythematosus affects men eight because he has been extremely fatigued for several months
times more frequently than women. The patient’s place of and now has swollen lymph nodes in his neck. On palpation,
birth gives insight into ethnic ties. Where the patient has lived the area feels enlarged, nontender, hard, and fixed.
and does live may shed light on the current illness. The
patient’s occupation, such as that of a coal miner, may con- 1. What categories of data collection should the nurse
tribute to gastrointestinal symptoms. obtain?
Rare signs and symptoms found with immune system dis-
orders include fever, fatigue, joint pain, swollen glands,
weight gain, and skin rash.

History
2. What might the palpation findings indicate?
Food, medication, and environmental allergies should include
those that the patient experiences and those present in the
family history. With a family history, a previous exposure to
a substance is required before a severe reaction occurs. Con-
ditions such as allergic rhinitis, systemic lupus erythemato-
sus, ankylosing spondylitis, and asthma are thought to be
either familial or have a congenital predisposition. If the pa- 3. What categories of data collection would be important
tient’s thymus gland has been removed (thymectomy), B-cell to explore in detail?
production may be altered. Corticosteroids and immunosup-
pressants enhance the immune response. The patient’s
lifestyle may place the patient at low risk for contracting the
human immunodeficiency virus. The patient’s diet and usage
of vitamins give insight into the depletion of the immune

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 3. Which of the following immunoglobulins is first
1. A baby is born temporarily immune to the diseases to produced during an acute infection?
which the mother is immune. The nurse would explain 1. IgG
this to the mother as being which of the following types 2. IgM
of immunity? 3. IgE
1. Naturally acquired passive immunity 4. IgD
2. Artificially acquired passive immunity
3. Naturally acquired active immunity 4. Which of the following is the function of macrophages
4. Artificially acquired active immunity and neutrophils?
1. Phagocytosis
2. Immunity to a disease after recovery is possible because 2. Antibody production
the first exposure to the pathogen has stimulated the 3. Complement fixation
formation of which of the following? 4. Suppression of autoimmunity
1. Antigens
2. Memory cells
3. Complement
4. Natural killer cells
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Chapter 18 Immune System Function, Assessment, and Therapeutic Measures 67

5. The activation of B cells in humoral immunity is 6. Autoimmunity is defined as a phenomenon involving

assisted by which of the following? which of the following?
1. Cytotoxic T cells 1. Production of endotoxins that destroy
2. Helper T cells B lymphocytes.
3. Suppressor T cells 2. Inability to differentiate self from nonself.
4. Neutrophils 3. Overproduction of reagin antibody.
4. Depression of the immune response.

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 10. The nurse is caring for a patient undergoing a biopsy.
Which action is appropriate for the nurse to take?
7. Which of the following is used to determine the
1. Ask whether the patient has an iodine allergy.
presence of inflammation? Select all that apply.
2. Ensure that informed consent is obtained before the
1. IgM assay
procedure.
2. CD4+ count
3. Ask the patient about environmental allergies and
3. Western blot
the type of reaction that occurs.
4. C-reactive protein (CRP)
4. Check eosinophil level on the laboratory report.
5. Erythrocyte sedimentation rate (ESR)
11. While working with patients in an autoimmune disease
8. A mother brings her children into the clinic, and the
clinic, the nurse recognizes that which of the following
children are diagnosed with chickenpox. The mother
individuals is most likely to develop systemic lupus
had chickenpox as a child. Which of the following state-
erythematosus?
ments should the nurse include in the patient teaching?
1. A 38-year-old African American male who works in
1. “Because you have an active natural immunity to chick-
the construction industry
enpox, you can take care of the children at home.”
2. A 55-year-old white female who works as a medical
2. “You will need to wear a mask while caring for the
secretary
children to prevent contamination.”
3. A 19-year-old Asian female who is attending
3. “You will need to get a booster chickenpox vaccina-
college
tion to ensure that you don’t get reinfected.”
4. A 34-year-old Native American male who works as
4. “Because you’ve had chickenpox before and your
a lawyer
children are now ill, you should monitor yourself for
signs or symptoms of shingles for the next 2 weeks.”

9. Which of the following may stimulate antibody produc-

tion? Select all that apply.
1. Cold virus
2. Plant pollen
3. Transplanted organ
4. Bacterial toxins
5. Measles vaccine
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Nursing Care of Patients

19 With Immune Disorders

VOCABULARY
Match the term with its definition.
1. An anaphylactic-type reaction 1. Urticaria
2. The type of antibodies that attach 2. Angioedema
3. Anaphylaxis
to mast cells
4. Pernicious anemia
3. Elimination of the offending environ- 5. Hashimoto’s thyroiditis
mental stimuli 6. Idiopathic autoimmune hemolytic anemia
4. Very dry, pruritic, edematous skin 7. Hypogammaglobulinemia
8. Allergic rhinitis
5. Sudden, severe reaction characterized
9. Hives
by smooth muscle spasms and 10. Type I hypersensitivity reaction
capillary permeability changes 11. Immunoglobulin (Ig)E
6. Urticaria 12. Ankylosing spondylitis
13. Atopic dermatitis
7. A form of lupus that affects only the skin
14. Immunosuppressive
8. Types of drugs used to prevent 15. Systemic lupus erythematosus
transplant rejection 16. Discoid lupus erythematosus
9. Painless subcutaneous and dermal ery-
thremic eruptions with diffuse edema
10. Requires lifelong vitamin B12
11. Red blood cell (RBC) fragments seen
with microscope
12. Infant may be asymptomatic until
6 months old
13. Antimalarial and immunosuppressant
drugs may be used in treatment
14. Causes may include heat, cold,
pressure, and stress
15. Patient education includes a diet low
in iodine and high in bulk, protein,
and carbohydrates
16. Patient education includes frequent
movement and the use of a hard
mattress and no pillow when sleeping

68
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Chapter 19 Nursing Care of Patients With Immune Disorders 69

IMMUNE DISORDERS
Fill in the blank.
1. The way hypersensitivity reactions are classified include , , , and .
2. When allergic rhinitis occurs seasonally, it is called .
3. Complications of allergic rhinitis are , , , and .
4. is a complication of atopic dermatitis.
5. The first drug of choice for anaphylaxis is .
6. Urticaria is commonly called .
7. Angioedema differs from urticaria in that angioedema , , and .
8. The is used to diagnose a hemolytic transfusion reaction.
9. and are two complications that can occur with a hemolytic transfusion reaction.
10. Today, serum sickness tends to occur when and are administered to patients.
11. and are two food additives that can trigger an anaphylactic reaction.
12. is the most common cause of contact dermatitis.
13. Patients with pernicious anemia are unable to absorb .
14. is a process whereby abnormal RBCs are removed and replaced with normal RBCs.
15. Ankylosing spondylitis is a chronic progressive inflammatory disease of the , , and
joints.
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70 UNIT FOUR Understanding the Immune System

IMMUNE WORD SEARCH

Figure out what words the clues represent. Then find the words in the grid. Words can go horizontally, vertically, and
diagonally in all eight directions.

X Z Y G L L D W X T X L T J K R Y R M S G

X Q L L B J J P L Z W T L Z X N T R H I M

R T H A I R A C I T R U P V R L D W G T X

L C A T G Z N D B X K P T H T H M Q R I W

Y O K T C X L O D N P J N N K H Z N B L P

C R K K O L J T I D M R M W B H H F T Y L

T T H K N P L R D T N W Q H P V J M S D N

V I D F J F I T Q Y A L H N N I J M E N N

C C X V J C T C T K R N S L N M K D X O C

Z O P G T L Z D D K R L I F Z L T W E P Y

K S F Z L T Z N D E I Z E T M J M X L S G

H T J G T R P E D H R C F L U K H X P G T

Z E T R N N Y N P L T M V K Z L V Y M N M

C R N R K A Z O J I Q D A W T F G D O I R

R O X N L N N R O K N V T T M W N G C S N

K I V E B I G N K K B Y Q X I K Y R A O G

M D D D S K V Y L D H C F K B T N B R L C

P S K O L G V C M C B M C C R R I Y N Y R

T N E Z L G H K N G K N P Q R F Q S D K T

X R F Y Q Y N T T G F Q M W Q B L G P N T

L R F P W M M F C Y T O K I N E S R M A H

CLUES:
• When antigens clump.
• A nursing intervention for this disorder is a very firm mattress and no pillows when sleeping.
• A type I hypersensitivity that eventually leads to a thickening of the dermis with less sweat production in these areas.
• These are formed in type III hypersensitivity reactions, which then occlude blood vessels.
• These medications that are frequently used with immune system disorders should never be suddenly discontinued.
• Agents of the immune system that act to modify and enhance the immune and inflammatory responses.
• Type IV hypersensitivity reactions tend to be this—not immediate.
• These particular lymphocytes elevate in an allergic reaction as seen with type I hypersensitivities.
• The main complication for a patient with hypogammaglobulinemia.
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Chapter 19 Nursing Care of Patients With Immune Disorders 71

IMMUNE PUZZLE

1 2 3 4
5
6 7

9 10 11

12 13

14
15
16

17
18

19

20 21

Across Down
1. A type of anemia that will develop in patients with 1. Nowadays serum sickness tends to occur after adminis-
autoimmune gastritis. tration of sulfonamides and these drugs.
3. The number of minutes that a nurse should stay with a 2. A respiratory assessment finding that is considered an
patient at the beginning of a blood transfusion. emergency in a patient with angioedema.
6. This is a very serious type I hypersensitivity reaction. 4. A drug of choice during an anaphylactic reaction.
8. An antibody-mediated response produced by 5. This can overwhelmingly affect the activities of daily
B lymphocytes. living (ADLs) of a patient with SLE.
9. These phagocytic leukocytes are stationary. 7. This disorder is due to defective functioning B cells.
13. Hashimoto’s thyroiditis begins with this. 10. One group of joints that is affected in ankylosing
15. These are a complication of repeated episodes of allergic spondylitis.
rhinitis. 11. IgE antibodies attach to these cells in a type I hypersen-
17. Similar to urticaria although tends to be less pruritic, sitivity reaction.
lasts longer, and involves deeper tissue. 12. Currently a significant type of contact dermatitis.
19. The substance that is required in order for vitamin B12 14. Ankylosing spondylitis is attributed to this.
to be absorbed in the small intestine. 16. A foreign protein or cell capable of causing an immune
20. This facial rash will occur in about 60% to 80% of response.
systemic lupus erythematosus (SLE) patients. 18. An SLE flare trigger.
21. This form of lupus erythematosus affects only the skin.

WORDS FOR IMMUNE PUZZLE

Allergen Fifteen Nasal polyps

Anaphylaxis Humoral Obstruction
Angioedema Hypogammaglobulinemia Penicillins
Autoimmunity Hypothyroidism Pernicious
Butterfly Intrinsic factor Sacroiliac
Discoid Latex allergy Steroids
Epinephrine Mast cells Stress
Fatigue Monocytes
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72 UNIT FOUR Understanding the Immune System

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 3. Which of the following is a disease process character-
ized by a chronic progressive inflammation of the
1. As the nurse collects data on a patient, which of the
sacroiliac and costovertebral joints and adjacent
following is a symptom that the patient with anaphylaxis
soft tissue?
may be experiencing?
1. Rheumatoid arthritis
1. Dermatitis
2. Kyphosis
2. Delirium
3. Scoliosis
3. Sinusitis
4. Ankylosing spondylitis
4. Wheezing
4. The nurse understands that an anaphylactic reaction is
2. Which of the following is the medication of choice for
considered which of the following types of hypersensi-
anaphylaxis that the nurse should anticipate would be
tivity reactions?
ordered?
1. Type I
1. Epinephrine
2. Type II
2. Theophylline (Theo-Dur)
3. Type III
3. Digoxin (Lanoxin)
4. Type IV
4. Furosemide (Lasix)

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 8. A patient is admitted with a 2-month history of fatigue,
shortness of breath, pallor, and dizziness. The patient is
5. A patient has allergic rhinitis. In planning care for the
diagnosed with idiopathic autoimmune hemolytic ane-
patient, the nurse understands that if the patient does not
mia. On reviewing the laboratory results, the nurse notes
adhere to the treatment regimen, the patient is at risk for
which of the following that confirms this diagnosis?
developing which of the following?
1. RBC fragments
1. Sinusitis
2. Macrocytic, normochromic RBCs
2. Anaphylaxis
3. Microcytic, hypochromic RBCs
3. Lymphadenopathy
4. Hemoglobin molecules
4. Angioedema
9. A patient had a portion of stomach removed and must
6. A patient reports on admission being “very sick” after
take vitamin B12. Which of the following statements
taking erythromycin in the past. The patient is to receive
should be included in the patient teaching?
erythromycin now. Which of the following actions
1. “You will develop iron-deficiency anemia if you fail
should the nurse take regarding the antibiotic?
to take vitamin B12.”
1. Give the antibiotic.
2. “Pernicious anemia is a complication of this surgery,
2. Give half of the dose.
so you must take vitamin B12.”
3. Do not give the antibiotic.
3. “Most patients who do not take vitamin B12 develop
4. Discontinue the antibiotic.
sickle cell anemia.”
4. “Taking vitamin B12 is important if you want to
7. A patient is being given penicillin via intravenous (IV)
prevent acquired hemolytic anemia.”
infusion and develops an anaphylactic reaction. Which
of the following should be the nurse’s first action?
1. Call the doctor.
2. Call for help.
3. Maintain the antibiotic.
4. Turn off the antibiotic.
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Chapter 19 Nursing Care of Patients With Immune Disorders 73

10. A patient is diagnosed with Hashimoto’s thyroiditis and 13. The nurse would evaluate that the patient understands
asks what causes it. The nurse would respond that the what triggers allergic rhinitis by which of the following
destruction of the thyroid in this condition is due to patient responses?
which of the following? 1. “Injected medications”
1. Antigen-antibody complexes 2. “Topical creams and ointments”
2. Autoantibodies 3. “Ingested food and medications”
3. Viral infection 4. “Airborne pollens and molds”
4. Bacterial infection
14. In caring for a patient with angioedema, the nurse
11. A patient who was walking in the woods disturbed a understands that angioedema differs from urticaria
beehive, was stung, and was taken to the emergency in that angioedema is characterized by which of the
department immediately due to allergies to bee stings. following?
Which of the following symptoms would the nurse 1. Angioedema is more pruritic.
expect to see upon admission of this patient? Select all 2. Angioedema has a deeper and more widespread
that apply. edema.
1. Pallor around the sting bites 3. Angioedema has small, fluid-filled vesicles that
2. Numbness and tingling in the extremities crust.
3. Respiratory stridor 4. Angioedema lasts a shorter time.
4. Retinal hemorrhage
5. Tachycardia 15. Which of the following is a common nursing diagnosis
6. Dyspnea that the nurse will include in the plan of care for a
patient with SLE?
12. A patient has a long-standing history of allergies to 1. Fatigue
pollen. Which of the following actions indicates that 2. Impaired Mobility
further teaching is necessary? 3. Impaired Swallowing
1. The patient stays indoors on dry, windy days. 4. Impaired Tissue Perfusion
2. The patient drives the car with the windows open.
3. The patient avoids walking outside in the spring.
4. The patient works in the garden on sunny days.
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Nursing Care of Patients

20 With HIV Disease and AIDS

VOCABULARY
Fill in the blank.
1. is the final phase of a chronic, progressive immune function disorder caused by the
human immunodeficiency virus (HIV).
2. The cell is an important part of the human immune system and helps defend the body
against very primitive invaders such as fungi, yeast, and other viruses.
3. is a diagnostic test done to measure resistance to currently available antiviral
treatments.
4. are a primary complication of HIV infection and occur because of an
impaired immune system.
5. occurs in some patients with the acquired immune deficiency syn-
drome (AIDS) and is characterized by the occurrence of an involuntary baseline body weight loss of
more than 10% and weakness or fever for more than 30 days or chronic diarrhea of two loose stools
daily for more than 30 days.
6. measures the amount of HIV RNA in plasma and is extremely important for determin-
ing prognosis and monitoring the response to antiretroviral therapy.

DIAGNOSTIC TESTS 3. CD4+ cell count

Describe the procedure for each of the following diagnostic

tests.

1. Enzyme-linked immunosorbent assay (ELISA) test

4. Genotyping

2. Viral load

74
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Chapter 20 Nursing Care of Patients With HIV Disease and AIDS 75

HIV 2. When is the patient with HIV considered to have AIDS?

Fill in the blanks.

1. HIV is transmitted through , ,

, and .
2. HIV may stay latent for years. 3. Jack is started on a combination of trimethoprim and
3. Fatigue, headache, fever, and generalized lymph- sulfamethoxazole (Bactrim, Septra). Why?
adenopathy may be seen during the stage of
HIV infection.
4. are increasingly becoming infected with HIV.

HIV AND AIDS 4. Later, Jack is diagnosed with AIDS with a CD4+ count
Indicate whether the following are true or false, and cor- of 200.
rect false statements.
(a) Jack is 6 feet tall and weighs 135 lb. He is malnour-
1. If a health care worker is stuck with a needle from a
ished. What are possible reasons?
patient with AIDS, exposure to the virus may occur
even if gloves were worn.
2. HIV is caused by AIDS.
3. Individuals who are not men who have sex with men or
(b) What can you do as a nurse to improve Jack’s nutrition?
who are intravenous (IV) drug users probably do not
need to worry about contracting HIV and developing
AIDS.
4. If the nurse suctions a patient with a fresh tracheostomy
who is diagnosed with HIV and blood-tinged sputum 5. Six months after being diagnosed with AIDS, Jack
gets in the nurse’s eyes, the nurse may contract the develops dementia. Why?
virus.
5. Once a person is infected with HIV, the diagnosis can be
made using laboratory tests within 1 to 2 days.

6. A patient with AIDS should always be placed into 6. How can a nurse contract HIV from a patient?
isolation for the protection of health care workers.

CRITICAL THINKING
Answer the following questions. 7. How should the home health nurse teach family mem-
bers of a patient with AIDS to clean the patient’s home?
1. Jack Swope, age 26, has been diagnosed as HIV-positive.
He asks, “Do I have AIDS and am I going to die?” What
should you say to him?
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76 UNIT FOUR Understanding the Immune System

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 2. For most HIV-infected patients being treated with antiviral
medications, CBC, CD4+/C8+ T-lymphocyte count, and
1. Which of the following best defines acquired immuno-
viral load testing are repeated at what intervals?
deficiency syndrome (AIDS)?
1. Every month
1. AIDS is a syndrome that always develops after
2. Every 3 months
infection with HIV virus.
3. Every 6 months
2. AIDS is the final phase of a chronic progressive
4. Every 12 months
immune disorder caused by HIV.
3. AIDS is caused by HIV and characterized by CD4+ T
lymphocytes greater than 14% of total lymphocytes.
4. AIDS is an acute syndrome that is accompanied by
specific clinical conditions.

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 7. The nurse is taking vital signs of a pregnant woman
during her first prenatal visit. The patient asks the
3. In planning an educational session for a patient with
nurse if she has to have an HIV test. Which of the
HIV, the nurse would include which of the following as
following is the nurse’s best response?
a method of transmission for HIV? Select all that
1. “Yes, all pregnant women must have the test.”
apply.
2. “If you do not have multiple sex partners or inject
1. Saliva
drugs, it is not necessary.”
2. Tears
3. “Governmental guidelines require an HIV test for
3. Breast milk
all pregnant woman.”
4. Semen
4. “After voluntary pretest counseling, you decide
5. Blood
whether HIV testing should be done.”
6. Sweat
8. The nurse is caring for a patient with HIV. Which of
4. A patient who is being tested for HIV asks what tests the following foods would the nurse teach the patient is
are used. The nurse would be correct in stating that the safe to eat to reduce the risk of infection?
tests used to confirm HIV infection include which of 1. Raw fruits
the following? 2. Cooked vegetables
1. CD4+ cell count and thymus function 3. Raw vegetables
2. B-cell and T-cell count 4. Caesar dressing
3. ELISA and Western blot
4. CD4+, viral load, and ELISA 9. When caring for a patient with AIDS, which of the
following nursing actions would be most appropriate
5. The nurse is caring for a patient with HIV who has diar- for infection control?
rhea. Which of the following would be most therapeutic 1. Wear gloves at all times.
to teach the patient to avoid in the diet to reduce diarrhea? 2. Wear gloves for blood/body fluid contact.
1. Potassium-rich food 3. Wear gown and mask at all times.
2. Raw fruits and vegetables 4. Wear a mask during patient contact times.
3. Liquid nutritional supplements
4. Frozen products 10. The nurse is asked if male circumcision has any rela-
tionship to HIV. Which of the following responses by
6. The nurse is teaching a patient newly diagnosed with the nurse is best?
AIDS about complications of the disease. Which of the 1. “Circumcision in male infants is strictly a religious
following is the most common opportunistic infection preference.”
in AIDS? 2. “Males who have been circumcised are more likely
1. Pneumocystis pneumonia to acquire HIV with homosexual contact.”
2. Candidiasis 3. “No research is available to indicate a relationship
3. Toxoplasmosis between HIV and circumcision.”
4. Mycoplasma pneumonia 4. “There is evidence that males engaged in heterosex-
ual activity are less likely to be infected with HIV if
they’ve been circumcised.”
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unit FIVE

Understanding
the Cardiovascular
System
CHECKLIST FOR LEARNING SUCCESS
Review of Anatomy
and Physiology
and Aging Changes Major Disorders Nursing Assessment Diagnostic Tests Common Interventions
❑ Cardiovascular: Cardiovascular: ❑ Medical history ❑ Electrocardiogram ❑ Exercise
❑ Structures ❑ Hypertension ❑ Medications ❑ Computerized tomography ❑ Smoking cessation
❑ Function ❑ Valvular ❑ Family history ❑ Cardiac magnetic resonance ❑ Diet
❑ Aging effects ❑ Inflammatory ❑ Health promotion imaging ❑ Lifestyle and cardiac care
❑ Infectious ❑ Vital signs ❑ Exercise stress testing ❑ Antiembolism devices
❑ Occlusive ❑ Physical examination ❑ Echocardiogram ❑ Cardioversion/defibrillation
❑ Dysrhythmias ❑ Tilt table test ❑ Pacemaker
❑ Heart failure ❑ Radioisotope imaging ❑ Angioplasty
❑ Cardiac enzymes ❑ Valvuloplasty
❑ Cardiac troponin ❑ Surgery
❑ Myoglobin ❑ Cardiac rehabilitation
❑ Homocysteine
❑ Lipids
❑ Angiography
❑ Cardiac catheterization
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Cardiovascular System
21 Function, Assessment, and
Therapeutic Measures
STRUCTURES OF THE CARDIOVASCULAR SYSTEM
Label the following structures.

CARDIAC BLOOD FLOW

Number the following in proper sequence with respect to the flow of blood through the heart and to and from the lungs and
body. Begin with the caval veins.

1. Superior and inferior caval veins 6. Lungs 11. Mitral valve

2. Left ventricle 7. Pulmonary artery 12. Aortic valve
3. Right atrium 8. Pulmonary veins 13. Tricuspid valve
4. Right ventricle 9. Aorta 14. Pulmonic valve
5. Body 10. Left atrium

78
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Chapter 21 Cardiovascular System Function, Assessment, and Therapeutic Measures 79

AGING AND THE CARDIOVASCULAR SYSTEM 9. Tests to assess peripheral disease are plethys-
mography, Doppler ultrasound, pressure measurement,
Find the 11 errors and insert the correct information.
stress testing, , and arteriography.
It is believed that the “aging” of blood vessels, especially ar-
teries, begins in adulthood. Average resting blood pressure ACUTE CARDIOVASCULAR NURSING
tends to decrease with age and may contribute to stroke or ASSESSMENT
right-sided heart failure. The thicker walled veins, especially Identify a word that is obtained during a history that
those of the legs, may also weaken and stretch, making their matches the given assessment statement.
valves incompetent.
With age, the heart lining becomes less efficient, and there 1. Assessed before medication adminis-
is an increase in both maximum cardiac output and heart rate. tration, test dyes
The health of the myocardium depends on the lungs’ blood
supply. Hypertension causes the right ventricle to work
2. Modifiable risk factor for cardiovas-
harder, so it may atrophy. The heart valves may become thin-
ner from fibrosis, leading to heart murmurs. Dysrhythmias cular disorders that is a habit
become more common in older adults as the cells of the con-
duction pathway become more efficient. 3. Location: chest, calf; radiation: arms,
jaw neck
CARDIOVASCULAR SYSTEM
Fill in the blanks. 4. Sign resulting from right-sided heart
failure
1. The function of the is to carry oxygen
and nutrients to the tissues and remove waste products.
5. Lung sounds with left-sided heart
2. The function is to pump blood.
failure
3. The peripheral is composed of arteries,
veins, and lymph vessels. 6. Symptom of dysrhythmias
4. With aging, the walls of blood vessels .
5. The heart sound occurs at the beginning of sys- 7. Effect of decreased cardiac output
tole when the atrioventricular valves close, and the sound
dupp occurs at the start of when the semilunar 8. Classic symptom of acute heart failure
valves close. (pulmonary edema)
6. Palpation of pulse quality is recorded as 0;
CRITICAL THINKING
weak, thready 1+; 2+; bounding 3+.
Make a concept map for a patient who is to undergo a cardiac
7. Tests to assess function may include x-ray
catheterization. A concept map helps you visualize the
examination, electrocardiogram (ECG), stress test, patient’s needs. Think of possible categories of needs of this
echocardiogram, thallium scan, dipyridamole thallium patient and then complete activities and needs under each cat-
scan, multiple gated acquisition (MUGA), serum tro- egory. Some categories have been given to get you started,
but you may think of others to include. You can get even
ponin I, creatine kinase, (CK-MB), myoglobin, cardiac
more detailed and create subcategories for each activity
, and angiography. or need. A concept map has no defined ending point. See
8. The six Ps characterize vascular disease: DavisPlus, an F.A. Davis Internet site that provides nursing
, pulselessness, pallor, paresthesia, and resources, for a program that has been provided to help you
create concept maps.
paralysis.
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80 UNIT FIVE Understanding the Cardiovascular System

Preprocedure prep Sensory preparation

Cardiac Catheterization Teaching Plan

Postprocedure care Discharge

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 5. When blood pressure decreases, the kidneys help raise it
by secreting which of the following?
1. Each normal heartbeat is initiated by which of the
1. Renin
following?
2. Epinephrine
1. Sinoatrial node in the wall of the right atrium
3. Aldosterone
2. Bundle of His in the interventricular septum
4. Erythropoietin
3. Cardiac center in the medulla
4. Sympathetic nerves from the spinal cord
6. Which of the following prevents the backflow of blood
in veins?
2. During one cardiac cycle, which of the following occurs?
1. Precapillary sphincters
1. Ventricles contract first, followed by the atria
2. Middle layer
2. Atria contract first, followed by the ventricles
3. Smooth muscle layer
3. Atria and ventricles contract simultaneously
4. Valves
4. Ventricles contract twice for every contraction of the
atria
7. The mitral and tricuspid valves prevent backflow of
blood from which of the following?
3. Which of the following detects changes in blood pressure?
1. Ventricles to atria when the ventricles contract
1. Pressoreceptors in the medulla
2. Atria to ventricles when the ventricles relax
2. Blood vessels in the medulla
3. Ventricles to atria when the atria contract
3. Pressoreceptors in the carotid and aortic sinuses
4. Atria to ventricles when the atria contract
4. Coronary vessels in the myocardium
8. Which of the following describes the purpose of the en-
4. Epinephrine increases blood pressure because it does
docardium of the heart?
which of the following?
1. Covers the heart muscle and prevents friction.
1. Increases water resorption by the kidneys
2. Supports the coronary blood vessels.
2. Causes vasodilation in the skin and viscera
3. Lines the chambers of the heart and prevents abnor-
3. Decreases heart rate and force of contraction
mal clotting.
4. Increases heart rate and force of cardiac contraction
4. Prevents backflow of blood from atria to ventricles.
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Chapter 21 Cardiovascular System Function, Assessment, and Therapeutic Measures 81

9. Which of the following is the function of the coronary 11. Angiotensin II increases which of the following?
arteries? 1. Vasodilation and antidiuretic hormone (ADH)
1. Prevent abnormal clotting within the heart. secretion
2. Bring oxygenated blood to the myocardium. 2. Vasoconstriction and aldosterone secretion
3. Carry deoxygenated blood to the lungs. 3. Heart rate and vasodilation
4. Carry oxygenated blood to the lungs. 4. Heart rate and ADH secretion

10. Where in the nervous system is the cardiac center 12. The increase of resting blood pressure with age may
found? contribute to which of the following?
1. Cerebrum 1. Dysrhythmias
2. Hypothalamus 2. Thrombus formation
3. Spinal cord 3. Left-sided heart failure
4. Medulla 4. Peripheral edema

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 16. A patient’s pulse is 78 beats per minute (beats/min) and
blood pressure (BP) = 122/76 mm Hg while lying
13. A patient had a bilateral mastectomy 2 days ago, so
down. While the nurse checks the patient’s blood pres-
the nurse obtains blood pressure readings from the
sure for orthostatic hypotension, the patient’s heart rate
patient’s legs. The patient’s baseline blood pressure in
increases to 92 beats/min, and the BP = 116/68 mm Hg.
the arm was 112/78 mm Hg. Which of the following
Which of the following actions should the nurse take?
readings, when compared with baseline blood pressure,
1. Return the patient to a lying position immediately.
does the nurse expect when taking the blood pressure
2. Ask if the patient is experiencing chest pain.
in the leg?
3. Note that normal compensation occurred.
1. 122/84 mm Hg
4. Chart that the patient has orthostatic hypotension.
2. 102/68 mm Hg
3. 132/78 mm Hg
17. The nurse is inspecting a patient’s legs for data collec-
4. 96/58 mm Hg
tion and notes that there is bilateral decreased hair dis-
tribution, thick, brittle nails, and shiny, taut, dry skin.
14. The nurse obtains a lower blood pressure reading on a
The nurse understands that this can indicate which of
patient’s left arm than the right arm. As a result, which
the following?
of the following extremities should the nurse use for
1. Increased arterial blood flow
ongoing blood pressure measurement?
2. Decreased arterial blood flow
1. Left arm
3. Increased venous blood flow
2. Right arm
4. Decreased venous blood flow
3. Right leg
4. Either arm
18. The nurse is explaining to a patient that for a thallium
stress test dipyridamole (Persantine), a coronary va-
15. The nurse is checking a patient’s blood pressure for or-
sodilator, will be given. Which of the following would
thostatic hypotension. The patient’s BP lying down was
the nurse include in the teaching regarding the reason
142/88 mm Hg and 136/80 mm Hg when standing. The
this medication is being given?
patient asks the nurse why there is such a difference.
1. To decrease blood flow to cardiac cells
Which of the following is the best response by
2. To increase blood flow as exercise would
the nurse?
3. To prevent a clot from forming during the test
1. “Your blood pressure should go up about 15 mm
4. To reduce systemic vascular resistance
Hg, so we’ll need to have you move very slowly to
avoid a fall.”
19. Which of the following data would be most important
2. “Blood pressure usually compensates for a change
for the nurse to collect immediately for a patient who is
in position by going down by about 15 mm Hg, so
reporting fatigue and dizziness? Select all that apply.
this is normal.”
1. Presence of pain
3. “It is safe for the blood pressure to drop by as much
2. Weight
as 25 mm Hg, so you don’t need to worry.”
3. Vital signs
4. “Your blood pressure is still in a normal range so
4. Electrocardiogram tracing
there is no real concern.”
5. White blood cell count
6. Palpitations
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Nursing Care of Patients

22 With Hypertension

VOCABULARY
Match the word with its definition.

1. Atherosclerosis 1. Most common form of arteriosclerosis, in which

2. Peripheral vascular resistance fats are deposited on arterial walls
3. Normotensive 2. Amount of blood the heart pumps out each
4. Isolated systolic hypertension minute
5. Hypertension 3. Amount of pressure exerted on the wall of the
6. Diastolic blood pressure arteries when the ventricles are at rest; the bot-
7. Cardiac output tom number in a blood pressure reading
8. Systolic blood pressure 4. Abnormally elevated blood pressure
9. Secondary hypertension 5. Systolic pressure is 140 mm Hg or more, but the
10. Primary hypertension diastolic pressure is less than 90 mm Hg
11. Plaque 6. Normal blood pressure
7. Opposition to blood flow through the vessels
8. Deposit of fatty material in the artery
9. Abnormally elevated blood pressure, the cause
of which is unknown; also called essential
hypertension
10. High blood pressure that is a symptom of a spe-
cific cause, such as a kidney abnormality
11. Maximal pressure exerted on the arteries during
contraction of the left ventricle of the heart; top
number of a blood pressure reading

82
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Chapter 22 Nursing Care of Patients With Hypertension 83

DIURETICS
Select the number that identifies the type of each diuretic.

1. Spironolactone (Aldactone) 1. Thiazide or thiazide-like

2. Bumetanide (Bumex) 2. Loop
3. Chlorothiazide (Diuril) 3. Potassium sparing
4. Triamterene (Dyrenium)
5. Furosemide (Lasix)
6. Amiloride (Midamor)
7. Metolazone (Zaroxolyn)
8. Hydrochlorothiazide
9. Torsemide (Demadex)

HYPERTENSION RISK FACTORS 7. The recommended follow-up for a diastolic

Indicate whether the statement is true or false. blood pressure of more than 110 mm Hg is right now.
8. The recommended follow-up for a diastolic
1. Increased stress can cause hypertension.
blood pressure of 100 to 109 mm Hg is 2 months.
2. There is a link between a high-fat diet, obesity,
9. The recommended follow-up for a diastolic
and hypertension.
blood pressure less than 80 mm Hg is 2 years.
3. High calcium, potassium, and magnesium lev-
10. The recommended follow-up for a diastolic
els are important risk factors for the development of
blood pressure of 80 to 89 mm Hg is 1 year.
hypertension.
4. People who are not active on a regular basis are CRITICAL THINKING
at an increased risk of developing hypertension. Read the following case study and answer the questions.
5. A diet high in salt is also high in vitamins and
Mrs. Laura Martin, age 42, is seen in the hypertension clinic
minerals. for a follow-up visit for hypertension. Her blood pressure is
6. Inadequate sleep of less than 5 hours is a risk 160/92 mm Hg, and she is diagnosed with hypertension. The
factor for hypertension. health care provider encourages continued lifestyle modifi-
cation and prescribes hydrochlorothiazide.
7. Classical music for 30 minutes daily can reduce
blood pressure.
1. Why is hydrochlorothiazide prescribed?
STAGES OF HYPERTENSION AND
RECOMMENDATIONS FOR FOLLOW-UP
Indicate whether the statement is true or false and correct
the false statements. 2. What additional information should the nurse collect to
develop a teaching plan for lifestyle modifications and
1. The recommended follow-up for a systolic
the medication?
blood pressure of 120 to 139 mm Hg is 2 years.
2. The recommended follow-up for a systolic
blood pressure of less than 120 mm Hg is 2 years.
3. The recommended follow-up for a systolic 3. Develop a teaching plan for Mrs. Martin’s needs based
blood pressure more than 180 mm Hg is right now. on the data collected.
4. The recommended follow-up for a systolic
blood pressure of 160 to 179 mm Hg is 2 months.
5. The recommended follow-up for a systolic
blood pressure of 140 to 159 mm Hg is 2 months.
6. The recommended follow-up for a diastolic
blood pressure of 90 to 99 mm Hg is 1 month.
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84 UNIT FIVE Understanding the Cardiovascular System

4. What interventions will help Mrs. Martin reach her goal 5. How will you know when Mrs. Martin has reached her
for controlling her hypertension? goals?

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 3. The nurse would explain to the patient that the action of
enalapril maleate (Vasotec) is which of the following?
1. If the systolic blood pressure is elevated and the diastolic
1. It decreases levels of angiotensin II.
blood pressure is normal, the nurse recognizes that a pa-
2. It adjusts the extracellular volume.
tient is most likely to have which type of hypertension?
3. It dilates the arterioles and veins.
1. Primary
4. It decreases cardiac output.
2. Secondary
3. Isolated systolic
4. The nurse understands that which of the following best
describes the action of propranolol (Inderal) to teach the
2. The nurse explains to a patient with blood pressure read-
patient about the action of this medication?
ings of 164/102 mm Hg and 176/100 mm Hg on two
1. It increases heart rate.
separate occasions that this type of hypertension is clas-
2. It decreases cardiac output.
sified in which hypertension category?
3. It decreases fluid volume.
1. Prehypertension
4. It increases cardiac contractility.
2. Stage 1
3. Stage 2

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 8. A patient calls the hypertension clinic to report frequent
headaches with a newly prescribed medication. The
5. The nurse is developing a teaching plan for a patient.
nurse anticipates that this is a normal side effect if the
Which of the following is a modifiable risk factor for the
patient is taking which of the following medications?
development of hypertension? Select all that apply.
1. Furosemide (Lasix)
1. Race
2. Atenolol (Tenormin)
2. High cholesterol
3. Clonidine (Catapres)
3. Cigarette smoking
4. Adalat (Procardia)
4. Sedentary lifestyle
5. Less than 5 hours of sleep
9. A patient has been prescribed bumetanide (Bumex)
every morning for control of hypertension. Which of
6. The patient asks the nurse, “How is hypertension de-
the following statements indicates correct knowledge
fined?” Which of the following is the best response by
of the treatment regimen?
the nurse?
1. “I can travel to Florida and sunbathe all day.”
1. “It is measured as the heart pumps blood into the
2. “Now I can eat whatever I want, whenever I want.”
arteries.”
3. “I’ll take my medication in the morning, every
2. “It is blood pressure above 140/90 mm Hg on two
morning.”
separate occasions.”
4. “I won’t need medication once my pressure goes
3. “It is regulated by stress, activity, and emotions.”
down.”
4. “It is determined by peripheral vascular resistance.”
10. Which common side effect of metolazone (Zaroxolyn)
7. Which of the following should the nurse include when
should the nurse instruct a patient to report to the
counseling a patient about smoking and its effect on
health care provider?
blood pressure?
1. Numb hands
1. Smoking is associated with stages 1 and 2 hypertension.
2. Muscle weakness
2. Smoking does not affect blood pressure regulation.
3. Gastrointestinal distress
3. Smoking vasodilates the peripheral blood vessels.
4. Nightmares
4. Smoking causes sustained blood pressure elevations.
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Chapter 22 Nursing Care of Patients With Hypertension 85

11. The nurse understands that which of the following 14. Which of the following statements, if made by a
is a side effect most likely to be reported by patients patient with hypertension, indicates to the nurse a
receiving enalapril maleate (Vasotec)? need for more teaching?
1. Acne 1. “High blood pressure may affect the kidneys
2. Diarrhea and eyes.”
3. Cough 2. “Most people with hypertension watch their diet.”
4. Heartburn 3. “Medication will no longer be needed when I feel
better.”
12. What instruction should the nurse give to the patient 4. “Many people do not know when their blood
taking propranolol (Inderal) for hypertension? pressure is high.”
1. Have potassium level checked.
2. Report any changes in appetite. 15. The nurse is developing a patient teaching plan. The
3. Do not stop medication abruptly. teaching plan should include which of the following
4. Resume usual daily activities. lifestyle modifications to help control hypertension?
1. Regular aerobic exercise
13. Which of the following nursing diagnoses is the focus 2. Low-tar cigarettes
of care for a patient with hypertension? 3. Three alcoholic beverages per day
1. Activity Intolerance 4. Daily multivitamin supplements
2. Ineffective Airway Clearance
3. Impaired Physical Mobility
4. Deficient Knowledge
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Nursing Care of Patients

23 With Valvular,
Inflammatory, and
Infectious Cardiac or
Venous Disorders
VOCABULARY
Fill in the blank with the word that is formed by the word building.

1. annulus—ring + plasty—formed
2. commissura—joining together + tome—incision
3. in—not + sufficiens—sufficient
4. re—again + gurgitare—to flood
5. stenos—narrow
6. valvula—leaf of a folding door + plasty—formed
7. choreia—dance
8. peri—around + kardia—heart + itis—inflammation
9. myo—muscle + kardia—heart + itis—inflammation
10. petecchia—skin spot
11. peri—around + kardia—heart + kentesis—puncture
12. kardia—heart + tamponade—plug
13. kardia—heart + myo—muscle + pathy—disease
14. kardia—heart + mega—large
15. my—muscle + ectomy—cutting out
16. thromb—lump (clot) + phleb—vein + itis—inflammation

MITRAL VALVE PROLAPSE MVP tends to be hereditary, and the cause is known. In-
fections that damage the mitral valve may be a contributing
Find the eight errors and insert the correct information. factor. It is the most common form of valvular heart disease
During ventricular diastole, when pressures in the left ven- and typically occurs in men aged 20 to 55. Most patients
tricle rise, the leaflets of the mitral valve normally remain with MVP have symptoms. Symptoms that may occur in-
open. In mitral valve prolapse (MVP), however, the leaflets clude chest pain, dysrhythmias, palpitations, dizziness, and
bulge backward into the left ventricle during systole. Often syncope. No treatment is needed unless symptoms are pres-
there are functional problems seen with MVP. However, if ent. Stimulants and caffeine should be avoided to prevent
the leaflets do not fit together, mitral stenosis can occur with symptoms.
varying degrees of severity.

86
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Chapter 23 Nursing Care for Valvular, Inflammatory, Infectious Cardiac or Venous Disorders 87

VALVULAR DISORDERS 2. When obtaining Mrs. Murphy’s medical history, what

should the nurse ask that is relevant to the cause of
Indicate whether the statement is true or false and correct
false statements. aortic stenosis?

1. Stenosis is widening of the opening of a

heart valve.
2. Stenosis inhibits the forward flow of blood.
3. Regurgitation, or insufficiency, is failure of 3. How does the heart compensate for aortic stenosis?
the valve to close completely.
4. Regurgitation inhibits backflow of blood.
5. Rheumatic heart disease and congenital de-
fects are primary causes of valvular disease.
4. What should the nurse anticipate may occur in severe
6. The primary valves affected by disease are
aortic stenosis?
the tricuspid and pulmonic valves.
7. Compensatory mechanisms in valvular dis-
ease are dilation to handle the increased
blood volume and hypertrophy to increase
the strength of contractions. 5. Why is angina a common symptom of aortic stenosis?
8. Symptoms of valvular disease often occur
early and reflect decreased cardiac output
and pulmonary congestion: fatigue, dyspnea,
orthopnea, cough.
9. In severe valvular disease, heart failure oc- 6. Why does Mrs. Murphy’s chest x-ray examination show
curs, and symptoms reflect the backup of an enlarged heart?
blood from the failing chamber.
10. In acute valve disorders, symptoms of shock
are seen.
11. Valve disease diagnosis is made with electro-
7. Why is aortic stenosis treated with valvular replacement?
cardiogram (ECG), chest x-ray examination,
echocardiogram, and cardiac catheterization.
12. Valvuloplasty uses a balloon to separate the
valve leaflets.
13. Commissurotomy narrows the valve opening.
14. Annuloplasty surgically repairs the valve.
15. Patient teaching for valvular disorders includes
understanding the importance of prophylactic
antibiotics before all invasive procedures.

CRITICAL THINKING—MRS. MURPHY

Read the case study and answer the questions.
Mrs. Murphy, age 72, has aortic stenosis and is scheduled for
an aortic valve replacement. She reports fatigue and dyspnea
with exertion.
1. What may be the cause of Mrs. Murphy’s aortic stenosis?
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88 UNIT FIVE Understanding the Cardiovascular System

INFLAMMATORY AND INFECTIOUS

CARDIOVASCULAR DISORDERS
Match the word with its definition.
1. Solid, liquid, gaseous masses of undis- 1. Infective endocarditis
solved matter traveling with the current 2. Emboli
in a blood or lymphatic vessel.
3. International normalized ratio
2. Gram-positive bacteria whose group A
causes disease. 4. Rheumatic heart disease
3. Inflammation of the heart lining 5. Beta-hemolytic streptococci
caused by microorganisms.
4. Standardized test for reporting prothrom-
bin to prevent variability in testing results
and provide uniformity in monitoring
therapeutic levels for coagulation.
5. Severe damage to the heart from
rheumatic fever.

RHEUMATIC FEVER AND RHEUMATIC HEART DIAGNOSTIC TESTS FOR INFECTIVE

DISEASE ENDOCARDITIS
Find the six errors and insert the correct information. Match the test with its finding that is indicative of infective
endocarditis.
Rheumatic fever causes a streptococcal infection such as a
sore throat. Rheumatic fever signs and symptoms include pol- Test Finding
yarthritis, subcutaneous nodules, cholera with rapid and con-
trolled movements, carditis, fever, arthralgia, and pneumonia. 1. White blood cell 1. Vegetations on heart
A throat culture diagnoses rheumatic fever. The heart valves (WBC) count valves
and their structures can be scarred and damaged. Rheumatic 2. Dysrhythmias
2. Blood cultures
fever can be prevented by detecting and treating streptococcal 3. Slight elevation
3. Electrocardiogram 4. Heart failure
infections promptly with aspirin.
4. Chest x-ray examination 5. Identifies causative
5. Echocardiogram organism

THROMBOPHLEBITIS
Complete the rationale and evaluation of the nursing care plan for a patient with thrombophlebitis.

NURSING DIAGNOSIS
Acute Pain related to inflammation of vein

Interventions Rationale Evaluation

Assess pain using rating scale
such as 0 to 10.

Provide analgesics and

nonsteroidal anti-inflammatory
drugs (NSAIDs) as ordered.

Apply warm, moist soaks.

Maintain bedrest with leg

elevation above heart level.
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Chapter 23 Nursing Care for Valvular, Inflammatory, Infectious Cardiac or Venous Disorders 89

NURSING DIAGNOSIS
Deficient Knowledge related to lack of knowledge about disorder and treatment

Interventions Rationale Evaluation

Explain condition, symptoms,
and complications.

Explain medications, therapies

ordered, monthly lab test monitoring,
and need for medical identification.

Teach patient not to massage extremity.

CRITICAL THINKING—MR. EVANS 3. What diagnostic test will show hypertrophic cardiomy-
opathy and left-sided heart failure?
Read the case study and answer the questions.
Mr. Evans, age 68, is admitted to the hospital for heart failure
resulting from hypertrophic cardiomyopathy. He has dysp-
nea, fatigue, and angina. His lung sounds reveal crackles.
4. Why is digoxin contraindicated for Mr. Evans?
1. What is the pathophysiology of hypertrophic cardiomy-
opathy?

5. Why should Mr. Evans be taught to avoid (a) dehydration

and (b) exertion?
2. What occurs in hypertrophic cardiomyopathy to ventric-
ular size and ventricular filling with blood?

6. Why is it important for the family to learn cardiopul-

monary resuscitation (CPR)?

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 3. Which of the following compensatory mechanisms
does the nurse understand occurs with ventricular valve
1. Which of the following does the nurse understand
disorders?
occurs in aortic stenosis?
1. Decreased atrial kick
1. Aortic valve does not close tightly.
2. Atrial hypertrophy
2. Emptying of blood from left ventricle is impaired.
3. Ventricular hypertrophy
3. Blood backflows into the left atrium.
4. Systolic hypertension
4. Emptying of the left atrium is impaired.
4. Which of the following does the nurse understand
2. The nurse understands that which of the following
causes fatigue in patients with chronic aortic stenosis?
occurs in mitral regurgitation?
1. Atrial fibrillation
1. Backflow of blood into the left atrium
2. Left ventricular failure
2. Backflow of blood into the right atrium
3. Decreased pulmonary blood flow
3. Impaired emptying of the right ventricle
4. Increased coronary artery blood flow
4. Impaired emptying of the left ventricle
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90 UNIT FIVE Understanding the Cardiovascular System

5. Which of the following diagnostic tests does the nurse 7. Which of the following is the most common symptom
understand measures the pressures in the cardiac of pericarditis?
chambers? 1. Dyspnea
1. Electrocardiogram 2. Intermittent claudication
2. Exercise stress test 3. Chest pain
3. Echocardiogram 4. Calf pain
4. Cardiac catheterization

6. Which of the following does the nurse understand

usually precedes rheumatic fever?
1. A viral infection
2. A fungal infection
3. A staphylococcal infection
4. A beta-hemolytic streptococcal infection

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 12. The nurse is teaching a patient with heart failure how
to avoid activity that results in Valsalva’s maneuver.
8. Which of the following should the nurse include in the
Which of the following statements by the patient indi-
plan of care as a patient outcome for Deficient Knowl-
cates to the nurse that the teaching has been effective?
edge related to mitral stenosis?
1. “I will breathe normally when moving.”
1. Clear breath sounds, no edema or weight gain.
2. “I will use a straw to drink oral fluids.”
2. Normal changes in vital signs with less fatigue dur-
3. “I will take fewer but deeper breaths.”
ing self-care.
4. “I will clench my teeth when moving.”
3. Verbalizes knowledge of disorder.
4. States fear is reduced.
13. The nurse is planning care for a patient with chronic
mitral regurgitation. Which of the following assess-
9. Which of the following medications does the nurse an-
ments would be the highest priority?
ticipate that the patient will be given to prevent compli-
1. Cardiac rhythm
cations associated with decreased cardiac output?
2. Heart tones
Select all that apply.
3. Peripheral edema
1. Furosemide (Lasix)
4. Lung sounds
2. Cephalexin (Keflex)
3. Penicillin (Bicillin)
14. A patient with a history of endocarditis is undergoing
4. Warfarin (Coumadin)
dental work and is recommended to take prophylactic
5. rPA (Retavase)
antibiotics to prevent which of the following?
6. Potassium supplement
1. Infective endocarditis
2. Peritonitis
10. The nurse is caring for a patient, age 70, who has a
3. Vegetative emboli
nursing diagnosis of Deficient Knowledge related to
4. Inflammation
furosemide administration. Which of the following
interventions is essential to include when planning a
15. A patient has a positive Homans’ sign. Which of the
teaching session?
following does the nurse understand explains why
1. Determine patient’s learning priorities.
ambulation and performing the Homans’ sign is now
2. Tell patient what to learn first about furosemide.
contraindicated?
3. Assess patient’s dietary intake of potassium.
1. They can cause calf swelling.
4. Give patient a written test at the end of the teaching
2. They can cause patient pain.
session.
3. They can cause emboli.
4. They may cause a clot to form.
11. A patient, age 65, is being discharged after a mechani-
cal valve replacement for aortic stenosis. Which of the
following should be taught regarding warfarin
(Coumadin) therapy?
1. Wear medical identification.
2. Increase intake of green leafy vegetables.
3. Keep yearly blood test appointments.
4. Use a straight razor when shaving.
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Chapter 23 Nursing Care for Valvular, Inflammatory, Infectious Cardiac or Venous Disorders 91

16. A patient develops a postoperative deep venous throm- 22. Which of the following findings should be reported to
bosis and is started on intravenous (IV) heparin. Which the physician for a patient receiving warfarin therapy?
of the following laboratory tests does the nurse monitor 1. Bleeding time 3 (normal = 2–5 seconds)
during heparin therapy? 2. International normalized ratio (INR) 4 (therapeutic =
1. Plasma fibrinogen 2–3 seconds)
2. Prothrombin time (PT) 3. Partial thromboplastin time (PTT) 28 (normal =
3. Partial thromboplastin time (PTT) 30–45 seconds)
4. International normalized ratio (INR) 4. Prothrombin time (PT) 20 (therapeutic =
13.5–22 seconds)
17. The nurse is caring for a patient on warfarin
(Coumadin) with an elevated international normalized 23. A patient who has end-stage dilated cardiomyopathy
ration (INR) level. Which of the following would be comes to the emergency department with dyspnea. The
ordered as the antidote for warfarin? patient reports waking with a feeling of suffocation,
1. Vitamin K which was frightening. Which of the following re-
2. Vitamin B12 sponses by the nurse is most appropriate?
3. Calcium chloride 1. “You must have been dreaming.”
4. Protamine sulfate 2. “Reclining decreases the heart’s ability to pump
blood.”
18. Which of the following is a desired outcome for the 3. “Sleeping increases heart rate, which increases the
nursing diagnosis of Acute Pain for a patient with acute body’s need for oxygen.”
thrombophlebitis? 4. “Reclining increases fluid returning to the heart,
1. States anxiety is decreased. which builds up fluid in the lungs.”
2. States pain is satisfactorily relieved.
3. Is able to participate in desired activities. 24. Which of the following assessments of a patient would
4. Reports ability to ambulate without pain. indicate a side effect of digoxin (Lanoxin) is occurring
that requires follow-up?
19. A patient visits the doctor for a severe sore throat and 1. Skin flushing
fever. As the nurse plans the patient’s care, which of 2. Anorexia
the following diagnostic tests is obtained to prevent 3. Hypertension
cardiac complications? 4. Constipation
1. Chest x-ray examination
2. Throat culture 25. The physician writes a “now” order for codeine 45 mg
3. White blood cell count intramuscular (IM) for a patient with thrombophlebitis.
4. Erythrocyte sedimentation rate The nurse has on hand codeine 60 mg/2 mL. Which of
the following doses should be given?
20. The nurse is reviewing the daily international normal- 1. 1.45 mL
ized ration (INR) and prothrombin time (PT) levels for 2. 1.5 mL
a patient who had a mechanical valve replacement. The 3. 1.75 mL
INR is 3.7 and the PT level is 29. Which of the follow- 4. 2.15 mL
ing actions should the nurse take?
1. Give the next dose of warfarin (Coumadin) as 26. A patient, age 46, is admitted for observation with a
ordered. chest contusion after hitting the steering wheel in an
2. Inform the health care provider now. auto accident. Which of the following findings would
3. Give warfarin (Coumadin) now. be the highest priority?
4. Hold the next dose of warfarin (Coumadin). 1. Bronchovesicular sounds heard over the major
airways
21. A patient, who had a hysterectomy 2 days ago, reports 2. Patient reports chest soreness and tenderness
tenderness in her left calf. The nursing assessment re- 3. Sternal bruising noted
veals the following: left calf 17.5", right calf 14", left 4. Pericardial rub heard on auscultation
thigh 32", right thigh 28", and a shiny, warm, and red-
dened left leg. Which of the following interventions
should be given priority in the patient’s plan of care?
Select all that apply.
1. Maintain bedrest.
2. Encourage ambulation three times daily.
3. Encourage bilateral leg exercises.
4. Apply bilateral antiembolism stockings.
5. Apply right antiembolism stocking.
6. Apply warm moist heat as ordered.
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Nursing Care
24 of Patients With Occlusive
Cardiovascular Disorders
VOCABULARY
Match the term with its definition.

1. Lymphangitis 1. Varicose veins

2. Atherosclerosis 2. Procedure that compresses plaque against wall
3. Stenosis of artery
4. Ischemia 3. Unstable angina
5. Venous stasis ulcer 4. Bacterial infection of lymphatic channels
6. High-density lipoprotein 5. Angina pectoris
7. Collateral circulation 6. Obstructed blood flow in the coronary arteries
8. Balloon angioplasty 7. Stable angina
9. Chest pain caused by decreased blood 8. Raynaud’s disease
supply to the heart 9. Plaque buildup within arterial wall
10. Chest pain that usually subsides with 10. Lack of sufficient blood supply
rest 11. Aneurysm
11. Chest pain that increases in frequency 12. Vessels grow to compensate for blocked blood
and is not relieved by rest flow
12. Tortuous and bulging veins, usually in 13. Narrowing of a vessel
lower extremity 14. Myocardial infarction
13. Disease-causing venospasms when 15. A moving clot
exposed to cold 16. “Good” cholesterol
14. A bulging or dilation of an artery 17. A stationary clot
15. Death of a portion of the myocardium 18. Skin breakdown from chronic venous
16. Laboratory value that determines de- insufficiency
gree of damage to the heart 19. Troponin I
17. Embolism 20. Exertional calf pain that ceases with rest
18. Thrombus
19. Intermittent claudication
20. Coronary artery disease

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Chapter 24 Nursing Care of Patients With Occlusive Cardiovascular Disorders 93

ATHEROSCLEROSIS experiencing chest pain. Meperidine (Demerol) is the most

widely used narcotic for MI. It helps decrease anxiety, in-
Answer the following questions. creases respirations, and vasoconstricts the coronary arteries.
Oxygen is given usually at 1 L/hr via nasal cannula. Nitro-
1. What is the pathophysiology of atherosclerosis?
glycerin sublingual, topical, or by intravenous (IV) drip can
also be administered. Percutaneous coronary intervention is
a frequent treatment option for an occluded coronary artery.
A nursing care plan should include factors that may con-
2. What are modifiable risk factors that contribute to ather- tribute to decreased cardiac workload. Changes in diet, stress
reduction, regular exercise program, smoking cessation, and
osclerosis?
following a medication schedule require extensive patient
and family teaching.

PHARMACOLOGICAL TREATMENT
3. Develop a teaching plan for one of the modifiable risk Match the medication to the appropriate description.
factors for atherosclerosis.
1. Calcium channel 1. Nitroglycerin
blocker 2. Cholestyramine
(Questran)
2. Beta blocker
3. Propranolol (Inderal)
MYOCARDIAL INFARCTION 3. Drug of choice for 4. Amlodipine (Norvasc)
Find the 22 errors and insert the correct information. anginal attacks 5. Reteplase (Retavase)
4. Does not dissolve 6. Clopidogrel (Plavix)
Myocardial infarction (MI) is the death of a portion of the 7. Heparin
existing clots
pericardial sac caused by blockage or spasm of a coronary 8. Pentoxifylline
5. Bile acid (Trental)
artery. When the patient has an MI, the affected part of the
muscle becomes damaged and no longer functions properly. sequestrant 9. Isosorbide dinitrate
Ischemic injury takes a few minutes before complete necrosis 6. Antiplatelet (Isordil)
and infarction take place. The ischemic process affects the 10. Atorvastatin (Lipitor)
7. Long-acting nitrate
subendocardial layer, which is the least sensitive to hypoxia.
8. Thrombolytic
Myocardial contractility is depressed, so the body attempts
to compensate by triggering the parasympathetic nervous sys- therapy agent
tem. This causes a decrease in myocardial oxygen demand, 9. Decreases blood
which further depresses the myocardium. After necrosis, the viscosity
contractility function of the muscle is temporarily lost. If
10. Reduces choles-
treatment is initiated after several signs of an MI, the area of
damage can be minimized. If prolonged ischemia occurs, the terol synthesis
size of the infarction can be small.
The area that is affected by an MI depends on which coro- CRITICAL THINKING
nary artery is involved. The left anterior descending (LAD) Read the following case study and answer the questions.
branch of the left main coronary artery is the area that feeds
the lateral wall. The right coronary artery (RCA) feeds the Mr. Edwards is a 43-year-old man with a history of peripheral
anterior wall and parts of the atrioventricular node and the vascular disease and hypertension. He smokes two packs of
sinoatrial node. An occlusion of the RCA leads to an inferior cigarettes per day. He reports calf pain during minimal exer-
MI and to abnormalities of impulse conduction and forma- cise that decreases with rest.
tion. The left circumflex coronary artery feeds the inferior 1. Which of the following nursing diagnoses would be the
wall and part of the posterior wall of the heart. most appropriate relating to Mr. Edwards’s symptoms,
Pain is the least common symptom. The pain does not
and what would be the patient outcome?
radiate. The patient usually believes that an MI is occurring.
Other symptoms may include restlessness, a feeling of impend-
ing doom, nausea, diaphoresis, and cold, clammy, ashen skin.
The only symptom that might be present in the older adult is A. Ineffective Tissue Perfusion related to compromised
vomiting. Women may have atypical symptoms of an MI.
circulation
The three strong indicators of an MI are patient history,
abnormal electrocardiographic (ECG) readings, and high B. Fatigue related to pain on exertion
triglyceride levels. C. Impaired Mobility relating to stress associated with pain
Initially, patients are kept on bedrest to increase myocar- D. Self-Care Deficit related to pain and muscle spasms
dial oxygen demand. Patients are medicated promptly when
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94 UNIT FIVE Understanding the Cardiovascular System

2. Explain what happens when intermittent claudication 4. Describe how smoking contributes to decreased
occurs. circulation.

3. Why does rest decrease the pain?

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 4. The nurse is teaching the patient about diet. Which of
the following dietary actions may reduce low-density
1. Before a cardiac catheterization and coronary arteri-
lipid (LDL) cholesterol?
ogram, it is essential that the nurse ask a patient if the
1. Consuming <5 grams of soluble fiber daily
patient is allergic to which of the following?
2. Consuming >200 mg cholesterol daily
1. Eggs
3. <7% Kcal as saturated fat
2. Codeine
4. Using whole milk
3. Iodine
4. Penicillin
5. The nurse understands that pain associated with coro-
nary artery disease occurs from which of the following?
2. A patient, hospitalized with an MI, suddenly begins hav-
1. Lack of nutrients to the heart
ing severe respiratory distress with frothy sputum. These
2. Interrupted electrical activity to the areas of the heart
signs indicate that the patient probably has developed
3. Lack of sufficient oxygen to the myocardium
which of the following?
4. Overexertion of heart muscle due to the workload
1. Pneumonia
2. Cardiac tamponade
3. Pulmonary edema
4. Pneumothorax

3. As the nurse examines a patient for decreased circula-

tion in the lower extremities, which of the following
findings would indicate adequate circulation?
1. Loss of hair on the extremity
2. Capillary refill less than 3 seconds
3. Diminished pulses in the extremity
4. Thickened nails of the extremity

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 7. During a stress ECG, a patient reports chest pain, and
the test is stopped. When the patient is asked to undergo
6. A patient who has been scheduled for a stress electrocar-
a heart catheterization, the patient appears apprehensive
diogram (ECG) asks why this ECG is needed. Which of
and worried. Which of the following is the most appro-
the following is the nurse’s best response?
priate action for the nurse to take to reduce the patient’s
1. “It can predict whether the patient may soon have a
anxiety?
heart attack.”
1. Explain how coronary artery disease is treated.
2. “It verifies how much more physically fit the patient
2. Avoid discussing the heart catheterization until the
needs to become.”
patient has relaxed.
3. “It determines the patient’s potential target heart
3. Explain how well others have done after having this
rate.”
procedure.
4. “It shows how the heart performs during exercise.”
4. Listen to the patient express feelings about the situation.
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Chapter 24 Nursing Care of Patients With Occlusive Cardiovascular Disorders 95

8. Which of the following statements by a patient demon- 12. The nurse is collecting data on a patient. Which of the
strates to the nurse that the patient understands when to following clinical manifestations would the nurse ex-
replace nitroglycerin tablets? pect to find with acute venous insufficiency? Select all
1. Pills no longer cause tingling sensation when used. that apply.
2. Pills disintegrate when touched. 1. Full superficial veins
3. Pills smell like vinegar. 2. An aching, cramping type of pain
4. Pills become discolored. 3. Initial absence of edema
4. Cool and cyanotic skin
9. After hospitalization for a myocardial infarction, a 5. Positive Homans’ sign
patient is placed on a low-sodium diet. In discussing 6. Hyperemia
foods allowed on this diet, the nurse should inform the
patient that this list includes which of the following? 13. The nurse understands that which of the following are
1. Hot dogs the most characteristic symptoms of Buerger’s disease?
2. Fresh vegetables Select all that apply.
3. Milk and cheese 1. Numbness
4. Canned soups 2. Pain
3. Cramping
10. Which of the following does the nurse correctly 4. Swelling
include in a teaching plan as modifiable risk factors 5. Bounding pulses
for coronary artery disease? Select all that apply. 6. Intermittent claudication
1. Hypertension
2. Gender 14. A patient has been diagnosed with Raynaud’s disease
3. Age and asks the nurse what occurs with this disease. Which
4. Smoking of the following is the most appropriate response?
5. Diabetes 1. “Arterial vessel occlusion is caused by many clots
that develop in the heart and are carried to the
11. Which of the following should the nurse correctly bloodstream.”
include in a teaching plan as being high in saturated 2. “Arteriolar vasoconstriction occurs, most often in
fat? Select all that apply. the fingertips with symptoms of coldness, pain,
1. Avocado and pale skin.”
2. Tuna fish 3. “Peripheral vasospasm occurs in the lower limbs as a
3. Beef result of valve damage from long-standing venous
4. Olive oil stasis.”
5. Poultry 4. “Thrombosis related to prolonged vasoconstriction
6. Coconut oil caused by overexposure to the cold occurs.”
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Nursing Care of Patients

25 With Cardiac Dysrhythmias

VOCABULARY
Match the words and definitions.

1. Amplitude 1. Beat occurring every fourth complex, as in premature

2. Atrial depolarization ventricular contractions (PVCs)
3. Atrial systole 2. Belonging to anything naturally
4. Bigeminy 3. Coming or originating from one site
5. Cardioversion 4. Condition in which there is a complete dissociation
between atrial and ventricular systoles
6. Complete heart block
5. Contraction of the atria
7. Contractility
6. Contraction of the two ventricles
8. Decompensation
7. Defect in heart conduction system in which right bundle
9. Defibrillate
does not conduct impulses normally
10. Inherent 8. Elective procedure in which synchronized shock of 25 to
11. Ischemia 50 joules is delivered to restore normal sinus rhythm
12. Isoelectric line 9. Electrical activation of the atria
13. Multifocal 10. Electrical tracing is at zero and is neither positive nor
14. Quadrigeminy negative
15. Right bundle branch block 11. Failure of the heart to maintain adequate circulation
16. Trigeminy 12. Force with which left ventricular ejection occurs
17. Unifocal 13. Local deficiency of blood supply resulting from
18. Ventricular diastole obstruction of the circulation to another part
19. Ventricular escape rhythm 14. Occurring every third beat, as in PVCs
15. Occurs every second beat, as in PVCs
20. Ventricular repolarization
16. Originating from many foci or sites
21. Ventricular systole
17. Period of relaxation of the ventricle
18. Reestablishment of the polarized state of the muscle
after contraction
19. Size or fullness of voltage
20. Naturally occurring rhythm of the ventricles when the
rest of the conduction system fails
21. Use of electrical device to apply countershocks to the
heart through electrodes placed on the chest wall to stop
fibrillation

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Chapter 25 Nursing Care of Patients With Cardiac Dysrhythmias 97

COMPONENTS OF A CARDIAC CYCLE

Label the components of a cardiac cycle.

HEART RATE
Calculate the heart rate using the 6-second method.
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98 UNIT FIVE Understanding the Cardiovascular System

CARDIAC CONDUCTION
Match the words and definitions.

1. Sinoatrial node 1. Rate less than 60

2. Atrioventricular node 2. No QRS complexes seen—straight line
3. An early beat
3. Normal sinus rhythm
4. An early beat that has a P wave and a normal QRS
4. Right atrium complex
5. Right ventricle 5. Where normal cardiac impulse originates
6. Left atrium 6. A chaotic pattern—no visible cardiac cycles
7. No identifiable P waves with a normal QRS complex;
7. Left ventricle
irregularly irregular
8. Bradycardia 8. Wave that precedes a QRS complex
9. Tachycardia 9. Where an impulse is delayed before going to the
10. Q wave Purkinje fibers
10. An early beat with no P wave and a wide, bizarre
11. P wave
QRS complex
12. R wave 11. Successive beats of three or more wide, bizarre QRS
13. S wave complexes
14. T wave 12. Rhythm with normal P waves, QRS, T waves with a
heart rate of 60 to 100 beats per minute
15. U wave
13. The first negative deflection of a QRS complex
16. Premature 14. A small wave seen after the T wave
17. Sinus tachycardia 15. The first positive deflection on a QRS complex
18. Sinus bradycardia 16. Rhythm with normal P waves, QRS, T waves with a
heart rate of less than 60 beats per minute
19. Premature atrial contraction
17. The chamber of the heart that pumps the blood to the
20. Atrial fibrillation rest of the body
21. Premature ventricular contraction 18. The chamber that receives blood returning to the heart
22. Ventricular tachycardia 19. Rhythm with normal P waves, QRS, T waves with a
heart rate of more than 100 beats per minute
23. Ventricular fibrillation
20. The wave that follows the QRS complex
24. Asystole 21. The chamber that receives blood from the pulmonary
veins
22. The downward deflection after the R wave
23. Heart rate of more than 100 beats per minute
24. Chamber that propels blood into the pulmonary artery

ELECTROCARDIOGRAM INTERPRETATION
Analyze the electrocardiogram (ECG) rhythms using the six-step interpretation process.

A.
1. Rhythm:
2. Heart rate:
3. P waves:
4. PR interval:
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Chapter 25 Nursing Care of Patients With Cardiac Dysrhythmias 99

5. QRS interval:
6. QT interval:
7. ECG interpretation:

B.
1. Rhythm:
2. Heart rate:
3. P waves:
4. PR interval:
5. QRS interval:
6. QT interval:
7. ECG interpretation:

CRITICAL THINKING 3. What might some of the causes be for this dysrhythmia?
Read the following case study and answer the questions.
Mrs. Samuels is admitted to the hospital for chest pain. Tests
are run, and her electrocardiogram (ECG) shows bigeminal
PVCs of more than 6 per minute that are close to her T wave. 4. What additional symptoms might the nurse anticipate?
Her potassium level is 2.8 mEq/L. She is short of breath on ex-
ertion. Her blood pressure is 104/56 mm Hg, pulse is 72 beats
per minute, and respirations are 16 per minute.
5. What type of orders should the nurse expect from the
1. What should the nurse do first? health care provider?

2. What actions should the nurse take regarding the dys-

rhythmia?

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 2. The heart receives blood returning from the body
1. The nurse understands that which of the following de- through which of the following?
fines a cardiac cycle? 1. Pulmonary vein
1. Circulation of the blood through the body 2. Aorta
2. Circulation of the blood through the heart 3. Vena cavae
3. Depolarization and repolarization of heart chambers 4. Right coronary artery
4. Pumping action of the heart
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100 UNIT FIVE Understanding the Cardiovascular System

3. Which of the following separates the right side of the 6. Which of the following is the normal rate for the sinoa-
heart from the left? trial node?
1. Chamber 1. 20 to 40 beats per minute
2. Pericardium 2. 40 to 60 beats per minute
3. Valve 3. 60 to 100 beats per minute
4. Septum 4. More than 100 beats per minute

4. Which of the following chambers of the heart is largest 7. The nurse understands that rhythms arising from the
and has the thickest myocardium? primary pacing node of the heart are referred to as
1. Left ventricle which of the following?
2. Right ventricle 1. Escape beats
3. Right atrium 2. Bundle branch blocks
4. Left atrium 3. Sinus rhythms
4. Ectopic rhythms
5. Which of the following waveforms represents the rest-
ing state of the ventricle on the ECG?
1. P wave
2. QRS complex
3. U wave
4. T wave

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 11. Which of the following treatments can be appropriate
for a patient with atrial fibrillation? Select all that
8. The nurse notes a life-threatening dysrhythmia on a
apply.
patient’s cardiac monitor. Which of the following is
1. Amiodarone (Cordarone)
the nurse’s first appropriate action?
2. Nitroglycerin
1. Notify the health care provider immediately.
3. Warfarin (Coumadin)
2. Assess the patient.
4. Digoxin (Lanoxin)
3. Administer the appropriate medication for the noted
5. Cardioversion
dysrhythmia.
6. Epinephrine
4. Obtain vital signs.
12. The nurse is caring for a patient who has had a run of
9. The nurse is teaching a patient about digoxin. Which of
three or more PVCs together. The nurse should docu-
the following should the nurse include in the teaching?
ment this as which of the following?
1. Digoxin decreases ectopic beats.
1. Ventricular tachycardia
2. The force of contractions is increased with digoxin.
2. Bigeminy
3. The resting heart rate increases when digoxin is
3. Trigeminy
taken.
4. Multifocal PVCs
4. Digoxin raises the resting blood pressure.
13. The nurse is caring for a patient in ventricular tachy-
10. The nurse is providing care to a patient with atrial fib-
cardia who is hemodynamically stable. Which of the
rillation. Which of the following statements, if made
following is the initial treatment for this dysrhythmia?
by the patient, would be of the most concern?
1. Cardioversion
1. “Aspirin upsets my stomach, so I quit taking it.”
2. Pacemaker
2. “It seems like my feet are a little swollen.”
3. Defibrillation
3. “My wife and I got a membership at the local
4. Antiarrhythmic intravenous (IV) medication
health club.”
4. “I’ve been having trouble falling asleep at night.”
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Chapter 25 Nursing Care of Patients With Cardiac Dysrhythmias 101

14. The nurse is caring for a patient whose ECG monitor 16. The nurse is caring for a patient who is fatigued and
shows a total absence of electrical impulse. The nurse undergoing cardiac testing. For which of the following
does not detect a pulse. The nurse would document this dysrhythmias will the nurse anticipate the patient’s
as which of the following rhythms? need for a permanent pacemaker? Select all that
1. Agonal apply.
2. Asystole 1. Ventricular fibrillation
3. Sinus arrest 2. First-degree heart block
4. Ventricular standstill 3. Atrial fibrillation
4. Third-degree heart block
15. A patient with a cardiac disorder is having increased 5. Symptomatic bradycardia
PVCs and feels “anxious.” After assessment and vital 6. Premature atrial contractions (PACs)
signs, what is the next action for the nurse to take?
1. Order an ECG and cardiac enzymes.
2. Call the health care provider.
3. Elevate the head of the bed and start oxygen at
2 L/min.
4. Put the bed in modified Trendelenburg’s position.
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Nursing Care of Patients

26 With Heart Failure

VOCABULARY
Fill in the blank with the appropriate word found in the word list.

Afterload Peripheral vascular resistance

Cor pulmonale Preload
Hepatomegaly Pulmonary edema (acute heart failure)
Orthopnea Splenomegaly
Paroxysmal nocturnal dyspnea

1. is the acute inability of the heart to pump enough blood to meet the body’s oxygen and
nutrient needs.
2. occurs when the right side of the heart fails because of an increased workload caused by
pulmonary disease.
3. Organ enlargement that may occur with right-sided heart failure (HF) is known as and .
4. The goal of treatment for HF is to improve the heart’s pumping ability and decrease the heart’s workload by reducing
.
5. causes supine patients to awaken suddenly with a feeling of suffocation.
6. The end-diastole stretch in the ventricles produced by ventricular volume is .
7. The tension in the ventricular wall during systole necessary to overcome vascular resistance is
.
8. is dyspnea that occurs when the patient lies down.

102
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Chapter 26 Nursing Care of Patients With Heart Failure 103

FLUID ACCUMULATION PATTERNS CRITICAL THINKING

Label the backward accumulation of fluid and shade areas Read the following case study and answer the questions.
of fluid congestion.
Mr. Donner, age 72, is admitted to the cardiac unit for
The heart pumps blood in a closed circuit. If one side of increasing dyspnea on exertion and fatigue.
the heart fails to adequately pump blood forward, it pools
Subjective Data
and backs up from the failing chamber. On the drawing,
History of HF for 2 years
use arrows to mark the path of the backward accumulation
Unable to walk one block without increasing dyspnea
of fluid from the side of the heart that is failing. Shade in
Sleeps at 60-degree angle in reclining chair
areas where fluid congestion occurs.
Increasing fatigue during the last 2 weeks
To increase your understanding of where the backward
accumulation of fluid occurs from a certain side of the Objective Data
heart, use blue shading to illustrate the side with deoxy- BP 140/78 mm Hg, P 108 beats per minute, R 24 per
genated blood accumulation. Use red shading for the side minute, T 98.8°F (37.1°C)
with oxygenated blood accumulation. Jugular vein distention at 45 degrees
Has frequent dry cough
Bilateral crackles in lung bases
Nonpitting edema
Diagnostic studies
Chest x-ray examination: left and right ventricular
hypertrophy, bilateral fluid in lower lung lobes

1. Explain the cause of Mr. Donner’s fatigue, cough, and

shortness of breath.

2. Which of Mr. Donner’s signs and symptoms are from

left-sided HF and which are from right-sided HF?
Left:
Right:

3. Explain the purpose of each of the following therapies.

How would they be beneficial in treating Mr. Donner’s
heart failure?
SIGNS AND SYMPTOMS OF HEART FAILURE 1. Furosemide (Lasix) 40 mg by mouth (PO) twice
In HF, certain signs and symptoms occur based on the side daily:
of the heart that is failing as a pump.
2. Benazepril (Lotensin) 10 mg PO daily:
Match the following sign or symptom to the failing side of
the heart that is causing it.
3. 2 g sodium diet:
1. Dry cough 1. Left-sided HF 4. Oxygen 4 L/min:
2. Peripheral edema 2. Right-sided HF
3. Crackles
4. Hepatomegaly 4. Mr. Donner suddenly becomes dyspneic and anxious,
5. Jugular vein has moist crackles throughout his lungs, and pink frothy
distention sputum. Explain what is happening.
6. Dyspnea
7. Splenomegaly
8. Orthopnea
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104 UNIT FIVE Understanding the Cardiovascular System

5. Explain the purpose of each of the following therapies. 7. What are Mr. Donner’s health learning needs to manage
How are they beneficial in treating Mr. Donner’s acute his chronic condition?
HF?
1. High Fowler’s position:

2. Oxygen 6 L/min:

3. Furosemide (Lasix) intravenous push (IVP):

4. Nitroglycerin IV infusion:

5. Morphine 2 mg IVP:

6. List two priority nursing diagnoses and goals for

Mr. Donner’s chronic HF.

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 3. If a patient has elevated pulmonary vascular pressures,
the nurse understands that the patient is most likely to
1. A patient is being given digoxin (Lanoxin) to treat heart
develop which of the following physiological cardiac
failure. Which of the following is a usual adult daily
changes?
dosage of digoxin (Lanoxin)?
1. Left atrial atrophy
1. 0.005 mg
2. Right atrial atrophy
2. 0.025 mg
3. Left ventricular hypertrophy
3. 0.25 mg
4. Right ventricular hypertrophy
4. 2.5 mg

2. When the nurse is reviewing a patient’s daily laboratory

test results, which of the following electrolyte imbalances
should the nurse recognize as predisposing the patient to
digoxin toxicity?
1. Hypokalemia
2. Hyperkalemia
3. Hyponatremia
4. Hypernatremia
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Chapter 26 Nursing Care of Patients With Heart Failure 105

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 10. The patient is being discharged on furosemide (Lasix).
The nurse evaluates the patient as understanding med-
4. A patient is admitted to a medical unit with a diagnosis
ication teaching if the patient states that which of the fol-
of heart failure. The patient reports increasing fatigue
lowing laboratory tests will be monitored as ordered?
during the past 2 weeks. Which of the following is the
1. “I will have my urine sodium checked.”
most likely cause of this fatigue?
2. “I will have my calcium level checked.”
1. Dyspnea
3. “I will have my prothrombin time checked.”
2. Decreased cardiac output
4. “I will have my potassium level checked.”
3. Dry cough
4. Orthopnea
11. Which of the following does the nurse understand are
the reasons a patient with pulmonary edema is given
5. A patient asks the nurse what a diagnosis of heart failure
morphine sulfate? Select all that apply.
means. Which of the following is the nurse’s best re-
1. To reduce anxiety
sponse?
2. To relieve chest pain
1. “Your heart briefly stops.”
3. To strengthen heart contractions
2. “Your heart has an area of muscle that is dead.”
4. To increase blood pressure
3. “Your heart is pumping too much blood.”
5. To reduce preload and afterload
4. “Your heart is not an efficient pump.”
6. To induce amnesia
6. A patient’s chest x-ray examination indicates fluid in
12. The nurse evaluates that bumetanide (Bumex) IV is
both lung bases. Which of the following signs or symp-
effective in treating pulmonary edema if which of the
toms present during the nurse’s data collection most
following patient signs or symptoms is resolved?
reflects these x-ray examination findings?
1. Pedal edema
1. Fatigue
2. Jugular venous distention
2. Peripheral edema
3. Pink, frothy sputum
3. Bilateral crackles
4. Bradycardia
4. Jugular vein distention
13. A patient is being taught the action of digoxin, which
7. To monitor the severity of a patient’s heart failure, which
is an inotropic agent. The nurse defines an inotropic
of the following information is the most appropriate for
agent as a medication that has which of the following
the nurse to gather daily?
actions?
1. Weight
1. Decreases heart rate.
2. Calorie count
2. Increases heart rate.
3. Appetite
3. Increases conduction time.
4. Abdominal girth
4. Strengthens heart contraction.
8. Which of the following signs indicates to the nurse that
14. For a patient receiving furosemide, the nurse evaluates
digoxin (Lanoxin) has been effective for a patient?
the medication as being effective if which of the
1. Urine output decreases
following effects occurs?
2. Urine output increases
1. Bilateral crackles diminish.
3. Heart rate higher than 95 beats per minute
2. Serum potassium decreases.
4. Heart rate lower than 50 beats per minute
3. Heart rate increases.
4. Pulse pressure increases.
9. For a patient who is being discharged on digoxin
(Lanoxin), the nurse should include which of the
15. When caring for an anxious patient with dyspnea,
following in an explanation to the patient on the signs
which of the following nursing actions is most helpful
and symptoms of digoxin toxicity?
to include in the plan of care to relieve anxiety?
1. Poor appetite
1. Increase activity levels.
2. Constipation
2. Stay at patient’s bedside.
3. Halos around lights
3. Pull the privacy curtain.
4. Tachycardia
4. Close the patient’s door.
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unit SIX

Understanding the
Hematologic and
Lymphatic Systems
CHECKLIST FOR LEARNING SUCCESS
Review of Anatomy
and Physiology
and Aging Changes Major Disorders Nursing Assessment Diagnostic Tests Interventions Common Medications
❑ Blood components ❑ Anemias ❑ Signs and symptoms ❑ Complete blood cell ❑ Blood product ❑ Iron
❑ Functions of different ❑ Polycythemia of anemias count (CBC) administration ❑ Colony-stimulating
blood cells ❑ Disseminated ❑ Signs and symptoms ❑ White blood cell ❑ Chemotherapy factors
❑ Lymphatic system intravascular of bleeding (WBC) differential ❑ Thrombocytopenia ❑ Chemotherapy
structures and coagulation ❑ Lymph nodes ❑ Coagulation tests precautions ❑ Clotting factors
functions ❑ Idiopathic ❑ Skin ❑ Bone marrow biopsy ❑ Infection precautions
❑ Effects of aging thrombocytopenic ❑ Lymphangiography ❑ Bone marrow
purpura ❑ Lymph node biopsy transplant
❑ Hemophilia ❑ Splenectomy
❑ Leukemias
❑ Multiple myeloma
❑ Hodgkin’s disease
❑ Lymphomas
❑ Spleen disorders
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Hematologic and Lymphatic

27 System Function,
Assessment, and
Therapeutic Measures
VOCABULARY
Fill in the blank with the appropriate word.
1. is a blue-black discoloration from hemorrhage under the skin.
2. is the term used to describe swelling from blockage of lymph circulation.
3. Tiny hemorrhages into the skin creating a polka-dot appearance are called .
4. is caused by hemorrhages into the skin, mucous membranes, or internal organs.
5. The patient with has an increased risk for bleeding because of insufficient platelets.

LYMPHATIC SYSTEM REVIEW

Match each part of the lymphatic system with its proper description.

1. Lymph capillaries 1. Destroy pathogens in the lymph from the extremities before the
2. Lymph nodules lymph is returned to the blood
3. Thoracic duct 2. Collect tissue fluid from intercellular spaces
4. Lymph nodes 3. Prevent backflow of lymph in larger lymph vessels
5. Valves 4. Destroy pathogens that penetrate mucous membranes
5. Empties lymph from the lower body and upper left quadrant into
the left subclavian vein

108
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Chapter 27 Hematologic and Lymphatic System Function, Assessment, and Therapeutic Measures 109

STRUCTURES OF THE LYMPHATIC SYSTEM

Label the following structures.

1 _______________

2 _______________

3 __________________

4 __________________

6 __________________
5 __________________
7 __________________
Fe+

8 __________________ 9 _______________ 10 ________

HEMATOLOGIC SYSTEM REVIEW

Match each term with its definition.

1. Albumin 1. May become any kind of blood cell

2. Macrophages 2. Essential for chemical clotting
3. Calcium ions 3. Release histamine
4. Intrinsic factor 4. A hematopoietic tissue
5. Hemoglobin 5. May become cells that produce antibodies
6. Basophils 6. Large phagocytic cells
7. Red bone marrow 7. Promotes absorption of vitamin B12
8. Stem cell 8. Its fragments become platelets
9. Megakaryocyte 9. Carries oxygen in red blood cells (RBCs)
10. Lymphocytes 10. Pulls tissue fluid into capillaries to maintain blood volume
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110 UNIT SIX Understanding the Hematologic and Lymphatic Systems

CRITICAL THINKING
Read the case study and answer the questions.
Mr. Foster is receiving a unit of packed RBCs. You assist with identification of the patient before the transfusion begins. The
registered nurse (RN) then delegates monitoring of his vital signs every half hour to you.

1. Why should Mr. Foster be monitored for each of the following symptoms?
1. Fever

2. Back pain

3. Respiratory distress

4. Crackles

5. Hives

2. Mr. Foster’s respiratory rate increases from 16 to 20 breaths per minute. What do you do?

3. The physician asks that the transfusion be slowed down. How many hours can the blood hang before it must be stopped?

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 4. Which laboratory study is monitored for the patient
receiving heparin therapy?
1. What is the mineral necessary for chemical clotting? 1. International normalized ratio (INR)
1. Iron 2. Prothrombin time (PT)
2. Sodium 3. Partial thromboplastin time (PTT)
3. Potassium 4. Bleeding time
4. Calcium
5. Which blood product replaces missing clotting factors in
2. Through which of the following does lymph return to the patient who has a bleeding disorder?
the blood? 1. Platelets
1. Carotid arteries 2. Packed RBCs
2. Aorta 3. Albumin
3. Inferior vena cava 4. Cryoprecipitate
4. Subclavian veins
6. Which of the following items are transported in blood
3. Which of the following is a normal hemoglobin value? plasma? Select all that apply.
1. 38% to 48% 1. Oxygen
2. 12 to 18 g/100 mL 2. Nutrients
3. 48 to 54 mg % 3. Carbon dioxide
4. 27 to 36 g/dL 4. Hormones
5. Wastes
6. Electrolytes
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Chapter 27 Hematologic and Lymphatic System Function, Assessment, and Therapeutic Measures 111

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 9. The nurse is preparing to assist the physician with a
bone marrow biopsy. Which of the following interven-
7. A patient is on warfarin (Coumadin) therapy and has an
tions is most important for the nurse to carry out before
INR of 1.6. Which action by the nurse is appropriate?
the procedure?
1. Observe the patient for abnormal bleeding.
1. Explain the procedure to the patient’s family.
2. Notify the physician and expect an order to increase
2. Administer an analgesic to the patient.
the warfarin dose.
3. Observe the patient for bleeding.
3. Advise the patient to double today’s dose of
4. Drape the biopsy site.
warfarin.
4. Administer vitamin K per protocol.
10. The nurse is providing care for patients on a medical
surgical unit. Which of the following patients is at
8. A patient receiving a transfusion of packed RBCs
increased risk for infection?
reports chest and back pain. How should the nurse
1. A 57-year-old whose WBC count = 6500/mm3
respond?
2. A 63-year-old with a platelet count = 110,000/mm3
1. Do a complete head-to-toe examination.
3. A 49-year-old with a hematocrit = 44%
2. Ask the patient to rate the pain on a 0 to 10 scale.
4. An 88-year-old with a neutrophil count of 32%
3. Stop the transfusion and call the RN stat depending
on agency policy.
4. Administer an analgesic, as needed (prn).
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Nursing Care of Patients

28 With Hematologic and
Lymphatic Disorders
VOCABULARY
Label each statement true or false.

1. Anemia is a reduction in white blood cells (WBCs).

2. Hemolysis is the destruction of red blood cells (RBCs).
3. Pancytopenia is reduced numbers of all blood cells.
4. Polycythemia is the production of excess blood cells.
5. Phlebotomy is the excision of a vessel.
6. Disseminated intravascular coagulation (DIC) involves accelerated clotting throughout the
circulation.
7. Thrombocytopenia is an increase in platelets.
8. Hemarthrosis is bleeding into the muscles.
9. Leukemia literally means “white blood.”
10. Cancer of the lymph system is called lymphemia.
11. Abnormalities in B cells and T cells can result in lymphoma
12. Enlargement of the spleen is called splenomegaly.

CRITICAL THINKING: LEUKEMIA 3. The nursing assistant assigned to Mr. Frantzis has a
runny nose. What should you do?
Read the case study and answer the questions.
Mr. Frantzis is a 60-year-old man in the acute stage of chronic
lymphocytic leukemia. He is admitted to a nursing home
4. Mr. Frantzis calls you “Jennifer” when you enter his
because he has no family to help care for him. He has had
chemotherapy in the past but has decided against further room, but that is not your name. How do you respond?
treatment. You are assigned to his care today. You find him
pale and weak, with no energy to get out of bed. He also
reports pain in his chest.
5. You note bleeding from Mr. Frantzis’s gums. What care
1. Mr. Frantzis says he is too weak to get up for breakfast.
can you provide?
What do you do?

2. How do you follow up on the pain in his chest?

112
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Chapter 28 Nursing Care of Patients With Hematologic and Lymphatic Disorders 113

CRITICAL THINKING: HODGKIN’S DISEASE of a painful lump in his neck. He is also experiencing high
fevers and weight loss. The diagnosis was confirmed in a
Circle the errors in the following paragraph and write in
laboratory test by the presence of Reed-Sternberg cells. He
the correct information.
expresses his fears to his nurse, who tells him that Hodgkin’s
Joe is a 28-year-old construction worker diagnosed with stage disease is not really cancer, and that it is often curable. Joe takes
I Hodgkin’s disease. He initially went to his physician because a leave from work and begins palliative radiation therapy.

SICKLE CELL ANEMIA REVIEW

Fill in the signs and symptoms of sickle cell anemia.
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114 UNIT SIX Understanding the Hematologic and Lymphatic Systems

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 4. For which of the following problems should the nurse
monitor in the patient with multiple myeloma?
1. Which of the following foods will best help provide
1. Uncontrolled bleeding
dietary iron for a patient who has iron-deficiency anemia?
2. Respiratory distress
1. Fresh fruits
3. Liver engorgement
2. Lean red meats
4. Pathological fractures
3. Dairy products
4. Breads and cereals
5. Which of the following interventions can help minimize
complications related to hypercalcemia?
2. A 50-year-old African American patient is diagnosed with
1. Encourage 3 to 4 L of fluid daily.
anemia. Where can the nurse best observe for pallor?
2. Have the patient cough and deep breathe every
1. Scalp
2 hours.
2. Axillae
3. Place the patient on bedrest.
3. Chest
4. Apply heat to painful areas.
4. Conjunctivae
6. A patient is admitted for a splenectomy. Why is an
3. Which of the following is an early sign of anemia?
injection of vitamin K ordered before surgery?
1. Palpitations
1. To correct clotting problems
2. Glossitis
2. To promote healing
3. Pallor
3. To prevent postoperative infection
4. Weight loss
4. To dry secretions

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 10. A 27-year-old African American man is admitted in
sickle cell crisis. Which of the following events most
7. Which of the following conditions places a patient
likely contributed to the onset of the crisis?
at risk for respiratory complications following
1. He started a new job last week.
splenectomy?
2. He walked home in a cold rain yesterday.
1. A low platelet count
3. He had seafood for dinner last night.
2. An incision near the diaphragm
4. He has not exercised for a week.
3. Early ambulation
4. Early discharge
11. A patient has hand-foot syndrome related to sickle cell
anemia. What findings does the nurse expect to see as
8. Patients are at risk for overwhelming postsplenectomy
the patient is examined?
infection (OPSI) following splenectomy. Which of the
1. Unequal growth of fingers and toes
following symptoms alerts the nurse to this possibility?
2. Webbing between fingers and toes
1. Bruising around the operative site
3. Purplish discoloration of hands and feet
2. Irritability
4. Deformities of the wrists and ankles
3. Pain
4. Fever
12. The nurse has taught a patient with thrombocytopenia
how to prevent bleeding. Which of the following is the
9. A nurse is caring for a patient admitted with gastroin-
best evidence that the teaching has been effective?
testinal tract bleeding and a hemoglobin level of 6 g/dL.
1. The patient states the importance of avoiding injury.
The patient asks the nurse why the low hemoglobin
2. The patient can list signs and symptoms of
causes shortness of breath. Which response is best?
bleeding.
1. “Anemia prevents your lungs from absorbing oxygen
3. The patient uses an electric razor instead of a safety
effectively.”
razor.
2. “You do not have enough hemoglobin to carry
4. The patient lists symptoms that should be reported
oxygen to your tissues.”
to the doctor.
3. “You don’t have enough blood to feed your cells.”
4. “You have lost a lot of blood, and that has damaged
your lungs.”
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Chapter 28 Nursing Care of Patients With Hematologic and Lymphatic Disorders 115

13. A patient with a history of hemophilia A arrives in the 16. A patient is having difficulty coping with a new diag-
emergency department with a “funny feeling” in his nosis of leukemia. Which response by the nurse is most
elbow. The patient states that he thinks he is bleeding helpful initially?
into the joint. Which response by the nurse is correct? 1. “Don’t worry. You’ll be okay.”
1. Palpate the patient’s elbow to assess for swelling. 2. “The treatments you are receiving will make you
2. Notify the physician immediately and expect an feel better very soon.”
order for factor VIII. 3. “Who do you usually go to when you have a
3. Prepare the patient for an x-ray examination to problem?”
determine whether bleeding is occurring. 4. “Have you made end-of-life decisions?”
4. Apply heat to the elbow and wait for the physician
to examine the patient. 17. What discharge teaching is most important to help the
patient who has had a splenectomy prevent infection?
14. A patient with a new diagnosis of lymphoma is experi- 1. Avoid showering for 1 week.
encing fatigue. Which of the following is the best way 2. Sleep in a semi-Fowler’s position.
to assess the fatigue? 3. Receive a yearly flu vaccine.
1. Observe the patient’s activity level. 4. Stay on antibiotics for life.
2. Monitor for changes in vital signs.
3. Monitor hemoglobin and hematocrit values.
4. Have the patient rate the fatigue on a scale of 0 to 10.

15. A patient diagnosed with lymphoma is being dis-

charged from the hospital. Which of the following
statements should the nurse include in the patient
teaching?
1. “It is important to avoid crowds to reduce your risk
of infection.”
2. “Taking a walk outside will help reduce your stress
level.”
3. “It is important for you to increase your dietary
intake of iron.”
4. “Your disease often affects the eyes, so television
viewing should be minimized.”
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unit SEVEN

Understanding the
Respiratory System
CHECKLIST FOR LEARNING SUCCESS
Review of Anatomy
and Physiology
and Aging Changes Major Disorders Nursing Assessment Diagnostic Tests Interventions
❑ Lungs and bronchial tree ❑ Epistaxis ❑ Respiratory history ❑ Complete blood count (CBC) ❑ Smoking cessation
❑ Mechanisms of breathing ❑ Upper respiratory infections ❑ Adventitious lung sounds ❑ D-dimer ❑ Interventions for ineffective
❑ Acid–base balance ❑ Influenza ❑ Dyspnea ❑ Culture and sensitivity (C&S) airway clearance
❑ Protective mechanisms ❑ Cancer of the larynx ❑ Activity tolerance ❑ TB skin test ❑ Interventions for impaired gas
❑ Aging changes ❑ Pneumonia ❑ Oximetry exchange
❑ Tuberculosis (TB) ❑ Capnography ❑ Positioning
❑ Restrictive disorders ❑ Arterial blood gases (ABGs) ❑ Oxygen therapy
❑ Chronic obstructive ❑ Chest x-ray ❑ Nebulized mist treatments
pulmonary disease (COPD) ❑ CT scan ❑ Metered-dose inhalers
❑ Chronic bronchitis ❑ Ventilation-perfusion scan ❑ Chest physiotherapy
❑ Asthma ❑ Pulmonary function studies ❑ Incentive spirometry
❑ Emphysema ❑ Pulmonary angiography ❑ Chest drainage
❑ Cystic fibrosis ❑ Bronchoscopy ❑ Tracheostomy care/suctioning
❑ Pulmonary embolism ❑ Mechanical ventilation
❑ Chest trauma ❑ Noninvasive positive pressure
❑ Pneumothorax ventilation (NIPPV)
❑ Respiratory failure
❑ Lung cancer
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Respiratory System
29 Function, Assessment, and
Therapeutic Measures
VOCABULARY
Complete the sentences with the terms provided below.
Adventitious Barrel Dyspnea Thoracentesis Tracheostomy
Apnea Crepitus Excursion Tidaling Tracheotomy
1. A patient with a low oxygen saturation may develop .
2. may develop if air leaks into tissues from a chest tube site.
3. A may be necessary to reduce distress from severe pleural effusion.
4. The patient with air trapping may develop a -shaped chest.
5. The nurse can measure respiratory to check chest expansion.
6. Crackles are an example of a/an sound.
7. A patient who is choking may need an emergency .
8. The in the water-seal chamber shows that a chest tube is intact.
9. The absence of respirations is called .
10. A patient is taught to remove the inner cannula of a tube every 8 hours for cleaning.

ANATOMY REVIEW VENTILATION REVIEW

Number the following structures in the order in which air Number the events of breathing in proper sequence beginning
flows through them. with the medulla.

Nose The medulla generates motor impulses.

Trachea The chest cavity is enlarged in all
Secondary bronchi directions.
Primary bronchi The diaphragm and external intercostal
Bronchioles muscles contract.
Alveoli Intrapulmonic pressure decreases.
Larynx Motor impulses travel along the phrenic
Nasopharynx and intercostal nerves.
The chest wall expands the parietal pleura,
which expands the visceral pleura, which in turn ex-
pands the lungs.
Air enters the lungs until intrapulmonic
pressure equals atmospheric pressure.

118
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Chapter 29 Respiratory System Function, Assessment, and Therapeutic Measures 119

ADVENTITIOUS LUNG SOUNDS

Match the adventitious lung sound to its description.
1. Coarse crackles 1. Velcro® being torn apart
2. Fine crackles 2. Faint lung sounds
3. Wheezes 3. Leather rubbing together
4. Stridor 4. Loud crowing noise
5. Pleural friction rub 5. Moist bubbling
6. Diminished 6. High-pitched violins

CHEST DRAINAGE
Label the three chambers of the chest drainage system and explain the function of each.
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120 UNIT SEVEN Understanding the Respiratory System

THE RESPIRATORY SYSTEM

Label the parts of the respiratory system.
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Chapter 29 Respiratory System Function, Assessment, and Therapeutic Measures 121

CRITICAL THINKING
Read the following case study and answer the questions.
Bill, a licensed practical nurse (LPN), is collecting admission data on Mr. Howe, who has been admitted for dyspnea and weight
loss. While questioning Mr. Howe, Bill learns that he has had progressive weight loss during the past several months and that he
has a productive cough. He also reports waking up at night “wringing wet,” and his wife has to help him change the bed sheets.

1. What additional questions should Bill ask about Mr. Howe’s cough?

2. What disorder is suggested by Mr. Howe’s symptoms?

3. What diagnostic tests would you expect to be ordered?

4. Mr. Howe is scheduled for a bronchoscopy. What preprocedure care should Bill provide? Postprocedure?

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 4. Within the alveoli, surface tension is decreased and
inflation is possible because of the presence of which
1. Which of the following structures covers the larynx during
substance?
swallowing?
1. Tissue fluid
1. Hyoid cartilage
2. Surfactant
2. Vocal cords
3. Pulmonary blood
3. Soft palate
4. Mucus
4. Epiglottis
5. What is the function of the nasal mucosa?
2. Where are the respiratory centers located in the brain?
1. Assist with gas exchange.
1. Cerebral cortex and cerebellum
2. Sweep mucus and pathogens to the trachea.
2. Medulla and pons
3. Warm and moisten the incoming air.
3. Hypothalamus and cerebral cortex
4. Increase the oxygen content of the air.
4. Hypothalamus and temporal lobes
6. Deteriorating cilia in the respiratory tract predispose
3. What is the purpose of the serous fluid between the
older adults to which of the following problems?
pleural membranes?
1. Chronic hypoxia
1. Enhance exchange of gases.
2. Pulmonary hypertension
2. Facilitate coughing.
3. Respiratory infection
3. Destroy pathogens.
4. Decreased ventilation
4. Prevent friction.
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122 UNIT SEVEN Understanding the Respiratory System

7. Which of the following adventitious lung sounds is a 8. The purpose of pursed-lip breathing is to promote which
violin-like sound? of the following?
1. Crackles 1. Carbon dioxide excretion
2. Wheezes 2. Carbon dioxide retention
3. Friction rub 3. Oxygen excretion
4. Crepitus 4. Oxygen retention

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 12. The wife of a man with cystic fibrosis has been taught
how to perform chest physiotherapy. She asks the nurse
9. An LPN enters the room of a patient with chronic lung
to explain why this must be done. Which of the following
disease. The patient has removed the oxygen cannula,
responses is best?
and it is lying on the bed. The patient does not appear
1. “It helps strengthen chest muscles.”
to be in any distress. The pulse oximeter shows an oxy-
2. “It humidifies thick respiratory secretions.”
gen saturation of 79%. Which of the following actions
3. “It promotes lung expansion.”
should the nurse take?
4. “It helps him expectorate secretions.”
1. Call the registered nurse (RN) STAT.
2. Put the oxygen cannula back on the patient.
13. The nurse notes that the suction control chamber on a
3. Do a nebulized mist treatment.
chest drainage system is bubbling vigorously. Which
4. No action necessary; this is a normal oxygen
intervention is appropriate?
saturation.
1. Check the system for leaks.
2. Replace the drainage system with a new one.
10. A patient hospitalized with a right-sided pleural effu-
3. Reduce the level of wall suction.
sion calls the nurse and reports feeling short of breath.
4. Increase the water level in the suction control
Which of the following positions should the nurse
chamber.
suggest?
1. Prone
2. Supine with head on pillow
3. Trendelenburg
4. Side lying with good lung dependent

11. The nurse is caring for a patient with a transtracheal

catheter. Which of the following would the LPN expect
to be included in the plan of care?
1. Assist with cleaning the catheter two to three times
a day.
2. Provide supplemental oxygen via mask at all times.
3. Help remove the catheter at night for sleeping.
4. Assist to connect the catheter to a humidification
source.
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Nursing Care of Patients

With Upper Respiratory
Tract Disorders
30
VOCABULARY
Unscramble the letters of the following words to fill in the blanks in the statements below.

hiitsrin aadihpysg
pixessait daxueet
laiohnpstry cayetorlmyng
1. Surgical removal of the voice box is called a .
2. A nosebleed is called .
3. is the term used to describe drainage or pus.
4. A “nose job” is called .
5. Difficulty swallowing is called .
6. is the correct term for a runny nose.

CRITICAL THINKING: NASAL SURGERY

Read the following case study and answer the questions.
Mr. Jones had a broken nose as a young man, and now has a deviated nasal septum. He undergoes nasoseptoplasty for a
deviated nasal septum.

1. After surgery, you note that Mr. Jones is swallowing repeatedly while he sleeps. What do you do?

2. Before discharge you explain to Mr. Jones that he should not do anything that can increase bleeding, such as sneezing,
coughing, or straining to have a bowel movement. He says, “How can I avoid doing those things? It sounds impossible.”
How do you respond?

3. Mr. Jones asks if he can use aspirin for pain. What do you say?

123
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124 UNIT SEVEN Understanding the Respiratory System

CRITICAL THINKING: INFLUENZA

Read the following case study and answer the questions.
Your neighbor calls and describes symptoms of influenza. He is feverish, tired, and has a sore throat and headache. You advise
him to go to the urgent care center. The center does a throat culture and determines that the infection is viral. Your neighbor
is encouraged to drink fluids and take acetaminophen.

1. Why didn’t the health care provider (HCP) order antibiotics?

2. How will fluids help?

3. When should the acetaminophen be taken?

4. Your neighbor’s wife develops the same symptoms. Is it necessary to take her to the urgent care center?

5. Your neighbor’s older grandmother was visiting when your neighbor first developed symptoms. She now thinks she has
caught the flu, and her chest hurts. She asks what she should do. What should you tell her?

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 4. A 58-year-old man is diagnosed with cancer of the larynx.
Which of the following are early symptoms of this
1. When evaluating the effectiveness of nursing interven-
cancer?
tions for sinusitis pain, which data does the nurse collect?
1. Anemia and fatigue
1. White blood cell (WBC) count
2. Crackles and stridor
2. Amount and color of sinus drainage
3. A noticeable lump in the neck
3. Capillary refill
4. Dysphagia or hoarseness
4. Pain level on a 0 to 10 scale
5. A patient visits a nurse practitioner (NP) after having a
2. Which of the following communication methods is inap-
cold for a week; the patient is now experiencing a severe
propriate for a patient following laryngectomy surgery?
headache and fever. The NP diagnoses a sinus infection.
1. Placing a finger over the stoma
Which of the following additional symptoms is the
2. Using a special valve that diverts air into the esophagus
patient likely to exhibit?
3. Using a picture board
1. Facial tenderness
4. Learning esophageal speech
2. Chest pain
3. Photophobia
3. Why are narcotics given in low doses for pain to the
4. Ear drainage
patient who has had a laryngectomy?
1. They depress the respiratory rate and cough reflex.
2. They increase respiratory tract secretions.
3. They have a tendency to cause stomal edema.
4. They can cause addiction.
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Chapter 30 Nursing Care of Patients With Upper Respiratory Tract Disorders 125

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 9. A 17-year-old student enters the emergency department
with a nosebleed that won’t stop. Which of the following
6. In addition to antibiotics, which of the following recom-
positions should the nurse assist the patient to assume?
mendations can the nurse make to increase comfort for
1. Lying down with feet elevated
a patient experiencing sinusitis? Select all that apply.
2. Sitting up with neck extended
1. Coughing and deep breathing
3. Lying down with a small pillow under the head
2. Sinus irrigation
4. Sitting up leaning slightly forward
3. Hot moist packs
4. Room humidifier
10. The physician orders local application of phenyle-
5. Percussion and postural drainage
phrine solution to treat a nosebleed. The patient asks
6. Semi-Fowler’s position
how this will help. Which of the following responses
by the nurse is best?
7. Place the following four nursing actions for a patient who
1. “It will raise your blood pressure, which is necessary
has just had a laryngectomy in correct order of priority.
because of blood loss.”
1. Assist with ambulation.
2. “It will dilate your bronchioles and make your
2. Set up a visit from a well-adjusted patient who has
breathing easier.”
had a laryngectomy.
3. “It will help your blood to clot to reduce bleeding.”
3. Maintain a patent airway.
4. “It will constrict your vessels and slow down the
4. Control postoperative pain.
bleeding.”
8. The nurse teaches a patient how to live with a new
11. A nurse is providing community education related to
tracheostomy. Which of the following instructions is
swine flu. Which of the following statements by a
appropriate?
participant indicates that teaching has been effective?
1. “Never suction your tracheostomy; you might damage
1. “I’ve eliminated all pork from my diet.”
your trachea.”
2. “Swine flu can only be transmitted by pigs.”
2. “You should not feel bad about the tracheostomy—you
3. “Symptoms of swine flu are similar to other types
should feel lucky to be alive.”
of flu.”
3. “Be sure to protect your tracheostomy from pollutants
4. “There is a new medication just for swine flu
such as powders or hair.”
treatment.”
4. “Your tracheostomy will be cleaned each time you
visit your doctor.”
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Nursing Care of Patients

31 With Lower Respiratory
Tract Disorders
VOCABULARY
Complete the crossword puzzle.

Across Down
3. Acronym for a syndrome that is also called “white 1. Abbreviation for “front to back” when referring to the
lung” chest
4. Chest collapses during inspiration with this type of 2. Term used to describe hormones produced by tumors
respiration 3. Medication that relieves coughing
7. Bloody sputum 5. Treatment in addition to standard therapy
9. Abbreviation for inhaler 6. Abbreviation for laboratory tests done to measure
10. Respiratory membrane secretion respiratory status
13. Incision into the chest 8. Unable to react, as in skin testing
18. Abbreviation for inhaled nebulized medication 11. Continuous asthma is called asthmaticus.
20. Treatment for repeat pneumothorax 12. Drainage on infected tonsils
21. Blister on lung 14. Blood in the chest
22. Abbreviation for tuberculosis 15. Rapid respirations
16. Firm raised area in positive tuberculosis skin test
17. Smoking is a factor for cancer
19. Abbreviation for short of breath

126
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Chapter 31 Nursing Care of Patients With Lower Respiratory Tract Disorders 127

RESPIRATORY MEDICATIONS
Match the medication with its action.
1. Prednisone 1. Expectorant
2. Albuterol (Ventolin) 2. Potent anti-inflammatory
3. Tiotropium (Spiriva) 3. Leukotriene inhibitor (reduces inflammation in asthma)
4. Cromolyn sodium (Intal) 4. Short-acting beta-agonist bronchodilator
5. Guaifenesin (Humibid) 5. Anticholinergic bronchodilator
6. Zafirlukast (Accolate) 6. Mast cell stabilizer to prevent asthma symptoms
7. Codeine 7. Antitussive

CRITICAL THINKING
Read the following case study and answer the questions.
Edith is a 56-year-old homemaker admitted to the hospital with emphysema and acute dyspnea. She is a smoker with a
48-pack-year history.

1. What data do you collect for Edith’s admission database?

2. What does a 48-pack-year history mean?

3. Explain the pathophysiology involved in emphysema. How does the disease cause dyspnea?

4. What do you expect Edith’s lungs to sound like when you auscultate?

5. Why is it important for Edith to receive no more than 2 L of oxygen per minute, unless she is closely monitored?

6. Why might Edith be at risk for pneumothorax?

7. What position will help Edith’s shortness of breath? Why?

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128 UNIT SEVEN Understanding the Respiratory System

8. How can you encourage Edith to stop smoking?

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 3. Which of the following medications can be used to
quickly reduce shortness of breath in a crisis situation
1. A patient is treated with intravenous (IV) methylpred-
for a patient with end-stage respiratory disease?
nisolone (Solu-Medrol) for emphysema. What is the
1. Oral cortisone
purpose of corticosteroid treatment in lung disease?
2. Intramuscular meperidine (Demerol)
1. Dry secretions.
3. IV morphine
2. Treat the infection that causes an exacerbation.
4. IV propranolol (Inderal)
3. Improve the oxygen-carrying capacity of hemoglobin.
4. Reduce airway inflammation.
4. Which of the following risk factors presents the greatest
threat for respiratory disease?
2. How many liters per minute of oxygen should be admin-
1. Smoking
istered to the patient with emphysema?
2. High-fat diet
1. 2 L/min
3. Exposure to radiation
2. 6 L/min
4. Alcohol consumption
3. 10 L/min
4. 95 L/min

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 7. A patient is returned to the room after a bronchoscopy.
Which of the following actions should the nurse
5. A 72-year-old retired chemist has left lower lobe pneu-
take first?
monia. The nurse checks the patient’s oxygen saturation
1. Order a meal because the patient has been nil per os
and the result is 86%. Which of the following actions by
(NPO) for 8 hours.
the nurse is best?
2. Encourage fluids to flush dye from the patient’s
1. Contact the registered nurse (RN) or physician for an
system.
order for oxygen.
3. Monitor the patient for return to consciousness.
2. No action necessary; this is a normal SpO2.
4. Check for a gag reflex before allowing the patient
3. Call the respiratory therapist STAT for assistance.
to drink.
4. Walk the patient in the hall and recheck the O2
saturation.
8. A patient asks how to avoid lung cancer. Which of the
following should the nurse include in the patient teach-
6. The nurse is caring for a patient who is scheduled for a
ing? Select all that apply.
bronchoscopy. Which of the following would be in-
1. Live in a cold climate.
cluded in preprocedure teaching?
2. Stop smoking.
1. “The physician will place a small tube through your
3. Avoid exposure to passive smoke.
nose or mouth and into the bronchi to look at your
4. Avoid air pollution.
airways.”
5. Avoid crowded living conditions.
2. “You will breathe a radioactive substance that will
6. Consume a diet high in fruits and vegetables.
show diseased areas in your lungs.”
3. “You will need to drink a thick white liquid, which
9. A patient with a new diagnosis of small cell lung cancer
will be opaque on the x-rays.”
decides to have radiation therapy. Which of the follow-
4. “A dye will be injected to help visualize the struc-
ing expectations of this treatment is most appropriate?
tures of the bronchioles. Do you have any allergies?”
1. Complete cure of the cancer
2. Increased comfort
3. Prevention of the need for oxygen
4. Prevention of cancer spread
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Chapter 31 Nursing Care of Patients With Lower Respiratory Tract Disorders 129

10. A newly diagnosed patient asks the nurse to explain 12. How can the nurse help monitor effectiveness of ther-
asthma. Which of the following explanations by the apy for the patient with a pneumothorax and a chest
nurse is correct? drainage system?
1. “Your airways are inflamed and spastic.” 1. Palpate for crepitus.
2. “You have fluid in your lungs that is causing short- 2. Auscultate lung sounds.
ness of breath.” 3. Document color and amount of sputum.
3. “Your airways are stretched and nonfunctional.” 4. Monitor suction level.
4. “You have a low-grade infection that keeps your
bronchial tree irritated.”

11. Which of the following is the best explanation of

emphysema for a newly diagnosed patient?
1. “You have inflamed bronchioles, which causes a lot
of secretions.”
2. “The blood vessels that supply your lungs are dam-
aged, so you can’t absorb oxygen.”
3. “Your lungs have lost some of their elasticity, and
air gets trapped.”
4. “You have large dilated sacs of sputum in your
lungs.”
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unit EIGHT

Understanding the
Gastrointestinal,
Hepatic, and
Pancreatic Systems
CHECKLIST FOR LEARNING SUCCESS
Review of Anatomy
and Physiology and Nursing
Aging Changes Major Disorders Assessment Diagnostic Tests Interventions Common Medications
❑ Gastrointestinal (GI): ❑ Oral disorders ❑ Nursing data ❑ Laboratory tests ❑ GI intubation ❑ Antacids
❑ Oral cavity/pharynx ❑ Nausea/vomiting collection ❑ Flat plate of abdomen ❑ Tube feedings ❑ Antidiarrheals
❑ Esophagus ❑ Eating disorders ❑ Medical history ❑ Upper GI series ❑ Parenteral ❑ Antiemetics
❑ Stomach ❑ Oral/esophageal ❑ Physical ❑ Lower GI series nutrition ❑ Bulk-forming agents
❑ Small intestine cancer examination ❑ Esophagogastroduodenoscopy ❑ GI decompression ❑ H2 receptor antagonists
❑ Large intestine ❑ Gastroesophageal ❑ Pain (EGD) ❑ Gastric surgeries/ ❑ Laxatives
❑ Aging reflux disease (GERD) ❑ Alcohol use ❑ Colonoscopy complications ❑ Proton pump inhibitors
❑ Liver structure ❑ Gastritis history ❑ Gastric analysis ❑ Nursing care after ❑ Stool softeners
and function ❑ Peptic ulcer disease ❑ Medication ❑ Stool studies gastric surgery ❑ Vitamin B12
❑ Gallbladder structure ❑ Gastric bleeding history ❑ Immunoglobulin G ❑ Ostomy ❑ Diuretics
and function ❑ Gastric cancer ❑ GI signs and antibody test management ❑ Analgesics
❑ Pancreas structure ❑ Constipation/diarrhea symptoms ❑ Alanine transaminase, ❑ Transjugular ❑ Histamine antagonists
and function ❑ Appendicitis ❑ Skin Aspartate transaminase intrahepatic ❑ Lactulose
❑ Aging changes ❑ Peritonitis ❑ Abdomen ❑ Albumin portosystemic ❑ Neomycin
❑ Diverticulosis ❑ Mental status ❑ Amylase shunt
❑ Inflammatory bowel ❑ Ammonia ❑ Tamponade
disease ❑ Bilirubin ❑ Transplant
❑ Absorption disorders ❑ Prothrombin time ❑ Cholecystectomy
❑ Intestinal obstructions ❑ Occult blood ❑ Nutrition
❑ Lower gastrointestinal ❑ Upper GI, lower GI series ❑ Pain control
(GI) bleeding ❑ Cholecystogram
❑ Colon cancer ❑ Liver scan
❑ Hepatitis ❑ Endoscopic retrograde
❑ Liver failure cholangiopancreatography
❑ Pancreatitis ❑ Liver biopsy
❑ Cholecystitis
❑ Cholelithiasis
❑ Cancer
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Gastrointestinal,
32 Hepatobiliary, and
Pancreatic Systems
Function, Assessment, and
Therapeutic Measures
FUNCTIONS OF THE GASTROINTESTINAL SYSTEM
Fill in the blanks with the appropriate parts of the gastrointestinal (GI) system.
1. The sphincter prevents backup of stomach contents into the esophagus.
2. The valve prevents backup of fecal material from the large intestine into the small
intestine.
3. The sphincter prevents backup of duodenal contents into the stomach.
4. The absorption of most of the end products of digestion occurs in the intestine.
5. The digestion of protein begins in the .
6. Water and the vitamins produced by the normal flora are absorbed in the intestine.
7. The intestine is the site of action of bile and pancreatic enzymes.
8. The passageway for food into the stomach from the mouth is the .
9. Voluntary control of defecation is provided by the sphincter.
10. The watery secretion that permits taste and swallowing is produced by the glands.
11. The process of mechanical digestion is accomplished by the and in the
mouth.
12. The structures in the small intestine that contain capillaries and lacteals for absorption are the
.
13. The part of the colon that contracts in the defecation reflex is the .
14. The digestive function of the liver is the production of by the hepatocytes.

132
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Chapter 32 GI, Hepatobiliary, and Pancreatic Systems Function, Assessment, and Therapeutic Measures 133

STRUCTURES OF THE GASTROINTESTINAL SYSTEM

Label the following structures.

VOCABULARY 5. Immovable accumulation of feces in the bowels.

mipcaitno
Unscramble the letters to identify the word described by the
definition. 6. Resin obtained from trees to test for occult blood in
feces. gaiuca
1. Flexible or rigid device consisting of a tube and optical
7. Device consisting of a fluorescent screen that makes the
system for observing the inside of a hollow organ or
shadows of objects interposed between the tube and the
cavity. donscepeo
screen visible. ulfroocspeo
2. Gurgling and clicking heard over the abdomen caused by
8. Fatty stools. estaotrhrae
air and fluid movement from peristaltic action normally
9. A test performed to measure secretions of hydrochloric
occurring every 5 to 15 seconds at a rate of 5 to 35 per
acid and pepsin in the stomach. stgairc
minute. wlebo onudss
naayliss
3. Examination of the upper portion of the rectum with an
10. Examination of the stomach and abdominal cavity by
endoscope. locnooscypo
use of an endoscope. stgarsopcoy
4. Feeding via a tube placed in the stomach.
gvaaeg
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134 UNIT EIGHT Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems

LABORATORY TESTS
Match the test with its definition.
1. Stool for lipids 1. Levels may indicate colorectal or other cancer.
2. Stool cultures 2. Testing stool for blood that is not visible to
3. Stool for occult blood the eye
4. Carcinoembryonic antigen (CEA) 3. Testing stool for intestinal infections caused by
5. Stool for ova and parasites parasites
4. Testing stool for the presence of pathogenic
organisms in the GI tract
5. Testing stool for excessive amounts of fat

BOWEL PREPARATION 4. After a liver biopsy, the patient lies on the right side for
the first hours.
Circle the eight errors in the following paragraph, and in-
sert the correct information. 5. After a liver biopsy, nursing care focuses on monitoring
for .
A stomach preparation is required for several procedures that
visualize the lower bowel. This preparation is important for CRITICAL THINKING
effective test results. An incomplete bowel preparation may
Read the following case study and answer the questions.
prevent the test from being done or cause the need for it to
be repeated. This can result in the patient’s early discharge Mrs. Davis is a 41-year-old schoolteacher who is admitted to
and cost savings. The patient usually receives a soft diet your unit with recurrent lung cancer. She is debilitated and
24 hours before the test. A bowel preparation medication (liq- her physician orders parenteral nutrition to be started.
uid or pill) may be given. A cool tap-water enema or Fleet
enema may be given once. Older or debilitated patients should 1. Why is the parenteral nutrition rate started slowly at first?
be carefully assessed during the administration of multiple
enemas, which can fatigue the patient and increase elec-
trolytes. In patients with bleeding or constipation, the bowel
preparation may not be ordered by the health care provider.
2. Why are serum glucose levels monitored on Mrs. Davis
PANCREAS during parenteral nutrition administration?
State the pancreatic enzyme with its function.

1. Digests polypeptides to short chains of amino acids.

3. In what types of veins may parenteral nutrition be ad-

2. Digests emulsified fats to fatty acids and glycerol.
ministered with (a) dextrose of 12% or less; (b) dextrose
greater than 12%?
3. Digests starch to maltose.

4. Why is it necessary to use an infusion control pump for

LIVER parenteral nutrition?
Fill in the blanks with the appropriate words.

1. Liver or gallbladder disease may cause pale or 5. The parenteral nutrition is behind schedule. What action
colored stools. should the nurse take?
2. Liver disease may cause disorders.
3. A liver scan records the amount of mate-
rial taken up by the liver to form a composite “picture”
of the liver.
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Chapter 32 GI, Hepatobiliary, and Pancreatic Systems Function, Assessment, and Therapeutic Measures 135

6. When parenteral nutrition is discontinued, why might 8. Identify one nursing diagnosis and outcome with inter-
the infusion be slowly weaned off? ventions for the patient on parenteral nutrition.
Nursing Diagnosis

Patient Outcome
7. When parenteral nutrition is ordered to be stopped, why
should the patient be fed first, if it is not contraindi-
cated? Interventions

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 7. Which of the following diagnostic procedures on
stool specimens must the nurse collect using sterile
1. Which of the following structures are connected by the
technique?
ileocecal valve?
1. Stool for ova and parasites
1. Duodenum to the stomach
2. Stool for occult blood
2. Colon to the small intestine
3. Stool culture
3. Stomach to the esophagus
4. Stool for lipids
4. Ileum to the jejunum
8. Which of the following colors would the nurse recog-
2. Mechanical digestion in the stomach is accomplished by
nize as an expected finding for the patient’s stools
which of the following structures?
immediately after a barium swallow?
1. Mucosa
1. Brown
2. Smooth muscle layers
2. Black
3. Striated muscle layers
3. White
4. Gastric glands
4. Green
3. Gastric juice contributes to the digestion of which of the
9. Which of the following does the nurse understand is
following types of nutrients?
the primary reason a patient is non per os (NPO) until
1. Proteins
the gag reflex returns after an esophagogastroduo-
2. Fats
denoscopy (EGD) procedure?
3. Starch
1. To rest the vocal cords
2. To prevent aspiration
4. The enzymes of the small intestine contribute to the
3. To keep the throat dry
digestion of which of the following types of nutrients?
4. To prevent vomiting
1. Proteins
2. Fats
10. Which of the following positions would the nurse be
3. Disaccharides
correct in using for nasogastric (NG) tube insertion?
1. Trendelenburg’s
5. Which of the following structures carries bile and
2. Prone
pancreatic juices to the duodenum?
3. Sims’
1. Pancreatic duct
4. High-Fowler’s
2. Cystic duct
3. Hepatic duct
4. Common bile duct

6. Which of the following is a function of the liver?

1. Synthesis of plasma proteins
2. Elimination of carbohydrates
3. Concentration of bile
4. Secretion of cholecystokinin
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136 UNIT EIGHT Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 14. A patient who has an NG tube and an intravenous (IV)
line states, “I’m so embarrassed to have my family
11. Bowel sounds heard as soft clicks and gurgles at a rate
here I have tubes coming out of me everywhere.”
of 4 per minute would be documented by the nurse as
Which of the following would be an appropriate
which of the following types of findings?
nursing diagnosis?
1. Absent
1. Fear
2. Hyperactive
2. Defensive Coping
3. Hypoactive
3. Disturbed Body Image
4. Normal
4. Anxiety
12. Which of the following diagnostic procedures requires
15. In preparing a patient who is to have an NG tube in-
that a patient be NPO? Select all that apply.
serted, which of the following statements would the
1. Upper GI series (barium swallow)
nurse include in the patient teaching?
2. Flat plate of the abdomen
1. “This procedure often makes you cough.”
3. EGD
2. “You can help by swallowing or drinking liquids
4. Computed tomography (CT) scan
during the procedure.”
5. Endoscopic retrograde cholangiopancreatography
3. “It is very important that you hold your breath when
(ERCP)
I tell you to do so.”
4. “When instructed, I want you to exhale as quickly
13. Which of the following nursing diagnoses would be
and forcefully as you can.”
most appropriate to include in the patient’s plan of care
after a barium swallow? Select all that apply.
1. Risk for Constipation
2. Risk for Diarrhea
3. Risk for Pain
4. Imbalanced Nutrition: More Than Body
Requirements
5. Deficient Knowledge
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Nursing Care of
Patients With Upper
Gastrointestinal Disorders
33
VOCABULARY
Unscramble the letters to identify a word described by the definition.
1. Most common cause of peptic ulcers; its discovery has revolutionized treatment and cure of most peptic
ulcers. lehicbocatre ypoilr
2. Loss of appetite noraxeai
3. Inflammation of the stomach sagrtisti
4. Small, white, painful ulcers that appear on the inner cheeks, lips, gums, tongue, palate, and pharynx
hpatouhs tsoamtisti
5. Recurrent episodes of binge eating and self-induced vomiting lubiami
ernvsoa
6. Rapid entry of food into the jejunum causing dizziness, tachycardia, fainting, sweating, nausea, diar-
rhea, and abdominal cramping umdpnig nysdomre
7. Surgical removal of the stomach gtrasetcmyo
8. 20% to 30% over average weight for age, sex, and height boesiyt
9. Condition in which the stomach may protrude above the diaphragm
ihaatl erhian
10. Following surgical removal of part of the stomach, reanastomosis of the remaining portion to the
proximal jejunum satgorjujeonsotym

GASTRITIS
Match the description with the type of gastritis associated with it.
1. Heartburn or indigestion 1. Acute gastritis
2. Autoimmune gastritis 2. Chronic gastritis type A
3. Often caused by overeating 3. Chronic gastritis type B
4. Associated with the bacteria Helicobacter
pylori
5. Associated with difficulty in absorbing
vitamin B12
6. Can lead to peritonitis
7. Can be treated with antibiotics
8. Treatment includes a bland diet

137
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138 UNIT EIGHT Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems

PEPTIC ULCER DISEASE CRITICAL THINKING

Circle the seven errors in the following paragraph and Read the following case study and answer the questions.
write the correct information.
Mrs. Sheffield has just returned from surgery. She had a gas-
troduodenostomy (Billroth I) procedure. She has a nasogas-
Most peptic ulcers are caused by stress. Peptic ulcers are
tric (NG) tube, a 1000-mL intravenous (IV) of lactated
commonly found in the sigmoid colon. Symptoms of peptic
Ringer’s solution infusing at 100 mL/hr, and a Foley catheter.
ulcers include burning and a gnawing pain in the chest. With
She is nil per os (NPO). Her vital signs are stable: blood pres-
a duodenal ulcer, there is pain and discomfort with a full
sure 118/90 mm Hg, pulse 80 beats per minute, respirations
stomach, which may be relieved by avoiding food. Peptic ul-
16 per minute, and temperature 98°F (36.6°C). Her abdomi-
cers cannot be cured. Medication treatment for most peptic
nal dressing is clean, dry, and intact. She is drowsy but easily
ulcers should include anticoagulants as indicated.
aroused. After getting Mrs. Sheffield settled in bed, the nurse
connects her NG tube to intermittent low-wall suction as or-
GASTRECTOMY dered by her health care provider (HCP) and adds another
blanket to warm her. Mrs. Sheffield requests something for
Label the structures as they appear following various types
pain. The nurse administers morphine 5 mg intramuscularly
of gastric surgery.
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Chapter 33 Nursing Care of Patients With Upper Gastrointestinal Disorders 139

and allows her to rest. An hour later, the nursing assistant tells 4. As the nurse lightly palpates Mrs. Sheffield’s abdomen,
the nurse that Mrs. Sheffield is vomiting bright red blood. it feels slightly distended, and the nurse suspects that
The nurse goes to her room and finds her lying on her side
she may be bleeding into her peritoneum. What is the
propped up on one arm vomiting into an emesis basin. Her
NG suction catheter contains 250 mL of bright red drainage. nurse’s next step?
Her dressing remains clean and dry. She is diaphoretic and
reporting nausea.
5. What should the nurse tell the HCP?
1. What should be the nurse’s first response?

6. The HCP orders a stat hematocrit and hemoglobin, elec-

2. What is the nurse’s next action? trolytes, and oxygen at 2 L/min via nasal cannula. The
HCP also tells the nurse to get Mrs. Sheffield ready to re-
turn to surgery. What is the nurse’s priority nursing action?

3. Vital signs are now blood pressure 86/60 mm Hg, pulse

96 beats per minute, respirations 24 per minute, and
temperature 97.6°F (36.4°C). What is the nurse’s assess-
ment of the new data, and what is the nurse’s next step?

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 3. Which of the following procedures does the nurse
understand is done palliatively for the dysphagia that
1. Which of the following surgical procedures is the most
occurs in inoperable esophageal cancer?
likely treatment for a patient with gastric cancer?
1. Gastrectomy
1. Gastroplasty
2. Esophageal dilation
2. Gastrorrhaphy
3. Radical neck dissection
3. Gastric stapling
4. Modified neck dissection
4. Gastrectomy

2. Which of the following does the nurse understand is a

sign or symptom of oral cancer?
1. Painless ulcer
2. White painful ulcers
3. Feeling of fullness
4. Heartburn

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 5. A patient is admitted with chronic gastritis type B.
Which of the following signs and symptoms is the
4. A patient has a duodenal peptic ulcer and is taking
nurse likely to find on assessment?
cimetidine (Tagamet). Which of the following side
1. Anorexia
effects related to cimetidine should be included in the
2. Dysphagia
teaching plan?
3. Diarrhea
1. Confusion
4. Feeling of fullness
2. Hypertension
3. Blurred vision
4. Dry mouth
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140 UNIT EIGHT Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems

6. An asymptomatic patient is admitted with gastric bleed- 10. A patient is having an acute episode of gastric bleed-
ing. For which of the following signs or symptoms of ing. The HCP orders an IV of 1000 mL of 0.9% normal
severe gastric bleeding should the nurse monitor? Select saline, a complete blood cell (CBC) count, a nasogas-
all that apply. tric tube to low-wall suction, and oxygen by nasal can-
1. Hypertension nula. Which of the following orders should the nurse
2. Diaphoresis perform first?
3. Bounding pulse 1. Administer the IV of 1000 mL of 0.9% normal
4. Hypotension saline.
5. Confusion 2. Draw the blood for the CBC cell.
3. Insert the NG tube.
7. A patient had a gastrectomy 2 months ago. The patient 4. Apply oxygen by nasal cannula.
comes to the clinic for treatment for greasy stools and
frequent bowel movements. After the patient’s surgical 11. A patient is taught preventive measure for gastro-
recovery and current eating habits are assessed, which esophageal reflux disease. Which of the following
of the following types of diet would be most appropriate patient statements indicates that teaching has been
for the nurse to teach the patient to use? effective?
1. Bland diet 1. “I need to eat large meals.”
2. High-carbohydrate diet 2. “I will sleep without pillows.”
3. Low-fat diet 3. “I need to lie down for 2 hours after each meal.”
4. Pureed diet 4. “I will identify foods that cause discomfort.”

8. A patient visits her HCP and reports that she is very un- 12. The nurse is caring for a patient who recently returned
happy with her weight, which is 310 lb on her 5-foot from surgery after fundoplication. Which of the follow-
7-inch frame. When planning her care, the nurse knows ing symptoms is essential to report to the physician?
that the initial treatment for obesity includes which of 1. Nausea
the following? 2. Pain rated as 4 out of 10
1. Gastroplasty 3. Dysphagia
2. Billroth I procedure 4. Thirst
3. Billroth II procedure
4. Diet management

9. A patient has been diagnosed with a hiatal hernia. The

patient has heartburn and occasional regurgitation.
Which of the following interventions should the nurse
teach the patient to reduce the symptoms?
1. Eat small, frequent meals.
2. Recline for 1 hour after meals.
3. Sleep flat without a pillow.
4. Eat a bedtime snack.
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Nursing Care of
Patients With Lower
Gastrointestinal Disorders
34
VOCABULARY
Match the vocabulary word to the correct definition.
1. Appendicitis 1. Outpouchings in colon
2. Colectomy 2. Inflammation of colon
3. Telescoping of the bowel
3. Colitis
4. Tunnel connection between bowel and another
4. Colostomy organ
5. Diverticulosis 5. Blood in stool
6. Fistula 6. Twisting of bowel
7. Inflammation or infection of peritoneum
7. Hernia
8. Bulging of abdominal contents through abdomi-
8. Ileostomy nal wall
9. Intussusception 9. Diversion of small bowel through abdominal wall
10. Melena 10. Removal of large bowel
11. Diversion of large bowel through abdominal wall
11. Peritonitis
12. Inflamed appendix
12. Volvulus

OSTOMIES semiformed and that he will have to irrigate his ostomy

every 1 to 2 days to have bowel movements. The nurse
Circle the four errors in each of the following paragraphs contacts the dietitian to provide a list of the high-fiber
and insert the correct information. foods that he should eat.
1. Michelle Braun is a 16-year-old with ulcerative colitis.
She is taking cortisone. She is on a high-residue diet. CRITICAL THINKING
She has just been admitted to the hospital for a colec- Read the following case study and answer the questions.
tomy and elective loop ostomy. The nurse monitors her
intake and output (I&O), daily weights, and electrolytes. Mrs. Millie Hendricks is a 90-year-old resident in a nursing
The nurse also monitors for signs of inflammation in her home. Mrs. Hendricks has a history of severe osteoarthritis,
joints, skin, and other parts of her body. The nurse and she has no teeth or dentures, but otherwise she is quite
teaches her to restrict fluids following surgery to limit healthy. She normally has a bowel movement every other
the number of stools she has daily. day but has occasional constipation, which she takes care of
herself by requesting a dose of milk of magnesia. Today
when the nurse takes Mrs. Hendricks’s medications to her,
she says, “I think I need a second dose of that milk of mag-
nesia; my bowels haven’t moved in 3 days.” The nurse looks
2. James Key is a 46-year-old with a new sigmoid at the medication administration record and finds as needed
colostomy. Following surgery the nurse monitors his (prn) orders for milk of magnesia, psyllium (Metamucil),
stoma every shift for 3 days to ensure that it remains senna (Senokot), or a tap water enema.
gray and moist. The nurse explains that the stool will be

141
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142 UNIT EIGHT Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems

1. What should the nurse do before administering more 4. What nondrug interventions will help Mrs. Hendricks
medication? move her bowels?

2. What factors most likely led to Mrs. Hendricks’s consti- 5. After Mrs. Hendricks’s bowels have moved, what meas-
pation? ures can be instituted to prevent constipation next time?

3. What will happen if Mrs. Hendricks’s bowels do not

move today?

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 3. Which of the following drugs would the nurse expect to
1. What differentiates diverticulitis from diverticulosis? be prescribed for a woman with IBS and constipation?
Select all that apply. 1. Amitriptyline (Elavil)
1. Presence of weakness in bowel wall 2. Dicyclomine (Bentyl)
2. Presence of outpouchings on bowel mucous membrane 3. Paroxetine HCl (Paxil)
3. Presence of inflammation and infection 4. Hyoscyamine (Levbid)
4. Lack of symptoms
5. Involves the large intestine.

2. A pattern of alternating constipation and diarrhea is

most characteristic of which of the following gastro-
intestinal (GI) tract disorders?
1. Crohn’s disease
2. Ulcerative colitis
3. Irritable bowel syndrome (IBS)
4. Large bowel obstruction
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Chapter 34 Nursing Care of Patients With Lower Gastrointestinal Disorders 143

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 9. Which of the following dietary instructions is most im-
portant to include in the plan of care to prevent compli-
4. A patient who has ulcerative colitis is taken to the emer-
cations for a patient with an ileostomy?
gency department with severe rectal bleeding. Which of
1. “Drink lots of fluids to prevent dehydration.”
the following is the best option for maintaining nutri-
2. “Avoid fruits and vegetables to prevent diarrhea.”
tional status for this patient with ulcerative colitis who
3. “Avoid milk products to prevent gas.”
must be nil per os (NPO) for an extended period of time?
4. “Eat plenty of fiber to prevent constipation.”
1. Nasogastric (NG) tube feedings
2. Percutaneous endoscopic gastrostomy (PEG) tube
10. A patient is concerned about ileostomy odor. Which of
feedings
the following responses by the nurse would be best?
3. Parenteral nutrition (PN)
1. “A teaspoon of baking soda in your pouch will
4. Intravenous (IV) 5% dextrose and water
absorb all the odor.”
2. “The plastic your pouch is made of is odor-proof.
5. A patient is diagnosed with acute diverticulitis. Which
You shouldn’t have to worry about odor as long as
of the following may have placed the patient at risk for
you don’t have a leak.”
developing diverticulitis?
3. “Effluent from an ileostomy has no odor. It is
1. Eating a low-fiber diet
colostomies that can smell bad from time to time.”
2. Chronic diarrhea
4. “Changing your pouch and face plate daily will help
3. History of nonsteroidal anti-inflammatory drug
prevent odor.”
(NSAID) use
4. Family history of colon cancer
11. The nurse is counseling a patient with frequent anal fis-
sures and a history of constipation. Which of the fol-
6. Which of the following foods might a patient with di-
lowing indicates that teaching has been effective?
verticulitis be instructed to avoid?
1. “I guess there isn’t much I can do except seek pain
1. Peanuts and raspberries
relief whenever I have a fissure.”
2. Apples and pears
2. “It is important that I not ignore the urge to have a
3. Red meat and dairy products
bowel movement.”
4. Bran and whole grains
3. “Decreasing the amount of fluid I drink each
day will reduce stool frequency and subsequent
7. Which of the following nursing diagnoses is most ap-
irritation.”
propriate to include in the plan of care for a patient with
4. “Narcotic pain medications are probably needed to
symptoms of a bowel obstruction?
help with this condition.”
1. Risk for Impaired Swallowing related to NPO status
2. Risk for Urinary Retention related to fluid volume
depletion
3. Risk for Deficient Fluid Volume related to nausea and
vomiting
4. Risk for Ineffective Coping related to prolonged hos-
pitalization

8. Which of the following explanations by the nurse to re-

inforce the patient’s preoperative education for a loop
ostomy would be correct?
1. “You will have a stoma in the middle of your ab-
domen that will constantly drain liquid stool.”
2. “You will have a looped bag system to collect stool
from your stoma.”
3. “You will have a loop of bowel on your abdomen,
but it will not drain stool.”
4. “You will have a loop of bowel on your abdomen
that can be returned to your abdomen after your
bowel has healed.”
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Nursing Care of Patients

35 With Liver, Pancreatic, and
Gallbladder Disorders
VOCABULARY
Match the following terms with the appropriate description.
1. Ascites 1. Yellowing of the sclerae and skin from excess
2. Asterixis bilirubin
2. Removal of all or part of the pancreas
3. Cirrhosis
3. Liver flap
4. Encephalopathy 4. Fluid in the abdomen from decreased albumin
5. Fetor hepaticus 5. Neurologic changes from excess ammonia
6. Hepatorenal syndrome 6. Weakened, swollen veins
7. Foul breath
7. Hepatitis
8. Fatty, foul-smelling stools
8. Jaundice 9. Increased pressure in the portal circulation
9. Portal hypertension 10. Scarring and hardening of the liver from
10. Pancreatectomy inflammation
11. Oliguria and sodium retention without kidney
11. Steatorrhea
defects
12. Varices 12. Inflammation of the liver cells

144
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Chapter 35 Nursing Care of Patients With Liver, Pancreatic, and Gallbladder Disorders 145

LIVER
Fill in the crossword with terms related to the liver.

Across Down
2. Abbreviation for serum hepatitis 1. Confusion and coma are symptoms
6. Visible veins around umbilicus 2. This syndrome causes oliguria
9. Abbreviation for liver shunt 3. Abdomen circulation
10. Liver flap 4. Liver inflammation
11. Abbreviation for infectious hepatitis 5. Abbreviation for liver location
6. Progressive, irreversible replacement of liver tissue with
scar tissue
7. Collection of fluid in peritoneal cavity
8. Dilated esophageal veins

GALLBLADDER
Match the following terms with the appropriate description.

1. Cholecystitis 1. Pigment from the breakdown of hemoglobin in red

2. Cholesterol blood cells
2. Dissolves cholesterol gallstones
3. Flatulence
3. Use of an endoscope to explore the common bile duct
4. Murphy’s sign 4. Inflammation of the gallbladder
5. Bilirubin 5. Inability to take a deep breath when fingers are pressed
6. Extracorporeal shock wave lithotripsy under liver margin
6. Substance found in gallstones
(ESWL)
7. Intestinal gas expelled via the rectum
7. T-tube 8. A procedure that shatters gallstones using sound waves
8. Laparoscopic cholecystectomy 9. A surgical drain used to ensure that bile drains freely
9. Chenodeoxycholic acid from the gallbladder after surgery
10. Removal of the gallbladder through a small abdominal
10. Choledochoscopy
incision
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146 UNIT EIGHT Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems

PANCREAS 3. Why is Ms. Smythe exhibiting pitting edema and ab-

dominal distention?
In the space on the left, write N or A to indicate whether the
assessment finding is normal or abnormal. If the finding is
abnormal, indicate the possible (liver-, gallbladder-, or
pancreas-related) cause for the finding.

1. Serum glucose >150 mg%

2. Serum amylase >500 international unit/L
4. What medical treatments can the nurse expect will be
3. Serum lipase = 15 unit/L
ordered for hepatic encephalopathy?
4. Pleural effusion
5. Blood pressure and pulse 15% from patient’s
baseline
6. Serum albumin <3.2 g/dL
7. Positive Cullen’s sign
Two days after Ms. Smythe was admitted, there is bright red
8. Urinary output <30 mL/hr
blood in her emesis. Ms. Smythe also reports feeling cold,
9. Positive Chvostek’s sign
and her pulse is 115 beats per minute and thready. The nurse
10. Foul-smelling, fatty stools
calls for help and places Ms. Smythe on her side.
CRITICAL THINKING
5. What further treatment can be anticipated for Ms. Smythe?
Read the following case study and answer the questions.
Ms. Bettina Smythe has been diagnosed with hepatic en-
cephalopathy secondary to cirrhosis. During the admission
process, the nurse notes the following findings: abdomen
grossly distended, yellow sclerae and skin, multiple bruises,
and pitting edema of the lower extremities. The nurse also
notes that Ms. Smythe is irritable and has difficulty answering 6. What observations should be made to detect bleeding
questions and appears to doze off frequently during the in- from lack of clotting factors?
terview. The nurse observes that Ms. Smythe scratches her
arms and legs frequently. Her laboratory data indicate that
her serum bilirubin, ammonia, and prothrombin time are el-
evated and that her serum albumin, total protein, and potas-
sium are below normal. 7. What nursing measures can be provided to help Ms.
Smythe maintain her fluid balance?
1. What data support the diagnosis of cirrhosis?

8. What should Ms. Smythe be taught about taking aceta-

minophen (Tylenol)? Why?

2. What data suggest that Ms. Smythe has hepatic en-

cephalopathy? What other evidence might be observed?
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Chapter 35 Nursing Care of Patients With Liver, Pancreatic, and Gallbladder Disorders 147

WORD SEARCH

Gallbladder

C W J V L S U P O M C Q R S M R W S M X

W D Q I Y W A W E W V H U L U I K W V S

O E Y L V X Z B S N L S W V F N V P Q R

W V S D N O U C T E A S X U W I F L U S

F T K T J G Z H H Q E C W P S B I N G V

L - Q Y B C D O H V U X R C H U P Z L X

A T K M K H D L G K W H Z K U R A Z B F

T U F U C C F E Q X P X C G O I C E M S

U B Y R Y P O C S O H C O D E L O H C Q

L E H P B E Y Y L Z M D M X O I P L L K

E G E H D K V S P O G M P Q D B O C S D

N N P Y V N X T B Q M B A J B R I S D L

C P S ‘ Y J T I G N A A P C E O V K N R

E I F S M T O T F L O E W T V I W H V J

U S L S O L B I Z P P X S C O D H N J X

S X O I O M E S G L S E W P Y M X U W O

R D J G S V Z M B B L R H J Z B C E A T

M R C N G Y A T H O R Z Z F V U I P Z Z

J O R L P Q F Q H N H Y B N O Y S T C W

L Q N L S U W C F S R V L O I D O S R U

Write the definition of the word and then find the word on the preceding figure.
1. Bilirubin 6. Flatulence
2. Choledochoscopy 7. Murphy’s sign
3. Cholesterol 8. T-tube
4. Cholecystitis 9. Ursodiol
5. ESWL
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148 UNIT EIGHT Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 4. Which of the following is a nonsurgical intervention for
the management of biliary colic?
1. Which of the following precautions will protect the
1. Encouraging a high-fat diet
nurse who is caring for the patient with hepatitis B?
2. Administering vitamin K
1. Reverse isolation
3. Administering chenodeoxycholic acid (Chenodiol)
2. Standard precautions
4. Administering propantheline (Pro-Banthine)
3. Respiratory precautions
4. Enteric precautions
5. Patients with a history of pancreatic disease commonly
have a history of which of the following?
2. Acute liver failure is most often caused by which of the
1. High-protein diet
following?
2. Very-low-fat diet
1. Antibiotic use
3. Excessive alcohol consumption
2. Daily vitamins
4. Excessive intake of vitamin C
3. Alcohol use
4. Acetaminophen (Tylenol) overdose
6. Patients with acute pancreatitis frequently describe their
pain as which of the following?
3. Which of the following is a treatment for bleeding
1. Dull, boring, beginning in the mid epigastrium and
esophageal varices? Select all that apply.
radiating to the back
1. Variceal ligation (banding)
2. Knifelike, centered in the left lower quadrant
2. Octreotide (Sandostatin) intravenous (IV)
3. Burning, focused over the left flank and radiating to
3. Soft diet
the shoulder
4. Sclerotherapy
4. Sharp, severe pain that begins in the right upper
quadrant

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 9. Which of the following instructions should be given to
the patient with portal hypertension? Select all that
7. A patient with ascites is placed on a low-sodium diet.
apply.
The nurse knows that diet teaching has been successful
1. Cough and deep breathe every 2 hours.
if the patient selects which of the following meals?
2. Avoid straining to have a bowel movement.
1. Cottage cheese and peaches with tomato juice
3. Avoid heavy lifting
2. Frankfurter on a bun with pickle relish and skim milk
4. Increase fluid intake.
3. Baked chicken, white rice, and apple juice
5. Take vitamin K supplements.
4. Turkey and lettuce sandwich on whole-wheat bread
with tomato soup
10. A patient with cirrhosis has asterixis and fetor hepati-
cus and is confused. The nurse recognizes these as
8. Which of the following are risk factors for gallbladder
symptoms of which complication?
disease? Select all that apply.
1. Hepatic encephalopathy
1. Male gender
2. Hepatorenal syndrome
2. Obesity
3. Portal hypertension
3. Multiple pregnancies
4. Ascites
4. Age 40 or older
5. Fasting
6. Diabetes mellitus
4069_Ch36_149-153 24/11/14 4:01 PM Page 149

unit NINE

Understanding the
Urinary System
CHECKLIST FOR LEARNING SUCCESS
Review of Anatomy
and Physiology
and Aging Changes Major Disorders Nursing Assessment Diagnostic Tests Interventions Common Medications
❑ Kidneys ❑ Incontinence ❑ Medical history ❑ Urinalysis ❑ Urinary catheters ❑ Diuretics
❑ Urine ❑ Urinary retention ❑ Medications ❑ Urine culture ❑ Lithotripsy ❑ Sodium polystyrene
❑ Elimination of urine ❑ Urinary tract ❑ Vital signs ❑ Blood urea nitrogen ❑ Hemodialysis sulfonate (Kayexalate)
❑ Aging effects infections ❑ Physical examination ❑ Creatinine ❑ Peritoneal dialysis ❑ Phosphate binder
❑ Urological ❑ Intake and output ❑ Creatinine clearance ❑ Continuous renal
obstructions ❑ Daily weights ❑ Kidneys-ureter-bladder replacement therapy
❑ Tumors ❑ Intravenous (IV) ❑ Urinary diversion
❑ Polycystic kidney pyelogram
disease ❑ Cystoscopy and
❑ Chronic renal pyelogram
diseases
❑ Acute kidney injury
❑ Chronic kidney
disease
❑ Kidney
transplantation
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Urinary System Function,

36 Assessment, and
Therapeutic Measures
VOCABULARY
Match the term for an abnormality of the urine or urination with the correct description.
1. Hematuria 1. Painful urination
2. Dysuria 2. Decreased urine output (<400 mL per 24 hours)
3. Blood in the urine
3. Nocturia
4. Voiding during the night
4. Oliguria 5. Excessive urination (>2000 mL per 24 hours)
5. Enuresis 6. Absence of urination
6. Anuria 7. Presence of pus in the urine
8. Bedwetting
7. Polyuria
8. Pyuria

ANATOMY REVIEW
Label the parts of the kidney and nephron.

150
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Chapter 36 Urinary System Function, Assessment, and Therapeutic Measures 151

SAMPLE URINALYSIS RESULTS

Review the urinalysis results of the following three patients and determine the most likely cause of the abnormal results.

Patient A Patient B Patient C

Color Yellow Dark amber Yellow-green
Character Cloudy Concentrated Clear
Glucose Negative Negative Negative
Bilirubin Negative Negative 2+
Ketones Small Negative Negative
Specific gravity (1.010–1.025) 1.024 1.035 1.025
Hemoglobin Small Negative Negative
pH (5.0–9.0) 6.0 5.2 5.5
Protein 100 Negative Negative
Urobilinogen (0.2–1.0) 0.2 0.2 0.2
Nitrite Positive Negative Negative
Urine microscopic casts White blood cell (WBC), red blood cell (RBC) Negative Negative
WBCs (0–4 HPF) 400 4 1
RBCs (0–4 HPF) 90 2 2
Crystals Negative 2 Negative
Amorphous Negative Negative Negative
Epithelial cells (negative) 3 Negative 2
Bacteria (negative) 4+ Negative Negative
Yeast (negative) Negative Negative Negative
Patient A:

Patient B:

Patient C:
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152 UNIT NINE Understanding the Urinary System

RENAL DIAGNOSTIC TESTS 2. What teaching could be done to help her decrease her
incontinence?
Label each statement as true or false and correct the false
statements.

1. An x-ray of the renal structures after injection

Mrs. Simmon is a 79-year-old woman with a fractured hip
of a radiopaque dye into the venous system is called a
and a previous cerebrovascular accident (CVA). She has poor
renal ultrasound. vision but is alert mentally. The nurse finds her lying in bed
2. A diagnostic test in which sound waves are in a puddle of urine, crying. She explains that she was unable
used to outline the structure of the kidney is a pyelogram. to find her call light. The nurse finds it lying on the floor out
of her reach.
3. A urine sample that is cultured to determine
the kind of bacteria it contains is called a creatinine
3. What kind of incontinence did Mrs. Simmon experience?
clearance urine test.
4. A diagnostic test in which the inside of the
bladder is visualized is called a cystoscopy.
5. The radiopaque dye used when doing diag-
nostic tests of the renal system is harmless.
4. What actions should the nurse take to ensure that this
CRITICAL THINKING
does not happen again?
Read the following case studies and answer the questions.
Mrs. Bohke is a 64-year-old female patient admitted to the
hospital with a diagnosis of pneumonia. During her stay, she
tells the nurse she has trouble getting to the bathroom on time
and often dribbles before she can get to the bathroom.
5. When caring for a patient with incontinence, is it helpful
1. What type of urinary incontinence does she have? to decrease fluid intake? Why or why not?

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless otherwise directed. 3. The kidneys are located behind which of the following
1. Which of the following is secreted when the blood level structures?
of oxygen decreases? 1. Spinal column
1. Erythropoietin 2. Diaphragm
2. Renin 3. Peritoneum
3. Angiotensin II 4. Inferior vena cava
4. Vitamin D
4. The renal pyramids make up which kidney structure?
2. Urea is a nitrogenous waste product from the metabo- 1. Renal cortex
lism of which of the following? 2. Renal medulla
1. Nucleic acids 3. Renal pelvis
2. Amino acids 4. Renal fascia
3. Muscle tissue
4. Carbohydrates
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Chapter 36 Urinary System Function, Assessment, and Therapeutic Measures 153

5. The process of tubular resorption takes place in which 7. Which of the following are functions of the kidney?
of the following parts of the kidney? Select all that apply.
1. From the glomerulus to Bowman’s capsule 1. Maintaining acid–base balance
2. From the afferent arteriole to the efferent arteriole 2. Removal of waste products
3. From the peritubular capillaries to the glomerulus 3. Regulation of the blood volume
4. From the renal tubule to the peritubular capillaries 4. Regulation of electrolytes
5. Removal of CO2
6. Where is urine formed? 6. Production of erythropoietin
1. Nephrons
2. Ureters
3. Urethra
4. Bladder

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless otherwise directed. 12. The patient is scheduled for a cystoscopy. Which of the
following is the most important nursing care after this
8. When collecting a urine specimen on a newly admitted
kind of surgery?
female patient, the nurse should take which of the
1. Measuring urine output
following actions?
2. Monitoring daily weights
1. Direct the patient to wash perineum before collect-
3. Observing for symptoms of acute kidney injury
ing the urine specimen.
4. Limiting fluid intake
2. Have the patient void, throw that urine away, and
then collect another specimen. 13. A patient, age 48, has urge incontinence. When assess-
3. Obtain the last voided urine of the day. ing the patient, the nurse would expect to find which of
4. Direct the patient to drink at least three glasses of the following symptoms?
water. 1. Patient is unable to reach the bathroom in time and
ends up urinating in underwear.
9. A patient’s urinalysis results show the following find- 2. Patient is incontinent of small amounts of urine
ings: urine, dark amber; bacteria, small amount; nitrite, when coughs, sneezes, or bears down.
negative; specific gravity, 1.035. Which of the follow- 3. Patient is incontinent of urine when has many re-
ing is the best explanation for these results? sponsibilities and becomes overloaded.
1. Dehydration 4. Patient is incontinent because unable to tell when
2. Urinary tract infection needs to urinate and unable to control urination.
3. Contamination of the specimen from bacteria on the
perineum 14. Which of the following actions should the nurse take to
4. Contamination from menstruation prevent development of a urinary tract infection in a
patient who has a urinary catheter inserted?
10. Which of the following diagnostic test results would 1. Limit fluid intake to 2000 mL per 24 hours to
the nurse evaluate as being related to renal disease? decrease the flow of urine, which can result in
Select all that apply. increased contamination.
1. Hematocrit: 39% 2. Wash the perineum with an antibacterial soap three
2. Potassium: 4.0 mEq/L times per 24 hours.
3. Uric acid: 2 ng/dL 3. Keep catheter securely taped to the patient, prevent-
4. Creatinine: 3 mg/dL ing back-and-forth motion of the catheter.
5. BUN: 35 mg/dL 4. Empty the urinary catheter bag only when needed to
6. Urine specific gravity: 1.020 prevent contamination of the exit spout.

11. A patient is scheduled for a pyelogram with contrast. 15. Which of the following actions should the nurse take
When giving care, the nurse should recognize that for a patient who has total urinary incontinence?
restriction of which of the following is part of the 1. Give patient cranberry juice to keep the urine acidic.
preparation for a pyelogram? 2. Ensure that patient has ready access to the urinal.
1. Salt intake 3. Teach patient how to do Kegel exercises to increase
2. Fluid intake perineal tone.
3. Use of tobacco 4. Apply an adult incontinence brief to catch urine and
4. Physical activities change when necessary.
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Nursing Care of Patients

37 With Disorders of the
Urinary System
VOCABULARY
Fill in the blank with the correct term.
1. is inflammation of the urethra.
2. is inflammation of the bladder.
3. is inflammation of the kidney.
4. Surgical repair of the urethra is called .
5. Kidney stones are also called .
6. is surgical incision into the kidney to remove a stone.
7. Unrelieved obstruction of the urinary tract can lead to .
8. A tube may be inserted directly into the kidney pelvis to drain urine.
9. Surgical removal of a kidney is called a .
10. Thickening and hardening of the renal blood vessels is called .

URINARY TRACT INFECTIONS. 5. Compare cystitis (bladder infection) versus pyelonephri-

tis (kidney infection) by filling out the following table.
Answer the following questions.

1. What is the usual cause of urinary tract infections Things to Compare Cystitis Pyelonephritis
(UTIs) in women? Symptoms

2. What is the usual cause of UTIs in men?

Urinalysis Results

3. What advice regarding fluids should be given to patients

who are susceptible to UTIs?

Prognosis

4. What is the single most important thing a patient with a URINARY TRACT OBSTRUCTIONS
history of UTIs should be taught?
Answer the following questions.

1. What is the most common symptom of cancer of the

bladder?

154
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Chapter 37 Nursing Care of Patients With Disorders of the Urinary System 155

2. What is the most common risk factor for cancer of the Hemoglobin (Hgb): 7.2 g/100 mL
bladder? Hematocrit (Hct): 22%

1. Mrs. Zins has been having incidents of hypoglycemia.

3. What is the most common symptom of cancer of the
Why is this happening?
kidney?

4. What does the urine look like when a patient has an ileal
conduit? 2. With Mrs. Zins present blood sugar of 56, what kind of
juice should the nurse give her?
5. What nursing care should be provided for a patient with
an ileal conduit?

6. What is the most important care that should be given a 3. How does diabetes cause chronic kidney disease?
patient with a kidney stone?

7. What teaching should be done for the patient to prevent

further stone formation if the stone is composed of cal-
4. Is there anything Mrs. Zins could have done to decrease
cium oxalate? Uric acid?
the possibility of developing chronic kidney disease?

CRITICAL THINKING
Read the following case study and answer the questions.
Mrs. Zins is a 27-year-old woman who has had Type 1 diabetes
mellitus for more than 20 years. Recently she has begun having 5. Identify two nursing diagnoses that would be appropriate
incidents of hypoglycemia, she is edematous, and her blood for Mrs. Zins based on her assessment.
pressure has elevated. She is admitted to the hospital for diag-
nosis and treatment of probable chronic kidney disease.

History: Subjective Data 6. What diagnostic test was most indicative of chronic kid-
States that she has been exhausted lately and her skin ney disease for Mrs. Zins?
is itchy.
States that she has been very irritable and her husband
says she is difficult to live with.
7. Why is Mrs. Zins anemic?
Physical: Objective Data
BP 194/104 mm Hg, P 98 beats per minute, R 22 per
minute, T 98.4°F (36.9°C)
Jugular vein distention present at 45 degrees 8. What would be the three most important areas for nurs-
Generalized edema throughout body, including perior- ing data collection for Mrs. Zins related to her chronic
bital edema
kidney disease?
Pitting edema of feet and ankles
Weight gain of 20 pounds in 2 months
Skin very dry, flaky

Diagnostic Tests
9. What kind of diet will Mrs. Zins most likely receive?
Fasting blood sugar: 56 mg/100 L
Serum sodium: 145 mEq/L
Serum creatinine: 5.4 mg/100 L
Serum potassium: 5.9 mEq/L
Uric acid: 8.2 ng/dL
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156 UNIT NINE Understanding the Urinary System

CHRONIC KIDNEY DISEASE

Fill in the signs and symptoms of kidney disease under the body systems on the figure that follows.

Neurological system

Oral cavity

Respiratory system
Cardiovascular system

Renal system
Gastrointestinal system

Reproductive system Skin

Musculoskeletal system

Fluid volume
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Chapter 37 Nursing Care of Patients With Disorders of the Urinary System 157

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 3. Which of the following foods should the patient be
taught to avoid for a kidney stone composed of calcium
1. Which of the following is the most common symptom
oxalate?
of cancer of the bladder?
1. Bread
1. Nocturia
2. Beer
2. Dysuria
3. Beef
3. Urinary retention
4. Beans
4. Hematuria

2. When examining the patient, the nurse notes the follow-

ing diagnostic tests on the patient’s chart. Which of the
following diagnostic tests results is most indicative of
acute kidney injury?
1. BUN: 80 mg/100 mL (8–25 mg/100 L)
2. 24-hour creatinine clearance: 5 mL/min (100 mL/min)
3. Uric acid: 8 ng/dL (2.5–5.5 ng/dL)
4. Serum creatinine: 1.7 mg/100 L (0.5–1.5 mg/100 L)

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 7. A patient with severe right flank pain, general weakness,
and fever is hospitalized. The patient has a history of re-
4. Postoperatively, the nurse notes the presence of mucus
current urinary tract infection, and renal calculi are sus-
in the urinary drainage. Which of the following actions
pected. On the second hospital day, the patient’s urine
should the nurse take?
output drops to 300 mL/24 hr, and the patient has disten-
1. Notify the health care provider (HCP).
tion and pain in the suprapubic area. The nurse would
2. Collect a urine specimen for culture and sensitivity.
suspect which of the following to be the most likely
3. Measure the specific gravity of the urine.
cause for this sudden change?
4. Recognize that this is a normal occurrence.
1. Sudden decreased renal perfusion
2. Inadequate fluid intake
5. Which of the following is the most significant sign of
3. Interstitial fluid shift
acute kidney injury that the nurse should recognize dur-
4. Urinary tract obstruction
ing data collection?
1. A rise in blood pressure
8. Which of the following is appropriate patient teaching
2. An elevation in body temperature
to obtain a midstream urine specimen for culture and
3. A decrease in urine output
sensitivity?
4. An increase in urine specific gravity
1. A second-voided specimen is preferred.
2. The specimen should be collected early in the
6. A patient with acute kidney injury has been instructed to
morning.
limit potassium intake. The nurse recognizes that teach-
3. The patient should begin voiding, collect the
ing has been effective if the patient chooses which of the
specimen, and then finish voiding in the toilet.
following snacks? Select all that apply.
4. A 24-hour urine specimen is needed; the first void
1. Chocolates
should be discarded.
2. An orange
3. Grapefruit juice
4. A gelatin dessert
5. Cranberry juice
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158 UNIT NINE Understanding the Urinary System

9. A patient is admitted with chronic kidney disease. The 14. The patient has a permanent peritoneal catheter in-
patient has a potassium level of 6.4 mEq/L, is placed serted and is begun on continuous ambulatory peri-
on a cardiac monitor and given sodium polystyrene toneal dialysis (CAPD). The patient asks how it works.
sulfonate (kayexalate) by retention enema. Which of Which of the following would be the best explanation
the following is the most significant symptom that the of how this type of dialysis works?
nurse should recognize during data collection? 1. The peritoneum allows solutes in the dialysate to
1. Diarrhea pass into the intravascular system.
2. Irregular heart rhythm 2. The peritoneum acts as a semipermeable membrane
3. Increased blood pressure through which solutes move by diffusion and
4. Increased respiratory rate osmosis.
3. The presence of excess metabolites causes in-
10. The nursing diagnosis of Excess Fluid Volume is made creased permeability of the peritoneum and allows
for a patient with chronic kidney disease. Which of the excess fluid to drain.
following information is most important for the nurse to 4. The peritoneum permits diffusion of metabolites
collect for this patient based on the nursing diagnosis? from the intravascular to the interstitial space.
1. Intake and output
2. Vital signs 15. A patient on dialysis has a severe cerebrovascular acci-
3. Daily weight dent and is now semicomatose. His family decides that
4. Skin turgor dialysis should be stopped. He is sent home with his
daughter and hospice to die. As part of discharge plan-
11. A patient with newly diagnosed chronic kidney disease ning, his daughter should be taught to expect which of
has elevated sodium, potassium, and serum creatinine the following symptoms of untreated end-stage renal
levels. When the breakfast tray is served, there is a failure?
glass of orange juice on it. Which of the following 1. Polyuria, pruritus, and extreme irritability
actions should the nurse take? 2. Dehydration with sunken eyeballs and oliguria
1. Encourage the patient to drink the orange juice for 3. Edema, possible convulsions, then coma
vitamin C to help fight the infection. 4. Decreased respiratory rate and cyanosis
2. Remove the orange juice from the tray because it is
high in potassium. 16. A patient is admitted who was involved in a motor vehi-
3. Give the patient a smaller glass of orange juice be- cle accident resulting in trauma to the abdomen and
cause the patient is on a fluid restriction. back. The patient has a ruptured spleen and probable
4. Check the kind of diet the patient is on to determine trauma to the kidneys. For which of the following
any restrictions. changes in the patient’s urine should the nurse observe?
1. Dysuria
12. A patient goes to surgery for fistula creation for dialy- 2. Pyuria
sis. The patient asks why it needs to be done. Which of 3. Polyuria
the following is the best explanation by the nurse on 4. Hematuria
the advantages of a fistula over a two-tailed subclavian
catheter? 17. A patient is admitted with symptoms of a recent weight
1. “There is a larger blood flow, and dialysis is more gain, pitting edema of his feet, jugular vein distension,
efficient.” and lung crackles. Which of the following nursing di-
2. “There is less risk of clotting with the fistula.” agnoses is most appropriate for this patient’s plan
3. “It is easier to access the fistula than the two-tailed of care?
subclavian.” 1. Deficient Fluid Volume
4. “It is less likely to be damaged by trauma.” 2. Excess Fluid Volume
3. Imbalanced Nutrition: More Than Body Requirements
13. After hemodialysis, which of the following nursing in- 4. Noncompliance
terventions is imperative for the nurse to carry out? Se-
lect all that apply.
1. Document stool output.
2. Weigh the patient.
3. Check for jugular vein distention.
4. Obtain vital signs.
5. Allow patient to rest.
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unit TEN

Understanding the
Endocrine System
CHECKLIST FOR LEARNING SUCCESS
Review of Anatomy
and Physiology
and Aging Changes Major Disorders Nursing Assessment Diagnostic Tests Interventions Common Medications
❑ Antidiuretic hormone ❑ Diabetes insipidus ❑ History ❑ 24-hour urine ❑ Interventions for fluid ❑ Hormone replacement
❑ Growth hormone ❑ Syndrome of ❑ Fluid balance ❑ Hormone levels imbalances ❑ Calcium
❑ Thyroid-stimulating inappropriate ❑ Mood, affect ❑ Stimulation tests ❑ Pre- and post- ❑ Calcitonin
hormone antidiuretic hormone ❑ Exophthalmos ❑ Suppression tests thyroidectomy care ❑ Thyroid hormone
❑ Adrenocorticotropic secretion (SIADH) ❑ Skin ❑ Thyroid scan ❑ Pre- and post- ❑ Insulin
hormone ❑ Acromegaly ❑ Vital signs ❑ Blood glucose hypophysectomy care ❑ Oral hypoglycemic
❑ T3 and T4 ❑ Hypothyroidism ❑ Tremor ❑ Glycohemoglobin ❑ Teaching related to agents
❑ Calcitonin ❑ Hyperthyroidism ❑ Polyuria, polydipsia, ❑ Glucose tolerance test self-care
❑ Parathyroid hormone ❑ Goiter polyphagia ❑ Ultrasound ❑ Diabetes education
❑ Glucagon ❑ Thyroid cancer ❑ Self-monitoring of ❑ Biopsy
❑ Insulin ❑ Hypoparathyroidism blood glucose
❑ Norepinephrine ❑ Hyperparathyroidism (SMBG)
❑ Epinephrine ❑ Pheochromocytoma ❑ Knowledge of
❑ Aldosterone ❑ Addison’s disease self-care
❑ Cortisol ❑ Cushing’s syndrome
❑ Aging changes ❑ Diabetes mellitus
❑ Reactive
hypoglycemia
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Endocrine System
38 Function and Assessment

VOCABULARY
Complete the following sentences with the appropriate words.
1. Glucose is converted to for storage.
2. High blood glucose is called .
3. Emotional tone is called .
4. Bulging eyes, or , is a symptom of hyperthyroidism.
5. Hormone secretion is regulated through a system.

HORMONES
Match each hormone with its function. Use each number only once.

1. Antidiuretic hormone (ADH) 1. Stimulates growth and secretions of the thyroid gland
2. Oxytocin 2. Increases glucose uptake by cells and glycogen storage
in the liver
3. Thyroid-stimulating hormone
3. Decreases the resorption of calcium from bones; lowers
4. Adrenocorticotropic hormone blood calcium level
5. Growth hormone (GH) 4. Increases the use of fats and amino acids for energy and
6. Prolactin has an anti-inflammatory effect
5. Stimulates mitosis and protein synthesis
7. Follicle-stimulating hormone
6. Increases heart rate and force of contraction
8. Luteinizing hormone 7. Causes vasoconstriction throughout the body
9. Thyroxine 8. Increases secretion of cortisol by the adrenal cortex
10. Calcitonin 9. Increases energy production for a normal metabolic rate
10. Directly increases water reabsorption by the kidneys
11. Parathyroid hormone (PTH)
11. In men, stimulates secretion of testosterone
12. Epinephrine 12. Increases the conversion of glycogen to glucose in the
13. Norepinephrine liver between meals
14. Cortisol 13. Initiates milk production in the mammary glands
14. Increases the resorption of calcium from bones; raises
15. Aldosterone
blood calcium level
16. Insulin 15. Increases the resorption of sodium by the kidneys
17. Glucagon 16. In women, initiates development of ova in ovaries
17. Causes contraction of the myometrium during labor

160
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Chapter 38 Endocrine System Function and Assessment 161

ENDOCRINE GLANDS AND HORMONES

Label the figure with the glands of the endocrine system. List the hormone(s) secreted by each gland.

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 3. What happens when aldosterone increases the reabsorp-
tion of sodium ions by the kidneys?
1. Which two hormones help regulate the blood calcium
1. Water is also reabsorbed back to the blood.
level?
2. Bicarbonate ions are excreted in urine.
1. Insulin and glucagon
3. More water is excreted in urine.
2. Calcitonin and PTH
4. Potassium ions are also reabsorbed back into the
3. Thyroxine and epinephrine
blood.
4. Cortisol and aldosterone
4. Which of the following hormones has an anti-
2. Which hormone is most important for day-to-day regu-
inflammatory effect?
lation of metabolic rate?
1. Epinephrine
1. Insulin
2. Cortisol
2 Epinephrine
3. Aldosterone
3. GH
4. Thyroxine
4. Thyroxine
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162 UNIT TEN Understanding the Endocrine System

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 8. A patient asks the nurse, “My doctor told me my thyroid
scan showed a ‘cold spot.’ What does that mean?”
5. Which of the following hormones help maintain blood
Which of the following responses by the nurse is best?
volume and blood pressure? Select all that apply.
1. “That means you have cancer of the thyroid gland.”
1. Thyroxine
2. “Cold spots are areas that have no living tissue.”
2. Glucagon
3. “A cold spot is an area that did not pick up the ra-
3. Aldosterone
dioactive material they injected.”
4. Cortisol
4. “It doesn’t mean anything. A cold spot is just part of
5. ADH
your thyroid gland.”
6. Insulin
9. A patient with a suspected autoimmune disease has lab-
6. A patient is completing a 24-hour urine test. What
oratory work ordered, including a cortisol level. The
should the nurse do to complete the test at the end of the
nurse recognizes that cortisol is responsible for which of
24 hours?
the following? Select all that apply.
1. Have the patient void exactly 24 hours after the test
1. Stimulates conversion of triglycerides to glucose.
was begun and discard the specimen.
2. Stimulates the storage of excess glucose.
2. Save the last specimen and send it in a separate
3. Increases the breakdown of lipids to fatty acids.
container.
4. Increases the breakdown of proteins to amino acids.
3. Have the patient void exactly 24 hours after the test
5. Blocks the effect of histamine.
was begun, and add this urine to the remainder of the
specimen.
4. Send only the specimen voided at 24 hours.

7. A female patient is admitted to the hospital with hyper-

thyroidism. What related assessment should the nurse
perform?
1. Check the patient’s heart rate.
2. Palpate the thyroid gland for enlargement.
3. Do a capillary blood glucose level.
4. Observe for a “buffalo hump” on the patient’s back.
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Nursing Care
of Patients With
Endocrine Disorders
39
VOCABULARY
Use the following terms to fill in the blanks.
Amenorrhea Myxedema
Dysphagia Nocturia
Ectopic Polydipsia
Euthyroid Polyuria
Goiter Pheochromocytoma
1. A normally functioning thyroid gland produces a state.
2. Enlargement of the thyroid gland is called a .
3. Excessive thirst is called .
4. Excessive urination is called .
5. A is a tumor of the adrenal medulla.
6. Difficulty swallowing is called .
7. Untreated hypothyroidism can lead to coma.
8. is the word for getting up to void during the night.
9. Absence of menses is called .
10. Sometimes hormones are produced outside the endocrine gland in a/an site.

HORMONES
Match the disorder in column 1 to a hormone imbalance in column 2 and signs and symptoms in column 3.
Disorder Hormone Problem Major Signs and Symptoms
Diabetes insipidus Antidiuretic hormone (ADH) Polyuria
Syndrome of inappropriate deficiency Growing hands and feet
antidiuretic hormone (SIADH) Growth hormone (GH) deficiency Moon face
Cushing’s syndrome High serum calcium Labile hypertension
Addison’s disease ADH excess Tetany
Graves’ disease Steroid excess Muscle weakness, brittle bones
Hypothyroidism Deficient steroids Failure to grow and develop
Pheochromocytoma Epinephrine excess Water retention
Hyperparathyroidism GH excess Weight gain and fatigue
Short stature Low T3 and T4 Exophthalmos
Acromegaly Low serum calcium Hypotension
Hypoparathyroidism High T3 and T4

163
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164 UNIT TEN Understanding the Endocrine System

CRITICAL THINKING 8. What symptoms do diabetes insipidus and diabetes

mellitus (DM) have in common?
Read the following case studies and answer the questions.
Mr. Samuels is diagnosed with SIADH related to lung cancer.
He enters the hospital for treatment of symptoms.

1. What (fluid-related) nursing diagnosis would be most

9. Will Mrs. Jorgensen’s urine specific gravity be high or
appropriate for Mr. Samuels?
low? Why?

2. How will you monitor Mr. Samuels’ fluid balance?

10. Will Mrs. Jorgensen’s serum osmolality be high or
low? Why?

3. Why is Mr. Samuels at risk for seizures?

11. For which (fluid-related) nursing diagnosis is
Mrs. Jorgensen at risk?

4. How will you reduce his risk for injury from seizures?
12. Mrs. Jorgensen begins treatment with DDAVP (desmo-
pressin acetate tablets). To what signs of overdose
should Mrs. Jorgensen be alert?

5. What do you expect Mr. Samuels’s urine to look like?

THYROID DISORDERS
Label each symptom with an R if it suggests hyperthy-
6. How will Mr. Samuels’s urine look after treatment is roidism or an O if it suggests hypothyroidism.
begun? 1. Bradycardia
2. Lethargy
3. Restlessness
4. Frequent stools
Mrs. Jorgensen is hospitalized following a motor vehicle
5. Hypercholesterolemia
accident in which she sustained a head injury. She develops
6. Dry hair
diabetes insipidus (DI).
7. Tremor
8. Insomnia
7. Why does head injury place Mrs. Jorgensen at risk for DI?
9. Mental dullness, confusion
10. Warm, diaphoretic skin
11. Weight loss
12. Decreased appetite
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Chapter 39 Nursing Care of Patients With Endocrine Disorders 165

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 4. An excess of which hormone is responsible for
acromegaly?
1. Following surgery for thyroidectomy, the nurse watches
1. Thyroid stimulating hormone (TSH)
carefully for which of the following signs and symptoms
2. Insulin
of tetany?
3. Growth hormone (GH)
1. Numb fingers, muscle cramps
4. Adrenocorticotropic hormone (ACTH)
2. Weakness, muscle fatigue
3. Hallucinations, delusions
5. Which of the following nursing diagnoses is most ap-
4. Dyspnea and tachycardia
propriate for the patient admitted in addisonian crisis?
1. Imbalanced Nutrition: More than Body Requirements
2. What assessment findings should the nurse monitor to
2. Disturbed Body Image
detect the onset of thyrotoxicosis in a patient with
3. Deficient Fluid Volume
hyperthyroidism?
4. Acute Pain
1. Peripheral pulses
2. Serum sodium
3. Vital signs
4. Incision site

3. Which of the following dietary recommendations will

reduce the risk of kidney stones in the patient with
hyperparathyroidism?
1. Limit meat products
2. Limit bread products
3. Increase fluids
4. Increase citrus fruits

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 8. A patient with hypothyroidism is started on levothyrox-
6. A 42-year-old patient enters an outpatient clinic with ine (Synthroid). Which of the following statements
symptoms of weight gain and fatigue. Laboratory studies shows that the patient understands teaching related to
are done, and a diagnosis of primary hypothyroidism is the new medication?
made. The patient asks why the TSH level is elevated. 1. “I know I should call my doctor if my heart races.”
Which of the following is the best response by the nurse? 2. “I understand that I may develop a moon-shaped
1. “The thyroid makes more TSH to take the place of face.”
the deficient T3 and T4.” 3. “The sleepiness I experience when I start this med-
ication will subside within 2 weeks.”
2. “The TSH tries to directly raise the metabolic rate
4. “I’ll have to watch my diet to avoid further weight
when there is not enough T3 and T4.”
gain while on this medication.”
3. “The pituitary makes more TSH to try to stimulate
the underactive thyroid.”
9. A 26-year-old patient is hospitalized for radioactive
4. “The extra fat cells from your weight gain make ex-
iodine treatment for hyperthyroidism. Which of the
cess TSH.”
following precautions by the nurse is appropriate?
1. Talk with the patient only over the intercom system.
7. Which of the following nursing diagnoses would be
2. Wear gloves when emptying the bedside commode.
most appropriate for a patient with fatigue related to
3. Maintain reverse isolation for 3 months.
hypothyroidism?
4. No precautions are necessary because the dose is so
1. Imbalanced Nutrition: More Than Body Require-
small.
ments related to excessive food intake
2. Impaired Gas Exchange related to weight gain
3. Activity Intolerance related to fatigue
4. Ineffective Coping related to depression
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166 UNIT TEN Understanding the Endocrine System

10. The nurse needs to accomplish all the following interven- 12. A patient enters a clinic with possible Cushing’s syn-
tions for a patient who is 24 hours post-thyroidectomy. drome. Which of the following physical examination
Place the interventions in the correct order in which findings support this diagnosis?
they should be completed. 1. Weight loss, pale skin
1. Check the surgical site dressing for signs of 2. Buffalo hump, easy bruising
bleeding. 3. Nausea, vomiting
2. Verify that the airway is patent. 4. Polyuria, polydipsia
3. Assess vital signs.
4. Administer an analgesic for postoperative pain. 13. Which data is most important for the nurse to monitor
5. Teach the patient about Synthroid (levothyroxine) in a patient with a pheochromocytoma?
use after discharge. 1. Vital signs
6. Assist with range of motion exercises of the neck. 2. Daily weights
3. Peripheral pulses
11. The nurse develops the nursing diagnosis of Acute 4. Bowel sounds
Pain related to bone demineralization for a patient with
hypoparathyroidism. Which of the following goals is
most appropriate?
1. Serum calcium level will be <20mg/dL.
2. Patient will state correct dietary restrictions.
3. Patient will perform activities of daily living
(ADLs) without injury.
4. Patient will verbalize acceptable pain level.
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Nursing Care of Patients

With Disorders of the
Endocrine Pancreas
40
VOCABULARY
Fill in the blanks.
1. Glucose in the urine is called .
2. is too much sugar in the blood.
3. is too little sugar in the blood.
4. Deep, sighing respirations from diabetic acidosis are called respirations.
5. Excessive hunger is called .
6. Excessive thirst is called .
7. The term used to document getting up to urinate at night is .
8. The time when insulin is working its hardest after injection is called its
action time.
9. The length of time insulin works is called its .
10. The Diabetes Control and Complications Trial (DCCT) found that individuals who maintain
control of their diabetes will have fewer long-term complications.

HYPOGLYCEMIA AND HYPERGLYCEMIA

Place an R in front of each symptom of hyperglycemia and an O in front of each symptom of hypoglycemia.

1. Tremor
2. Polydipsia
3. Polyuria
4. Lethargy
5. Irritability
6. Fruity breath
7. Sweating
8. Abdominal pain

167
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168 UNIT TEN Understanding the Endocrine System

LONG-TERM COMPLICATIONS OF DIABETES

Match the complication with its signs and symptoms.
1. Retinopathy 1. Ketones in the blood and urine
2. Neuropathy 2. Burning pain in legs and feet
3. Hyperosmolar hyperglycemic state 3. Fever
4. Profound hyperglycemia without ketonemia
4. Diabetic ketoacidosis (DKA)
5. Impaired vision
5. Nephropathy 6. Food intolerance
6. Gastroparesis 7. Microalbuminuria
7. Infection

CRITICAL THINKING
Read the following case study and answer the questions.
Jennie is a 56-year-old overweight woman admitted to your medical unit with cellulitis of the left leg. She has a long history
of diabetes mellitus; her blood sugar level is 436. She tells you that she takes insulin glargine (Lantus) 18 units every bedtime
and insulin lispro (Humalog) 12 units with each meal. She also takes metformin (Glucophage) twice a day.

1. Jennie tells you that her physician wants her to keep her blood sugar level between 100 and 150 mg/dL. You know that a
normal blood sugar level is 70 to 100. Why the discrepancy?

2. When you enter Jennie’s room to check her 1600 vital signs, she says she has a headache. By the time you finish taking
her blood pressure, she has developed a cold sweat. What is happening? What should you do?

3. At 1700, you check Jennie’s blood sugar level and find that it is 80 mg/dL. What is your next step?

4. List three things that may have caused Jennie’s blood sugar level to drop.

5. You explain to Jennie the importance of eating three meals a day on a regular schedule. She asks why. How do you ex-
plain this to her?
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Chapter 40 Nursing Care of Patients With Disorders of the Endocrine Pancreas 169

6. Jennie is discharged and follows her diet, exercise, and insulin regimen carefully. She even loses 50 lb. One year after
her first admission, she is brought into the emergency department with a blood sugar level of 32. Why has her blood
sugar level dropped?

7. What are two ways that metformin works?

8. Does Jennie have type 1 or type 2 diabetes? How do you know?

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 4. Which of the following are symptoms of hypoglycemia?
1. Which of the following is an acceptable premeal blood 1. Nausea and vomiting
sugar range for most patients with diabetes? 2. Glycosuria
1. 46 to 98 mg/dL 3. Cold sweat and tremor
2. 70 to 130 mg/dL 4. Polyuria and polydipsia
3. 180 to 250 mg/dL
4. 350 to 600 mg/dL 5. In addition to stimulating insulin production, glyburide
(Micronase) has which of the following effects?
2. Before giving insulin, the nurse always checks which 1. Stimulates gluconeogenesis.
test result? 2. Promotes fat breakdown.
1. Recent potassium level 3. Increases tissue sensitivity to insulin.
2. Blood glucose level 4. Enhances appetite.
3. Urine ketones
4. White blood cell count

3. At what point after injection does the peak action of

insulin lispro (Humalog) occur?
1. 30 to 90 minutes
2. 2 to 3 hours
3. 4 to 5 hours
4. 8 to 12 hours

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 7. A patient with diabetes forgot to take a daily dose of
glyburide (Micronase). For which of the following
6. A 26-year-old patient is admitted to the hospital with a
symptoms should the nurse be vigilant?
new diagnosis of diabetes, a blood glucose of 680
1. Cold, clammy sweat
mg/dL, and ketones in the blood and urine. Which type
2. Tachycardia, nervousness, hunger
of diabetes should the nurse suspect?
3. Chest pain, shortness of breath
1. Type 1
4. Fatigue, thirst, blurred vision
2. Type 2
3. Prediabetes
4. Gestational
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170 UNIT TEN Understanding the Endocrine System

8. By which routes can insulin be administered? Select 11. The nurse recognizes that teaching is effective if a pa-
all that apply. tient with diabetes knows to use subcutaneous
1. Oral glucagon for an emergency episode of which of the fol-
2. Topical lowing conditions?
3. Intravenous (IV) 1. Hyperglycemia
4. Subcutaneous 2. Ketonuria
5. Intramuscular 3. Diabetic ketoacidosis
4. Hypoglycemia
9. While providing discharge instructions to a patient
newly taking NPH insulin every morning, the nurse 12. A patient on an American Diabetes Association diet re-
recognizes that teaching has been effective if the pa- ceives a breakfast tray and does not care for the oat-
tient knows to observe for signs and symptoms of low meal. Which of the following foods can the nurse
blood sugar level at which of the following times? substitute for a half cup of oatmeal?
1. 1 hour after administration of insulin 1. 4 oz of orange juice
2. 6 to 12 hours after administration of insulin 2. Two strips of bacon
3. 24 to 36 hours after administration of insulin 3. 1 oz of cheese
4. NPH insulin does not cause low blood sugar level 4. A slice of wheat toast

10. A patient with newly diagnosed diabetes asks the nurse

what to take for low blood sugar. Which of the follow-
ing would be most appropriate for the nurse to suggest?
1. Raisins
2. Cheese
3. acetaminophen (Tylenol)
4. Beef jerky
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unit ELEVEN

Understanding the
Genitourinary and
Reproductive
System
CHECKLIST FOR LEARNING SUCCESS
Review of Anatomy
and Physiology
and Aging Changes Major Disorders Nursing Assessment Diagnostic Tests Interventions Common Medications
❑ Female reproductive ❑ Breast cancer ❑ History ❑ Mammogram ❑ Breast surgeries ❑ Antibiotics
system ❑ Menstrual disorders ❑ Breast examination ❑ Biopsy ❑ Hysterectomy ❑ Hormone replacement
❑ Female hormones ❑ Endometriosis ❑ Breast self- ❑ Bone health ❑ Contraception therapy
❑ The menstrual cycle ❑ Infections examination (BSE) assessment ❑ Pregnancy termination ❑ Oral contraceptives
❑ Male reproductive ❑ Displacement ❑ Sexual function ❑ Hormone tests ❑ Prostatectomy
system disorders ❑ Testicular self- ❑ Pelvic examination ❑ Transurethral resection
❑ Male hormones ❑ Fertility disorders examination (TSE) ❑ Papanicolaou (Pap) of the prostate (TURP)
❑ Aging changes ❑ Tumors of the cervix, smear ❑ STI prevention
uterus, and ovaries ❑ Swabs and smears
❑ Prostatitis ❑ Endoscopic
❑ Benign prostatic examinations
hypertrophy (BPH) ❑ Cystourethroscopy
❑ Prostate cancer ❑ Digital rectal
❑ Penile disorders examination (DRE)
❑ Testicular disorders ❑ Prostate-specific
❑ Erectile dysfunction antigen (PSA)
❑ Sexually transmitted ❑ Fertility testing
infections (STIs)
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Genitourinary and
41 Reproductive System
Function and Assessment
VOCABULARY
Complete the following sentences with the correct term from the chapter.
1. A may be done to view the inside of the uterus with an endoscope.
2. During some diagnostic procedures, a body cavity is filled with carbon dioxide to make it easier for the
physician to view structures. This is called .
3. A male patient should have a yearly examination to detect
prostate cancer.
4. Some men have excessive breast tissue, which is called .
5. If the urethral opening is on the underside of the penis, it is called .
6. Fluid in the scrotum is called a .
7. If the scrotum feels like a bag of worms when palpated, it is called a .
8. Another word for sexual desire is .
9. The beginning of menstruation in the female is called .
10. X-ray examination of the breasts is called .

ANATOMY AND PHYSIOLOGY

Label the structures of the male and female reproductive systems.

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Chapter 41 Genitourinary and Reproductive System Function and Assessment 173

FEMALE REPRODUCTIVE STRUCTURES

Match the female reproductive structures with the correct descriptive statement.

1. Fallopian tube 1. Site of development of an ovum

2. Myometrium 2. Becomes the maternal side of the placenta
3. Bartholin’s glands 3. Contains the urethral and vaginal openings
4. Vestibule 4. Secretes progesterone and estrogen after ovulation
5. Endometrium 5. The usual site of fertilization
6. Ovarian follicle 6. Secrete mucus at the vaginal orifice
7. Corpus luteum 7. Contracts for labor and delivery

MALE REPRODUCTIVE SYSTEM

Number the following in proper sequence with respect to the pathway sperm travel from their site of origin.

Ejaculatory duct
Epididymis
Urethra
Testes
Ductus deferens
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174 UNIT ELEVEN Understanding the Genitourinary and Reproductive System

DIAGNOSTIC TESTS REVIEW

Match the following tests with their descriptions.

1. Cytology 1. Endoscopic examination of the vagina

2. Colposcopy 2. Examination of cells using a microscope
3. Sonography 3. Mapping of tissues according to their densities using
4. Computed tomographic (CT) scan sound waves
5. Magnetic resonance imaging 4. Mapping of tissue by using radio-frequency radiation
6. Digital rectal examination (DRE) and magnetic fields
5. Screening examination for prostate disorders
6. Computer-assisted recording of very precise x-ray
pictures of layers of tissue

CRITICAL THINKING 3. Ms. Wilson comes to the clinic and reports excessive
vaginal discharge. While asking her some initial ques-
Read the scenarios and answer the following questions.
tions, you learn that she has multiple sex partners. What
1. Mr. White comes to see his physician for a yearly do you anticipate for her examination? What teaching is
checkup. As you are taking his blood pressure, he says, important?
“I don’t need that rectal examination, do I? I had
prostate surgery last year.” How do you respond?

4. Mr. Brown is being admitted to the hospital for complica-

tions of diabetes. While collecting initial data, you learn
that although he is married, he is no longer sexually ac-
2. Mrs. Bitner has just returned from having an endoscopic tive. How do you respond?
examination. She says, “Something went wrong, I just
know it. Look at my belly. I look like I’m 9 months
pregnant.” How do you respond?
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Chapter 41 Genitourinary and Reproductive System Function and Assessment 175

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 5. Strong contractions of the smooth muscle of the uterus
for labor and delivery are brought about by which of the
1. Which of the following male reproductive structures
following hormones?
carries semen through the penis to the exterior?
1. Progesterone
1. Urethra
2. Follicle-stimulating hormone (FSH)
2. Epididymis
3. Oxytocin
3. Ductus deferens
4. Luteinizing hormone (LH)
4. Ejaculatory duct
6. According to the American Cancer Society, how often
2. Which layer of the uterus will become the maternal
should a 40-year-old woman have a mammogram done?
portion of the placenta?
1. Weekly
1. Myometrium
2. Monthly
2. Endometrium
3. Yearly
3. Epimetrium
4. Semiannually
4. Serosa
7. When should men over age 40 have digital rectal
3. Which of the following descriptions best describes the
examinations?
position of the uterus?
1. Weekly
1. Superior to the bladder with the fundus most anterior
2. Monthly
2. Anterior to the bladder with the cervix most inferior
3. Every other month
3. Inferior to the bladder with the cervix most superior
4. During yearly physician visit
4. Posterior to the bladder with the fundus most inferior

4. Which of the following hormones stimulates the

mammary glands to produce milk after pregnancy?
1. Progesterone
2. Estrogen
3. Oxytocin
4. Prolactin

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 9. The nurse is helping a woman prepare for a routine
Pap smear. Which of the following actions should the
8. A patient being prepared for cystourethrography asks
nurse take?
what is going to be done to him. Which is the best
1. Give the woman an enema.
explanation by the nurse?
2. Ask the woman to empty her bladder.
1. “The doctor will put a tiny endoscope into your
3. Ask the woman to take a deep breath and hold it.
bladder.”
4. Set out a suture tray and local anesthetic.
2. “You will have a catheter put in, then a dye will be
injected and x-rays will be taken.”
10. A nurse is teaching BSE. Which of the following
3. “You will have a small needle inserted through your
positions would the nurse advise the patient to use
lower abdomen and into your bladder.”
for a portion of the exam?
4. “You will have an intravenous injection of dye, then
1. Supine
x-rays will be taken as it travels through your kidneys.”
2. Simm’s
3. Kneeling
4. Fowler’s
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176 UNIT ELEVEN Understanding the Genitourinary and Reproductive System

11. A woman receives notice that her screening mammo- 12. A nurse practitioner completes a wet-mount specimen
gram is abnormal, and she is instructed to schedule di- on a patient with a suspected STI, then leaves the
agnostic scans. The woman calls the office and asks the room. As the assisting LPN prepares to take the slide to
nurse, “Can you please tell me why I need more tests?” the lab, the patient says, “I’m really scared that I have
The nurse will base the response on which of the fol- something serious. What do you think I should do?”
lowing understandings? Which response by the LPN is best?
1. A mammogram needs no other verification. 1. Sit next to the patient and say, “What frightens you
2. Mammograms are unable to show lesions in breast the most?”
tissue. 2. Stand at the foot of the examination table and say,
3. A mammogram can show only breast cysts, not “There is nothing to be worried about until we get
cancers. the test results.”
4. Many things can cause shadows on a mammogram 3. Give the patient time to verbalize concerns, then
besides cancer. advise that she have her partner tested.
4. Touch her lightly on the arm and say, “Let me get
this slide to the lab, then I’ll come back and
we’ll talk.”
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Nursing Care of Women

With Reproductive System
Disorders
42
VOCABULARY
Match the term with its definition.
1. Imperforate 1. Bladder sags into vaginal space
2. Colporrhaphy 2. Painful menstruation
3. Dysmenorrhea 3. Not having expected opening
4. Cryotherapy 4. Surgical repair of a part of the vagina
5. Agenesis 5. Undeveloped
6. Dyspareunia 6. Rectum sags into the vagina
7. Cystocele 7. Painful intercourse
8. Rectocele 8. Forward turning
9. Anteversion 9. Removal of the ovaries
10. Oophorectomy 10. Freezing of tissue

BREAST SURGERIES
Match the following breast surgery terms with their descriptions.

1. Mastopexy 1. Surgery to remove a breast

2. Mastectomy 2. Surgery to increase the size of the breasts
3. Reduction mammoplasty 3. Surgery to decrease the size of the breasts
4. Augmentation mammoplasty 4. Surgery to rebuild a breast after mastectomy
5. Reconstructive mammoplasty 5. Surgery to change the position of the breasts

MENSTRUAL DISORDERS
Match the following menstrual disorders with their definitions.

1. Amenorrhea 1. Difficult or painful menstruation

2. Menorrhagia 2. Menses more often than every 21 days
3. Dysmenorrhea 3. Passing more than 80 mL of blood per menses
4. Polymenorrhea 4. Less than expected amount of menstrual bleeding
5. Hypomenorrhea 5. Absence of menstrual periods for 6 months or three pre-
vious cycle lengths once cycles have been established

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178 UNIT ELEVEN Understanding the Genitourinary and Reproductive System

MASTECTOMY CARE CRITICAL THINKING

Circle the six errors in the following scenario and write the Read the following case study and answer the questions.
correct information in the space provided.
A 21-year-old female college student comes in to the physi-
cian’s office where you work and comments with evident
You are assigned to care for Mrs. Joseph, who is 1 day post-
frustration that she has a yeast infection again. She has type
operative following a right radical mastectomy. You know that
1 diabetes mellitus and takes her insulin routinely. However,
she is not anxious, because she had a left mastectomy a year
she seldom tests her blood glucose level, because, she says,
ago and knows everything to expect. You listen to her breath
“I don’t have time to mess with that stuff as often as I
sounds and find them clear, so it is not necessary to have her
should.” She comments that every time she goes home on
cough and deep breathe. You encourage her to lie on her right
weekends to visit her parents (a 3-hour bus trip), she develops
side to prevent bleeding. You use her right arm for blood pres-
a very uncomfortable vaginal yeast infection.
sures, because both arms are affected and the right one is more
convenient. You also encourage her to avoid use of her right
arm to prevent injury to the surgical site. You provide a bal- 1. What factors may be contributing to her frequent yeast
anced diet and plenty of fluids to aid in her recovery. overgrowths?

2. What suggestions can you give her to help prevent this

problem?

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 3. Which of the following is a risk factor for development
of breast cancer?
1. How will a douche affect a vaginal examination to
1. Late menarche
determine the type of pathogen present?
2. High-fat diet
1. A douche will help clear the area for better
3. Early menopause
visualization.
4. Early first pregnancy
2. A douche does not affect the outcome negatively or
positively.
3. Douching can wash away evidence of the pathogen,
making diagnosis difficult.
4. Douching is recommended before the examination to
neutralize the pH.

2. Which of the following is a known risk factor for

cervical cancer?
1. Tight clothing
2. A high-sodium diet
3. Multiple sexual partners
4. Beginning sexual activity late in life
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Chapter 42 Nursing Care of Women With Reproductive System Disorders 179

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 8. A patient who had a total hysterectomy 4 days ago for
4. Which of the following lifestyle habits are most likely to endometrial cancer learns that she has metastases to
increase premenstrual syndrome symptoms? Select all her lungs. When asked about her plans after discharge,
that apply. she answers sharply that she “cannot plan for any
1. Drinking alcohol future, because there isn’t going to be any!” She then
2. Smoking starts to cry. Which of the following nursing diagnoses
3. Drinking coffee best fits this situation?
4. Eating a low-salt diet 1. Anticipatory Grieving
5. Avoiding exercise before menses 2. Disturbed Body Image
3. Disturbed Sleep Pattern
5. A nurse is teaching a patient about use of a condom with 4. Noncompliance
spermicide for contraception. Which statement by the
patient indicates the need for further teaching? 9. A patient with breast cancer is being treated with
1. “This method will be affordable.” tamoxifen citrate, which deprives cancer cells of the
2. “I am glad that barrier methods are 100% effective.” estrogen that makes them grow. This is an example of
3. “I’m glad there are fewer side effects than there are which mode of therapy?
with the pill.” 1. Hormonal therapy
4. “I know that both I and my husband will need to be 2. Radiation therapy
diligent to use the method all the time.” 3. Cytotoxic chemotherapy
4. Biological response modifier therapy
6. Place the following nursing diagnoses for the woman
who has just had a mastectomy for breast cancer in cor- 10. A 38-year-old patient had a reduction mammoplasty
rect priority order. 4 days ago. When changing her dressing, the home
1. Ineffective Tissue Perfusion care nurse notes redness, swelling, and some thick yel-
2. Risk for Ineffective Coping low drainage escaping from areas of the incision line
3. Ineffective Breathing Pattern around her left nipple. Which of the following nursing
4. Anxiety interventions is appropriate?
1. Monitor it for 24 hours, and if there is no improve-
7. Which of the following nursing interventions will help ment, notify the registered nurse or physician.
prevent swelling after a radical mastectomy with lymph 2. Inform the patient that the incision is not healing
node removal? properly and that she should see her physician as
1. Restricting all movement of the affected arm soon as possible.
2. Raising the affected arm above the heart on pillows 3. Clean the incision with normal saline and redress it,
3. Applying warm moist heat to the arm and recheck it the following day.
4. Holding the arm close to the body with a sling 4. Promptly report the situation to the registered nurse
or physician and document it in the patient’s chart.
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Nursing Care of
43 Male Patients With
Genitourinary Disorders
VOCABULARY
Fill in the blanks in the following sentences with terms from the chapter.
1. When semen goes into the bladder during intercourse, it is called ejaculation.
2. An erection that lasts too long is called .
3. is the term used to describe uncircumcised foreskin that cannot be extended over
the head of the penis.
4. is a cottage cheese–like secretion made by the gland of the foreskin.
5. Surgical removal of the foreskin is called .
6. is a birth condition in which one or both of the testicles have not descended into
the scrotum.
7. Inflammation or infection of a testicle is called .
8. The correct term for male impotence is .
9. A is varicose veins of the scrotum.
10. Surgical interruption of the vas deferens as a method of birth control is called a .

DISORDERS OF THE MALE REPRODUCTIVE SYSTEM

Match the disorder with its definition.

1. Benign prostatic hypertrophy (BPH) 1. Blood in the urine

2. Hydronephrosis 2. Curved penis
3. Hematuria 3. Noncancerous overgrowth of prostate tissue
4. Peyronie’s disease 4. Inability to reproduce
5. Priapism 5. Distention of kidney with retained urine
6. Epididymitis 6. Inflammation of the testicles
7. Infertility 7. Inflammation or infection of the tube where sperm
8. Orchitis matures
9. Dysuria 8. Painful or difficult urination
10. Reflux 9. Backward flow of urine
10. Prolonged erection

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Chapter 43 Nursing Care of Male Patients With Genitourinary Disorders 181

ERECTILE DYSFUNCTION REVIEW 4. What can result if the problem continues untreated?

Unscramble the following causes of erectile dysfunction.

1. aeiioctdmn
2. sssrte
Mr. Washington is transferred to the local hospital, where BPH
3. eeiophysnntr is confirmed. He is scheduled for a transurethral resection of
4. PRUT the prostate (TURP). He asks the nurse, “What’s a TURP?”
5. threa flraeiu
6. tiellpum lersssoic 5. How can the nurse explain a TURP to Mr. Washington?

CRITICAL THINKING
Read the following case study and answer the questions.
Mr. Washington is a 62-year-old retired teacher who comes to
the urgent care center reporting that he “can’t pass water.” 6. After surgery, Mr. Washington has a three-way Foley
catheter. What is the purpose of this type of catheter?
1. What initial questions do you ask to further assess How should the nurse total intake and output (I&O) at
Mr. Washington’s problem? the end of the shift?

2. What do you think is happening? 7. Bladder spasms are common after TURP. How will the
nurse know if this is happening? What interventions will
help?

3. What care do you anticipate as the physician examines 8. Mr. Washington is discharged. The next day he calls the
him? nursing unit and says in a panicky voice, “I just wet my
pants! I can’t hold my urine! This is worse than not
being able to go at all!” How should the nurse respond?
What can Mr. Washington do?

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 2. What should be included when teaching young men to
detect testicular cancer early?
1. Which of the following nursing actions is most appro-
1. Monthly testicular self-examination (TSE)
priate when doing perineal care on an uncircumcised
2. Yearly digital rectal examination (DRE)
male patient?
3. Annual physician examination
1. Leave the foreskin retracted so air can keep the
4. Annual ultrasonography
area dry.
2. Do not retract the foreskin during washing.
3. Replace the foreskin over the head of the penis after
washing.
4. Use alcohol and a cotton swab to clean under the
foreskin.
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182 UNIT ELEVEN Understanding the Genitourinary and Reproductive System

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 7. A post-TURP patient experiences dribbling following
removal of his catheter. Which action should the
3. The nurse completes a nursing history on a patient ad-
nurse take?
mitted for a TURP. Which symptoms of BPH does the
1. Have him restrict fluid intake to 1000 mL/day.
nurse expect the patient to report? Select all answers
2. Teach him to perform Kegel’s exercises 10 to
that apply.
20 times per hour.
1. A feeling of incomplete bladder emptying after
3. Reinsert the Foley catheter until he regains urinary
voiding
control.
2. Difficulty maintaining an erection
4. Reassure him that incontinence never lasts more
3. Difficulty urinating
than a few days.
4. Grossly bloody urine
5. Pain in the lower back that radiates to the hips during
8. A 36-year-old man is scheduled for a unilateral or-
urination
chiectomy for treatment of testicular cancer. He is
6. Nocturia
withdrawn and does not interact with the nurse.
Which action is most appropriate?
4. A patient tells his nurse that he has delayed having a
1. Identify the problem with a nursing diagnosis of
TURP because he is afraid it will affect his sexual func-
Impaired Communication related to the diagnosis
tion. Which response by the nurse is most appropriate?
of cancer.
1. “Don’t worry about sterility; sperm production is not
2. Set a patient outcome that the patient will verbalize
affected by this surgery.”
his concerns about his diagnosis.
2. “Would you like some information about implants
3. Ask the patient whether he is worried about future
used for impotence?”
sexual functioning.
3. “This type of surgery rarely affects the ability to have
4. Say, “You seem quiet. Are you feeling concerned
an erection or ejaculation.”
about your diagnosis or treatment?”
4. “There are many methods of sexual expression that
are alternatives to sexual intercourse.”
9. A 28-year-old man is diagnosed with acute epididymi-
tis. For which of the following symptoms should the
5. A patient returns from surgery following a TURP with a
nurse assess?
three-way Foley catheter and continuous bladder irriga-
1. Burning and pain on urination
tion. Postoperative orders include meperidine (Demerol)
2. Severe tenderness and swelling in the scrotum
75 mg IM every three hours (q3h) as needed for pain,
3. Foul-smelling ejaculate and severe scrotal swelling
belladonna and opium (B&O) suppository q4h as
4. Foul-smelling urine and pain on urination
needed, and strict I&O. The patient reports painful blad-
der spasms, and the nurse observes blood-tinged urine
10. A man with a history of diabetes and chronic lung dis-
on the sheets. Which action should the nurse take first?
ease is admitted to the hospital with prostate cancer. He
1. Give the Demerol.
has all the following symptoms. Which should the
2. Give the B&O suppository.
nurse address first?
3. Warm the irrigation solution to body temperature.
1. Fever of 101°F (38.3°C)
4. Notify the physician stat.
2. Respiratory rate of 36 per minute
3. Difficulty urinating
6. A patient who has just had a TURP asks his nurse to ex-
4. Painful legs and feet
plain why he has to have the bladder irrigation because
it seems to increase his pain. Which of the following ex-
11. The nurse is providing care for a patient scheduled for
planations by the nurse is best?
a vasectomy. Which of the following statements indi-
1. “The bladder irrigation is needed to stop the bleeding
cates further teaching is necessary?
in the bladder.”
1. “I will need to have my testosterone levels checked
2. “Antibiotics are being administered into the bladder
periodically to ensure the success of the surgery.”
to prevent infection.”
2. “Another method of birth control should be used for
3. “The irrigation is needed to keep the catheter from
the next three months.”
becoming occluded by blood clots.”
3. “The amount and color of my ejaculate should be
4. “Normal production of urine is maintained with the
the same as before surgery.”
irrigations until healing can occur.”
4. “I’ll have to bring a sample of semen back for eval-
uation after the surgery.”
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Nursing Care of Patients

With Sexually Transmitted
Infections
44
VOCABULARY
Match the term with its definition.
1. Condylomatous 1. Relating to herpes
2. Gumma 2. Rubbery tumor
3. Chancre 3. Red ulcer from syphilis
4. Cytotoxic 4. Wartlike
5. Herpetic 5. Poison to cells
6. Puerperal 6. Time following childbirth

INFLAMMATORY DISORDERS
Match the following inflammation words with their definitions.

1. Proctitis 1. Inflammation of the rectum and anus

2. Urethritis 2. Inflammation of the cervix
3. Cervicitis 3. Inflammation of the urethra
4. Endometritis 4. Inflammation of parts of the eye
5. Conjunctivitis 5. Inflammation of the lining of the uterus

BARRIER METHODS FOR SAFER SEX

List the teaching that should accompany each of the following barriers against sexually transmitted infections (STIs).

1. Male condoms

2. Female condoms

3. Diaphragms

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184 UNIT ELEVEN Understanding the Genitourinary and Reproductive System

4. Rubber gloves

5. Double condoms

CRITICAL THINKING
Read the following case study and answer the questions.
James, 32 years old, arrives at an outpatient clinic requesting STI testing for him and his fiancée. You learn that he met his fi-
ancée through an international dating agency and that she has come here to marry him. She does not speak English. He asks
you to give him the paperwork for both of them to get the blood test for STIs—just to make sure they don’t have anything
contagious. He seems in a hurry and asks if they can have their blood drawn first and then he could come back in an hour or
two and see the doctor for the results for both of them.

1. What misunderstandings does James have about STI diagnosis?

2. Legally and ethically, does James have a right to be told his fiancée’s test results?

3. What procedures should occur before any testing is done?

4. Is James likely to get his answer about whether either he or his fiancée has a contagious STI today?

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 2. Which virus causes genital warts?
1. Cytomegalovirus
1. Which STI is associated with gummas?
2. Herpes simplex virus type II
1. Gonorrhea
3. Human papillomavirus
2. Herpes simplex
4. Human immunodeficiency virus
3. Trichomoniasis
4. Syphilis
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Chapter 44 Nursing Care of Patients With Sexually Transmitted Infections 185

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 7. A 16-year-old girl is diagnosed with genital herpes.
She has vesicles on her genitals and urethritis. She is
3. A 36-year-old woman who has had no prenatal care
tearful as she asks what she can do to prevent compli-
comes into the hospital in active labor for her fourth
cations of the disease. On the basis of the data pro-
child. She has vesicles evident on her perineum. Which
vided, which nursing diagnosis is appropriate for her
of the following nursing actions are appropriate to pro-
plan of care?
tect the unborn baby and the staff? Select all that apply.
1. Risk for Infection
1. Maintain standard precautions.
2. Health-Seeking Behaviors
2. Reprimand the mother for putting her baby at risk
3. Pain
for herpes.
4. Ineffective Sexuality Pattern
3. Prepare for the possibility that the baby may be
delivered by cesarean section.
8. A patient has cloudy penile discharge. For which addi-
4. Notify the obstetrician or nurse midwife about the
tional symptoms of urethritis should the nurse assess?
vesicles as soon as possible.
1. Throat or rectal infection
5. Apply antibiotic ointment to the vesicles.
2. Chancres or vesicles on the genitals
6. Place the mother in reverse isolation.
3. Painful and frequent urination
4. Oliguria and flank pain
4. A 23-year-old woman is seen at an outpatient clinic for a
routine Papanicolaou (Pap) smear. When questioned,
9. A woman with pelvic inflammatory disease says she
she states she is deciding whether to engage in sexual
has lower abdominal pain. Which action should the
activity with a man she is just getting to know. She asks
nurse take first?
how she can tell if he has an STI. Which response by the
1. Have her rate her pain on a 0 to 10 scale.
nurse is best?
2. Administer antibiotics as ordered.
1. “If the man appears clean and has been conscientious
3. Administer an analgesic as ordered.
about using condoms, he is likely infection free.”
4. Teach the patient about causes and prevention
2. “Look carefully for signs of lesions before engaging
of STIs.
in sexual activity.”
3. “Be sure to use either a male or female condom to
10. A nurse needs to administer an intramuscular injection
protect against possible transmission of infection.”
of 2.4 million units of penicillin G. It is supplied in a
4. “An examination by a physician with diagnostic test-
vial of 5,000,000 units of powder for injection. Instruc-
ing is the only way to know if he is infection free.”
tions state to dilute with 8 mL of sterile water. How
many mL should the nurse draw up?
5. A college student goes to the college clinic and asks the
best way to avoid contracting an STI. The nurse pro-
11. The nurse receives a phone call from a client who re-
vides the clinic’s standard STI teaching. Which state-
ports engaging in recent sexual activity with a partner
ment by the student indicates the need for additional
who just informed her that he has herpes. Which of the
instruction?
following statements by the nurse is best?
1. “There is no guarantee that I won’t contract an STI if
1. “How long has your partner had herpes?”
I choose to be sexually active.”
2. “Did you notice any rash or other lesions on his
2. “Abstinence is the only sure way to avoid an STI.”
face or genitalia?”
3. “If I use a condom with spermicide, I will be safer
3. “You need to use a diaphragm if you engage in
than if I don’t use one.”
sexual intercourse with him again.”
4. “If I question my partner about past sexual encoun-
4. “If you notice flulike symptoms, symptoms of a
ters, I can avoid STIs.”
bladder infection, or vaginal drainage within the
next two weeks you need to be seen right away.”
6. While bathing an 82-year-old man hospitalized with
pneumonia, a nurse notes an ulcerated area on his penis.
What action should the nurse take first?
1. Report the ulcer to the admitting care provider.
2. Teach the man about STI prevention.
3. Ask the man if he has a history of syphilis.
4. Clean the ulcer; reporting is not necessary because an
STI is unlikely in a man this age.
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unit TWELVE

Understanding the
Musculoskeletal
System
CHECKLIST FOR LEARNING SUCCESS
Review of Anatomy
and Physiology
and Aging Changes Major Disorders Nursing Assessment Diagnostic Tests Interventions Common Medications
❑ Skeletal system ❑ Osteoarthritis ❑ History ❑ Alkaline phosphatase ❑ Amputation ❑ Allopurinol (Zyloprim)
❑ Muscular system ❑ Rheumatoid arthritis ❑ Medications ❑ Erythrocyte ❑ Prosthesis ❑ Analgesics
❑ Aging effects ❑ Gout ❑ Vital signs sedimentation rate ❑ Casts ❑ Anticoagulants
❑ Carpal tunnel ❑ Physical examination ❑ Serum ❑ Closed reduction ❑ Antirheumatic drugs
syndrome ❑ Deformities/limb calcium/phosphorus/ ❑ Diet therapy ❑ Bisphosphonates
❑ Fractures length uric acid ❑ External fixation ❑ Calcitonin (Calcimar)
❑ Complications of ❑ Crepitation ❑ Creatinine kinase ❑ Heat and cold ❑ Corticosteroids
fractures ❑ Swelling ❑ Myoglobin ❑ Open reduction/ ❑ Cox-2 selective
❑ Rhabdomyolysis ❑ Range of motion ❑ Rheumatoid factor internal fixation inhibitors
❑ Osteomyelitis ❑ Muscle strength ❑ Arthrocentesis ❑ Rest, ice, ❑ Muscle relaxants
❑ Osteoporosis ❑ Pain ❑ Arthrography compression, ❑ Nonsteroidal anti-
❑ Paget’s disease ❑ Neurovascular checks ❑ Arthroscopy elevation inflammatory drugs
❑ Bone cancer ❑ Bone scan ❑ Total joint (NSAIDs)
❑ Electromyography replacement ❑ Raloxifene (Evista)
(EMG) ❑ Traction
❑ Magnetic resonance
imaging (MRI)
❑ Myelogram
❑ X-rays
❑ Dual energy x-ray
absorptiometry
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Musculoskeletal Function
45 and Assessment

STRUCTURE OF NEUROMUSCULAR JUNCTION AND SARCOMERES

Label the structures from the following word list.
Acetylcholine receptors Sarcoplasmic reticulum
Motor Neuron Synaptic cleft
Myofilaments T Tubules
Sarcolemma Vesicle of acetylcholine
Sarcomere

2 3

188
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Chapter 45 Musculoskeletal Function and Assessment 189

NEUROMUSCULAR JUNCTION
Match each part of the neuromuscular junction with the proper descriptions. Each part will have two correct answers.

1. Synapse 1. Contains the transmitter acetylcholine

2. Axon terminal 2. The cell membrane of the muscle fiber
3. Sarcolemma 3. The space between the muscle fiber and the motor neuron
4. Has receptors for acetylcholine
5. An impulse is transmitted by the diffusion of acetylcholine
6. The end of the motor neuron

SYNOVIAL JOINTS
Match each part of a synovial joint with the correct function.

1. Articular cartilage 1. Lines the joint capsule and secretes synovial fluid
2. Joint capsule 2. Prevents friction within the joint cavity
3. Synovial membrane 3. Encloses the joint similar to a sleeve
4. Synovial fluid 4. Permit tendons to slide easily across a joint
5. Bursae 5. Provides a smooth surface on the joint surfaces of bones

VOCABULARY
Match the word on the left with its definition on the right.

1. Symphysis 1. Movement in all planes

2. Ball and socket 2. Rotation
3. Hinge 3. Disk of fibrous cartilage between bones
4. Condyloid 4. Movement in one plane
5. Pivot 5. Hinge with some lateral movement
6. Gliding 6. Side-to-side movement
7. Saddle 7. Small sacs of synovial fluid between joints and tendons
8. Bursa 8. Movement in several planes
9. Crepitation 9. Swollen synovial tissue within the joint
10. Synovitis 10. Grating sound as joint or bone moves

DIAGNOSTIC TESTS
Match each diagnostic test to its appropriate description.

1. X-ray 1. Dye required to view joint structures: tendons, ligaments,

2. Arthrogram cartilage
3. MRI 2. Radio waves and magnetic field view of soft tissue
4. Arthroscopy 3. Bones show up as white areas
5. Arthrocentesis 4. Insertion of a needle into a joint space to remove fluid,
6. Bone scan obtain a specimen, or instill medication
7. Alkaline phosphatase 5. An endoscopy of joints with local or general anesthesia
8. Calcium 6. Serum level of enzyme that is made by osteoblasts to
9. Phosphorus mineralize bone
10. Erythrocyte sedimentation rate 7. After injection, a radioisotope is taken up by bone and
11. Uric acid 2 hours later a camera scans the body front and back
12. Dual energy x-ray absorptiometry (DEXA) 8. Serum level of substance stored in bone that makes
bone rigid
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190 UNIT TWELVE Understanding the Musculoskeletal System

9. Serum test for inflammation

10. Serum level of substance that mineralizes bones and
teeth
11. Serum level for end product of purine metabolism
12. Special x-ray used to evaluate bone density

CRITICAL THINKING 3. What tests can the nurse anticipate will be done on
Mr. Allen?
Read the following case study and answer the questions.
Mr. John Allen, age 45, was in an automobile accident and
comes to the emergency department with a fractured femur.

4. What types of teaching should the nurse do?

1. What information should the nurse include in Mr.
Allen’s history?

2. What areas should Mr. Allen’s physical examination

focus on first?

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 4. Which of the following is the part of the brain that initi-
ates muscle contraction?
1. Absorbing shock between adjacent vertebrae is the func-
1. Parietal lobe
tion of disks made of which of the following?
2. Cerebellum
1. Smooth muscle
3. Frontal lobe
2. Synovial fluid
4. Temporal lobe
3. Fibrous cartilage
4. Adipose tissue
5. Which of the following organ systems is not considered
directly necessary for muscle contraction?
2. Which of the following is the transmitter at neuromus-
1. Circulatory system
cular junctions?
2. Digestive system
1. Sodium ions
3. Respiratory system
2. Acetylcholine
4. Nervous system
3. A nerve impulse
4. Cholinesterase
6. Which of the following is the function of synovial fluid
in joints?
3. Muscles are attached to bones by which of the following?
1. Exchange nutrients
1. Tendons
2. Prevent friction
2. Ligaments
3. Absorb water
3. Fascia
4. Wear away rough surfaces
4. Other muscles
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Chapter 45 Musculoskeletal Function and Assessment 191

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 10. Following a patient’s bone biopsy, the nurse inspects
the biopsy site. The nurse is monitoring for which of
7. The nurse is inspecting the knee of a patient who reports
the following complications that may occur immedi-
pain and stiffness in it. As the patient moves the knee
ately following a biopsy?
the nurse hears a grating sound. The nurse documents
1. Joint dislocation
the grating sound as which of the following?
2. Crackles
1. Friction rub
3. Infection
2. Crepitation
4. Hematoma formation
3. Effusion
4. Subcutaneous emphysema
11. The nurse is caring for a patient after a biopsy. The
nurse understands that increased pain that is unrespon-
8. The nurse is caring for a patient who reports knee pain.
sive to analgesic medication in a patient who has had a
When the nurse observes a joint that has a grating sound
biopsy may indicate which of the following biopsy
with movement, which of the following actions should
complications?
the nurse take next?
1. Bleeding in soft tissue
1. Adduct the extremity.
2. A low pain tolerance
2. Flex the joint.
3. An allergic reaction
3. Avoid joint movement.
4. Inadequate analgesic dose
4. Abduct the extremity.

9. The nurse is gathering functional data on a patient with

rheumatoid arthritis. Which of the following areas
would the nurse include in the assessment?
1. Response to treatment
2. Ability to prepare food
3. Appearance of joints
4. Lung sounds
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Nursing Care of Patients

46 With Musculoskeletal and
Connective Tissue Disorders
VOCABULARY
Fill in the blank with the word that is formed by the word building.
1. arthro—joint + itis—inflammation
2. arthro—joint + plasty—creation of
3. synovia—synovial fluid or tissue + itis—inflammation
4. arthro—joint + centesis—puncture of a cavity
5. hyper—excessive + uric—uric acid + emia—in blood
6. vascul—blood vessel + itis—inflammation
7. a—without + vascular—blood + necrosis—death
8. re—again + plant—to plant + tion—process
9. hemi—half + pelv—pelvis + ectomy—removal of
10. fascia—fibrous tissue + otomy—opening into
11. osteo—bone + myel—bone marrow + itis—inflammation
12. osteo—bone + sarco—flesh + oma—tumor

FRACTURES
Match the type of fracture with its definition.

1. More than two fragments that appear to float 1. Transverse

2. At right angle to bone 2. Stress
3. Splintered and bent, occurring mainly in children 3. Spiral
4. More than two fragments driven into each other 4. Pathological
5. Extends into articular surface 5. Oblique
6. Runs along axis of bone 6. Longitudinal
7. Oblique fracture line 7. Interarticular
8. Spontaneous fracture from bone disease 8. Impacted
9. Fracture spirals around shaft of bone 9. Greenstick
10. From repeated stress (jogging) 10. Comminuted

192
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Chapter 46 Nursing Care of Patients With Musculoskeletal and Connective Tissue Disorders 193

PROSTHESIS CARE EDUCATION HEALTH PROMOTION FOR PATIENTS

WITH GOUT
Indicate whether the statement is true or false, and correct
false statements. Fill in the blanks.

1. Replace shoes when they wear out with new 1. Avoid high foods, such as organ meats,
ones of a different height and type. shellfish, and oily fish such as .
2. Clean the prosthesis socket with alcohol and 2. alcohol.
water, and dry it completely. 3. Drink plenty of , especially water.
3. Replace worn inserts and liners when they be- 4. Avoid all forms of and drugs containing
come too soiled to clean adequately. .
4. Use garters to keep socks or stockings in place. 5. diuretics.
5. Oil the mechanical parts as instructed by the 6. Avoid excessive physical or emotional .
physician.

CRITICAL THINKING
Complete the nursing care plan for the nursing diagnosis Impaired Physical Mobility for a patient with a hip replacement.

NURSING DIAGNOSIS
Impaired Physical Mobility related to hip precautions and surgical pain

Interventions Rationale Evaluation

Activity is restricted due to hip
precautions and weight-bearing
limitations.

Place overhead frame and trapeze Does patient use over-bed

on bed; teach patient how to use it. frame and trapeze for
movement?

Monitor the patient for and take Is the patient free from compli-
measures to prevent complications cations of immobility?
of immobility:
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194 UNIT TWELVE Understanding the Musculoskeletal System

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 2. Which of these laboratory values should the nurse moni-
tor for a patient with gout?
1. Which of the following is the recommended protocol for
1. Blood urea nitrogen
caring for a severed body part that may be replanted?
2. Creatinine
1. Cover it with a warm dry towel.
3. Uric acid
2. Wrap it in a clean moist cloth.
4. Cholesterol
3. Place it directly in ice.
4. Wrap it in a dry sterile dressing.

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 7. The nurse turns a 2-day postoperative patient with a
right total hip replacement using three pillows between
3. A patient is in skin traction using a foam boot with
the legs. The nurse later returns and finds the patient
Velcro® fasteners for a fractured hip. The nurse would
lying supine with legs crossed. Which of the following
document this type of skin traction as which of the
should the nurse monitor to determine whether a com-
following?
plication has developed?
1. Gardner’s tongs
1. The right knee for crepitation
2. Buck’s traction
2. The left leg for internal rotation
3. Crutchfield’s tongs
3. The left leg for loss of function
4. Steinmann’s pin
4. The right leg for shortening
4. A patient sustains a closed fracture of the right tibia and
8. Discharge teaching for patients who have gout includes
is placed in a long-leg plaster cast, which is still damp.
diet teaching. Patients will require additional teaching if
Which of the following methods should the nurse use to
they say they will be eating which one of the following?
move the cast without causing complications?
1. Cod
1. Have the patient move own leg.
2. Chicken
2. Palm the cast to move it.
3. Eggs
3. Use fingertips to grasp cast.
4. Liver
4. Avoid moving the cast until it is dry.
9. Which of the following medications should a patient
5. A patient is being treated with gold therapy for rheuma-
with gout be encouraged to avoid to prevent a gout
toid arthritis. Which of the following interventions is
attack?
essential when gold therapy is started? Select all that
1. Aspirin
apply.
2. Tylenol
1. Removing all metal objects patient is wearing
3. Nonsteroidal anti-inflammatory drugs
2. Assessing allergies to iodine
4. Narcotics
3. Giving a test dose of gold
4. Planning a biweekly dosing schedule
10. The nurse is reviewing an erythrocyte sedimentation
5. Monitoring the patient after the injection
rate (ESR) for a patient. Which of the following does
6. Teaching the patient to perform daily weights
the nurse understand is the purpose of an ESR test?
1. To identify the number of red blood cells the
6. The nurse is caring for a patient who has a fractured
patient has
ankle that is in a cast. The patient has morphine 10 to
2. To determine sedimentation found in red blood cells
15 mg intramuscularly ordered every 3 to 4 hours.
3. To identify the presence of systemic inflammation
The patient received morphine 10 mg 2 hours and
4. To diagnose various types of arthritis
45 minutes ago and is rating the pain at 10+ and moans
that the leg hurts. The patient has good capillary refill.
Which of the following actions is most appropriate for
the nurse to take next?
1. Apply ice to the cast.
2. Notify the physician immediately.
3. Remove the pillow under the cast.
4. Prepare morphine 15 mg for administration.
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Chapter 46 Nursing Care of Patients With Musculoskeletal and Connective Tissue Disorders 195

11. A patient asks why a test dose of gold therapy is neces- 12. Which of the following symptoms would the nurse
sary. Which of the following is the most appropriate re- most likely be told was the first symptom that caused a
sponse by the nurse? patient with rheumatoid arthritis to seek health care?
1. “To avoid waste of expensive gold.” 1. Cold intolerance
2. “To determine the necessary dose.” 2. Stiff, sore joints
3. “To determine the therapeutic response.” 3. Shortness of breath
4. “To assess for an allergic reaction.” 4. Crepitation
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unit THIRTEEN

Understanding the
Neurologic System
CHECKLIST FOR LEARNING SUCCESS
Review of Anatomy
and Physiology
and Aging Changes Major Disorders Nursing Assessment Diagnostic Tests Interventions Common Medications
❑ Central nervous ❑ CNS infections ❑ Health history ❑ Lumbar puncture ❑ Positioning ❑ Anticoagulants
system (CNS) structure ❑ Increased intracranial ❑ Level of ❑ Computed ❑ Interventions for ❑ Thrombolytics
and function pressure (ICP) consciousness tomographic (CT) swallowing ❑ Corticosteroids
❑ Peripheral nervous ❑ Headaches (LOC; Glasgow scan ❑ Activities of daily ❑ Platelet aggregation
system (PNS) ❑ Seizures and FOUR Score ❑ Magnetic resonance living (ADLs) inhibitors
❑ Cranial nerves ❑ Traumatic brain coma scales) imaging (MRI) ❑ Communication ❑ Diuretics
❑ Spinal nerves injury (TBI) ❑ Mental status ❑ Angiogram ❑ Nutrition ❑ Anticonvulsants
❑ Sympathetic ❑ Hematomas ❑ Eyes ❑ Myelogram ❑ Rehabilitation
❑ Parasympathetic ❑ Brain tumors ❑ Muscle function ❑ Electroencephalogram ❑ Interventions for
❑ Aging changes ❑ Herniated disk ❑ Cranial nerves (EEG) increased ICP
❑ Spinal cord injury ❑ ICP ❑ Interventions for
❑ Parkinson’s disease seizures
❑ Alzheimer’s disease ❑ Interventions for
❑ Transient ischemic chronic confusion
attack (TIA)
❑ Stroke—
hemorrhagic,
ischemic
❑ Multiple sclerosis
❑ Myasthenia gravis
❑ Amyotrophic lateral
sclerosis (ALS)
❑ Guillain-Barré
syndrome
❑ Postpolio syndrome
❑ Cranial nerve
disorders
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Neurologic System
47 Function, Assessment, and
Therapeutic Measures
VOCABULARY
Fill in the blank with the correct term.
1. Difficulty swallowing is called .
2. An is a test that uses scalp electrodes to evaluate brain activity.
3. A patient might say his leg feels like it is asleep to describe .
4. Abnormal flexion posturing when eliciting best motor response is called posturing.
5. Abnormal extension posturing when eliciting best motor response is called posturing.
6. is the term that describes unequal pupils.
7. Involuntary eye movement is called .
8. Permanent muscle contractions are called .
9. Difficulty speaking because of muscle dysfunction is called .
10. Patients who have difficulty speaking after a stroke are experiencing .

DIAGNOSTIC TESTS
Describe the procedure and nursing care before and after each of the following diagnostic tests used for neurological diag-
noses. (See DavisPlus for complete descriptions.)

1. Myelogram

2. EEG

3. Lumbar puncture

4. MRI

198
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Chapter 47 Neurologic System Function, Assessment, and Therapeutic Measures 199

5. CT scan

ANATOMY
Label the parts of the cerebrum.
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200 UNIT THIRTEEN Understanding the Neurologic System

Label the parts of the neuron.

ANATOMY REVIEW
Match the part of the brain with the function it controls.

1. Cerebrum 1. Vision center

2. Medulla oblongata 2. Speech
3. Occipital lobe 3. Equilibrium and coordination
4. Cerebellum 4. Respiratory center
5. Temporal lobe 5. Information storage
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Chapter 47 Neurologic System Function, Assessment, and Therapeutic Measures 201

ASSESSMENT OF CRANIAL NERVES

Match the following assessment tools with the nerve to be tested.

1. Cotton ball 1. Vestibulocochlear (VIII)

2. Snellen chart 2. Accessory (XI)
3. Use of hands to check neck/shoulder strength 3. Trigeminal (V)
4. Tuning fork or whisper 4. Optic (II)
5. Tongue blade and cotton swab 5. Vagus (X)

CRITICAL THINKING
Read the following case study and answer the following questions.
Mrs. Pickett is admitted to the nursing home where you work as a nurse. She had a stroke 2 weeks ago and is not strong enough
to go to a rehabilitation facility. She has left-sided weakness. You collect admitting data to help determine her plan of care.

1. Mrs. Pickett tells you she needs to get up to go to the bathroom. What are some things you can do to determine if she is
able to do this?

2. Mrs. Pickett’s first meal is served. What can you do to determine her ability to eat safely?

3. Mrs. Pickett says, “Will you go to the kitchen and get me one of those cookies I like?” How do you determine whether
she is confused?

4. Mrs. Pickett is weak on her left side. Why do you think her blood pressure will be more accurate in her right arm?

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 3. Which part of the brain controls breathing?
1. Medulla
1. Which of the following parts of a neuron transmits im-
2. Cerebellum
pulses away from the cell body?
3. Cerebrum
1. Dendrite
4. Thalamus
2. Axon
3. Neurolemma
4. When a neurologist asks a patient to smile, which cra-
4. Synapse
nial nerve is being tested?
1. II optic
2. Which type of neuron transmits impulses from the CNS
2. VII facial
to the muscles and glands?
3. X vagus
1. Afferent
4. XI accessory
2. Efferent
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202 UNIT THIRTEEN Understanding the Neurologic System

5. The neurologist tests the fourth (trochlear) and sixth 7. Which neurotransmitter mediates the sympathetic
(abducens) cranial nerves together by having a patient response?
do which of the following? 1. Acetylcholine
1. Turn his head to the right and left. 2. Prostaglandin
2. Identify whispering in his ears. 3. Norepinephrine
3. Say “ahhh.” 4. Serotonin
4. Follow a finger with the eyes.

6. Which of the following responses indicates sympathetic

nervous system activation?
1. Tachycardia, dilated pupils
2. Increased peristalsis, abdominal cramping
3. Hypoglycemia, headache
4. Pupil constriction, bronchoconstriction

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise.
11. The nurse knows that the patient understands instructions
8. Which of the following actions are controlled by for an MRI when the patient makes which statement?
nerves exiting from the cervical portion of the spinal 1. “I will have a small Band-Aid on the puncture site.”
cord? Select all that apply. 2. “I will need to wash my hair following the MRI.”
1. Blinking 3. “I should avoid eating or drinking for 4 hours after
2. Writing the procedure.”
3. Sticking out the tongue 4. “I should be sure to remove all metal jewelry.”
4. Nodding
5. Urinating 12. The nurse is providing care for a patient scheduled for
6. Homans’ sign a computerized tomography (CT) scan of the brain.
Which of the following statements should be included
9. The nurse is assisting a patient to prepare for a lumbar in the patient teaching? Select all that apply.
puncture. Which of the following actions should the 1. “You will need to lie still for 1 to 2 hours during the
nurse take first? exam.”
1. Administer enemas until clear. 2. “Notify the staff if you have any nausea, sweating,
2. Remove all metal jewelry. or itching during the exam.”
3. Position the patient on his or her side. 3. “Mild sedation can be given if you become
4. Remove the patient’s dentures. uncomfortable.”
4. “You may have a feeling of warmth throughout
10. When caring for a patient who has just undergone a your body after the dye is injected.”
lumbar puncture, which of the following nursing ac- 5. “The table may be moved to various positions dur-
tions takes the highest priority? ing the test.”
1. Have the patient lie flat for 6 to 8 hours. 6. “This test can’t be used if you have any metal in
2. Keep the patient nil per os (NPO) for 4 hours. your body.”
3. Monitor the patient’s pedal pulses every four hours.
4. Encourage the patient to deep breathe and cough.
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Nursing Care of Patients

With Central Nervous
System Disorders
48
VOCABULARY
Match the term with the correct definition.
1. Contralateral hemiparesis 1. All four extremities paralyzed
2. Ipsilateral hemiplegia 2. Sensitive to light
3. Quadriplegia 3. Inflammation of the brain
4. Paraplegia 4. Slow movement
5. Photophobia 5. Surgical opening in the skull
6. Bradykinesia 6. Paralyzed on same side
7. Craniotomy 7. Paralyzed lower extremities
8. Encephalitis 8. Neck pain and stiffness
9. Nuchal rigidity 9. Weak on opposite side
10. Prodromal 10. Warning sign

DRUGS USED FOR CENTRAL NERVOUS SYSTEM DISORDERS

Match the drug with its action.

1. Mannitol 1. Anticonvulsant
2. Tacrine (Cognex) 2. Osmotic diuretic
3. Carbamazepine (Tegretol) 3. Cholinesterase inhibitor
4. Dexamethasone (Decadron) 4. Converts to dopamine in the brain
5. Levodopa/carbidopa (Sinemet) 5. Corticosteroid

ALZHEIMER’S DISEASE REVIEW

Match the stage of disease with its primary symptom.

1. Stage 1 1. Terminal
2. Stage 2 2. Confused
3. Stage 3 3. Forgetful
4. Stage 4 4. Ambulatory dementia

203
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204 UNIT THIRTEEN Understanding the Neurologic System

CENTRAL NERVOUS SYSTEM DISORDERS

Match the signs and symptoms at the left with the correct
disorders at the right.

1. Unconscious at accident scene 1. Spinal shock

2. Polyuria and polydipsia following head 2. Absence seizure
injury 3. Migraine
3. Hypotension, loss of sympathetic function 4. Increased intracranial pressure (ICP)
4. Nuchal rigidity 5. Meningitis
5. High blood pressure, bradycardia, diaphoresis 6. Diabetes insipidus
6. Brief period of staring 7. Autonomic dysreflexia
7. Automatic repetitive movement such as 8. Complex partial seizure
picking or lip smacking 9. Epidural bleed
8. Status epilepticus 10. Continuous seizure
9. Cushing’s triad
10. Cerebral vasoconstriction followed by
vasodilation

SPINAL DISORDERS 2. Why are Mr. Granger’s respirations shallow?

Determine whether each of the following symptoms is asso-

ciated with lumbar spine or cervical spine dysfunction. In-
dicate L for lumbar and C for cervical.

1. Radiating pain to the ankle

3. Explain the purpose of each of the following therapies.
2. Deltoid weakness
How will they benefit Mr. Granger?
3. Diminished triceps reflex
a. Cervical traction:
4. Footdrop
5. Inability to walk on the toes

CRITICAL THINKING: SPINAL CORD INJURY

Mr. Granger is a 23-year-old admitted to your unit with a
b. Vasopressor administration:
C5–C6 spinal cord injury after an automobile accident. You
collect the following data:

Subjective Data
Pain in cervical spine
c. Insertion of a urinary catheter:
No sensation below the level of the injury

Objective Data
No movement below the level of the injury
Blood pressure 80/60 mm Hg
4. Mr. Granger suddenly becomes anxious and dyspneic.
Pulse 45 beats per minute
Respirations shallow He is using his accessory muscles with each breath. Ex-
Temperature 97°F (36.1°C) plain what might be happening.

1. Explain Mr. Granger’s hypotension, hypothermia, and

bradycardia.
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Chapter 48 Nursing Care of Patients With Central Nervous System Disorders 205

5. What treatment would you expect for the dyspnea, and 7. What are two health learning needs Mr. Granger faces in
why will it be beneficial to Mr. Granger? his acute stage?

6. List two priority nursing diagnoses and goals for the

acute stage of Mr. Granger’s injury.

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 3. Which of the following blood pressure changes alerts
the nurse to increasing ICP and should be reported
1. Which of the following settings is most therapeutic for
immediately?
an agitated patient with a head injury?
1. Gradual increase
1. A day room with family visitors and a variety of
2. Rapid drop followed by gradual increase
caregivers
3. Widening pulse pressure
2. A semiprivate room with one or two consistent
4. Rapid fluctuations
caregivers
3. A ward with other patients who have head injuries
4. Which of the following nursing interventions will help
and volunteers to assist with needs
prevent a further increase in ICP?
4. A hallway near the nurse’s station with adequate
1. Encourage fluids.
sensory stimulation
2. Elevate the head of the bed.
3. Provide physical therapy.
2. Decreasing level of consciousness is a symptom of
4. Reposition the patient frequently.
which of the following physiological phenomena?
1. Increased ICP
2. Sympathetic response
3. Parasympathetic response
4. Increased cerebral blood flow

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 6. A patient asks the nurse what side effects to expect from
a muscle relaxant medication that has been prescribed.
5. A 90-year-old nursing home resident with stage 2
Which of the following side effects should the nurse
Alzheimer’s disease is found alone and crying in the
relate?
dining room. She says she lost her mother and doesn’t
1. Hypoglycemia
know what to do. Which response by the nurse will help
2. Hypotension
calm the resident?
3. Drowsiness
1. “Remember your mother has been dead for 30 years.
4. Dyspnea
You forgot again, didn’t you?”
2. “I’m sorry you lost your mother; let’s go and try to
find her.”
3. “Are you feeling frightened? I’m here and I will
help you.”
4. “You are 90 years old. It is impossible for your
mother to still be living. I know if you try, you can
figure out what to do.”
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206 UNIT THIRTEEN Understanding the Neurologic System

7. A nurse caring for a patient with a herniated lumbar disk 10. Which nursing interventions can help prevent falls in a
develops a plan of care for impaired mobility related to patient with Parkinson’s disease? Select all that apply.
nerve compression. Which patient outcome indicates 1. Keep the patient’s call light within reach.
that the plan has been successful? 2. Apply a soft vest restraint when the patient is
1. The patient rates the pain at 3 to 4 on a 0-to-10 scale. in bed.
2. The patient has full range of motion of the upper 3. Avoid use of throw rugs.
extremities. 4. Maintain the patient’s bed in a low position.
3. The patient demonstrates correct self-administration 5. Encourage the patient to be independent for as long
of analgesics. as possible.
4. The patient is able to ambulate 25 feet without pain. 6. Provide a cane or walker for ambulation.

8. Which of the following problems during the immediate 11. The nurse is counseling a young woman with a spinal
postoperative course following lumbar microdiskectomy cord injury at C7. Which of the following birth control
should be reported to the physician immediately? options would the nurse recommend for this client?
1. Incisional pain Select all that apply.
2. Two-inch area of bleeding on dressing 1. Condom
3. Inability to move affected leg 2. Oral contraceptives
4. Muscle spasm of affected leg 3. Diaphragm
4. Implantable device
9. A patient with a brain tumor is admitted to the medical 5. Intrauterine device
unit to begin radiation treatments. Which nursing 6. No birth control is needed because she will be
action should take priority? infertile.
1. Pad the patient’s side rails.
2. Assess the patient’s pain level.
3. Teach the patient what to expect during radiation
treatments.
4. Place the patient in isolation.
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Nursing Care of Patients

With Cerebrovascular
Disorders
49
VOCABULARY
Match the term with the correct definition.
1. Thrombotic 1. Difficulty swallowing
2. Aphasia 2. Deficient blood flow to organ or tissue
3. Dysphagia 3. Inability to speak or understand language
4. Hemianopsia 4. Vision lost in half of visual field
5. Flaccid 5. Without muscle tone
6. Ataxia 6. Imbalanced, staggering gait
7. Diplopia 7. Caused by a clot
8. Hemiplegia 8. Healthy tissue surrounding an infarct
9. Penumbra 9. Double vision
10. Ischemic 10. Paralyzed on one side of the body

DRUGS USED FOR CEREBROVASCULAR DISORDERS

Match the drug with its action.

1. Heparin 1. Anticoagulant
2. Clopidogrel (Plavix) 2. Cholesterol-lowering agent
3. Tissue plasminogen activator (tPA) 3. Antiplatelet
4. Simvastatin (Zocor) 4. Thrombolytic

CRITICAL THINKING: STROKE 1. Explain the pathophysiology of a CVA. Which type

of stroke is most likely the cause of Mrs. Saunders’s
Read the following case study and answer the questions.
symptoms?
Mrs. Saunders is a 70-year-old retired secretary admitted to
your unit from the emergency department with a diagnosis
of stroke (cerebrovascular accident, or CVA). She has a his-
tory of hypertension and atherosclerosis, and she had a
carotid endarterectomy 6 years ago. She is 40% over her ideal
body weight and has a 20-pack-year smoking history. Her 2. Mrs. Saunders is flaccid on her right side. What is the
daughter says her mother has been having short episodes of
term used to describe this?
confusion and memory loss for the past few weeks. This
morning she found her mother slumped to the right in her
recliner, unable to speak.

207
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208 UNIT ELEVEN Understanding the Neurologic System

3. Which hemisphere of Mrs. Saunders’ brain is damaged? 10. How will you protect Mrs. Saunders’s skin? List at
least three interventions.

4. List four risk factors for stroke evident in Mrs. Saunders’s

history. 11. As you enter Mrs. Saunders’s room on her third day on
your unit, you find her agitated, trying to speak, and
trying to get out of bed. List at least three ways to try to
find out what she wants.

5. Mrs. Saunders appears to understand when you speak to

her but is only able to speak in garbled words. What is
the term for this?
12. What should you do before feeding Mrs. Saunders for
the first time?

6. Neurologic checks are ordered every 2 hours for 4 hours,

then every 4 hours for 4 days. When you enter her room
and call her name, she opens her eyes. She is able to
squeeze your hand with her left hand. However, she is 13. Mrs. Saunders has some difficulty swallowing and pock-
only able to make incomprehensible sounds. What is her ets her food in her right cheek. List three interventions
score on the Glasgow Coma Scale? you can try.

7. List at least three early symptoms of increasing

intracranial pressure (ICP) for which you will be
vigilant. (You may want to refer back to Chapter 48.) 14. Mrs. Saunders begins to move her right hand slightly
and is able to say her daughter’s name when she enters
the room. She is prepared for discharge to a rehabilita-
tion facility. List three ways you can prepare her family
for her move and her eventual discharge home.

8. List two medications that the physician may order. Why

might they be used?

15. What class of drugs might be ordered for Mrs. Saunders

to prevent another stroke?
9. Identify a nursing diagnosis related to Mrs. Saunders’s
right-sided paralysis. List three interventions to prevent
complications.
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Chapter 49 Nursing Care of Patients With Cerebrovascular Disorders 209

REVIW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 2. A post–myocardial infarction (MI) patient experiencing
atrial fibrillation is most at risk for which type of stroke?
1. What is the term or acronym for a temporary impairment
1. Hemorrhagic stroke
of cerebral circulation that causes symptoms lasting min-
2. Embolic stroke
utes to hours but results in no permanent neurologic
3. Thrombotic stroke
changes?
4. Cerebral aneurysm
1. TIA
2. CVA
3. SAH
4. Stroke

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 6. A patient is unable to control his bowels after a subarach-
noid hemorrhage. Which intervention by the nurse can
3. A nurse approaches a hospitalized poststroke patient
help reduce episodes of bowel incontinence?
from the patient’s left side to provide morning care. The
1. Ask the patient frequently if he has to have a bowel
patient is staring straight ahead and does not respond to
movement.
the nurse’s presence or voice. Which action should the
2. Place incontinence pads on the patient’s bed and chair.
nurse take first?
3. Toilet the patient according to his preillness schedule,
1. Walk to the other side of the bed and try again.
whether or not he feels the urge.
2. Speak more loudly and clearly.
4. Take care not to embarrass the patient when inconti-
3. Wave his or her fingers in front of the patient’s face.
nent episodes occur.
4. Use a picture board to explain to the patient what the
nurse is going to do.
7. The nurse needs to administer aspirin 62 mg to a post-
stroke patient. It is supplied in 1-grain tablets. How
4. A 72-year-old man is admitted to a skilled care facility
many tablets should the nurse prepare?
following a stroke. When the nursing assistant is bathing
him, he makes a sexual remark and tries to touch her in-
8. A patient is hospitalized following a stroke. Three days
appropriately. The assistant finishes the bath, then tells
after admission, the patient is able to converse clearly
the licensed practical nurse (LPN) in charge, “I refuse to
with the nurse in the morning. Early in the afternoon, the
take care of that dirty old man!” Which response by the
patient’s daughter runs out of the room and says, “My
nurse is best?
mother can’t talk. Somebody help!” Which response by
1. “The next time he tries to touch you inappropriately,
the nurse is best?
lightly smack his hand and tell him NO!”
1. Explain to the daughter that this is not uncommon,
2. “His stroke has made him less inhibited. We’ll see if
especially in the afternoon when the patient is tired
we can find a male assistant to help him.”
from morning care activities.
3. “We have to take care of all patients equally, even the
2. Do a quick assessment to confirm the change in the
dirty old men.”
patient’s status, then notify the registered nurse (RN)
4. “He didn’t mean anything by it; just ignore it.”
or physician stat.
3. Call the speech therapist to come and do a compre-
5. A patient is having difficulty swallowing following a
hensive speech assessment.
stroke, and a swallowing evaluation is ordered. Which
4. Show the daughter how to help her mother do the
nursing interventions might be recommended to help
speech exercises that were provided by the therapist.
prevent aspiration during eating? Select all that apply.
1. Place the patient in a semi-Fowler’s position.
9. The nurse is caring for a patient recently admitted with
2. Encourage the use of a straw for liquids.
a CVA. The patient is experiencing nausea and begins
3. Provide clear liquids only until the patient can swallow
to vomit. Which of the following actions should the
solid foods.
nurse take first?
4. Have the patient swallow twice after each bite.
1. Call for an aide to get suction set up.
5. Place food on the unaffected side of the patient’s
2. Assist the patient to turn to his side.
mouth.
3. Give an antiemetic as ordered.
6. Check the patient’s mouth for pocketing of food.
4. Perform a test for blood on the emesis.
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210 UNIT ELEVEN Understanding the Neurologic System

10. The nurse is providing care for a patient with a hemor- 11. A 67-year-old gentleman being evaluated and treated in
rhagic stroke. Which of the following medication orders the emergency department for a CVA has clopidogrel
would the nurse question? Select all that apply. (Plavix) ordered per os (PO) now. Which of the follow-
1. Simvastatin (Zocor) ing would cause the nurse to hold the medication?
2. Clopidogrel (Plavix) Select all that apply.
3. Carbamazepine (Tegretol) 1. The patient has weak grip strength in the right hand
4. Tissue plasminogen activator (tPA) and strong in the left.
5. Metoprolol (Toprol) 2. The patient’s smile is crooked.
6. Warfarin (Coumadin) 3. The patient’s gag reflex is positive.
4. The patient’s voice sounds gurgly after taking a sip
of water.
5. The patient’s blood pressure is 168/90 mm Hg.
6. The patient has an allergy to aspirin.
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Nursing Care of Patients

With Peripheral Nervous
System Disorders
50
VOCABULARY
Fill in the blanks with the correct terms.
1. Muscles that are not used become wasted, or .
2. Some diseases are characterized by remissions and .
3. Nerve pain is also called .
4. An early symptom of myasthenia gravis is drooping eyelids, also called .
5. Symptoms of Guillain-Barré syndrome are caused by of axons.
6. Myasthenia gravis is sometimes treated with , which separates blood cells from
plasma to remove antibodies.
7. Muscle twitching, or , occur in amyotrophic lateral sclerosis.
8. Medications for myasthenia gravis that can increase acetylcholine at the neuromuscular junction are
called agents.

PERIPHERAL NERVOUS SYSTEM DISORDERS his left wrist. The physician orders a narcotic analgesic
because Mr. Newby’s third cranial nerve is inflamed.
Underline incorrect information in the following case stud-
ies. Write the correct information in the space provided. Once the acute pain has subsided, Mr. Newby is dis-
charged with instructions to get plenty of fresh air and
1. Ms. Mary Garvey sees her physician because she has
to take his gabapentin (Neurontin) as ordered.
been seeing double off and on for several weeks and has
been fatigued. Her physician suspects myasthenia gravis
and schedules her for a carotid ultrasound. He confirms
his suspicions with a Tensilon (edrophonium chloride) 3. Mrs. Mattie Schultz is admitted with exacerbated multi-
test. He explains to Ms. Garvey that she has a disease ple sclerosis (MS). Her legs are becoming weaker,
that is characterized by a decrease in the neurotransmit- causing difficulty walking, and she has been having dif-
ter norepinephrine. He begins her on Mastodon and ficulty swallowing. You know that build up of myelin on
prednisone. Her nurse teaches her the importance of her neurons is responsible for her weakness. You assess
getting regular exercise and recommends joining a local her for stressors that might have caused her exacerba-
health and exercise club. tion, such as a urinary tract infection (UTI) or upper
respiratory tract infection (URI). Mrs. Schultz is started
on thyroid-stimulating hormone (TSH) to stimulate her
2. Mr. Tom Newby has a history of trigeminal neuralgia. thyroid, which will help reduce her symptoms. She is
He enters the emergency department with severe pain in also placed on trimethoprim/sulfamethoxazole (Bactrim)

211
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212 UNIT THIRTEEN Understanding the Neurologic System

for the UTI you identified through your excellent assess- 3. Reverend Wilson is concerned about continuing in his
ment and on diazepam (Valium) for urinary retention. job and asks if his mind is going to be affected. How do
you respond?

4. He develops painful muscle spasms. What medications

CRITICAL THINKING might be ordered to help relieve them?
Read the following case study and answer the questions.
Reverend Wilson is a 50-year-old minister who sees his
physician when he develops weakness in his arms and legs
and has difficulty carrying out his job duties. He is diagnosed 5. Reverend Wilson stabilizes for a while. A year later, he
with amyotrophic lateral sclerosis (ALS). is admitted to the hospital with aspiration pneumonia.
What probably happened? What nursing diagnosis is ap-
1. Reverend Wilson’s wife asks what ALS is. How do you
propriate in this situation? List an appropriate goal and
describe it for her?
two or three interventions.

2. Reverend Wilson returns to the physician’s office sev-

eral months after his initial diagnosis because he fell
walking to the podium to preach. What is happening?
What can he do about it?
6. Reverend Wilson’s condition deteriorates, and he has to
retire. He becomes confined to a wheelchair. He has a
gastrostomy tube inserted because he is no longer able
to swallow. What additional nursing diagnoses are now
appropriate?

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 3. Which data collection activity will help the nurse deter-
mine if the patient with Bell’s palsy is receiving adequate
1. Which drug class is used to reduce symptoms of muscle
nutrition?
weakness from myasthenia gravis?
1. Monitor meal trays.
1. Anticholinesterase drugs
2. Measure intake and output.
2. Anticholinergic drugs
3. Check twice-weekly weights.
3. Adrenergic drugs
4. Evaluate swallowing reflex.
4. Beta-blocker drugs

2. Which of the following nursing interventions will help

prevent complications in the patient with Bell’s palsy?
1. Megavitamin therapy
2. Elastic bandages
3. Application of ice to the affected area
4. Lubricating eye drops
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Chapter 50 Nursing Care of Patients With Peripheral Nervous System Disorders 213

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 8. A patient who is newly diagnosed with MS asks what
medications are used to help control symptoms and
4. A 32-year-old patient is admitted to a medical unit with
treat the disease. Which of the following medications
a diagnosis of Guillain-Barré syndrome. The patient’s
would the nurse include in the teaching?
legs are weak, causing difficulty walking without assis-
1. Acyclovir (Zovirax)
tance. Which of the following is most likely responsible
2. Adrenocorticotropic hormone (ACTH)
for this syndrome?
3. Thyrotropin
1. Bacterial infection
4. Diphenhydramine (Benadryl)
2. Heredity
3. High-fat diet
9. A home care nurse is developing a plan of care designed
4. Autoimmune reaction
to prevent complications in a patient with impaired res-
piratory function secondary to a neurological disorder.
5. Patients with Guillain-Barré syndrome should be closely
Which of the following would the nurse include in the
monitored. Which of the following lab results is most
plan?
important to monitor for acute complications?
1. Antibiotics as needed
1. Blood urea nitrogen (BUN) and creatinine
2. Elevate the head of the bed
2. Arterial blood gases (ABG)
3. Bedrest
3. Hemoglobin (Hgb) and hematocrit (Hct)
4. Suction every 4 hours
4. Serum potassium
10. A nurse is preparing an intramuscular injection of pred-
6. A woman sees her primary care provider because of
nisolone acetate, 30 mg. It is supplied as 50 mg/mL.
extreme fatigue for the past 2 months; she has difficulty
How many milliliters should the nurse prepare?
lifting even light objects. Her physician suspects myas-
thenia gravis. Which of the following tests should the
nurse anticipate assisting with to confirm this diagnosis?
11. The nurse notes frequent muscle twitching when
1. Mestinon test
collecting admission data on a patient admitted for
2. Quinine tolerance test
increasing muscle weakness. Which of the following
3. Pulmonary function studies
terms should be used to document this?
4. Tensilon test
1. Fasciculations
2. Atrophy
7. A 39-year-old patient sees the physician after falling
3. Chorea
twice for seemingly no reason. Diagnostic tests are
4. Neuropathy
done, and the patient is diagnosed with MS. Which
of the following explanations will help the patient
12. A 19-year-old student develops trigeminal neuralgia.
understand the disease?
Which of the following actions is most likely to trigger
1. “You have a buildup of myelin in your nervous
pain?
system, causing congestion and muscle weakness.”
1. Sleeping
2. “You are missing a neurotransmitter that is important
2. Eating
to muscle contraction.”
3. Reading
3. “The receptor sites on your muscles are damaged,
4. Cooking
so they can’t contract correctly.”
4. “The insulation on your nerve cells is damaged,
which slows the impulses to the muscles.”
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4069_Ch51_215-220 26/11/14 1:27 PM Page 215

unit FOURTEEN

Understanding the
Sensory System
CHECKLIST FOR LEARNING SUCCESS
Review of Anatomy
and Physiology
and Aging Changes Major Disorders Nursing Assessment Diagnostic Tests Interventions Common Medications
❑ Eye structures ❑ Vision: ❑ Medical history ❑ Vision: ❑ Vision: ❑ Vision:
❑ Eye function ❑ Eye infections/ ❑ Psychosocial history ❑ Amsler grid ❑ Corrective eyewear ❑ Cycloplegics
❑ Ear structures inflammation ❑ Medications ❑ Angiography ❑ Trabeculoplasty ❑ Cholinergics
❑ Ear function ❑ Refractive errors ❑ Physical examination ❑ Digital imaging ❑ Trabeculectomy (miotics)
❑ Aging effects ❑ Blindness ❑ Vision: ❑ Intraocular pressure ❑ Cyclocryotherapy ❑ Acetazolamide
❑ Diabetic retinopathy ❑ Pupillary reflexes ❑ Ophthalmoscopy ❑ Iridotomy/ (Diamox)
❑ Retinal detachment ❑ Accommodation ❑ Slit lamp iridectomy ❑ Timolol (Timoptic)
❑ Glaucoma ❑ Romberg’s test ❑ Visual acuity ❑ Scleral buckling ❑ Hearing:
❑ Cataracts ❑ Hearing: ❑ Hearing: ❑ Supportive services ❑ Cerumenolytics
❑ Macular ❑ Rinne test ❑ Audiometric ❑ Postoperative eye
degeneration ❑ Weber test ❑ Caloric test care
❑ Hearing: ❑ Otoscopic ❑ Irrigation
❑ Hearing loss ❑ Tympanometry ❑ Hearing:
❑ Infection ❑ Hearing aids
❑ Otosclerosis ❑ Myringotomy
❑ Ménière’s disease ❑ Stapedectomy
❑ Postoperative
ear care
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Sensory System Function,

51 Assessment, and
Therapeutic Measures:
Vision and Hearing
STRUCTURES OF THE EYE
Label the following structures.
Anterior chamber Fovea Pupil
Aqueous humor Inferior rectus muscle Retina
Canal of Schlemm Iris Retinal artery and vein
Choroid layer Lens Sclera
Ciliary body Optic disc Superior rectus muscle
Conjunctiva Optic nerve Suspensory ligaments
Cornea Posterior chamber Vitreous humor

216
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Chapter 51 Sensory System Function, Assessment, and Therapeutic Measures: Vision and Hearing 217

STRUCTURES OF THE EAR

Label the following structures.
Auricle Incus
Cochlea Malleus
Ear canal Semicircular canals
Eighth cranial nerve Stapes
Eustachian tube Tympanic membrane (eardrum)

VISION
Number the following in the proper sequence as they are involved in the process of producing a visual image from the
beginning to end.

Cornea Occipital lobe

Vitreous humor Lens
Optic nerve Retina
Aqueous humor

HEARING
Number the following in the order they function in the process of hearing when sound waves enter the ear canal.

Eardrum Stapes
Oval window Fluid in the cochlea
Incus Hair cells in the organ of Corti
Eighth cranial nerve Temporal lobes
Malleus
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218 UNIT FOURTEEN Understanding the Sensory System

VOCABULARY
Define the following terms and use them in a sentence.
Nystagmus
Definition:
Sentence:

Tropia
Definition:
Sentence:

Accommodation
Definition:
Sentence:

Ptosis
Definition:
Sentence:

Arcus senilis
Definition:
Sentence:

Ophthalmologist
Definition:
Sentence:

Optometrist
Definition:
Sentence:

Optician
Definition:
Sentence:
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Chapter 51 Sensory System Function, Assessment, and Therapeutic Measures: Vision and Hearing 219

DIAGNOSTIC TESTS
Fill in the table.
Assessment Test Purpose of Test Normal Test Results
Snellen chart OD 20/20, OS 20/20, OU 20/20
Visual fields
Cardinal fields of gaze Extraocular movement
Accommodation Eyes turn inward and pupils constrict
when focusing on a near object.
Rinne Air conduction greater than bone conduction.
Weber
Romberg’s Balance/vestibular function

CRITICAL THINKING
Read the following case study and answer the questions.
Ms. Sally Litley works on a computer as a data processor. She reports that she has recurring eye discomfort about 2 hours
after she begins work each day.
1. What might the nurse suspect is occurring with Ms. Litley?

2. For what environmental factors should the nurse gather data?

3. To protect Ms. Litley from eye strain, what safety measures should be implemented in her office?

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 4. Which of the following tests would the nurse use as an
initial screening test to determine hearing loss?
1. Which of the following, if documented in the patient’s
1. Romberg’s test
history, would indicate that the patient has a normal
2. Otoscopic examination
corneal light reflex?
3. Caloric test
1. The eye focuses the image in the center of the pupil.
4. Whisper voice test
2. The eyes converge to focus on the light.
3. Constriction of both pupils occurs in response to
5. Which of the following would the nurse use to document
bright light.
a finding that the patient’s ear is draining?
4. Light is reflected at the same spot in both eyes.
1. Otorrhea
2. Otalgia
2. When testing visual fields, the nurse examines which of
3. Ototoxic
the following parts of vision?
4. Tinnitus
1. Peripheral vision
2. Near vision
6. The nurse is reading the patient’s medical history.
3. Distance vision
Which of the following terms indicates that the patient
4. Central vision
has a hearing loss caused by aging?
1. Otoplasty
3. Which of the following terms would indicate to the
2. Otalgia
nurse that a substance is toxic to the ear?
3. Presbycusis
1. Otoplasty
4. Tinnitus
2. Otalgia
3. Ototoxic
4. Tinnitus
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220 UNIT FOURTEEN Understanding the Sensory System

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 12. Which of the following statements would the nurse un-
derstand is true when checking normal auditory acuity
7. Which of the following explanations would the nurse
using the Rinne test?
give to the patient who had a Snellen chart finding of
1. The patient perceives sound equally in both ears.
20/80?
2. Air conduction is heard longer than bone conduction
1. “You can see at 80 feet what those with normal
in both ears.
vision can see at 20 feet.”
3. Bone conduction is heard longer than air conduction
2. “You can see at 20 feet what those with normal
in both ears.
vision can see at 80 feet.”
4. The patient’s left ear will perceive the sound better
3. “You can see four times farther than those with
than the right ear.
normal vision can see.”
4. “Your vision is normal.”
13. Which of the following subjective data questions
would assist the nurse in assessing the patient’s eye
8. The examiner shines a light in the patient’s eyes and
health?
notes that the pupils are round and constrict from 4 to
1. “Have you had any recent upper respiratory
2 mm bilaterally. Next, the examiner asks the patient to
infections?”
focus on a far object, then on the examiner’s finger as
2. “Have you ridden in a car recently?”
it is brought from a distance of 3 feet to 5 inches. The
3. “Have you been scuba diving lately?”
pupils constrict bilaterally and the eyes turn inward.
4. “Have you seen halos around lights?”
Which of the following would be the correct documen-
tation of these findings?
14. When assessing the external ear, the nurse palpates a
1. Pupils 2 mm.
small protrusion of the helix called a Darwin tubercle.
2. Pupils constricted.
The nurse would document this finding as which of the
3. Pupils equal, round, and reactive to light and
following?
accommodation (PERRLA).
1. A normal finding
4. Pupils normal.
2. An abnormal finding
3. A normal finding only in the older adult
9. In planning safe care for the older adult, which of the
4. An abnormal finding only in the older adult
following conditions does the nurse recognize would
cause visual problems? Select all that apply.
1. Glaucoma
2. Cataracts
3. Arcus senilis
4. Macular degeneration
5. Esotropia
6. Presbycusis

10. Which of the following statements does the nurse

understand is true concerning air conduction of sound
in the ear?
1. It is caused by the vibration of bones in the skull.
2. It is less efficient than bone conduction.
3. It is heard longer than bone conduction.
4. It is caused by transmission of heat through the air.

11. Which of the following data collection findings could

indicate to the nurse that the patient has a hearing loss?
Select all that apply.
1. Patient converses easily with nurse.
2. Patient answers questions appropriately.
3. Patient’s face is relaxed during conversation.
4. Patient speaks in a very loud voice.
5. Patient turns toward person speaking.
6. Patient is withdrawn.
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Nursing Care of Patients

With Sensory Disorders:
Vision and Hearing
52
VOCABULARY
Match the following terms with their appropriate definitions.
1. Carbuncle 1. Hearing loss caused by aging
2. Cholesteatoma 2. Inflammation or infection of the inner ear
3. Mastoiditis 3. Complication of otitis media
4. Barotrauma 4. Epithelial cystlike sac filled with skin and
5. Labyrinthitis sebaceous material
6. Presbycusis 5. Several hair follicles forming an abscess
6. Pressure in the middle ear caused by atmospheric
changes

ERRORS OF REFRACTION
Draw pictures showing the eye size and focal point differences in (a) hyperopia and (b) myopia.

221
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222 UNIT FOURTEEN Understanding the Sensory System

PRESBYOPIA CONDUCTIVE HEARING LOSS

Circle the seven errors in the following paragraph and insert Circle the six errors in the following paragraph and insert
the correct information. the correct information.

Presbyopia is a condition in which the lenses increase their Conductive hearing loss is interference with conduction of
elasticity resulting in a decrease in ability to focus on far ob- light waves through the external auditory canal, eardrum, or
jects. The loss of elasticity causes light rays to focus in front middle ear. The inner ear is involved in a pure conductive
of the retina, resulting in hyperopia. This condition is usually hearing loss. Conductive hearing loss is a neural problem.
associated with aging and generally occurs before age 40. Be- Causes of conductive hearing loss include cerumen, foreign
cause accommodation for close vision is accomplished by lens bodies, infection, perforation of the tympanic membrane,
contraction, people with presbyopia exhibit the ability to see trauma, fluid in the middle ear, cysts, tumor, and otosclerosis.
objects at close range. They often compensate for blurred Many causes of conductive hearing loss, such as infection,
close vision by holding objects to be viewed closer. Com- foreign bodies, or impacted cerumen, cannot be corrected.
plaints of eye strain and mild occipital headache are common. Hearing devices may not improve hearing for conditions that
cannot be corrected. Hearing devices are most effective with
VISUAL AND HEARING DATA COLLECTION conductive hearing loss when inner ear and nerve damage are
present.
Describe how the nurse would know that a patient has the
following condition based on data collection (include diag-
OTOSCLEROSIS
nostic tests and examinations).
Circle the nine errors in the following paragraph and insert
Macular degeneration (dry type)
the correct information.

Otosclerosis results from the formation of new bone along

Cataract the incus. With new bone growth, the incus becomes mobile
and causes conductive hearing loss. Hearing loss is most ap-
parent after the sixth decade. Otosclerosis usually occurs less
frequently in women than in men. The disease usually affects
Hordeolum
one ear. It is thought to be a hereditary disease. The primary
symptom of otosclerosis is rapid hearing loss. The patient
usually experiences bilateral conductive hearing loss, par-
Acute angle-closure glaucoma ticularly with soft, high tones. Otectomy is the treatment of
choice.

External otitis
CRITICAL THINKING
Read the following case study and answer the questions.
Mr. Nyugen, age 70, reports that he has difficulty seeing at
Impacted cerumen night, and has given up driving. When questioned further, he
also states, “I used to be an avid reader, but I guess I’m get-
ting too old to read. The words aren’t very clear.” The nurse
examines his eye and finds that he is sensitive to light, has
Otitis media
opacity of both lenses, and denies any pain.

1. What might the nurse suspect is occurring with

Otosclerosis
Mr. Nyugen?

GLAUCOMA
Circle the seven errors in the following paragraph and in-
sert the correct information.
Glaucoma may be characterized by abnormal pressure out- 2. For which diagnostic tests should the nurse prepare
side the eyeball. This pressure causes damage to the cells of Mr. Nyugen?
the acoustic nerve, the structure responsible for transmitting
visual information from the ear to the brain. The damage is
evident, progressive, and reversible until the end stage, when
loss of central vision occurs and eventually blindness. Once
glaucoma occurs, the patient can be cured.
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Chapter 52 Nursing Care of Patients With Sensory Disorders: Vision and Hearing 223

3. After the physician has made a definitive diagnosis,

Mr. Nyugen asks the nurse to explain the surgical proce-
dure for cataracts and the recovery regimen to him. Out-
line a teaching plan.

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 4. Which of the following types of hearing loss does the
nurse understand is most improved with the use of a
1. Which of the following type of eyedrops is given to
hearing aid?
constrict the pupil, permitting aqueous humor to flow
1. Conductive
around the lens?
2. Sensorineural
1. Osmotic
3. Mixed
2. Myotic
4. Central
3. Mydriatic
4. Cycloplegic
5. Which of the following would the nurse teach the
patient is the most common site for ear infections?
2. Which of the following procedures does the nurse
1. Outer ear
understand is used to correct otosclerosis?
2. Inner ear
1. Myringotomy
3. Middle ear
2. Myringoplasty
4. Semicircular canal
3. Mastoidectomy
4. Stapedectomy

3. The nurse understands that labyrinthitis is treated

primarily with which of the following drug categories?
1. Antihistamines
2. Antispasmodics
3. Anti-inflammatories
4. Antiemetics

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 7. The nurse is caring for a patient after cataract surgery.
Which of the following safety instructions should the
6. The nurse is assisting with data collection for a patient
nurse give this patient? Select all that apply.
with macular degeneration. Which of the following
1. Elevate the head of your bed 45 degrees.
symptoms would the nurse expect to be present?
2. Do not drive until after your follow-up appointment.
Select all that apply.
3. Wear sunglasses.
1. Decreased ability to distinguish colors
4. Avoid caffeinated beverages.
2. Sudden loss of vision
5. Avoid straining.
3. Loss of near vision
4. Loss of central vision
8. The nurse is assisting a patient who has recently
5. Loss of peripheral vision
received a hearing aid. Which of the following would
6. Increased periodic dizziness
the nurse include in the teaching?
1. “This device will amplify background noise so you
can hear more clearly.”
2. “This occludes the ear to increase the transport of
sound to nerve endings.”
3. “A hearing aid is used to amplify musical sounds.”
4. “The hearing aid improves your ability to hear.”
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224 UNIT FOURTEEN Understanding the Sensory System

9. The nurse is reinforcing teaching for a patient with 13. The nurse is caring for a patient after eye surgery.
Ménière’s disease. Which of the following would the Which of the following nursing interventions would
nurse explain to the patient is the triad of symptoms have the highest priority in the plan of care for the
associated with Ménière’s disease? postoperative eye patient?
1. Hearing loss, vertigo, and tinnitus 1. Do not leave the patient unattended at any time.
2. Nystagmus, headache, and vomiting 2. Teach the patient not to bend over.
3. Nausea, vomiting, and pain 3. Report sudden onset of acute pain.
4. Nystagmus, vomiting, and pain 4. Apply sandbags to either side of the head.

10. The nurse is assisting with the plan of care for a patient 14. The nurse is caring for a patient with newly diagnosed
with vertigo. Which of the following actions would the glaucoma. Which of the following descriptions by the
nurse include in the plan of care to reduce the symptoms nurse would best explain glaucoma to the patient?
of the patient who has vertigo? 1. “There is an increase in the amount of vitreous
1. Avoid noises. humor.”
2. Avoid sudden movements. 2. “There is an increase in the intraocular pressure.”
3. Encourage fluid intake. 3. “There is a decrease in the amount of aqueous
4. Administer analgesics. humor.”
4. “There is a decrease in the intraocular pressure.”
11. The nurse is caring for a patient diagnosed with acute
bacterial conjunctivitis. In providing patient teaching, 15. The nurse is caring for a patient with acute angle-
the nurse would tell the patient that this condition is closure glaucoma. Which of the following symptoms
more commonly known as which of the following? would the nurse expect to find during data collection
1. Glaucoma for this patient?
2. Astigmatism 1. Flashing lights
3. Color blindness 2. Lens opacity
4. Pinkeye 3. Halos around lights
4. Vertigo
12. The nurse is collecting data on a patient with a cataract.
Which of the following is usually the first symptom 16. The nurse is caring for a patient after eye surgery.
of a cataract that the nurse would expect a patient to Which of the following activities would the nurse
report? teach a patient to avoid so that intraocular pressure is
1. Dry eyes not increased after eye surgery?
2. Eye pain 1. Sitting upright in bed
3. Blurring of vision 2. Coughing
4. Loss of peripheral vision 3. Chewing food vigorously
4. Reading a book
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unit FIFTEEN

Understanding the
Integumentary
System
CHECKLIST FOR LEARNING SUCCESS
Review of Anatomy
and Physiology
and Aging Changes Major Disorders Nursing Assessment Diagnostic Tests Interventions Common Medications
❑ Epidermis ❑ Pressure ulcers ❑ History ❑ Cultures ❑ Debridement ❑ Antibiotics
❑ Dermis ❑ Dermatitis ❑ Color ❑ Biopsy ❑ Balneotherapy ❑ Antivirals
❑ Appendages ❑ Psoriasis ❑ Lesions ❑ Wood’s light ❑ Topical medications ❑ Corticosteroids
❑ Subcutaneous tissue ❑ Herpes simplex ❑ Moisture ❑ Skin tests ❑ Dressings ❑ Analgesics
❑ Aging changes ❑ Herpes zoster ❑ Edema ❑ Negative pressure ❑ Chemotherapy
❑ Fungal infections ❑ Vascular markings wound therapy
❑ Cellulitis ❑ Integrity ❑ Plastic surgery
❑ Acne ❑ Cleanliness ❑ Burn care
❑ Parasites ❑ Pressure ulcer risk
❑ Pemphigus assessment (Braden
❑ Malignant lesions scale) and staging
❑ Burns ❑ Burn assessment
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Integumentary System
53 Function, Assessment, and
Therapeutic Measures

INTEGUMENTARY STRUCTURES
Match each integumentary structure with its appropriate description.
1. Epidermis 1. If unbroken, prevents entry of pathogens
2. Dermis 2. Give strength to the dermis
3. Subcutaneous tissue 3. Detect changes in the external environment
4. Collagen fibers 4. Contains the accessory structures of the skin,
5. Eccrine glands such as glands
6. Receptors 5. Made of both living and nonliving cells
7. Melanin 6. Mitosis takes place to produce new epidermis
8. Stratum corneum 7. Stores fat
9. Stratum germinativum 8. Acts as a barrier to ultraviolet (UV) light
9. Stimulated by exercise or heat

VOCABULARY
Match the word at the right with its definition at the left.

1. Absence or loss of hair 1. Ecchymosis

2. Blue-black bruise, changing to greenish-brown 2. Erythema
or yellow with time 3. Petechiae
3. Diffuse redness over the skin 4. Turgor
4. Small, purplish, hemorrhagic spots on the skin 5. Alopecia
5. Measure of skin elasticity and hydration

DIAGNOSTIC SKIN TESTS

Match the test with its definition.

1. Skin biopsy 1. Superficial testing with allergen for immediate reaction

2. Wood’s light examination 2. Excision of small piece of tissue for microscopic assessment
3. Scratch test 3. Superficial testing with allergen for delayed hypersensitivity reaction
4. Patch test 4. Use of UV rays to detect fluorescent materials in skin and hair

226
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Chapter 53 Integumentary System Function, Assessment, and Therapeutic Measures 227

PRIMARY SKIN LESIONS

Match the lesion with its description.

1. Macule 1. Vesicle or blister larger than 1 cm

2. Papule 2. Flat, nonpalpable change in skin color
3. Vesicle 3. Round, transient elevation of the skin caused by dermal edema and surrounding
4. Bulla capillary dilation
5. Pustule 4. Patch or solid, raised lesion on the skin or mucous membrane that is greater than 1 cm
6. Wheal 5. Palpable solid raised lesion
7. Plaque 6. Small elevation of skin or vesicle or bulla that contains pus
8. Cyst 7. Closed sac or pouch tumor that consists of semisolid, solid, or liquid material
8. Small raised area that contains serous fluid, less than 1 cm

CRITICAL THINKING
Read the following case study and answer the questions.
Mr. Carr is admitted to a medical unit after having a hemorrhagic stroke. His vital signs are stable, but he is disoriented except
to person. He is on bed rest and is often restless. He responds appropriately to questions intermittently. His left side is flaccid,
but he can move his right side. The nurse notes that Mr. Carr rarely moves himself into a different position. He is of thin build.
He is receiving 5% dextrose/0.9% normal saline intravenously. He has difficulty swallowing and has not eaten. Mr. Carr is
diaphoretic and his gown is damp.
1. Why is Mr. Carr at high risk for developing pressure ulcers?

2. What are priority nursing diagnoses and nursing interventions for Mr. Carr related to his skin needs?

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 3. Which substances are formed when the UV rays of the
sun strike the skin?
1. How do arterioles in the dermis respond to a cold
1. Vitamin A and keratin
environment?
2. Melanin and vitamin D
1. Dilate to release heat
3. Sebum and vitamin A
2. Constrict to release heat
4. Keratin and melanin
3. Dilate to conserve heat
4. Constrict to conserve heat

2. Which of the following tissues stores fat in subcutaneous

tissue?
1. Fibrous connective tissue
2. Stratified squamous epithelium
3. Adipose tissue
4. Areolar connective tissue
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228 UNIT FIFTEEN Understanding the Integumentary System

4. Which layer of skin, if unbroken, prevents the entry of 5. White blood cells, which destroy pathogens that enter
most pathogens? breaks in the skin, are found in which of the following
1. Stratum corneum structures?
2. Papillary layer 1. Stratum corneum
3. Stratum germinativum 2. Keratinized layer
4. Dermis 3. Subcutaneous tissue
4. Adipose cells

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 9. Which of the following dressing types is most appro-
priate for the nurse to apply to a skin tear in an older
6. The nurse is reviewing a patient chart and notes the
adult patient?
following: “poor elasticity and dry thin skin noted.”
1. Moist sterile gauze
The nurse recognizes this is a normal finding for which
2. OpSite transparent dressing
of the following patient groups?
3. Paste
1. Adolescents
4. Nonadherent dressing
2. Young adults
3. Middle-aged adults
10. Which of the following actions should the nurse take
4. Older adults
when new petechiae are observed on a patient’s skin?
1. Cleanse the skin.
7. When assessing a patient in hospice who is near death,
2. Apply cool compresses.
the nurse notes a bluish discoloration and mottled
3. Inform the registered nurse or physician.
appearance to the patient’s feet and lower legs. Which
4. Apply heat to the area.
of the following terms would the nurse use to best
document this finding?
11. A nurse is preparing to collect a wound culture. Which
1. Cyanosis
of the following would be included in the collection
2. Erythema
process? Select all that apply.
3. Jaundice
1. Swab wound and wound edges in a rotating motion.
4. Pallor
2. Swab over areas of eschar.
3. Use sterile saline to remove excess debris before
8. A nurse is providing care for an older adult patient who
culture.
reports being sensitive to cold temperatures. The nurse
4. Use clean cotton-tipped swab to collect purulent
would base teaching on which of the following principles?
drainage.
1. There is slower cell division in the epidermis with
5. Swab wound 10 times in a diagonal pattern.
aging.
6. Obtain sterile calcium alginate swab for culture
2. Older adults experience deterioration of collagen and
collection.
elastin fibers.
3. There is less fat in the subcutaneous layer with age.
4. Death of melanocytes in the skin occurs with age.
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Nursing Care of Patients

With Skin Disorders 54
VOCABULARY
Match the word with its definition.
1. To lose color 1. Seborrhea
2. Inflammation of cellular or connective tissue 2. Pyoderma
3. Skin lesion that occurs in acne vulgaris 3. Purulent
4. Inflammation of the skin 4. Psoriasis
5. A fungal infection of the skin 5. Pruritus
6. The growth of skin over a wound 6. Pemphigus
7. Thickened or hardened from continued irritation 7. Pediculosis
8. Disease of the nails due to fungus 8. Onychomycosis
9. Infestation with lice 9. Lichenified
10. Acute or chronic serious skin disease characterized by bullae on 10. Epithelialization
skin and mucous membranes 11. Dermatophytosis
11. Severe itching 12. Dermatitis
12. Chronic inflammatory skin disorder in which epidermal cells pro- 13. Comedo
liferate abnormally quickly 14. Cellulitis
13. Describes fluid that contains pus 15. Blanch
14. Any acute, inflammatory, purulent bacterial dermatitis
15. Disease of the sebaceous glands marked by increase in the
amount, and often alteration of the quality, of sebaceous secretion

BENIGN SKIN LESIONS

Match the lesion with its definition.

1. Cyst 1. Small, common growths caused by a virus

2. Seborrheic keratosis 2. Vascular tumors of dilated blood vessels
3. Keloid 3. Saclike growth with a definite wall
4. Pigmented nevi 4. Excessive scar formation at site of trauma or surgical incision
5. Warts 5. Light brown to dark brown patches, plaques, or papules that occur
6. Hemangiomas mainly in older patients
6. Flesh-colored to dark brown macule or papule

229
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230 UNIT FIFTEEN Understanding the Integumentary System

PLASTIC SURGERY PROCEDURES 1. Why did these areas develop?

Fill in the blanks.

1. A is done to correct nasal shape or
septal defects.
2. To plan Mrs. Miller’s care, how would you stage these
2. A is referred to as a rhytidoplasty.
3. Removal of bags under the eyes is known as . lesions?

CRITICAL THINKING
Read the following case study and answer the questions.
The surgeon is notified of these areas and orders turning
Mrs. Miller, age 59, is admitted for a femoral-popliteal by-
every 2 hours, elevation of the right foot, and a special
pass graft. She has type 2 diabetes mellitus. After surgery,
pressure-reducing bed.
she is in the intensive care unit (ICU) and is hypotensive for
24 hours. Her operative leg is painful and she barely moves.
During her bath, the nurse notes a shallow, open, reddened 3. What is the benefit and effectiveness of each of these
area 2 inches in diameter on her sacral area and a large tender ordered interventions?
purple area with intact skin on the heel of her right foot.

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 2. Which of the following dressings should a nurse choose
for a deep pressure ulcer that has purulent drainage?
1. Which of the following activities creates a mechanical
1. Sterile gauze
force that can lead to the formation of a pressure ulcer?
2. Transparent film (OpSite)
1. Massaging nonreddened areas
3. Hydrocolloid (DuoDERM)
2. Whirlpool baths
4. Occlusive
3. Pulling a patient up in bed
4. Range-of-motion exercises

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 5. The nurse is providing care for a patient with a non-
3. A nurse is caring for a nursing home resident with a red, infected pressure ulcer. Which of the following actions
pruritic skin rash. The patient is confused and scratches is most appropriate?
the rash, which results in broken skin. Which interven- 1. Flushing the wound with 45-psi pressure
tions will help the rash heal? Select all that apply. 2. Gentle flushing with a needleless 30-mL syringe
1. Pat the skin dry after bathing. 3. Gentle scrubbing with gauze and normal saline
2. Leave topical agent as ordered at the bedside so the 4. Flushing with a 30-mL syringe with an 18-gauge
patient can apply when itching is severe. needle
3. Place a transparent dressing on the rash to prevent
scratching. 6. A 62-year-old woman is admitted to the hospital with a
4. Place gloves or mitts on the patient. lesion on her face that is a small, pearly papule. It has a
5. Keep the patient’s fingernails short. rolled, waxy edge with crusting and ulceration. Which
6. Place wrist restraints on the patient during the night. action by the nurse is best?
1. Notify the physician.
4. A patient has a wound draining moderate blood-tinged 2. Clean the lesion.
clear fluid. Which of the following would be an appropri- 3. Place a gauze dressing on the lesion.
ate description of this drainage for the nurse to document? 4. Place an occlusive dressing on the lesion.
1. Purulent drainage
2. Serosanguineous drainage
3. Copious drainage
4. Serous drainage
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Chapter 54 Nursing Care of Patients With Skin Disorders 231

7. Place the wounds in correct order from stage I to stage IV. 9. The nurse recognizes that which of the following indi-
1. Skin appears abraded viduals should be evaluated for a specialty bed that
2. Skin red, intact, nonblanchable provides a pressure-relieving surface?
3. Full-thickness skin loss, muscle and bone showing 1. A 46-year-old with scoliosis who has a urinary tract
4. Full-thickness skin loss, no muscle or bone involvement infection
2. A 94-year-old with a Braden score of 15 and left arm
8. A 92-year-old woman is admitted from a nursing home weakness from a cardiovascular accident (CVA)
to the hospital for a colon resection. Four days postoper- 3. An 88-year-old with foot drop who has a Foley
atively, she reports that her perineum is sore. It is red- catheter
dened and has whitish discharge. She has been on three 4. A 15-year-old with a Braden score of 9 who experi-
intravenous (IV) antibiotics. Which of the following ences pain with turning
problems does the nurse suspect?
1. Candidiasis
2. Psoriasis
3. Herpes zoster
4. Contact dermatitis
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Nursing Care of Patients

55 With Burns

VOCABULARY
Match each phrase with the type of burn or burn term.
1. Leathery skin, usually painless 1. Débridement
2. Pink to red moist skin, blisters may be present 2. Eschar
3. The growth of skin over a wound 3. Epithelialization
4. Removal of a slough or scab formed on skin and under- 4. Superficial burn
lying tissue of severely burned skin 5. Partial-thickness deep burn
5. Epidermis and dermis involved, pain from exposed 6. Full-thickness burn
nerve endings
6. Hard scab or dry crust from necrotic tissue

CRITICAL THINKING
Read the following case study and answer the questions.
Mr. Patel is a 45-year-old patient in County General Hospital’s Burn Unit. He was admitted with a 20% electrical burn over
his right arm, right shoulder, right leg, and right foot. The entry wound is on his right shoulder and the exit wound is on his
right foot. When you check on him at the beginning of your shift, you find his right radial pulse is diminished and his right
forearm has a small spot that is beginning to change color to a whitish gray.

1. What might be causing his change in circulation?

2. What additional data should you collect?

3. What interventions are important to perform right away?

232
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Chapter 55 Nursing Care of Patients With Burns 233

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 2. Which type of burn is caused by a hot liquid?
1. Radiation
1. Which cause of or type of burn is commonly associated
2. Contact
with an inhalation injury?
3. Scald
1. Electrical
4. Chemical
2. Flame
3. Scald
4. Contact

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 7. A homebound patient is receiving intravenous (IV) an-
tibiotics for an infected burn site. Instructions are to use
3. During morning report, a nurse is assigned a patient
gravity to infuse 100 mL over 1 hour. How many drops
who is in stage III burn care. What care can the nurse
per minute should the nurse administer if the tubing has
anticipate providing during the shift?
a drip factor of 15?
1. Dressing changes
2. Débridement
8. A nurse is providing care for a patient with burns across
3. Pain management
30% of the body. Which of the following observations
4. Exercises
would cause the nurse to contact the registered nurse
(RN) or physician?
4. A patient is brought to the emergency department with
1. Urinary output of 50 mL in the past 2 hours
burns over 40% of the body from an apartment fire.
2. Patient reports pain of 6/10; oral narcotic is due in
Which assessment should take priority?
10 minutes
1. Burn depth
3. Respiratory rate is 20 and oxygen saturation is 94%
2. Percent of body surface burned
4. Blood sugar is 175 mg/dL
3. Respiratory status
4. Circulatory status
9. While caring for a 28-year-old patient newly admitted
for burns received in a household fire, the nurse would
5. A home care nurse visits an 82-year-old patient. On
be most concerned by which of the following?
entering the home, the nurse finds that the patient has
1. Hematocrit = 48%
just dropped a pot of boiling water on both legs. What
2. Blood pressure = 92/40 mm Hg
action should the nurse take first?
3. Pulse = 96 beats per minute
1. Call 911.
4. Respiratory rate = 22 per minute
2. Remove the clothing from the affected area.
3. Place ice on the affected area.
4. Assess the extent of the burn.

6. A patient has a burn encircling the left thigh from a mo-

torcycle accident. When the nurse enters the room dur-
ing rounds, the patient appears very anxious and reports
a funny feeling in the left foot. What should the nurse
do first?
1. Check circulatory status in the foot and report
changes.
2. Explain that some numbness and tingling in the
affected extremity are normal following a burn.
3. Check the burn dressing for an increase in drainage.
4. Determine the cause of the patient’s anxiety.
4069_Ch55_232-234 24/11/14 4:08 PM Page 234
4069_Ch56_235-238 24/11/14 4:08 PM Page 235

unit SIXTEEN

Understanding
Mental Health Care
CHECKLIST FOR LEARNING SUCCESS
Review of Basic
Concepts Major Disorders Nursing Assessment Diagnostic Tests Interventions Common Medications
❑ Mental health ❑ Anxiety disorders ❑ Appearance and ❑ DSM-5 ❑ Therapeutic ❑ Antipsychotics
❑ Mental illness ❑ Mood disorders behavior ❑ Laboratory tests communication ❑ Antidepressants
❑ Etiologies of mental ❑ Somatoform disorders ❑ Awareness and ❑ Computed tomographic ❑ Milieu therapy ❑ Antianxiety agents
illness ❑ Schizophrenia orientation (CT) scan ❑ Psychopharmacology ❑ Anticonvulsant mood
❑ Spirituality and ❑ Substance abuse ❑ Thinking ❑ Positron emission ❑ Psychotherapies stabilizers
religion disorders ❑ Memory therapy (PET) scan ❑ Cognitive therapies ❑ Lithium
❑ Coping ❑ Speech ❑ Counseling ❑ Antiparkinsonism agents
❑ Mood and affect ❑ Group therapy
❑ Judgment ❑ Electroconvulsive
❑ Perception therapy (ECT)
❑ Relaxation therapy
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Mental Health Function,

56 Assessment, and
Therapeutic Measures

VOCABULARY
Fill in the blanks with the correct terms.
1. is the way one adapts to a stressor.
2. The ability to think rationally and process thoughts is referred to as ability.
3. is the use of medication to treat psychological disorders.
4. therapy uses an electric current to stimulate neurotransmitters in severely depressed
patients.
5. A therapeutic is a structured environment that aids in treatment of mental health
disorders.
6. Psychoanalytic therapy can help clarify the meaning, and therefore help the patient gain
into an event or feeling.
7. is assessed by asking a patient questions such as “Where are you now?” and “What
year is it?”
8. The outward expression of feelings is called .

DEFENSE MECHANISMS 4. A teen who didn’t make the football team says, “I’ve de-
cided to give up trying to play in sports. I’m much better
Name the defense mechanism being used in each of the
following statements. at piano.”
5. A woman who was raped says, “Why are you calling me
1. A patient with cancer says, “I know if I take my vitamins,
to set up rape counseling? I was not raped and I do not
I’ll be fine.”
need counseling.”
2. A student comes unprepared to class and says, “I woke
6. A man who is passed over for a promotion yells at his
up late because my instructor gave us so much work to
son for a minor mistake, “You messed up again. You
do and I had to stay up all night, and my kids are sick
never do anything right.”
and the car isn’t working.”
7. An adolescent says to his mother, “I got a C on my project
3. A man who always wanted to be a lawyer but was not
because you told me to do it all wrong.”
accepted into law school says, “Lawyers are all crooked.
I would never trust one.”

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Chapter 56 Mental Health Function, Assessment, and Therapeutic Measures 237

8. The woman who cheated on an examination turns in 3. How might you determine whether Mrs. Jewel’s thought
extra work and states, “Here is some extra work I did. processes are intact?
I really want to learn this material.”
9. A teen tells her date, “I’m sorry I can’t go out tonight; I
have to wash my hair.”
10. The student nurse tells the instructor, “I don’t think I 4. What questions can you ask to determine Mrs. Jewel’s
can do that catheter. I am feeling sick to my stomach. I recent and remote memory?
think I ate some bad food in the cafeteria.”

CRITICAL THINKING 5. How do you determine speech and ability to communicate?

Read the following case study and answer the questions.
Mrs. Jewel is a 48-year-old woman admitted to your unit with
cellulitis of her lower legs and diabetes mellitus. She has
arthritis and morbid obesity. As you collect some initial data,
you notice that her hair is dirty and unkempt, her clothes are 6. You determine that Mrs. Jewel’s affect is inappropriate.
dirty, and she has an unpleasant body odor. You also find that
What does this mean?
she does not appear to have a good understanding of her health
or self-care needs. You decide to assess her mental status.
1. What factors related to Mrs. Jewel’s appearance provide
information about her mental status? How can you find
out if this is unusual behavior for her?
7. How can you evaluate Mrs. Jewel’s judgment?

2. Mrs. Jewel is alert. What questions can you ask to assess

orientation?
8. How can perception be assessed?

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 3. An office worker has an argument with the boss, and on
arriving home, yells at the spouse and children. Which
1. Which behavior in a patient with a chronic physical ill-
defense mechanism is being displayed?
ness alerts the nurse to possible mental health concerns?
1. Rationalization
1. The patient prays for healing from illness.
2. Denial
2. The patient reads self-help books to gain insight into
3. Reaction formation
his problems.
4. Displacement
3. The patient has developed ways to cope with chronic
illness.
4. The patient does not have any close friends.

2. Which defense mechanism is being used by the person

who always seems to blame others for personal problems?
1. Denial
2. Projection
3. Rationalization
4. Transference
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238 UNIT SIXTEEN Understanding Mental Health Care

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 8. A patient who quit drinking 4 months earlier is consider-
ing entering an inpatient alcohol rehabilitation program,
4. The nurse is providing care for a patient immediately
and asks for the nurse’s opinion. Which response by the
following electroconvulsive therapy. Which of the
nurse is best?
following nursing actions is most appropriate?
1. “That is an excellent idea. I will help you start the
1. Restrain the patient’s extremities.
paperwork.”
2. Monitor the patient closely until he or she is
2. “Why do you think you need a rehabilitation
oriented.
program?”
3. Discharge the patient to home with instructions
3. “What do you think you should do?”
to rest.
4. “You have done so well to be alcohol-free for
4. Administer oxygen at 4 L per minute.
4 months.”
5. The nurse is collecting admission data on a new patient
9. A nurse is caring for a 36-year-old developmentally
with a long health history. Which of the following life
delayed patient admitted to the hospital for pneumonia.
events is considered a stressor?
The patient becomes upset when the dinner tray is late,
1. Gallbladder surgery at age 46
and cries “Mama” repeatedly. The patient’s mother
2. Divorce at age 50
later says this is unusual behavior for the patient.
3. Loss of job at age 55
Which of the following is the best explanation for this
4. Whatever the patient says is stressful
behavior?
1. The patient is having a conversion reaction based
6. A patient is admitted to the hospital mental health unit
on the hospitalization.
for behavior changes. The patient asks why a magnetic
2. The patient is likely having a side effect to a new
resonance imaging test (MRI) has been ordered. Which
medication.
response by the nurse is best?
3. The patient is having symptoms of regression.
1. “MRI can determine levels of important neurotrans-
4. The patient is repressing feelings about the illness.
mitters, so the doctor will know how to treat your
problem.”
10. A patient stands up during a morning community
2. “MRI is used to rule out physical problems that
meeting and screams, “Get out of here right now! The
could be causing your symptoms.”
demons are coming!” Which response by the nurse
3. “MRI uses magnetic energy to treat certain psychi-
is best?
atric disorders.”
1. “Why do you think the demons are coming?”
4. “MRI monitors electrical activity in the brain to help
2. “Yes, we should all leave right now.”
diagnose mental health problems.”
3. “If you have something to say, you must only say it
when it is your turn to share.”
7. A patient with panic disorder tells the nurse that she has
4. “I know you think the demons are coming, but there
a lot of job-related stress. Which response by the nurse
are no demons. You are safe here.”
is most therapeutic for this patient?
1. “Can you identify some of the things in your job that
are causing you to feel stressed?”
2. “I’m really sorry you have so much job stress.”
3. “It is important to eliminate stressful situations so
you can reduce your panic attacks.”
4. “You need to avoid stressful situations—it would be
wise to start looking for another job.”
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Nursing Care of Patients

With Mental Health
Disorders
57
VOCABULARY
Fill in the blanks with the correct terms.
1. A patient with schizophrenia who is unable to speak is experiencing .
2. A situation in which family members exist to enable a substance abuser is called .
3. An irrational fear is called a/an .
4. A repetitive thought or urge is called a/an .
5. Manic-depressive illness is more appropriately called depression.
6. spectrum disorder is characterized by social deficits and restricted repetitive behaviors.
7. People with cannot distinguish between their reality and society’s reality.
8. Abrupt withdrawal from alcohol may cause symptoms called tremens.
9. is the repeated compulsive use of a substance despite negative consequences.
10. refers to the loss of ability to enjoy things that are usually pleasurable.

CRITICAL THINKING 2. What implications does his behavior have for surgery
this morning?
Read the following case study and answer the questions.
You are caring for Mr. Joers, a 72-year-old man admitted to
your surgical unit from a nursing home after he fell and broke
his hip. He is scheduled for surgery this morning at 0800.
During morning report, you learn that he has a history of
Parkinson’s disease, schizophrenia, and anxiety but that he 3. What may have precipitated his worsening symptoms?
was oriented and appropriate during admission and through-
out the night. When you enter his room to check his vital
signs and complete his preoperative checklist, he has a wild
look in his eyes, and says, “Don’t come near me! They told
me what you’re up to!”

1. What is your initial response to Mr. Joers?

4. What actions do you need to take after your initial
response to Mr. Joers?

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240 UNIT SIXTEEN Understanding Mental Health Care

5. What safety concerns do you have?

REVIEW QUESTIONS—CONTENT REVIEW

Choose the best answer unless directed otherwise. 2. Which of the following is the most effective treatment
for alcoholism?
1. Which of the following responses to anxiety is a cause
1. Group support, such as Alcoholics Anonymous
for concern?
2. Drug therapy
1. A student studies late into the night to prepare for a
3. Electroconvulsive therapy
difficult examination.
4. Slowly reducing amount of alcohol consumption
2. A woman takes deep breaths before going into the
grocery store because shopping makes her nervous.
3. A nurse has a glass of wine before a stressful night shift.
4. A young man gets the opinions of several of his
friends before asking a woman out.

REVIEW QUESTIONS—TEST PREPARATION

Choose the best answer unless directed otherwise. 6. Which of the following behaviors by a nurse may
aggravate the behavior of a patient with schizophrenia?
3. A patient being treated with lorazepam (Ativan) during
1. Providing written instructions on when to take
alcohol withdrawal becomes sleepy after the first two
medications
doses, then becomes difficult to arouse when the nurse
2. Speaking in short, simple sentences
attempts to give the third dose. Which of the following
3. Maintaining a structured environment
actions should the nurse take first?
4. Speaking quietly to other staff members when the
1. Hold the dose and notify the registered nurse (RN) or
patient is present
physician.
2. Understand that tolerance will occur with benzodi-
7. A patient has an order for carbamazepine (Tegretol)
azepines and give the drug.
150 mg twice daily for bipolar disorder. It is supplied as
3. Get the patient up and have him walk with assistance
a suspension, 100 mg in 5 mL. How many milliliters
until he is more alert.
should the nurse prepare? _______
4. Administer an antidote.
8. Which statement by a patient with depression indicates
4. A patient calls a nurse into the room and says, “Quick,
that nursing interventions have been helpful?
nurse, there is a dog in the corner. Please get him out.
1. “His comment upset me, but I reminded myself that
I am terrified of dogs.” The nurse sees no dog in the
it really isn’t true.”
corner. Which of the following responses is best?
2. “I feel so hopeless about everything, but I am glad
1. “You know we don’t allow dogs in the hospital.”
you are a good listener.”
2. “We have been through this before. You know full
3. “I feel so much better now that I know how to
well that there is no dog in the corner.”
control my husband’s behavior.”
3. “I do not see a dog. Let’s take a walk down to the
4. “I am really trying to understand why everyone is
snack room.”
against me.”
4. “What kind of a dog is it? What makes you so scared
of dogs?”

5. A patient is starting on lithium for bipolar disorder.

Which of the following nutrients should the nurse teach
about maintaining in the diet?
1. Potassium
2. Sodium
3. Selenium
4. Tyramine
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Chapter 57 Nursing Care of Patients With Mental Health Disorders 241

9. A patient is beginning treatment with paroxetine (Paxil) 10. The licensed practical nurse (LPN) is providing care
for unipolar depression, but after 10 days is still with- for a 28-year-old who is to begin taking phenelzine
drawn and unable to participate in therapy. Which action (Nardil) for depression. Which of the following
by the nurse is best? statements indicates the need for further teaching?
1. Contact the ordering physician for an increase in the 1. “It is very important that I not take other antidepres-
dose. sant medication while I’m on this drug.”
2. Contact the ordering physician for an alternative 2. “If I notice any dizziness I should immediately stop
antidepressant. taking the drug.”
3. Continue to support the patient while waiting for 3. “The bread and cereal food group is generally safe,
symptoms to subside. but I will need to avoid certain foods from other
4. Encourage the patient to include St. John’s wort, an food groups.”
herbal supplement, in the treatment regimen. 4. “I will have to stop drinking beer or wine now that
I’m taking this medication.”
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Answers
Evaluation
CHAPTER 1 Definition: Examination of outcomes and interventions
to determine progress toward desired outcomes and
VOCABULARY effectiveness of interventions.

Nursing process Vigilance

Definition: An organizing framework that links thinking Definition: The act of being attentive, alert, and
with nursing actions. Steps include assessment/data watchful.
collection, nursing diagnosis, planning, implementation,
and evaluation. SUBJECTIVE AND OBJECTIVE DATA
Critical thinking 1. Subjective (symptom)
Definition: The use of those cognitive (knowledge) skills 2. Subjective (symptom)
or strategies that increase the probability of a desirable 3. Objective (sign)
outcome. Also involves reflection, problem solving, and 4. Objective (sign)
related thinking skills. 5. Subjective (symptom)
6. Objective (sign)
Assessment 7. Subjective (symptom)
Definition: Gathering subjective and objective data to 8. Objective (sign)
plan care. 9. Subjective (symptom)
10. Subjective (symptom)
Objective data 11. Objective (sign)
Definition: Factual information obtained through physical 12. Objective (sign)
assessment and diagnostic tests. Objective data are ob- 13. Subjective (symptom)
servable or knowable through the health care worker’s 14. Objective (sign)
five senses. Referred to as signs. 15. Objective (sign)
Subjective data
Definition: Information that is provided verbally by the
CRITICAL THINKING
patient and referred to as symptoms. This is just one possible way to complete a cognitive map.

Could it be low Am I diabetic? Frontal area "Sick" feeling Hard Tylenol helps Hunger makes
blood sugar? it worse

Patient's Where is it? Quality Aggravating and

perception alleviating factors

Food helps
Headache

Useful other Severity Timing

data

Sometimes feel Mother is 7–8 on 0–10 Lasts 1–2 hours Before meals Early in the
sick to stomach diabetic scale once starts morning

1
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2 Answers

REVIEW QUESTIONS—CONTENT REVIEW taking vital signs; assessment is the first step in the
nursing process. (2, 3, 4) are all steps in the nursing
The correct answers are in boldface. process for which the registered nurse (RN) is responsi-
1. (3) is a nursing diagnosis. (1, 2, 4) are medical ble; the LPN/LVN may assist the RN with these.
diagnoses. 8. (3) is data the nurse can collect through use of the five
2. (1) is a medical diagnosis. (2, 3, 4) are nursing senses. (1, 2, 4) are subjective data that the patient must
diagnoses. report.
3. (1) the nurse who is not afraid to ask questions is demon- 9. (2) indicates that the patient is concerned about freedom
strating intellectual humility. (2, 3, 4) are incorrect. from injury and harm. (1) relates to basic needs such as
4. (3, 4, 5, 1, 2) air, oxygen, and water. (3) relates to feeling loved. (4) is
5. (1) is the best definition. (2, 3, 4) do not define critical related to having positive self-esteem.
thinking, but are examples of good thinking. 10. (4) is objective, realistic, and measurable with a time
frame. (1, 2, and 3) are all good outcomes, but they re-
REVIEW QUESTIONS—TEST PREPARATION late to airway clearance, nutrition, and strength, not di-
rectly to swallowing.
The correct answers are in boldface. 11. (2) The three parts of a diagnosis include the problem
6. (4) Evaluation determines whether goals are achieved (from the NANDA list), etiology (“related to”), and
and interventions effective. (2) is the role of the physi- symptoms (“as evidenced by”). (1) does not include
cian; (1, 3) encompass data collection and implementa- symptoms; (3) is a medical diagnosis; (4) is not a
tion, which are earlier steps in the nursing process. NANDA diagnosis and the evidence is not related to
7. (1) The licensed practical nurse/licensed vocational dyspnea.
nurse (LPN/LVN) can collect data, which includes
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Answers
5. Evaluate the results to determine whether the change
CHAPTER 2 made a significant difference and if it was worthwhile in
terms of cost and time.
VOCABULARY
REVIEW QUESTIONS—CONTENT REVIEW
1. Evidence-based practice: A systematic process that uses
current evidence in making decisions about patient care. The correct answers are in boldface.
2. Randomized controlled trials: True experimental studies 1. (2) is Level I evidence. (1, 3, 4) are not examples of the
in which as many factors that could falsely change the best evidence.
results are controlled as possible. 2. (1) is a nursing database. (2, 3, 4) are primarily medical
3. Research: Scientific study, investigation, or experimenta- databases.
tion to establish facts and analyze their significance. 3. (3) is the website for the Joint Commission’s 2014
4. Systematic review: A review of relevant research using National Patient Safety Goals. (1, 2, 4) are not correct.
guidelines. 4. (2) is the definition of a randomized clinical trial.
(1, 3, 4) are not correct.
EVIDENCE-BASED PRACTICE 5. (1) Evidence-based practice begins with a burning ques-
1. proof tion designed to solve a clinical problem. (2, 3, 4) are not
2. context correct.
3. quality
4. care REVIEW QUESTIONS—TEST PREPARATION
5. best, randomized The correct answers are in boldface.
6. outcomes
7. gold 6. (2, 3, 4, 5, 6) are all independent nursing interventions
8. nursing because no health care provider’s (HCP’s) order is re-
9. patient’s quired. (1) is a dependent function because it requires a
10. information HCP’s order.
7. (1, 5) are Level I research. (2, 3, 4) are not systematic
CRITICAL THINKING reviews of randomized controlled trials.
8. (1, 3, 5, 6) because the EBP process involves
1. By questioning the existing way of doing things to ASKMME: ask, search, think, measure, make it happen
ensure that the patient receives the best care possible. and evaluate. (b, d) are not steps in the process.
2. A thorough search of the literature in the area of music 9. (3) is correct because evidence shows frequent reality
therapy. orientation improves thought processes in patients with
3. Cumulative Index of Nursing and Allied Health Alzheimer’s. (1, 2, 4) do not relate to reality orientation.
(CINAHL); Joanna Briggs Best Practices; Cochrane 10. (4) The search should be narrowed to include the focus
Reviews; Medline/PubMed. on the question. (1, 2, 3) do not focus on the question
4. Measure patient outcomes before instituting the evidence- being asked.
based change in practice so comparisons can be made
after implementation to determine if the intervention
worked.

1
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Answers
3. (4) is correct. (1, 2, 3) are incorrect.
CHAPTER 3 4. (2) is the first step. (1, 3, 4) are incorrect.
5. (1) is correct. (2, 3, 4) are incorrect.
VOCABULARY 6. (3) is correct. (1, 2, 4) are incorrect.
7. (4) Criminal punishment can result in loss of freedom;
1. (2) 4. (3) (1, 2, 3) are related to civil liability.
2. (1) 5. (4) 8. (1) is correct. (2, 3, 4) are intentional torts.
3. (5) 6. (6)
REVIEW QUESTIONS—TEST PREPARATION
NURSING PRACTICE, ETHICAL AND LEGAL
PRINCIPLES The correct answers are in boldface.

1. high-level, life 9. (4) The patient is chronically ill but able to meet most
2. state, protect, quality goals so has moderate wellness. (1) The patient is not
3. Caring near death; (2) because the patient cannot meet all
4. dignity, maintaining goals, high-level wellness is not being achieved; (3) the
5. knowledgeable, role models, humor, respect patient is not in poor health because most goals are met
through adaptation.
VALUES CLARIFICATION 10. (2) The nurse–patient relationship is based on trust that
the nurse will maintain all patients’ rights. (1) is a con-
There are no answers to this section because this is an exer- stitutional right, not an ethical issue. (3) is a legal issue.
cise requiring personal responses. (4) is not an ethical principle.
11. (2) is correct. (1, 3, 4) are incorrect.
CRITICAL THINKING 12. (1) is correct. (2, 3, 4) are incorrect.
There are no correct answers to this section because this is 13. (1, 2, 4, 5) These are all part of the five steps of delega-
an ethical exercise that has many choices to be considered tion. (3) In delegation it is the right person not right
for the best outcome for the patient. patient that is considered. (6) The right route relates to
medication administration.
REVIEW QUESTIONS—CONTENT REVIEW
The correct answers are in boldface.
1. (3) is correct. (1, 2, 4) are incorrect.
2. (1) is correct. (2, 3, 4) are incorrect.

1
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Answers
is the fourth day without a bath, skipping the bath is not
CHAPTER 4 a good option.

VOCABULARY REVIEW QUESTIONS—CONTENT REVIEW

1. (2) 7. (7) The correct answers are in boldface.
2. (3) 8. (12) 1. (4) is correct. Tay-Sachs disease is an inherited disease
3. (11) 9. (9) that progressively destroys the nervous system, usually
4. (8) 10. (1) resulting in death by age 5. It is most common among
5. (5) 11. (4) people of Eastern European Jewish (Ashkenazi) heritage,
6. (6) 12. (10) but it also occurs among some French-Canadians and
Cajuns in Louisiana. (1, 2, 3) are not correct.
CULTURAL CHARACTERISTICS 2. (3) is correct. Ethnocentrism is the tendency for human
1. Primary characteristics of culture include nationality, beings to think that their ways of thinking, acting, and
race, skin color, gender, age, and religious affiliation. believing are the only right, proper, and natural ways.
2. Secondary characteristics of culture include socioeco- (1, 2, 4) are not correct.
nomic status, education, occupation, military status, politi- 3. (higher) is correct. Hispanic Americans and American
cal beliefs, length of time away from the country of origin, Indians generally have a higher glucose level than whites.
urban versus rural residence, marital status, parental status, They also have a higher than average risk of diabetes.
physical attributes, sexual orientation, and gender issues.
3. Traditional practitioners are health care practitioners REVIEW QUESTION—TEST PREPARATION
from a patient’s native culture. They are typically native The correct answers are in boldface.
to another country, although they may practice in the
United States. Examples include curanderos, espirituis- 4. (1) is correct. Many American Indians are not time
tas, sobadors, acupuncturists, and crystal gazers. conscious. She may not keep her appointment if you
4. Present-oriented people accept the day as it comes with reschedule, so give the immunizations now. (2) is incor-
little regard for the past—the future is unpredictable. rect; she may not keep her appointment. (3) is incorrect;
Past-oriented people may worship ancestors. Future- she may not return to have her stitches removed. (4) is
oriented people anticipate a bigger and better future and incorrect; to ensure that the children get the immuniza-
place a high value on change. Some individuals balance tions, give them now.
all three views; they respect the past, enjoy living in the 5. (3) is correct. Many Hispanics are openly expressive of
present, and plan for the future. their grief. Her bereavement behaviors are culturally
congruent. Remaining with her is supportive. (1) is in-
CRITICAL THINKING: IMMIGRANTS correct; there is no need to call the cardiac arrest team.
AND PERSONAL INSIGHTS (2) is incorrect; lying on the floor is more disconcerting
to the nurse than it is to the bereaved woman. (4) is in-
There are no correct or incorrect answers to these sections correct. This is not the best intervention. Expressive be-
because these are exercises requiring personal responses. reavement is normal. However, a later strategy may
include a sedative.
CRITICAL THINKING: BATHING 6. (2) is correct. Cupping is a traditional Chinese practice
1. In this patient’s culture, it is improper for someone of that is harmless in most cases. Further assessment should
the opposite sex to help with bathing. It is important to be done to confirm cupping as a cause. (1) is incorrect.
assess whether this is the case with this gentleman. Cupping is not considered child abuse. (3) is incorrect.
2. Find a male nurse’s aide, ask a family member to help, or The situation should be reported to the mother by the
skip the bath again. school nurse. (4) is incorrect. The nurse has acted in
3. Having a male aide do the bath is the best solution. If no good faith and has done nothing wrong.
male aide is available, the family may be approached for 7. (1) is correct. In certain Arabic countries, organs can be
help, although this is not the best solution. Because this purchased for transplantation. This is currently illegal in

1
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2 Answers

the United States. (2) is incorrect. The patient does not numbers of family members in the cafeteria may cause
have an ethical dilemma; however, the nurse may have further disruption in the cafeteria. (2) is incorrect. Large
one. (3) is incorrect. There is no need to call the super- groups in the lobby may cause overcrowding for other
visor. (4) is incorrect. Although there is no harm in giv- families. (3) is incorrect. All family members should be
ing him the telephone number, this does not take care of allowed to visit. It may help to have them choose a
the immediate response. The organ center will tell him spokesperson to control visiting for this patient.
the same thing. 11. (2) is correct. Reducing portion size decreases the over-
8. (3) is correct. Initially you must assess how traditional the all calorie and fat consumption. (1) is incorrect; telling
family’s food practices are before a dietary regimen can a patient to not purchase lard does not mean she will
be set up. (1) is incorrect. Giving a traditional ethnic indi- comply. (3) is incorrect; rarely does a person bake two
vidual an exchange list of foods does not ensure that he or separate pies. The goal is to reduce overall fat and calo-
she will change dietary practices to an American food- rie consumption. (4) is incorrect; it is inconsistent with
exchange list. (2) is incorrect. Being able to calculate the goal of reducing fat and calories.
calories does not ensure that the family knows how to 12. (2) is correct. She has to make her own decision, but
balance a diabetic diet. (4) is incorrect. Although this is she should be fully aware of the consequences. (1) is
certainly an option for the future, the initial step is to incorrect. Scare tactics are not appropriate; she may
obtain a dietary assessment. live whether or not she receives radiation therapy. (3) is
9. (4) is correct. Patients are allowed to have a Santero incorrect; it borders on harassment by the staff. (4) is
visit as long as he or she does not do anything to inter- incorrect; radiation therapy may be the best choice for
fere with treatment or cause a safety problem. (1) is this type of cancer.
incorrect. It is not necessary to get the supervisor’s 13. (2) is correct. Changing the schedule slightly is preferable
permission. However, it is a good idea to let the super- to omitting the medication. (1) is incorrect. Blood levels
visor know that a Santero is going to visit. (2) is incor- can be maintained on a different schedule, as long as the
rect. All religious counselors are allowed to visit. (3) is doses are reasonably spread out. (3) is incorrect. Omitting
incorrect. The patient has the right to see her own reli- the medication will alter blood levels. (4) is incorrect. It
gious counselor. does not respect the patient’s religious beliefs.
10. (4) is correct because family is usually very important
to Hispanic patients’ spirituality. (1) is incorrect. Large
4069_Ans_Ch05_001-002 24/11/14 10:50 AM Page 1

Answers
rehabilitation is a traditional therapy. (3) would be con-
CHAPTER 5 sidered an alternative therapy because the echinacea is
being used in place of a traditional therapy.
VOCABULARY 2. (1) is correct. Hydrotherapy would be considered alterna-
1. (5) tive because it is being used in place of nonsteroidal
2. (4) anti-inflammatory drugs. (2) is incorrect. Because
3. (6) chemotherapy is still being used, the addition of the
4. (2) spiritual healer would be considered complementary.
5. (1) (3) is incorrect. Antibiotics and bronchodilators are both
6. (3) traditional medical therapy. (4) is incorrect. Aspirin is
traditional therapy for a headache.
COMPLEMENTARY MODALITY: GUIDED 3. (3) is correct. Allopathy is the proper term for traditional
IMAGERY Western medicine. (1, 2, 4) are all nontraditional medical
practices.
Purpose: To help the patient use mental images to reduce 4. (1) is correct; echinacea has been shown in some studies to
stress and promote changes in attitude or behavior. May be be potentially effective against colds and viruses. (2) is in-
useful in treating stress-related conditions, such as high blood correct. Feverfew is used for headaches and inflammation,
pressure or insomnia, and may even boost the immune system. among other things. (3) is incorrect. Chamomile is used for
Teaching Plan: See Box 5-2 in your textbook. anxiety. (4) is incorrect. Ginger is used for nausea.
5. (1, 2, 6) are correct. Energetic modalities include
biofeedback, healing touch, magnet therapy, polarity
CRITICAL THINKING therapy, Reiki, spiritual healing, and therapeutic touch.
1. Feverfew is used for migraine headaches, inflammation, (3) Music therapy and (5) yoga are mind–body therapies.
and menstrual problems, among other things. (4) Hydrotherapy is considered a miscellaneous therapy
2. Capsaicin is used for pain associated with a variety of and is not designed to alter energy fields.
disorders.
3. St. John’s wort is used for depression. REVIEW QUESTIONS—TEST PREPARATION
4. Several sources should be consulted before taking herbs. The correct answers are in boldface.
The Internet has a lot of good information, but the source
should be carefully evaluated; www.mayoclinic.com is 6. (4) is correct. The patient should keep his or her eyes
an excellent resource. A pharmacist knowledgeable in closed during imagery, so this statement indicates that
herbs and herb–drug interactions, as well as the primary more teaching is needed. (1, 2, 3) are all parts of guided
physician or care provider, should be consulted. imagery.
5. “Mrs. Lawless, I am concerned that your herbs could in- 7. (2) is correct. Chiropractors do not perform surgery.
teract with your heart failure medications. I will check (1, 3, 4) are potentially true, but the nurse needs to safe-
with your doctor and the hospital pharmacist to be sure guard the patient by informing her that a chiropractor is
they are safe before you take them.” not trained or qualified to do surgery.
8. (2) is correct. The primary care practitioner can help de-
REVIEW QUESTIONS—CONTENT REVIEW termine which alternative therapies are safe. (1) is incor-
rect. Any therapy can be potentially safe or unsafe. (3) is
The correct answers are in boldface. incorrect. Many alternative therapies are safe when used
1. (4) is correct. Progressive muscle relaxation is being correctly. (4) is incorrect. Alternative and complemen-
added to a traditional therapy, making it complementary. tary therapies can be effective for chronic pain.
(1) is incorrect. Inhalers and oral medications are both 9. (3) is correct. It is least appropriate to tell the patient
traditional therapies for asthma. (2) is incorrect. Cardiac he will be able to reduce his pain medications; this is a

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possibility but not a guarantee. (1, 2, 4) are all appropriate lower glucose, but it should not be encouraged without
measures to take before beginning to practice any new provider approval. (2) is incorrect. The patient may or
alternative therapy. may not check out a website before taking the ginseng.
10. (4) is correct. Ginseng can lower blood glucose and can He must be educated while he is still in the hospital.
interfere with warfarin and aspirin. The patient needs to (3) is incorrect. It might be safe to take some herbal
be aware of the risks and then be encouraged to speak agents with the prescribed medications; patients need
with his primary care provider. (1) is incorrect. It can to understand how to exercise caution.
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CRITICAL THINKING
CHAPTER 6
1. Check Mr. James’s vital signs. Elevated blood pressure,
bounding pulse, and shallow, rapid respirations are com-
VOCABULARY mon signs of fluid overload. If he is able to stand, weigh
1. diffusion him to see if his weight has increased since yesterday.
2. isotonic Auscultation of his lungs may reveal new-onset or wors-
3. hypertonic ening crackles (he may have had crackles on admission
4. hypovolemia related to his bronchitis).
5. cations 2. Kidney function declines in the older adult, and the intra-
6. hypernatremia venous (IV) fluids may have been too much for him.
7. hypokalemia Regular assessment and caution with IV therapy can
8. hypocalcemia prevent overload from occurring.
9. Acidosis 3. The registered nurse may decide to reduce the IV infu-
10. alkalosis sion rate until orders are obtained. The LPN can elevate
the patient’s head to ease breathing. Make sure oxygen
DEHYDRATION therapy is being administered as ordered. Stay with him
to help him feel less anxious. Anticipate a possible di-
Corrections are in boldface.
uretic order. Continue to monitor fluid balance.
Mrs. White is a 78-year-old woman admitted to the hospital 4. If a diuretic is administered, urine output should in-
with a diagnosis of severe dehydration. The licensed practi- crease, but this does not signal resolution of the problem.
cal nurse/licensed vocational nurse (LPN/LVN) assigned to It is probably unrealistic to expect Mr. James’s lungs to
Mrs. White is asked to collect data related to fluid status. clear completely because he was admitted with bronchi-
The LPN expects Mrs. White’s blood pressure to be low be- tis. However, return of lung sounds to admission baseline
cause of fluid loss. The nurse also finds Mrs. White’s skin would signal resolution of the acute overload. Other
turgor to be poor, and she notes that the urine output is signs would include return to admission vital signs and
scant and dark amber. The nurse asks Mrs. White if she weight and ability to walk to the bathroom again without
knows where she is and what day it is because severe dehy- excessive shortness of breath.
dration may cause confusion. In addition, the nurse initiates
daily weights because this is the most accurate way to mon- REVIEW QUESTIONS—CONTENT REVIEW
itor fluid balance.
The correct answers are in boldface.
• Blood pressure will be low, not elevated, due to loss of
1. (2) is correct; 0.9% is isotonic, making 0.45% hypotonic.
intravascular volume.
(1) is isotonic; (3, 4) are hypertonic.
• The skin will have poor turgor and will tent when
2. (3) is correct. Aldosterone retains sodium and therefore
pinched. Remember, the best place to check for tenting
water in the body. (2) Thyroid hormone and (4) insulin
in the older patient is over the sternum or forehead.
do not affect sodium; (1) Antidiuretic hormone (ADH)
• Urine volume will be diminished as the body attempts to
retains water.
conserve fluid.
3. (2) is correct. Cheeses are high in sodium. (1) Apples,
• Daily weights are the most reliable indicator of fluid loss
(3) chicken, and (4) broccoli are not high in sodium.
or gain.
4. (3) is correct. Potatoes are high in potassium. (1) Bread,
(2) eggs, and (4) cereal are not high in potassium.
ELECTROLYTE IMBALANCES 5. (2) is correct. Fluid gains and losses are evidenced in
1. (4) 4. (3) weight gains and losses. (1) Intake and output (I&O),
2. (5) 5. (1) (3) vital signs, and (4) skin turgor are all ways to monitor
3. (2) fluid balance, but they are not as reliable. I&O may be

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inaccurate, vital signs may be affected by other factors, Diuretic therapy increases the risk for dehydration.
and measurement of skin turgor is subjective. (2) Asthma, (3) diabetes (as long as it is stable), and
6. (2) is correct. Vomiting and diarrhea and profuse sweat- (5) fractures do not cause fluid loss.
ing can cause dehydration that may manifest itself by 9. (1) is correct. Hyponatremia accompanied by fluid loss
thirst, a rapid heartbeat but weak pulse, low blood pres- results in dehydration and mental status changes.
sure, dark urine, dry skin and mucous membranes, and (2) Hyperkalemia, (3) hypercalcemia, and (4) hypomag-
elevated blood urea nitrogen (BUN) and hematocrit nesemia are not as likely to affect fluid balance and
levels. Temperature often increases in cases of dehydra- mental status.
tion, but that may not be apparent in older people who 10. (3) is correct. Ambulation can help prevent bone loss.
often have a lower normal body temperature than younger Because the patient is weak and is at risk for falls and
people. (4) Hyponatremia, or low sodium level, may fractures, assistance should be provided. (1) Bedrest pro-
occur with dehydration, but that can be confirmed only motes bone loss, (2) fluids will not help bone or calcium
by laboratory tests. In any case, the fluid imbalance must levels, and (4) the patient needs calcium, not protein.
be assessed and treated first. (1) Hypervolemia, or over- 11. (2) is correct. He is probably hyperventilating because
hydration, is the opposite of dehydration. Excess fluid of the anxiety. Rebreathing carbon dioxide exhaled into
may result in (3) edema in the lower extremities as well a paper bag can temporarily relieve symptoms of
as elevated blood pressure, increased rate of respiration, alkalosis until the underlying cause is corrected.
pale cool skin, and diluted urine. (1) Oxygen, (3) positioning, and (4) coughing and deep
breathing all help increase oxygenation, which is not
REVIEW QUESTIONS—TEST PREPARATION needed at this time.
12. (2) is the correct answer. Hypoventilation related to
The correct answers are in boldface.
lung disease causes retention of carbon dioxide, which
7. (2) is correct. Failing kidneys cannot effectively excrete causes acidosis. (1) Hyperventilation causes alkalosis,
water, making the patient at risk for overload. (1) Menin- (3) loss of acid causes alkalosis, and (4) loss of base
gitis, (3) psoriasis, and (4) influenza do not cause fluid causes acidosis, but it is not the cause in this case.
retention. Influenza can cause fluid loss if vomiting or 13. (3, 4, 6) are correct. Potassium supplements should be
diarrhea is present. taken with food; Slow-K should not be crushed; diar-
8. (1, 4, 6) are correct. The patient with an ileostomy loses rhea is not expected and should be reported to the
large amounts of water with continuous liquid stools. physician. If the patient makes these statements, more
Fever is associated with an increased risk of dehydration. teaching is needed.
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Answers
to be discontinued. NEVER attempt to flush the catheter be-
CHAPTER 7 cause this could dislodge a clot into the circulation. The role
of the LPN varies by state. In many states, the RN would need
VOCABULARY to be consulted before discontinuing and restarting a new
IV site. The RN may attempt to withdraw a clot by aspiration.
1. (1) 5. (5)
2. (6) 6. (8) CALCULATION PRACTICE
3. (7) 7. (4)
4. (2) 8. (3)
1. 83 mL 1 hour 15 gtts 21 gtts
=
PERIPHERAL VEINS 1 hour 60 minutes mL minute

2. 50 mL 10 gtts 25 gtts
=
20 minutes mL minute

3. 1 L 1000 mL 83 mL
=
12 hours 1L hour

4. 800 units 500 mL 8 mL

=
1 hour 50,000 units hour

5. 1000 mL 1 hour 60 gtts 42 gtts

=
24 hours 60 minutes 1 mL minute

REVIEW QUESTIONS—CONTENT REVIEW

The correct answers are in boldface.

COMPLICATIONS OF IV THERAPY 1. (2) is correct. The basilic vein is the most distal vein. The
nurse should always start distally and then use more
1. phlebitis proximal veins for future IV sites. (1, 3, 4) are all
2. local infection proximal and are reserved for central insertions.
3. extravasation 2. (3) is correct. The site must be cleaned for at least
4. circulatory overload 30 seconds regardless of solution used to effectively
5. infiltration rid the skin of bacteria. (1, 2) are incorrect. (4) is not
6. septicemia the best answer.
7. venous spasm 3. (1) is correct. A clot could be flushed from the cannula
8. air embolism into the circulation and lodge in a pulmonary artery,
causing a pulmonary embolism. (2) Air, not a clot,
CRITICAL THINKING causes an air embolism. (3) Arterial spasm is caused
Begin by observing the infusion site: look for redness and by injecting medication. (4) Extravasation is caused by
signs of infiltration (such as coolness and swelling), compare infiltration of vesicant drugs.
extremities, and check catheter/administration hub connec- 4. (3) is correct. Leakage of IV fluid into tissues causes
tion to make sure it is secure. Next assess for mechanical puffiness. (1, 2, 4) indicate infection or inflammation.
problems such as position of the catheter by moving the ex- 5. (1) is correct. Phlebitis, an inflammation of a vein, has
tremity around to see if the intravenous (IV) is simply “posi- signs and symptoms of redness, warmth, swelling, and
tional.” Check the tubing for kinks, and the clamp to be sure pain at the infusion site. A (2) thrombosis, on the other
it is open. If the infusion is still not running, the catheter may hand, is manifested by a slowed-to-stopped infusion,
be occluded with a fibrin or blood clot. The catheter may need fever and malaise; a (3) hematoma evidenced by

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swelling and bruising; and (d) signs of infiltration are 8. (3) 125 mL/hr is correct. (1, 2, 4) are incorrect.
swelling and a resistance or inability to advance or flush
1000 mL 125 mL
the catheter. =
8 hours hour
REVIEW QUESTIONS—TEST PREPARATION 9. (3) 50 gtt per minute is correct. (1, 2, 4) are incorrect.
The correct answers are in boldface. 50 mL 1 hour 60 gtt 50 gtt
=
1 hour 60 minutes 1 mL minute
6. (4) is correct. Fluid overload could be worsened with the
use of continuous fluids. (1, 2, 3) All would benefit from 10. (1) is correct. (2, 3) Small veins do not tolerate large
continuous fluid administration. volumes of fluid, high infusion rates or irritating solu-
7. (2) is correct. IV medications act rapidly because they are tions. (4) The antecubital space is avoided if possible.
instantly in the bloodstream. (1) Furosemide (Lasix) can be
given orally. (3) IV dosing is not necessarily more accurate.
(4) Oral furosemide does not cause more side effects.
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PATHOGEN TRANSMISSION
CHAPTER 8
1. (3) 6. (2)
2. (4) 7. (3)
VOCABULARY 3. (3) 8. (2)
Antigen 4. (4) 9. (2)
Definition: A protein marker on a cell’s surface that identi- 5. (2) 10. (1)
fies the cell as self or nonself.
PATHOGENS AND INFECTIOUS DISEASES
Asepsis
Definition: A condition free from germs, infection, and any 1. staphylococci
form of life. 2. fungi
3. Candida albicans
Bacteria 4. Epstein-Barr
Definition: One-celled organisms that can reproduce but 5. pneumonia (histoplasmosis)
need a host for food and a supportive environment. Bac- 6. toxoplasmosis
teria can be harmless normal flora or disease-producing 7. protozoa
pathogens. 8. viruses
9. Rickettsiae
Clostridium difficile (C. diff) 10. Clostridium difficile (C. difficile)
Definition: A Gram-positive bacteria normally found in the
intestine that can multiply after antibiotic therapy and re- CRITICAL THINKING
lease toxins that cause diarrhea.
1. Mask, gown, gloves, a sign reading “Contact Precau-
Hand Hygiene tions,” soap and paper towels, special bags for linen and
Definition: Cleansing of the hands with hand washing or trash, wash area in the room.
the use of alcohol-based hand rubs. 2. Disposable thermometer, disposable or autoclavable
blood pressure (BP) cuff, stethoscope that remains in the
Pathogens room and can be disinfected, grooming items, bedpan,
Definition: Microorganisms or substances capable of pro- bath basin, separate container for sharps. Intravenous (IV)
ducing a disease. equipment and any other equipment needed for the care
of the patient must be able to be disinfected.
Personal Protective Equipment
3. Because visitors are limited the patient has few social
Definition: Items such as gloves, gowns, masks, goggles,
contacts and may lack a support system as a result.
and face shields that help prevent the spread of infection
Environmental stimuli are limited. Activities are limited.
to those wearing them.
Patient is dependent on others for some needs due to
Phagocytosis confinement.
Definition: Ingestion and digestion of bacteria and particles 4. Allow visitors as appropriate and instruct them on how
by phagocytes that destroy particulate substances such as to implement isolation precautions. Offer visitors masks
bacteria, protozoa, and cell debris. or respirators as appropriate. Encourage contact via tele-
phone with family and friends who cannot visit. Main-
Sepsis tain a cheery environment; open curtains; maintain
Definition: Immune system response to a serious infection sensory stimuli by remaining with the patient as long as
with systemic inflammation. possible. Encourage diversional activities, things the
patient likes to do, such as TV or reading books. Always
Virulence answer call light immediately.
Definition: The ability of the organisms to produce disease. 5. C. difficile
6. Probiotics
Viruses
Definition: Small intracellular parasites that can live only in-
side cells and may produce disease when they enter a cell.
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REVIEW QUESTIONS—CONTENT REVIEW 7. (1) Surgical asepsis is aimed at the destruction of mi-
crobes before they enter the body. (2, 4) describe med-
The correct answers are in boldface. ical asepsis. (3) is not related to surgical asepsis.
1. (1) Warm skin is a sign of local infection. (2, 4) are seen 8. (1, 5, 6) All pathogens require moisture, food, and
in shock. (3) is typical of a systemic infection. warmth. (2, 3, 4) are incorrect. All pathogenic organisms
2. (2) Use of autoclaves is a method of sterile technique. need darkness to multiply. Some need oxygen, but others
(1, 3, 4) are all medical asepsis practices. do not.
3. (3) is correct. Healthcare-acquired infections result from 9. (3) The only way to obtain a sterile specimen is to
hospitalization. (1) is a chronic infection, (2) is due to a catheterize the patient. (1, 2, 4, 5, 6) are incorrect be-
sexually transmitted infection, and (4) the infection was cause any voided specimen is contaminated and the spec-
present before hospitalization. imen must be placed into a sterile specimen container.
4. (4) is correct. Vancomycin is the treatment of choice for 10. (1) Urinary catheters are a cause of health care–
methicillin-resistant Staphylococcus aureus (MRSA). acquired infections and should be avoided if possible.
(1, 2, 3) are incorrect. (2, 3, 4) do not prevent infection, and restricting fluids
5. (4) is correct. Tuberculosis is passed by airborne trans- may promote infection and dehydration.
mission, and anyone entering the room of a patient with 11. (4) A high fever indicates that the patient has developed
tuberculosis should wear a fit-tested HEPA mask, which a secondary bacterial infection. (1, 2, 3) are incorrect.
filters the tiniest particles from the air. Other types of Viral infections such as the common cold are usually
masks and personal protective equipment will not pro- associated with a low-grade fever. Symptoms of the
vide protection from airborne pathogens. (1, 2, 3) are common cold include stuffy nose with watery dis-
incorrect because they are not transmitted by air. charge, scratchy throat, dry cough, sneezing, and
watery eyes.
REVIEW QUESTIONS—TEST PREPARATION 12. (1) A culture identifies pathogen presence. (2) A drug
level or peak and trough measures antibiotic levels.
The correct answers are in boldface. (3) A sensitivity report indicates what pathogens are
6. (3) Washing hands before and after patient contact is sensitive to certain antibiotics. (4) is incorrect.
considered the most important method of infection pre- 13. (2, 5) Irritability and pacing behavior can be signs of
vention. (1) Hands cannot be sterilized. (2) is a good ac- infection in an older adult. (1, 3, 4, 6) are not signs of
tion, but alone it is not sufficient for infection control. infection.
(4) Gloves are worn only during certain procedures, 14. (2) Sterile water should be used instead of tap water for
when the caregiver is likely to come in contact with a an immunocompromised patient to prevent infection.
moist body surface. Even when gloves are worn, hand (1, 3, 4) are appropriate actions.
washing before and after wearing the gloves is essential
for infection control.
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CRITICAL THINKING
CHAPTER 9
1. Stage: Irreversible
Category of Shock: Hypovolemic
VOCABULARY Initial Action: Notify health care provider, aid volume
1. acidosis 6. cyanosis restoration by monitoring intravenous (IV) infusion
2. anaerobic 7. tachypnea 2. Stage: Compensating
3. anaphylaxis 8. oliguria Category of Shock: Septic
4. dysrhythmia 9. tachycardia Initial Action: Notify health care provider, maintain
5. cardiogenic 10. hypoperfusion oxygen
3. Stage: Progressive
MATCHING Category of Shock: Cardiogenic
Initial Action: Stop IV infusion, notify health care
1. (3) 4. (2)
provider
2. (1) 5. (2)
3. (2) 6. (3)

SIGNS AND SYMPTOMS OF SHOCK PHASES

Signs/Symptoms Phases
Compensating Progressive Irreversible
Heart rate Elevated Tachycardia Slowing
Pulses Bounding Weaker, thready Absent
Systolic blood pressure Normal <90 mm Hg <60 mm Hg
*In hypertensive, 25% below
baseline
Diastolic blood pressure Normal Decreased Decreasing to 0
Respirations Elevated Tachypnea Slowing
Depth Deep Shallow Irregular, shallow
Temperature Varies Decreased Decreasing
*May elevate in septic shock
Level of consciousness Anxious, restless, irritable, Confused, lethargy Unconscious, comatose
alert, oriented
Skin/mucous membranes Cool, pale Cold, moist, clammy, pale Cyanosis, mottled, cold,
clammy
Urine output Normal Decreasing to <20 mL/hr 15 mL/hr decreasing to anuria
Bowel sounds Normal Decreasing Absent

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REVIEW QUESTIONS—CONTENT REVIEW 8. (2) The pulse elevates to compensate for decreasing
cardiac output in compensating shock and is therefore
The correct answers are in boldface. the earliest indication of compromise from these op-
1. (2) Decreased peripheral tissue perfusion may be seen tions. (1, 3, 4) are found in progressive shock and
first as slow capillary refill, except in the older patient. would be seen later than tachycardia.
(1, 3, 4) do not convey peripheral tissue perfusion status. 9. (1) is of highest concern because it is a symptom of
2. (1) Tachypnea is compensatory to maintain normal oxy- progressive shock. (2, 3, 4) are found in compensating
gen levels when cardiac output decreases. (1) If anxiety shock.
occurs, it is not the primary cause of tachypnea. (2) De- 10. (2) Inform the registered nurse so the IV rate can be in-
creasing retention of carbon dioxide is not the primary rea- creased while the physician is being notified because the
son for tachypnea, although it is a benefit. (4) is incorrect. patient is hypovolemic. (1, 3, 4) are incorrect because
3. (3) Blood pressure is dropping and peripheral vasocon- the patient needs immediate intervention. (1) provides
striction occurs, resulting in less blood flow to the ex- no intervention, although vital signs will be monitored
tremities; sympathetic nervous system compensation continuously, and (3, 4) can worsen the condition.
causes sweating to cool the body for “fight or flight.” 11. (2) increases blood pressure. (1, 3, 4) are incorrect as
(1, 2, 4) are incorrect. they do not increase blood pressure.
4. (3) is a 25% decrease from baseline. (1, 2, 4) are incorrect. 12. (4, 2, 5, 6, 1, 3) Use Maslow’s hierarchy as a guide:
5. (2) The goal is to increase understanding when knowl- Airway is considered first (4), then oxygen (2); deter-
edge is deficient. (1, 3, 4) are incorrect. mining vital signs (5) will guide further treatment;
IV fluids are needed to replace lost fluid in hypov-
REVIEW QUESTIONS—TEST PREPARATION olemic shock so ordered IV needs to be monitored and
maintained (6); and urine output monitoring will help
The correct answers are in boldface. guide treatment (1). (3) is not a priority at this time.
6. (3) Notify the health care provider immediately because 13. (1, 2, 5, 6) Symptoms of obstructive shock are similar
the patient is hypovolemic and needs intravenous (IV) to those of hypovolemic shock except that jugular veins
fluids. (1) This is not the type of IV fluid the patient are usually distended. BP is low, urine output less than
needs; an isotonic IV solution such as 0.9% normal 20 mL per hour, and changes in level of consciousness
saline would be appropriate. (2) is not a priority at this including confusion and lethargy are seen. (c, d) are in-
time. (4) The patient requires intervention now and more correct because tachycardia and tachypnea would occur.
frequent monitoring.
7. (2) Elevated creatinine indicates possible renal damage.
(1, 3, 4) are near normal and not indicative of a problem.
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4. Common side effects of opioids included drowsiness,
CHAPTER 10 nausea, and constipation. Respiratory depression and
constricted pupils are signs of overdose.
VOCABULARY 5. If the morphine has been effective, Ms. Murphy will be
able to ambulate and cough with minimal difficulty and
1. (4) 6. (8) will rate her pain at a level that is acceptable to her.
2. (3) 7. (10) 6. According to the equianalgesic chart, the 30 mg of oral
3. (6) 8. (5) codeine in Tylenol No. 3 would be equal to about 2.5 mg
4. (1) 9. (2) of IV morphine, a much smaller dose than she has been
5. (9) 10. (7) receiving. The health care provider should be contacted
for a more appropriate order.
CULTURAL COMPETENCE 7. Relaxation, distraction, back rubs, music, and imagery
Remember that each patient is an individual and may or might all be effective in addition to the morphine. She has
may not act like others from his or her cultural group. already been using distraction as she visits with her family.

• Native Americans might not ask for pain medication. REVIEW QUESTIONS—CONTENT REVIEW
They may believe pain is something that must be endured.
• European Americans may be stoic and avoid taking med- The correct answers are in boldface.
ication even when it is necessary. They may fear addiction 1. (4) is correct. Pain is whatever the experiencing person
or dependence. says it is, occurring whenever the experiencing person
• African Americans may express pain more freely and may says it does. (1, 2, 3) may all be true in some situations
feel pain and suffering are inevitable. but are not general definitions of pain and do not guide
• Hispanic Americans from Puerto Rico may moan or cry. nursing care.
Those from Mexico may be more stoic, especially the 2. (3) is correct. Suffering is the term used to describe the
men, who do not want to appear weak. sense of threat that can accompany pain. (1, 2, 4) may all
• Asian Americans tend to be stoic and not express pain be present with pain, but they are not the same as suffering.
freely. 3. (1) is correct. Constipation is a common side effect. (2) is
• Arab Americans may express pain openly to family mem- serious but not common, (3) is not a side effect of opioids,
bers, but less so with caregivers. and (4) is not common and is different from a side effect.
4. (3) is correct. The patient’s self-assessment is the best
CRITICAL THINKING measure of pain available. (1) Some patients may moan
1. Using the WHAT’S UP? format, you would assess or cry, but others may not—this may be a cultural varia-
where her pain is, how it feels, what makes it better or tion; (2) vital signs are an indirect measure and are most
worse, when it began, how severe it is on a scale of 0 to reliable when assessing acute pain; and (4) the patient’s
10, related symptoms, and her perception of the pain and request for pain medication may be unrelated to the
what will relieve it. severity of pain.
2. Morphine is an opioid that works by binding to opioid 5. (2) is correct. Distraction can be effective when used
receptors in the central nervous system. Even though the with analgesics. (1) Some patients may deny their pain,
RN gives the medication, you are in a position to observe but most will not; (3) laughing and talking do not mean
for therapeutic and side effects. pain is not present; and (4) there is no evidence that
3. Because you can expect Ms. Murphy to be in pain on her laughing changes the duration of action of medications.
operative day, it is most beneficial to administer her anal-
gesic every 4 hours, before pain begins to recur (as long REVIEW QUESTIONS—TEST PREPARATION
as her level of sedation and respiratory rate are within The correct answers are in boldface.
safe parameters). This will help her walk and cough and
prevent postoperative complications. Often postoperative 6. (4) is correct. Meperidine has a toxic metabolite called
analgesics are administered via patient-controlled anes- normeperidine, which can build up and cause cerebral irri-
thesia (PCA). tation. It is inappropriate for use in most people. (1, 2, 3)

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may all be appropriate, but the nurse must first consider 10. (3) is correct. Most patients who are too drowsy to push
the patient’s safety before trying other approaches. the button are not in pain. Further assessment is needed to
7. (3) is correct. Pain level should be assessed before giving determine if he is in pain and how to proceed. (1, 2) No
any analgesic, and respiratory rate should be assessed be- one but the patient should ever push the button. (4) The
fore giving any medication that can depress respirations. medication should be increased only as ordered after a
(1) Liver and kidney function are not routinely assessed complete assessment and assurance that the patient is safe.
with normal doses of medication, (2) tachycardia may be 11. (2) is correct. The patient should always be believed.
present with acute pain, but blood glucose and pulse rate (1, 3, 4) may all be true, but if the nurse makes a wrong
are not routinely assessed, and (4) the emotional and phys- assumption, a patient in pain may go without treatment.
ical cause of pain may not always be known. Injuries sustained in a motorcycle accident are likely to
8. (1) is correct. Naloxone is a narcotic antagonist. (2, 3, 4) be very painful.
are not narcotic antagonists. 12. (1) is correct. The maximum safe dose of acetamino-
9. (3) is correct. There is no research to justify the use of phen (Tylenol) is 4 g per day, and less in the alcohol
placebos to treat pain. (1, 2, 4) all imply that the placebo user so the nurse would be concerned by the patient’s
will be given. Placebos should be given only report of high alcohol use.
in research settings with patient consent.
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2. Thrombocytopenia: Teach Delmae the importance of
CHAPTER 11 avoiding injury to prevent bleeding. Avoid intramuscular
injections. Teach her to watch for and report symptoms
VOCABULARY of bleeding, such as bruising, petechiae, or blood in
urine, stool, or emesis.
1. alopecia 3. Anemia: Provide a balanced diet, with supplements as
2. anorexia prescribed. Administer oxygen as ordered for dyspnea.
3. leukopenia or neutropenia Provide opportunities to rest. Assist with blood transfu-
4. xerostomia sions as ordered.
5. palliative 4. Stomatitis: Offer soft, mild foods. Offer frequent sips of
6. chemotherapy water. Provide a mouthwash such as diphenhydramine
7. cytotoxic diluted in water or saline. Teach her to avoid hot, cold,
8. neoplasm spicy, and acidic foods.
9. metastasizes 5. Nausea and vomiting: Administer antiemetics as ordered.
10. benign Use prophylactically, not just when nausea is present.
11. biopsy Provide mouth care before meals. Provide small, fre-
12. cytoprotective quent meals and room-temperature or cool foods. Serve
meals in a clean, pleasant environment that is free from
CELLS odors and unpleasant sights. Offer hard candy. Use music
1. True or relaxation as distractions.
2. False—for one protein 6. Alopecia: Offer an accepting attitude. Help the patient
3. False—to the ribosomes locate a wig or other head covering if she wishes. Assure
4. True her that her hair will grow back.
5. False—on the messenger RNA
6. True REVIEW QUESTIONS—CONTENT REVIEW
7. False—only those needed for its specific functions are The correct answers are in boldface.
active
8. False—46 1. (2) is correct.
9. False—Each cell has a full 46 chromosomes. 2. (3) is correct.
10. False—It is also necessary for repair of tissues. 3. (2) is correct. High-fat foods may increase the risk of
some cancers. (1) Broccoli and cauliflower help reduce
BENIGN VERSUS MALIGNANT TUMORS cancer risk. (3) Chicken and fish are low-fat meats that are
healthy choices. (4) Cakes and breads are not problems
Benign tumors typically grow slowly, cause minor tissue unless they are high in fat or other high-risk ingredients.
damage, remain localized, and seldom recur after treatment. 4. (2) is correct. Remember the importance of time, dis-
Cells resemble tissue of origin. Malignant tumors often grow tance, and shielding. (1) Leaving the patient alone for
quickly, cause damage to surrounding tissue, spread to other 24 hours is inappropriate. (3) Body fluids should not be
parts of the body (metastasize), and recur after treatment. touched, but it is not feasible to care for the patient and
Cells are altered to be less like their tissue of origin. avoid touching altogether. (4) A “contaminated” sign will
make the patient feel even more isolated and afraid.
CRITICAL THINKING
1. Leukopenia: Use careful hand washing; teach Delmae REVIEW QUESTIONS—TEST PREPARATION
and her family the importance of doing the same. Teach The correct answers are in boldface.
her to avoid crowds, people with infections, and bird,
cat, or dog excreta. Instruct her to avoid eating fresh 5. (3) is correct. A biopsy enables the pathologist to exam-
fruits or vegetables that cannot be peeled. Teach her ine and positively identify the cancer. (1) Cultures diag-
signs and symptoms of infection to report. Make sure she nose infection. (2) X-rays can help locate a tumor but
talks to her doctor about the risks of returning to work cannot determine whether it is benign or malignant.
while on chemotherapy.
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(4) A bronchoscopy may be done, but a biopsy is support of family at this time. (6) Fresh fruits and vegeta-
necessary to positively identify the cancer. bles can transmit infection.
6. (1) is correct. Frequent mouth care will help prevent the 9. (4) is correct. Alternative methods for pain control can
discomfort and dryness that accompany mucositis. be helpful but should never be expected to substitute for
(2) Cold liquids may worsen mucositis. (3) High- analgesics in the patient with cancer. (1) Distraction
carbohydrate foods will not help. (4) Juices are acidic should be used with, not instead of, medication. (2) The
and can irritate the mucous membranes. nurse must believe the patient’s report of pain. (3) Dis-
7. (2) is correct. Petechiae are small hemorrhages into traction can be effective when used with medication and
the skin. (1) Fever is a sign of infection. (3) Pain is not in no way indicates that the patient’s pain is not real.
usually a sign of bleeding. (4) Vomiting is not a sign of 10. (3, 5, 6) are correct. The goal of hospice is to help pa-
bleeding unless it is bloody. tients achieve a comfortable death and to provide emo-
8. (1, 4, 5) are correct. (1) Washing hands frequently is an tional or physical assistance to family members and
excellent way to help prevent infection in the patient at other caregivers during the patient’s dying process.
risk. (4) Colony stimulating factors are provided to stimu- Respite care for family members may be provided and
late increased production of white blood cells and reduce follow-up counseling is available for up to a year after
the length or severity of leukopenia. (5) Taking vital signs the patient’s death. (1, 2, 4) are not correct. They are all
frequently and monitoring for signs of an infection is an aimed at curing the patient’s cancer. If cure is the goal,
important part of early detection, which helps reduce addi- a referral to hospice is inappropriate.
tional complications related to neutropenia. (2, 3, 6) are in- 11. (3) is correct. Accurate identification of a cancer can
correct. (2) Avoiding injections will help prevent bleeding only be done by biopsy; surgery is not always the treat-
but will do little to prevent infection. (3) Visitors with in- ment of choice.
fections should be discouraged, but the patient needs the
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growth, skin integrity, and cell-mediated immunity. Pro-
CHAPTER 12 teins are essential for controlling fluid balance and manufac-
turing antibodies and white blood cells. Hypoalbuminemia,
VOCABULARY a low serum albumin, impedes the return of interstitial
fluid to the venous return system, increasing the risk of
1. Surgeons shock. A serum albumin level is a useful measure of pro-
2. perioperative tein status.
3. postoperative
4. Induction MEDICATIONS
5. preoperative
6. intraoperative 1. True
7. adjunct 2. False—The surgeon determines if the anticoagulant
8. dehiscence therapy is stopped several days before surgery, which it
9. Anesthesiologists often is.
10. Anesthesia 3. False—The patient may be told by the health care
11. Atelectasis provider to either take no insulin, the normal dose of
12. Debridement insulin, or half of the normal dose.
13. Hypothermia 4. True
14. Evisceration 5. True
6. False—Surgery is a serious stressor for the body.
SURGERY URGENCY LEVELS 7. True
8. False—Circulatory collapse can develop if steroids are
1. (4) 6. (1) stopped abruptly.
2. (3) 7. (2)
3. (3) 8. (1)
4. (4) 9. (3) INTRAOPERATIVE NURSING DIAGNOSES
5. (2) 10. (1) AND OUTCOMES
1. Will remain free from injury.
NOURISHING THE SURGICAL PATIENT 2. Will maintain skin integrity.
3. Will maintain blood pressure, pulse, and urine output
Corrections are in boldface.
within normal limits.
Healing requires increased vitamin A and D for collagen 4. Will be free of symptoms of infection.
formation, vitamin K for blood clotting, and zinc for tissue 5. Will report pain is relieved to satisfactory level.

WOUND HEALING PHASES

Phase Time Frame Wound Healing Patient Effect

Phase I Incision to second postoperative day Inflammatory response Fever, malaise
Phase II Third to fourteenth postoperative day Granulation tissue forms Feeling better
Phase III Third to sixth postoperative week Collagen deposited Raised scar formed
Phase IV Months to 1 year Wound contracts and shrinks Flat, thin scar

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CRITICAL THINKING 3. (2) Skin integrity is maintained during surgery with

proper positioning and avoidance of pressure points.
1. For nursing interview, diagnostic testing, anesthesia in- (1, 3, 4) are preoperative goals.
terview, and preoperative teaching to ensure patient is in 4. (1) Oxygen saturation must be above 90%. (2) is incor-
the best possible condition for surgery. rect. (3) Patients do not have to void before perianesthe-
2. Laboratory tests: blood glucose, creatinine, blood urea sia care unit (PACU) discharge. (4) IV narcotics cannot
nitrogen (BUN), electrolytes, complete blood count have been given less than 30 minutes ago.
(CBC), international normalized ratio (INR)/prothrom- 5. (3) Patients and a responsible adult must understand dis-
bin time (PT), partial thromboplastin time (PTT), bleed- charge instructions before discharge. (1) Patients cannot
ing time, type and screen, and urinalysis are some drive home. (2) Patient does not have to have home tele-
common tests; oxygen saturation, electrocardiogram phone but must be able to be contacted in some way for
(ECG), chest x-ray. follow-up. (4) IV narcotics cannot have been given less
3. Explain what is to be done in preadmission testing; than 30 minutes ago.
explain preadmission prep: bathing, scrubs, preps, med-
ications, nil per os (NPO) time, no nail polish or makeup; REVIEW QUESTIONS—TEST PREPARATION
admission procedures the day of surgery: registration,
nursing unit, emotional support, consent signed, preoper- The correct answers are in boldface.
ative checklist completion; intravenous (IV) line inser- 6. (2) The registered nurse must be informed so the sur-
tion, medications, surgery, postanesthesia care unit and geon can be notified. (1, 3, 4) are not appropriate inter-
family waiting locations, surgery time frames; postopera- ventions, and if the patient is extremely scared, the
tive care: pain control, deep breathing and coughing, leg surgeon must be told because surgery may need to
exercises, activity, leg abduction, drains. be canceled.
4. Explain admission procedures; get consent signed, 7. (1) Higher steroid levels are needed during stress to the
preoperative checklist completion; IV insertion; give body, which surgery produces. (2, 3, 4) are not compli-
medications. cations of steroid withdrawal; circulatory collapse is.
5. Greeting the patient; verifying patient’s name, age, and al- 8. (4) Eliminate background noise as the older adult is
lergies; surgeon performing the surgery; consent; surgical not able to filter out noise. (1) This increases glare,
procedure, especially right or left when applicable, and which will interfere with vision. (2) Large black-
medical history; answering questions; and alleviating anx- on-white print should be used. (3) A low tone should
iety. Explain what to expect in surgery: “The room may be used.
feel cool, but you can request extra blankets.” “There is a 9. (3) Pneumonia can be prevented with lung expansion
lot of equipment, including a table and large bright over- promoted by ambulation. (1, 2, 4) are not prevented
head lights.” “Several health care team members will in- with ambulation.
troduce themselves to you.” “The surgeon will greet you.” 10. (2) Use two people to assist patient for first time in
6. Licensed practical nurses/licensed vocational nurses case patient is lightheaded. (1) One person may not
(LPN/LVNs) can scrub in surgery to hand instruments to be enough to support patient if fainting occurs.
the surgeon. The LPN/LVN must know sterile technique, (3) For safety reasons, patient should not self-dangle.
surgical instruments, and medications placed in the ster- (4) Narcotics should be given about 1 hour before
ile field for use during surgery. ambulation so patient is comfortable but hypotension
7. Maintaining the patient’s airway and safety. is less likely.
8. Pain control is essential to prevent physiological harm to 11. (3) Presence of flatus occurs with normal bowel func-
the patient and to ensure that the patient can participate tion. (1, 4) indicate the bowel is not functioning nor-
in recovery activities, such as deep breathing and cough- mally. (2) is not related to bowel function.
ing, and physical activity. Deep breathing and coughing 12. (3) Have patient lie down to reduce pressure on the in-
prevent atelectasis and pneumonia. Leg exercises and ac- cisional area to help prevent evisceration. (1) Having
tivity prevent thrombophlebitis. Drains might be inserted patient sit upright promotes evisceration. (2) Intra-
to prevent fluid accumulation. venous (IV) fluids should be maintained at ordered rate
and increased fluid needs anticipated because of large
REVIEW QUESTIONS—CONTENT REVIEW fluid loss occurring with dehiscence and evisceration.
(4) This would not be the nurse’s first action, and the
The correct answers are in boldface.
patient would likely be prepared for surgery.
1. (3) The LPN/LVN can offer emotional support as needed 13. (4) Exhaling deeply to reach target is incorrect and
to patients. (1) is the role of the registered nurse (RN). would indicate need for teaching. (1, 2, 3) are
(2, 4) are roles of the health care provider. incorrect because they are appropriate ways to use
2. (4) The nurse’s signature verifies that it was the patient the spirometer.
who signed the consent after informed consent was pro- 14. (1) The sympathetic nervous system saves fluid in re-
vided by the surgeon. (1, 2, 3) are not the role of the nurse sponse to stress of surgery, which reduces urine output
and are not indicated by the witnessing of the consent. initially. (2, 3, 4) are incorrect.
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Answers 3

15. (2, 5) New-onset fever occurring shortly after surgery is (3) Tylenol is not necessary for a low-grade fever, which
often due to atelectasis because a new infection related is part of the body’s defense system and will not help the
to surgery would take longer to develop, so encouraging cause. (4) Fluid intake should be maintained to help thin
coughing and deep breathing and ambulating to expand lung secretions. (5) Intake and output should be moni-
lungs can help prevent pneumonia. (1) An infection tored routinely, but will not help reduce the risk of a
is not usually the cause of a fever in this time frame. postoperative respiratory complication.
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Answers
3. called in, discharged
CHAPTER 13 4. triage, stabilization
5. seriously, full
VOCABULARY 6. drills
7. familiar, role
1. (3) 5. (4) 9. (9) 8. natural
2. (2) 6. (7) 10. (10)
3. (1) 7. (6) CRITICAL THINKING
4. (5) 8. (8)
1. Unresolved grieving of his wife’s death.
PRINCIPLES FOR TREATING SHOCK 2. Withdrawn, rarely leaves home, has not bathed, wearing
soiled clothing, refrigerator is empty, curtains drawn,
1. True paces, and says, “I want to die.” He is exhibiting cogni-
2. False—direct pressure tive, emotional, and behavioral disorganization.
3. False—Apply blanket to warm patient. 3. He no longer possesses coping skills necessary to main-
4. True tain usual level of functioning. His moods, thoughts, and
5. False—Take frequent vital signs. actions are so disordered that they have the potential to
6. False—Do not give the patient oral fluids. lead to suicide if the situation is not quickly controlled.
7. True 4. Grieving related to spouse’s unexpected death; Risk for
Injury related to impaired judgment; Ineffective Health
SIGNS AND SYMPTOMS OF INCREASED Maintenance related to disturbed thought processes.
INTRACRANIAL PRESSURE 5. Establish an atmosphere of trust. Use active listening.
1. (2) 7. (2) Make environment safe. Reduce external sources of
2. (1) 8. (1) stimulation. Speak directly and truthfully to patient. In-
3. (1) 9. (1) clude supportive members of patient’s family. Patient is
4. (2) 10. (1) prepared for each new development as circumstances
5. (1) 11. (2) evolve. Threatening, challenging, or arguing with dis-
6. (2) 12. (2) turbed patient is not done.

ASSESSMENT OF MOTOR FUNCTION REVIEW QUESTIONS—CONTENT REVIEW

If the patient is unable to The lesion is above the level of The correct answers are in boldface.
Extend and flex arms C-5 to C-7 1. (3) Respiratory distress may be experienced in anaphy-
Extend and flex legs L-2 to L-4 lactic shock because of fluid in the airways and con-
Flex foot, extend toes L-4 to L-5 stricted bronchi. (1, 2, 3) are not common with
Tighten anus S-3 to S-5 anaphylactic shock.
2. (1) Arterial blood flow is assessed with capillary refill.
HYPERTHERMIA (2, 3, 4) are not assessed with capillary refill.
1. (1) 6. (2) 3. (3) A rapid, thready pulse indicates compensation (rapid)
2. (1) 7. (1) and loss of blood volume (thready). (1, 2, 4) are incorrect.
3. (2) 8. (2)
4. (2) 9. (2) REVIEW QUESTIONS—TEST PREPARATION
5. (1) 10. (1) The correct answers are in boldface.

PRINCIPLES FOR DISASTER OR BIOTERRORISM 4. (1) Morbidity and mortality are usually from pulmonary
RESPONSE aspiration secondary to loss of the gag reflex. (2, 3, 4)
are neurologic signs that would occur later with compli-
1. overwhelms cations. The nurse’s priority is monitoring that will pre-
2. disaster plans vent complications from occurring.

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5. (2) Activated charcoal might be given in this severe case rate is slow; tachycardia is expected with large amounts
to help absorb the medication. (1, 2, 4) would not be of blood loss. (4) A bounding pulse would not be noted
appropriate for a semiconscious patient. with hemorrhage.
6. (2) Patient is alert and oriented. (1, 3, 4) are incorrect. 9. (3, 2, 1, 4) Airway is the first priority, then breathing,
Core body temperature should be within normal range. circulation, disability.
Skin should be warm and dry. 10. (2) The brachial artery is the proximal artery to the ra-
7. (3) (3 mg/5 mg) × 1 mL = 3/5 = 0.6 mL. (1, 2, 4) are dial artery. (1, 3, 4) are not the most proximal arteries to
incorrect. the radial artery.
8. (1) A rapid, thready pulse indicates compensation (rapid) 11. (2, 3, 4) are needed for the unvaccinated nurse when
and loss of blood volume (thready) requiring intervention caring for a patient with smallpox. (a) is for the vacci-
by the nurse. (2) is a normal pulse finding. (3) This pulse nated nurse and (5, 6) are not required.
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REVIEW QUESTIONS—CONTENT REVIEW
CHAPTER 14
The correct answers are in boldface.
VOCABULARY 1. (4) Integrity versus despair. (1, 2, 3) are developmental
stages typically carried out in earlier years of life.
1. respite care
2. (4) Stress decreases when the caregiver is given personal
2. powerlessness
time away from the patient, which everyone needs. If
3. chronic
respite care is not available then (1) personal time de-
4. spirituality
creases and (2) rest time decreases. (3) There is no cost
5. hopelessness
for most volunteer respite services, so costs would not be
6. developmental stage
increased.
3. (4) Allowing the patient to make informed decisions
CHRONIC ILLNESS AND THE OLDER ADULT should foster health promotion. (1, 2, 3) Making the
Corrections are in boldface. choices for the patient and family may not result in im-
plementation of those choices because input was not ob-
Older adults constitute one of the largest age groups living
tained from them.
with chronic illness. Older adult spouses or older family
4. (1) Peripheral vascular disease is a chronic illness. (2, 3, 4)
members are increasingly being called on to care for a
are acute illnesses.
chronically ill family member. Children of older adults who
5. (1) Being willing and able to carry out the medical regi-
themselves are reaching their 60s are being expected to care
men is important in dealing positively with the illness.
for their parents. These older adult caregivers may also be
(2, 3, 4) would be unhelpful behaviors in adapting to a
experiencing chronic illness themselves. For older adult
chronic illness.
spouses, it is usually the less ill spouse who provides care to
the other spouse. The older adult family unit is at great risk
REVIEW QUESTIONS—TEST PREPARATION
for ineffective coping or further development of health prob-
lems. Nurses should assess all members of the older adult The correct answers are in boldface.
family to ensure that their health needs are being met.
6. (2, 6) Malabsorption syndrome and spina bifida are
Older adults are very concerned about becoming depen-
congenital chronic disorders. (1, 3, 4) are acquired ill-
dent and a burden to others. They may become depressed
nesses. (5) is a genetic illness.
and give up hope if they feel that they are a burden to others.
7. (1) Stress management directly influences how a patient
Establishing short-term goals or self-care activities that
ages. (2, 3, 4) do not directly influence a patient’s aging.
allow them to participate or have small successes are impor-
8. (4) This empowers patients to control their own health
tant nursing actions that can increase their self-esteem.
care. (1, 2, 3) take control away from the patient.
9. (2) Home care nurses can strengthen a patient’s self-
CRITICAL THINKING care capacity by saying, “Let me assist you” instead of
1. The nurse should explore Mrs. Martin’s spiritual needs: “Let me do this for you.” (1) Being a caretaker instead
Is she hopeful? What makes her feel at peace? How does of a partner is not helpful in improving self-esteem.
she usually meet her spiritual needs? Does she have cer- (3) Empowering the patient instead of doing it all for
tain religious customs? the patient would be helpful. (4) Doing everything for
2. Spiritual Distress; Readiness for Enhanced Spiritual the patient instead of assisting makes the patient feel
Well-Being; Hopelessness; Powerlessness. dependent and useless.
3. Interventions may include using the meditation room for 10. (1) Offering praise for small patient efforts shows interest
quiet reflection or prayer, chaplain visits, or worship in the patient and motivates the patient to try other tasks.
services; assisting Mrs. Martin with transportation to the (2) If praise is offered only for major patient efforts,
meditation room or worship services; and providing de- opportunities to praise small tasks are lost; if the patient
sired reading material such as a Bible or prayer book. never accomplishes major tasks, no praise is ever given.
4. If Mrs. Martin expresses a feeling of peace or hopefulness. (3) If activities of daily living (ADLs) are done for the

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patient, no opportunity for independence and success is 12. (1) Providing educational information empowers the
allowed for the patient. (4) Assisting patient at first sign of patient to make informed choices. (2) Limiting visiting
difficulty with ADLs allows the patient no opportunity to hours for family members isolates the patient and does
succeed at a difficult task. not allow patient free choice. (3) Asking family mem-
11. (2) Using humor can be helpful, and this is one method bers to provide care makes the patient dependent if
of using humor. (1) Avoiding the use of humor is not some independence is possible. (4) Setting the goals
beneficial because humor has been shown to enhance for the patient and family takes the decision-making
health. (3) A serious manner may not be helpful in im- process away from the patient.
proving a patient’s mood. (4) Limiting conversation to 13. (1) is a genetic condition. (2, 3, 4) are incorrect.
a minimum further isolates the patient.
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5. True
CHAPTER 15 6. False—Recognize that high-frequency tones and consonant
sounds are lost first—z, sh, ch, d, g.
VOCABULARY 7. True

1. activities of daily living MEDICATIONS

2. arrhythmia
3. cataract Corrections are in boldface.
4. attitude Older patients are more susceptible to drug-induced illness
5. aspiration and adverse medication side effects for various reasons. They
6. edema take many medicines for the more than one chronic illness
7. glaucoma that they have. Different medications interact and produce
8. expectoration side effects that can be dangerous. Over-the-counter medi-
9. constipation cines that older patients take, as well as the self-prescribed
10. homeostasis extracts, elixirs, herbal teas, cultural healing substances, and
11. contracture other home remedies commonly used by individuals of their
12. pressure ulcer age cohort, do influence other medications.
13. nocturia If an older patient crushes a large enteric-coated pill so that
14. extrinsic factors it can be taken in food and is easily swallowed, it destroys
15. macular degeneration the enteric protection and can inadvertently cause damage to
16. osteoporosis the stomach and intestinal system. Some patients intention-
17. sensory deprivation ally skip prescribed doses in an effort to save money. When
18. optimal functioning prescribed doses are not being taken as expected, problems
19. reality orientation do not clear up as quickly, and new problems may result. The
20. sensory overload nurse should educate the older patient and the patient’s family.
Patients need to know what each prescribed pill is for, when
AGING CHANGES it is prescribed to be taken, and how it should be taken.
1. (1) 14. (12)
2. (3) 15. (15) CRITICAL THINKING
3. (5) 16. (16) This is a values clarification exercise, so answers are your
4. (6) 17. (17) own individualized answers that should be based on guid-
5. (2) 18. (18) ing principles.
6. (8) 19. (20)
7. (4) 20. (21) 1. Your individual response
8. (7) 21. (19) 2. Your values and beliefs (what are they)
9. (11) 22. (22) 3. Be tactful and provide privacy during situation resolution.
10. (14) 23. (23) 4. Consider professionalism issues, agency policy, patient
11. (13) 24. (26) safety.
12. (10) 25. (24) 5. Consider professionalism, respect for others’ values.
13. (9) 26. (25)
REVIEW QUESTIONS—CONTENT REVIEW
COMMUNICATING WITH PEOPLE WHO HAVE The correct answers are in boldface.
HEARING IMPAIRMENTS
1. (2) Wax can obstruct the conduction pathway, causing a
1. True bone-conduction problem. (1, 3, 4) are not related to a
2. False—Face patient so the speaker’s face is visible to bone-conduction problem, but a nerve problem.
patient. 2. (2) Psychological factors are the primary source of sex-
3. False—Speak toward patient’s best side of hearing. ual dysfunction, as documented in the literature. (1, 3, 4)
4. True are not the primary source.
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3. (2) Weight-bearing exercise helps fight the degenera- 7. (2) Circulatory status is the reason for slow, deliberate
tion of bone in osteoporosis. (1) Calcium intake should movements because gravity shifts body fluids with
be increased. (3, 4) do not have any influence on position change. (1, 3, 4) are incorrect.
osteoporosis. 8. (1) The older circulatory system is very sensitive to
fluid-overload situations, and intravenous (IV) ther-
REVIEW QUESTIONS—TEST PREPARATION apy increases the risk potential. (2, 3, 4) are incorrect.
9. (3) Whispering lowers the pitch of the sounds, making
The correct answers are in boldface.
your words easier to hear for someone who has lost
4. (3) is the only symptom for glaucoma. (1, 2, 4) are only high-pitched frequencies. (1, 2, 4) are incorrect for
incorrect. high-pitched hearing loss.
5. (4) There is a decreased taste sensitivity for salt and 10. (1) This puts the patient’s needs ahead of the nurse’s
sweet flavors. (1, 2, 3) are not aging changes. needs. (2, 3, 4) do not show respect for the patient’s needs.
6. (2) Peripheral vascular resistance increases with age, 11. (2) Older adults with a disability and older adults with
contributing to hypertension development. (1, 3, 4) no or partial high school education, tend to use inappro-
decrease with aging. priate medication more than those who went to college.
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Answers
REVIEW QUESTIONS—TEST PREPARATION
CHAPTER 16
The correct answers are in boldface.
VOCABULARY 4. (1) is correct because it shows caring, understanding,
and insight into the patient’s needs. (1, 2, 4) are incor-
1. (6) 6. (2)
rect.(2) is part of the process for making a visit but does
2. (4) 7. (8)
not influence trust. (3) should be done as needed as part
3. (5) 8. (10)
of providing nursing care but does not influence trust.
4. (3) 9. (1)
(4) reflects confidentiality requirements, but others may
5. (7) 10. (9)
be included with patient’s permission such as family
members as well as other health care team
HOME HEALTH SERVICES members involved in the patient’s care.
1. (4) 5. (1) 5. (4, 5, 6) are correct and are general safety measures for
2. (5) 6. (8) any person who is ambulating. (1, 2) are incorrect as the
3. (3) 7. (6) patient may need to get out of bed or ambulate when
4. (2) 8. (7) others are not there—the means to do so safely should
be provided. (3) is not a skilled nursing function. If there
CRITICAL THINKING are concerns with housekeeping, it can be discussed
with family and possibly addressed with other services.
1. Four times per week for 4 weeks.
6. (2) is correct. (1, 3, 4) are incorrect because they pro-
2. Dressing changes, reinforcement of medication teaching
mote the risk of infection.
including blood glucose monitoring, vital sign monitor-
7. 0.8 mL is correct.
ing, O2 therapy precautions, and management.
8. (2, 3, 4, 5) are correct to promote learning. (1) is incor-
3. “No smoking” signs need to be posted because
rect because information should be provided in brief,
Mrs. Thompson is receiving O2 therapy. Environment
organized concepts to allow learning and retention.
needs to be assessed for potential safety hazards including
9. (1) is correct so that the RN can perform an assess-
long O2 tubing, scatter rugs, inadequate lighting, need for
ment and determine an appropriate plan of action.
assistive devices, and need for monitoring system.
(2, 4) are not correct because it is inappropriate to
4. Yes, social services for meals on wheels, occupational
direct the patient as to what to do in the patient’s
therapy and physical therapy for strength training and
own home and washing the dishes is not the LPN’s
identification and instruction of assistive devices, and a
function. (3) is not correct because this is an assump-
home health aide.
tion that may not be true and requires assessment
by the RN.
REVIEW QUESTIONS—CONTENT REVIEW 10. (1, 3, 5, 6) are correct. (2) is not usually possible, so a
The correct answers are in boldface. time range should be given. (4) is not done for safety
but so that the nurse’s car is not blocked in.
1. (3) is correct. (1, 2, 4) are incorrect because those indi-
11. (1, 2, 3, 5) are correct. The nurse should perform a
viduals were involved in nursing in other ways.
complete patient assessment during each visit. Assess
2. (4) is correct because the spouse is the caregiver. (1, 2, 3)
the home environment for potential safety hazards and
are incorrect as they do not relate to the caregiver.
need for devices to assist with care. (4) Collecting a
3. (4) is correct. (1, 2, 3) are incorrect because the patient is
urine sample is not ordered or necessary.
in control in the home environment.

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REVIEW QUESTIONS—CONTENT REVIEW
CHAPTER 17
The correct answers are in boldface.
VOCABULARY 1. (2) is correct. (1, 4) are not associated with tube feeding.
(3) could occur but was not shown with research.
1. living will
2. (3) is correct. (1, 2, 4) are good questions but do not as-
2. durable power of attorney
sess the patient’s understanding.
3. hospice
3. (1) is correct and is a therapeutic response. (2, 3, 4) help
4. postmortem care
the staff or other patients but do not help the family.
5. advocate
REVIEW QUESTIONS—TEST PREPARATION
TRUE OR FALSE?
The correct answers are in boldface.
1. False—They usually lose weight.
2. False—Most companies provide a hospice benefit. 4. (2) is correct. (1, 4) are also effects of morphine but are
3. True not the reason it is given to a dying patient. (3) Mor-
4. True phine will not affect temperature.
5. False—They will only be discharged if they are no 5. (2) is correct. (1, 3, 4) may also be necessary steps, but al-
longer terminal. lowing the family time to spend with the patient (and hav-
6. True ing the patient look presentable) is the most important.
7. False—CPR must be started within 3 to 5 minutes. 6. (3) is correct. (1) Redirecting a patient is appropriate if
8. True he is expected to improve; (2) the medications may play
9. True a part, but this statement does not help the family;
10. False—Weight loss and functional decline are two (4) oxygen may be used for comfort, but may not im-
common indicators. prove the thought processes of a dying patient.
7. (4) is correct, and validates the wife’s feelings. This
CRITICAL THINKING may help her make a decision. (1) may be appropriate if
she needs clarification but is not the best response while
1. Dyspnea: Administer morphine, administer oxygen, ele-
she is upset. (2, 3) may be true but do not address her
vate head of bed, place a fan in the room, provide mas-
feelings of upset.
sage and muscle relaxation.
8. (4) is correct. (1, 2, 3) are important but do not address
2. Bowel and bladder incontinence: Keep perineal area
the specific circumstance of home resuscitation.
clean, change briefs often.
9. (2) is correct. Cultural traditions should be supported if
3. Copious oral secretions: Adjust patient’s head so secre-
at all possible. (1, 3, 4) are incorrect—they ignore the
tions go down throat, place humidifier in room, adminis-
importance of the family’s cultural tradition.
ter hyoscyamine or scopolamine, administer low-dose
10. (1, 2, 4) are correct. Dyspnea and swelling around tumors
morphine, suction.
are reduced when fluids are withheld; research has shown
4. Body temperature changes: Administer Tylenol, change
no benefit to hydration for patients who are actively dying
clothing as needed, provide warm blankets, change bed-
of cancer. It is theorized that dehydration results in in-
clothes and bed linens as needed.
creased production of endorphins, and research shows
5. Restlessness: Assess and treat discomfort such as urinary
that patients do not express feelings of hunger or thirst
retention, fecal impaction, medication toxicity; reposi-
near the end of life, although dry mouth is experienced.
tion in bed, administer oxygen.

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Answers
VOCABULARY
CHAPTER 18
1. Antigens
2. Immunity
STRUCTURES OF THE IMMUNE SYSTEM 3. Natural killer cells, T cells, B cells
4. T cells (or T lymphocytes)
5. immunoglobulins
6. Cell-mediated
7. Naturally acquired active
8. IgG
9. inflammation
10. neutrophils

IMMUNE SYSTEM
1. (7) 5. (2)
2. (4) 6. (8)
3. (5) 7. (3)
4. (1) 8. (6)

NURSING ASSESSMENT—HISTORY
Corrections are in boldface.
Demographic Data
The patient’s age, gender, race, and ethnic background are
important. Systemic lupus erythematosus affects women
eight times more frequently than men. The patient’s place
of birth gives insight into ethnic ties. Where the patient has
lived and does live may shed light on the current illness. The
patient’s occupation, such as that of a coal miner, may con-
tribute to respiratory symptoms.
Common signs and symptoms found with immune system
disorders include fever, fatigue, joint pain, swollen glands,
IMMUNE SYSTEM CELLS weight loss, and skin rash.

1. (4) 5. (3) History

2. (7) 6. (1) Food, medication, and environmental allergies should in-
3. (5) 7. (6) clude those that the patient experiences and those present
4. (2) in the family history. With a family history a previous ex-
posure to a substance is not required before a severe reac-
ANTIBODIES tion occurs. Conditions such as allergic rhinitis, systemic
lupus erythematosus, ankylosing spondylitis, and asthma
1. IgA
are thought to be either familial or have a genetic predis-
2. IgG
position. If the patient’s thymus gland has been removed
3. IgD
(thymectomy), T-cell production may be altered. Corticos-
4. IgE
teroids and immunosuppressants alter the immune re-
5. IgG
sponse. The patient’s lifestyle may place the patient at high
6. IgA
risk for contracting the human immunodeficiency virus.
7. IgM

1
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2 Answers

The patient’s diet and usage of vitamins give insight into REVIEW QUESTIONS—TEST PREPARATION
the reserve of the immune system. Stress (environmental,
physical, and psychological) can depress immune system The correct answers are in boldface.
function. 7. (4, 5) C-reactive protein and erythrocyte sedimentation
rate test for inflammation. (1, 2, 3) are incorrect. (1) IgM
CRITICAL THINKING is an immunoglobulin. (2) CD4 is indicative of immune
1. Demographic data (age, gender, race and ethnic back- function and is decreased in cancer, HIV, AIDS, or im-
ground, place of birth, place of residence, occupation munosuppression. (3) Western blot is used to detect
[past and present]); patient history (blood transfusions, HIV antigens.
high-risk behaviors, allergies [drug, food, environmen- 8. (1) This mother has a naturally acquired active immu-
tal], surgeries, diagnosed medical conditions [past, pres- nity to chickenpox and can care for the children without
ent]); physical (general appearance, cardiovascular, skin, a mask or a booster vaccine. (2, 3, 4) are incorrect.
mucous membranes, respiratory, gastrointestinal, renal, 9. (1, 2, 4, 5) Cold virus, plant pollen, bacterial toxins,
musculoskeletal, nervous). or vaccines can all stimulate the formation of anti-
2. Normal lymph nodes are not palpable. Nodes that are bodies. (3) Transplanted organs stimulate cell-
nontender, hard, fixed, and enlarged are frequently asso- mediated immunity, which does not involve the pro-
ciated with cancer. duction of antibodies.
3. If cancer is suspected: recent weight loss, occupational 10. (2) A biopsy requires that the patient sign an informed
exposures, any high-risk lifestyle behaviors such as consent. (1) Iodine is not typically used in a biopsy, but
smoking, sexual patterns, previous medical history, and it is used in a computed tomography (CT) scan and
family history. magnetic resonance imaging (MRI) scan. (3, 4) are
more appropriate when checking a patient with known
REVIEW QUESTIONS—CONTENT REVIEW allergies.
11. (3) Systemic lupus erythematosus (SLE), an autoim-
The correct answers are in boldface. mune disorder, tends to affect women eight times more
1. (1) than men. In addition, Hispanic, Native American,
2. (2) Asian, and African American women develop SLE two
3. (2) to three times more than Caucasian women.
4. (1)
5. (2)
6. (2)
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Answers
3. sinusitis, nasal polyps, asthma, chronic bronchitis
CHAPTER 19 4. Infection
5. epinephrine
VOCABULARY 6. hives
7. pruritic, edema, longer
1. (10) 9. (2) 8. Coombs’ test
2. (11) 10. (4) 9. Shock, renal failure
3. (8) 11. (6) 10. penicillins, sulfonamides
4. (13) 12. (7) 11. MSG, bisulfates
5. (3) 13. (15) 12. Poison ivy (or oak)
6. (9) 14. (1) 13. vitamin B12
7. (16) 15. (5) 14. Erythrocytapheresis
8. (14) 16. (12) 15. sacroiliac, costovertebral, large peripheral

IMMUNE DISORDERS
1. type I, type II, type III, type IV
2. hayfever

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2 Answers

IMMUNE WORD SEARCH SOLUTION

X Z Y G L L D W X T X L T J K R Y R M S G

X Q L L B J J P L Z W T L Z X N T R H I M

R T H A I R A C I T R U P V R L D W G T X

L C A T G Z N D B X K P T H T H M Q R I W

Y O K T C X L O D N P J N N K H Z N B L P

C R K K O L J T I D M R M W B H H F T Y L

T T H K N P L R D T N W Q H P V J M S D N

V I D F J F I T Q Y A L H N N I J M E N N

C C X V J C T C T K R N S L N M K D X O C

Z O P G T L Z D D K R L I F Z L T W E P Y

K S F Z L T Z N D E I Z E T M J M X L S G

H T J G T R P E D H R C F L U K H X P G T

Z E T R N N Y N P L T M V K Z L V Y M N M

C R N R K A Z O J I Q D A W T F G D O I R

R O X N L N N R O K N V T T M W N G C S N

K I V E B I G N K K B Y Q X I K Y R A O G

M D D D S K V Y L D H C F K B T N B R L C

P S K O L G V C M C B M C C R R I Y N Y R

T N E Z L G H K N G K N P Q R F Q S D K T

X R F Y Q Y N T T G F Q M W Q B L G P N T

L R F P W M M F C Y T O K I N E S R M A H

IMMUNE DISORDERS PUZZLE SOLUTION

Across Down
1. Pernicious 1. Penicillins
3. Fifteen 2. Obstruction
6. Anaphylaxis 4. Epinephrine
8. Humoral 5. Fatigue
9. Monocytes 7. Hypogammaglobulinemia
13. Hypothyroidism 10. Sacroiliac
15. Nasal polyps 11. Mast cells
17. Angioedema 12. Latex allergy
19. Intrinsic factor 14. Autoimmunity
20. Steroids 16. Allergen
21. Butterfly 18. Stress
22. Discord
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Answers 3

REVIEW QUESTIONS—CONTENT REVIEW enters the patient. (1, 2) would be done next or as the
antibiotic is stopped if assistance is available. (3) is
The correct answers are in boldface. incorrect.
1. (4) Respiratory distress with wheezing occurs in anaphy- 8. (1) Red blood cells are destroyed by this condition, so red
laxis. (1, 2, 3) are incorrect. cell fragments would be present. (2, 3, 4) are incorrect.
2. (1) Epinephrine is the initial treatment for anaphylaxis. 9. (2) When a portion of the stomach is removed, intrinsic
(2, 3, 4) are incorrect. factor, which is necessary for the absorption of vitamin
3. (4) is correct. (1, 2, 3) are incorrect. B12, is reduced. Patients must have lifelong vitamin B12
4. (1) is correct. (2, 3, 4) are incorrect. to prevent pernicious anemia from developing. (1, 3, 4)
are incorrect.
REVIEW QUESTIONS—TEST PREPARATION 10. (2) is correct. (1, 3, 4) are incorrect.
11. (3, 4, 5) Respiratory distress with stridor, dyspnea oc-
The correct answers are in boldface. curs in anaphylaxis. Tachycardia occurs as a compensa-
5. (1) An infection can develop if treatment is not followed. tory mechanism. (1, 2, 4) are incorrect.
(2, 3, 4) are incorrect. 12. (2) Opening windows will allow pollen to enter the car.
6. (3) The medication should not be given and the health (1, 3, 4) will control the allergy.
care provider must be informed to determine if the med- 13. (4) is correct. (1, 2, 3) are incorrect.
ication should be given. It is not within the nurse’s scope 14. (2) is correct. (1, 3, 4) are incorrect.
of practice to make that decision. (1, 2, 4) are 15. (1) occurs commonly in patients with systemic lupus
incorrect. erythematosus. (2, 3, 4) are not common nursing diag-
7. (4) The antibiotic, which is the cause of the problem, noses for systemic lupus erythematosus.
should be stopped immediately so that no more medication
4069_Ans_Ch20_001-002 24/11/14 10:58 AM Page 1

Answers
3. early
CHAPTER 20 4. Women

VOCABULARY HIV AND AIDS

1. Acquired immune deficiency syndrome (AIDS) 1. True
2. CD4+ 2. False—End stage of HIV infection is AIDS.
3. Genotyping 3. False—Anyone may contract HIV if exposure occurs.
4. Opportunistic infections 4. True
5. Human immunodeficiency virus (HIV) wasting 5. False—An incubation period occurs following exposure,
syndrome so testing 1 to 2 days later would be inconclusive; anti-
6. Viral load gens are detectable 2 weeks after infection with the virus.
6. False—Standard precautions are used with all patients,
DIAGNOSTIC TESTS so isolation is not routinely necessary for patients with
AIDS unless ordered for special reasons.
1. ELISA test: The typical HIV diagnostic tests and testing
pattern include the following: CRITICAL THINKING
1. ELISA test is done to detect antibodies to HIV
antigen on test plates. 1. The patient is told that he is HIV positive but does not
2. If positive, the ELISA test is repeated. have AIDS at this time. With treatment, HIV is consid-
3. If the ELISA test is again positive, another test, often ered a chronic condition that may not develop into AIDS
the Western blot, is done for confirmation. for many years. If AIDS develops, there is currently no
4. If all test results are positive, the patient is HIV- cure, but it is treatable in most cases.
antibody positive. 2. When the CD4+ T-cell count is less than 200/mL and/or
5. Other tests can be used, especially if initial test results in the presence of 1 of 25 clinical conditions. These con-
are not conclusive. It is important that the patient be ditions are often opportunistic infections or cancers.
counseled before and after the ELISA test is done. 3. To prevent Pneumocystis pneumonia (PCP) and toxo-
Patients need to be instructed on safe-sex practices, plasmosis opportunistic infections from developing.
resources, and support systems. 4. (a) Candidiasis, medications, and peripheral and central
2. Viral load: Measures the amount of HIV RNA in plasma nervous system disease tend to decrease the senses of
and is extremely important for determining prognosis taste and smell. This, along with discomfort, anorexia,
and monitoring the response to antiretroviral therapy. and fatigue, predisposes the patient with AIDS to nutri-
Viral loads should be performed at diagnosis, 1 month tional deficiencies. (b) Medicated swish and swallows,
after initiation of new treatments, and at 3- to 4-month topical anesthetic sprays, and flavor enhancers may
intervals thereafter. promote an increased food intake.
3. CD4+ cell count: Is essential for evaluating the status of 5. Dementia occurs from encephalopathy caused by direct
the immune system. In healthy adults, levels average ap- infection of brain tissue by HIV.
proximately 600 to 1400/mm3. It is recommended that 6. Bodily secretions of infected person coming in contact with
CD4+ cell counts be performed at 4-month intervals for recipient’s blood through a break in the recipient’s skin.
most patients. 7. The recommended disinfectant is household bleach in a
4. Genotyping: Genotyping measures resistance to cur- 1:10 dilution mixture. This needs to be prepared within
rently available antiviral treatments. This information 24 hours of use. Use it to (a) clean toilet seats and bathroom
guides health care providers in choosing treatment fixtures; (b) clean inside the refrigerator to avoid growth of
regimens that will most likely be effective against that mold; and (c) wash clothing separately that is soiled with
person’s virus. blood, urine, feces, or semen. Dishes are washed normally
in hot soapy water and rinsed thoroughly after use.
HIV
1. blood, semen, vaginal secretions, and breast milk
2. many

1
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2 Answers

REVIEW QUESTIONS—CONTENT REVIEW 5. (2) is correct. Fruits and vegetables increase bowel
function. (1, 3, 4) are incorrect.
The correct answers are in boldface. 6. (1) is correct. (2, 3, 4) are incorrect.
1. (2) is correct. AIDS is the final phase of a chronic progres- 7. (4) is correct. (1, 2, 3) are incorrect.
sive immune disorder caused by HIV. It is characterized 8. (2) is correct. Cooked vegetables are safer. (1, 3, 4) are
by a CD4+ T-lymphocyte percentage of less than 14% of incorrect because they contain raw foods, which are
total lymphocytes and the presence of one or more speci- riskier for infection.
fied clinical conditions, some of which are candidiasis, 9. (2) is correct. Standard precautions are used for all pa-
Pneumocystis pneumonia, cytomegalovirus (CMV) tients. (1, 3, 4) are incorrect.
disease, and Mycobacterium tuberculosis. (1, 3, 4) are 10. (4) is correct. Three large randomized controlled studies
incorrect. in Africa revealed strong evidence that male circumci-
2. (2) is correct. A complete blood count (CBC) and sion prevents men from acquiring HIV from heterosex-
CD4+/C8+ T-lymphocyte should be repeated at least ual sex. (a, b, c) are incorrect.
every 3 months. (1, 3, 4) are incorrect.

REVIEW QUESTIONS—TEST PREPARATION

The correct answers are in boldface.
3. (3, 4, 5) are correct. (1, 2) are incorrect.
4. (3) is correct. (1, 2, 4) are incorrect.
4069_Ans_Ch21_001-003 24/11/14 10:58 AM Page 1

Answers
CHAPTER 21
STRUCTURES OF THE CARDIOVASCULAR SYSTEM

Four pulmonary veins

Coronary arteries Left atrium

SA node
Aortic semilunar valve
Internodal pathway
Pulmonary semilunar valve Mitral valve
Left ventricle
Right atrium
Bundle of His
AV node
Tricuspid valve
Chordae tendineae
Papillary muscles Purkinje fibers

Right ventricle Bundle branches

CARDIAC BLOOD FLOW With age, the heart muscle becomes less efficient, and
there is a decrease in both maximum cardiac output and
1. 1 8. 8 heart rate. The health of the myocardium depends on
2. 11 9. 13 its blood supply. Hypertension causes the left ventricle to
3. 2 10. 9 work harder, so it may hypertrophy. The heart valves may
4. 4 11. 10 become thickened by fibrosis, leading to heart murmurs.
5. 14 12. 12 Dysrhythmias become more common in older adults as the
6. 7 13. 3 cells of the conduction pathway become less efficient.
7. 6 14. 5
CARDIOVASCULAR SYSTEM
AGING AND THE CARDIOVASCULAR SYSTEM
1. cardiovascular system
Corrections are in boldface. 2. heart’s
It is believed that the “aging” of blood vessels, especially 3. vascular system, capillaries
arteries, begins in childhood. Average resting blood pressure 4. stiffen
tends to increase with age and may contribute to stroke or 5. lubb, diastole
left-sided heart failure (HF). The thinner walled veins, espe- 6. absent, normal
cially those of the legs, may also weaken and stretch, making 7. cardiac, catheterization
their valves incompetent. 8. peripheral, pain, poikilothermia
9. vascular, venography

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ACUTE CARDIOVASCULAR NURSING

ASSESSMENT
1. Allergies 5. Crackles
2. Smoking 6. Dizziness
3. Pain 7. Fatigue
4. Weight gain 8. Pink-tinged sputum

CRITICAL THINKING: SUGGESTED ANSWERS

Constant monitoring of
Teaching vital signs, ECG Movable table used

Preprocedure prep NPO Procedure is 2 to Sensory preparation Awake

3 hours

Consent
Warm, flushing
Allergies—dye Room has a lot sensation with dye
of equipment

Cardiac Catheterization Teaching Plan

Dressing removal

Postprocedure care Activity restriction Discharge

Pulses Vital signs Follow-up care Activity

Insertion site pressure Insertion site care
applied/monitoring

REVIEW QUESTIONS—CONTENT REVIEW practical to use the leg because the higher reading arm
is available, although the leg could be used. (4) The arm
The correct answers are in boldface. with the lower reading should not be used.
1. (1) 15. (2) is correct. Blood pressure can drop by up to 15 mm
2. (2) Hg when a patient sits or stands, (1, 3) are incorrect,
3. (3) and (4) does not address the patient’s concerns or ex-
4. (4) plain the reason for the change.
5. (1) 16. (3) Pulse normally increases up to 20 beats per minute
6. (4) to compensate for the position change. (1) The patient
7. (1) does not need to return to bed. (2, 4) No cardiac symp-
8. (3) toms are expected because the body is compensating
9. (2) normally, and orthostatic hypotension is not present.
10. (4) 17. (2) Reduced blood supply results in a lack of oxygen
11. (2) and nutrients that contribute to the signs seen. (1, 3, 4)
12. (3) are incorrect.
18. (2) Medication is used in lieu of exercise when the patient
REVIEW QUESTIONS—TEST PREPARATION cannot tolerate exercise to simulate the increased blood
flow that would occur with exercise. (1, 3, 4) are incorrect.
The correct answers are in boldface. 19. (1, 3, 4, 6) are data related to a possible cardiac event or
13. (1) The leg reading is 10 mm Hg higher. (2, 3, 4) are dysrhythmia, which could be causing the fatigue and
incorrect. dizziness. (2, 5) are not of acute importance for these
14. (2) is the arm with the higher reading, which is what symptoms.
should be used. (1) The reading is lower. (3) It is not as
4069_Ans_Ch22_001-002 24/11/14 10:58 AM Page 1

Answers
hypertension treatment if lifestyle modification does not
CHAPTER 22 lower blood pressure.
2. Weight, smoking history, diet and salt intake, alcohol
VOCABULARY use, exercise patterns, life roles, finances, knowledge
base. Feedback: 5 feet 4 inches, 156 lb; does not smoke
1. (1) 7. (2) or use alcohol; salts food liberally, eats three meals and
2. (7) 8. (11) snacks, moderate fat intake; walks when time permits;
3. (6) 9. (10) deals with issues as they come, which is often in her
4. (5) 10. (9) roles as wife and mother to three children; has no pre-
5. (4) 11. (8) scription insurance coverage; knows very little about
6. (3) hypertension.
3. Individualized teaching plan for Mrs. Martin’s needs
DIURETICS should include addressing knowledge deficits through
1. (3) 6. (3) teaching according to protocols for weight management,
2. (2) 7. (1) diet and salt intake, exercise and sleep importance, and
3. (1) 8. (1) medications.
4. (3) 9. (2) 4. Provide information regarding the importance of control-
5. (2) ling her hypertension; financial assessment to ensure that
she has a funding source to buy medication because she
HYPERTENSION RISK FACTORS may need lifelong medication.
5. Blood pressure readings on follow-up visits are within
1. False normal limits with medication.
2. True
3. False REVIEW QUESTIONS—CONTENT REVIEW
4. True
5. False The correct answers are in boldface.
6. True 1. (3) Isolated systolic hypertension has been found in the
7. True older adult population when the systolic blood pressure
is 140 mm Hg or more but the diastolic blood pressure is
STAGES OF HYPERTENSION AND less than 90 mm Hg. (1) Primary hypertension is the re-
RECOMMENDATIONS FOR FOLLOW-UP sult of unknown causes. (2) Secondary hypertension has
1. False—1 year an identifiable cause.
2. True 2. (3) Stage 2 hypertension is classified as a systolic blood
3. True pressure of ⱖ160 mm Hg and a diastolic blood pressure
4. False—1 month of ⱖ100 mm Hg. (1) Prehypertension is systolic blood
5. True pressure 120 to 139 mm Hg and/or diastolic blood pres-
6. False—2 months sure 80 to 89 mm Hg. (2) Stage 1 is 140 to 159/90 to
7. True 99 mm Hg.
8. False—1 month 3. (1) Enalapril maleate (Vasotec) inhibits the conversion of
9. True angiotensin I to angiotensin II, thereby decreasing the
10. True levels of angiotensin II, which decreases vasopressor ac-
tivity and aldosterone secretion. (2, 3, 4) The actions of
CRITICAL THINKING enalapril maleate (Vasotec) achieve antihypertensive ef-
fects by suppression of the renin-angiotensin-aldosterone
1. Thiazide diuretics are one of the recommended first- system, but not by adjusting the fluid volume, dilating
line drugs. Diuretics remove excess salt and water to vessels, or decreasing cardiac output.
decrease blood volume and lower blood pressure. Hy- 4. (2) Propranolol (Inderal) blocks the effects of beta-
drochlorothiazide (HydroDIURIL) is a first-line drug for adrenergic stimulation, decreasing blood pressure,

1
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2 Answers

cardiac output, and cardiac contractility. (1, 3, 4) Propra- gastrointestinal distress, and nightmares are not com-
nolol (Inderal) does not increase heart rate, affect fluid mon side effects of metolazone.
volume, or increase cardiac contractility. 11. (3) Cough is a side effect of enalapril maleate. (1, 2, 4)
Acne, diarrhea, and heartburn are not common side ef-
REVIEW QUESTIONS—TEST PREPARATION fects of enalapril maleate.
12. (3) Stopping propranolol (Inderal) abruptly may cause
The correct answers are in boldface.
withdrawal syndrome. (1) Propranolol (Inderal) does
5. (2, 3, 4, 5) are modifiable risk factors for hypertension. not affect fluid volume or electrolytes unless combined
(1) Race is a nonmodifiable risk factor. with a diuretic. (2) Gastrointestinal side effects are not
6. (2) Hypertension is defined as a blood pressure of more common. (4) Patients are instructed to avoid prolonged
than 140/90 mm Hg on two separate occasions. standing and to make position changes slowly because
(1) Blood pressure measurement is the heart contracting they may experience hypotension.
or systolic, as well as relaxing, or diastolic. (3) Stress, ac- 13. (4) Knowledge is needed to control this chronic condi-
tivity, and emotions may temporarily raise blood pressure. tion. (1) Defining characteristics of activity intolerance
(4) Peripheral vascular resistance may help determine include abnormal electrocardiographic readings and
blood pressure, but it does not define hypertension. vital signs and reports of dyspnea or fatigue. (2) Ineffec-
7. (1) Smoking is associated with a high incidence of tive airway clearance is the state in which an individual
stages 1 and 2 hypertension. (2, 3) Patients who smoke is unable to clear secretions. (3) Impaired physical mo-
may show an increase in blood pressure because nico- bility is a temporary limitation of the ability to move
tine vasoconstricts the blood vessels. (4) Smoking is a freely, which is not the focus of care for hypertension.
major risk factor for cardiovascular disease but has not 14. (3) Although a patient may feel better after taking med-
been shown to cause hypertension. ication, the hypertension is well controlled but not cured.
8. (4) is correct. (1, 2, 3) do not have headache as a com- (1, 2, 4) Hypertension can damage the target organs if it
mon side effect. is not controlled. Accurate statements by patients regard-
9. (3) Medications for hypertension should be taken daily ing complications of hypertension and lifestyle modifica-
as directed. (1) Sunbathing may increase dehydration, a tions may indicate that patients are well informed.
side effect of the drug. (2) Lifestyle modifications are to 15. (1) The Joint National Committee (JNC) recommends
be continued with antihypertensive therapy. (4) The regular aerobic exercise to prevent and control hyperten-
medication is keeping the blood pressure lowered and sion. (2) Smoking, even low-tar cigarettes, is a risk fac-
will have to be taken daily. tor for heart disease. (3) Alcohol intake is limited to
10. (2) Thiazide diuretics reduce the reabsorption of potas- 1 oz/day by the JNC. (4) A daily multivitamin supplement
sium, so patients should be monitored for signs of hy- has not been shown to prevent or control hypertension.
pokalemia or muscle weakness. (1, 3, 4) Numb hands,
4069_Ans_Ch23_001-003 24/11/14 10:59 AM Page 1

Answers
13. False—enlarges
CHAPTER 23 14. True
15. False—Current guidelines consider antibiotics only for
VOCABULARY a few conditions before some invasive procedures.

1. annuloplasty 9. myocarditis CRITICAL THINKING—MRS. MURPHY

2. commissurotomy 10. petechiae
3. insufficiency 11. pericardiocentesis 1. Aging.
4. regurgitation 12. cardiac tamponade 2. Ask if there is a history of rheumatic fever.
5. stenosed 13. cardiomyopathy 3. The left ventricle increases atrial kick; the left ventricle
6. valvuloplasty 14. cardiomegaly hypertrophies to increase contractility.
7. chorea 15. myectomy 4. Left ventricular failure.
8. pericarditis 16. thrombophlebitis 5. Decreased coronary artery blood flow results from the
reduced cardiac output at the same time that the left
MITRAL VALVE PROLAPSE ventricular workload is increased. This imbalance in
oxygen supply and demand results in angina.
Corrections are in boldface. 6. Hypertrophy is a compensatory mechanism.
During ventricular systole, when pressures in the left ventri- 7. Sudden death may occur from aortic stenosis, so the
cle rise, the leaflets of the mitral valve normally remain valve is replaced.
closed. In mitral valve prolapse (MVP), however, the leaflets
bulge backward into the left atrium during systole. Often INFLAMMATORY AND INFECTIOUS
there are no functional problems seen with MVP. However, CARDIOVASCULAR DISORDERS
if the leaflets do not fit together, mitral regurgitation can 1. (2) 4. (3)
occur with varying degrees of severity. 2. (5) 5. (4)
MVP tends to be hereditary, and the cause is unknown. 3. (1)
Infections that damage the mitral valve may be a contributing
factor. It is the most common form of valvular heart disease RHEUMATIC FEVER AND RHEUMATIC
and typically occurs in women ages 20 to 55. Most patients HEART DISEASE
with MVP have no symptoms. Symptoms that may occur in-
clude chest pain, dysrhythmias, palpitations, dizziness, and Corrections are in boldface.
syncope. No treatment is needed unless symptoms are pres- Rheumatic fever is a complication of a streptococcal infec-
ent. Stimulants and caffeine should be avoided to prevent tion such as a sore throat. Rheumatic fever signs and symp-
symptoms. toms include polyarthritis, subcutaneous nodules, chorea
with rapid, uncontrolled movements, carditis, fever, arthral-
VALVULAR DISORDERS gia, and pneumonitis. A throat culture diagnoses a strepto-
1. False—narrowing coccal infection at the time of the infection. The heart
2. True valves and their structures can be scarred and damaged.
3. True Rheumatic fever can be prevented by detecting and treating
4. False—allows streptococcal infections promptly with penicillin.
5. True
6. False—mitral, aortic DIAGNOSTIC TESTS FOR INFECTIVE
7. True ENDOCARDITIS
8. False—late 1. (3)
9. True 2. (5)
10. True 3. (2)
11. True 4. (4)
12. True 5. (1)

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2 Answers

THROMBOPHLEBITIS

NURSING DIAGNOSIS
Acute Pain related to inflammation of vein

Interventions Rationale Evaluation

Assess pain using rating scale Self-report is the most reliable Does patient report pain using
such as 0 to 10. indicator of pain. scale?

Provide analgesics and Pain is reduced when inflamma- Is patient’s rating of pain lower
nonsteroidal anti-inflammatory tion is decreased. after medication?
drugs (NSAIDs) as ordered.

Apply warm, moist soaks. Heat relieves pain and vasodi- Does patient report increased
lates, which increases circulation comfort with warm, moist soaks?
to reduce swelling. Moist heat
penetrates more deeply.

Maintain bed rest with leg Elevation decreases swelling, Is swelling reduced?
elevation above heart level. which reduces pain.

NURSING DIAGNOSIS
Deficient Knowledge related to lack of knowledge about disorder and treatment

Interventions Rationale Evaluation

Explain condition, symptoms, Patient must have basic knowl- Is patient able to verbalize
and complications. edge to comply with therapy. knowledge taught?

Explain medications, therapies Adherence to the medication regi- Can patient explain medications,
ordered, monthly lab test men and safe use of medications therapies, lab tests, purpose of
monitoring, and need for Medic are promoted with an adequate Medic Alert identification?
Alert identification. knowledge base.

Teach patient not to massage Massage can dislodge an embolus. Does patient avoid massaging
extremity. extremity?

CRITICAL THINKING—MR. EVANS output, which the compromised heart is unable to pro-
vide, is not required.
1. Enlargement of heart muscle, especially along the sep- 6. The family will feel useful and included in the patient’s
tum without dilation of the ventricle, which does not care if they are taught cardiopulmonary resuscitation
relax or fill easily. (CPR). They will feel a sense of control and purpose in
2. Smaller, reduced because of decreased relaxation and the event that CPR is required.
size.
3. Chest x-ray. REVIEW QUESTIONS—CONTENT REVIEW
4. It would increase contractility in a heart that does not
relax easily, so filling would be decreased with even less The correct answers are in boldface.
relaxation. 1. (2) Impaired emptying of blood from the left ventricle
5. (a) Because cardiac output is reduced, dehydration must occurs because the blood cannot easily leave the left ven-
be avoided to prevent a further decrease in cardiac out- tricle through the narrowed aortic valve. (1) The aortic
put. (b) Exertion is avoided so that an increase in cardiac valve is narrowed. (3) Backflow of blood into the left
4069_Ans_Ch23_001-003 24/11/14 10:59 AM Page 3

Answers 3

atrium occurs with mitral regurgitation. (4) Impaired 14. (1) To prevent endocarditis from recurring because of in-
emptying of the left atrium occurs with mitral stenosis. creased risk from previous heart damage. (2) is not the rea-
2. (1) Backflow of blood into the left atrium occurs through son they are given. (3, 4) are not prevented by antibiotics.
the mitral valve, which does not close tightly. (2, 3, 4) 15. (3) They can cause the clot to dislodge and become
are incorrect. an embolus. (1) They do not prevent calf swelling.
3. (3) Ventricular hypertrophy occurs to help maintain car- (2) Preventing a life-threatening complication is the pri-
diac output. (1, 2, 4) are incorrect. ority. (4) They do not cause a clot to form.
4. (2) Left ventricular failure results in decreased cardiac 16. (3) is monitored for heparin. (1, 2, 4) are not monitored
output, which reduces oxygen to the tissues and causes for heparin; (2) and (4) are monitored for warfarin
fatigue. (1, 3, 4) are incorrect. (Coumadin) therapy.
5. (4) Cardiac catheterization measures chamber pressures. 17. (1) Vitamin K is the antidote. (2, 3, 4) are incorrect;
(1, 2, 3) do not. (4) is the antidote for heparin.
6. (4) is a bacterial infection that can precede rheumatic 18. (2) The desired outcome for pain is that it is satisfacto-
fever. (1, 2, 3) are incorrect. rily relieved according to patient. (1) is the outcome for
7. (3) Chest pain is the most common symptom, especially anxiety. (3, 4) would not be appropriate for a patient
with deep inspiration. (1, 2, 4) are incorrect. with acute thrombophlebitis because bedrest is ordered.
19. (2) A throat culture must be done to rule out a strepto-
REVIEW QUESTIONS—TEST PREPARATION coccal infection, which can lead to complications.
(1, 3, 4) are not as essential to prevent complications.
The correct answers are in boldface.
20. (2) The next dose of warfarin (Coumadin) should be
8. (3) The patient’s goal would be to be able to verbalize held and the health care provider informed because INR
knowledge of disorder. (1, 2, 4) are incorrect. and PT monitor Coumadin effects and they are over the
9. (1, 6) Furosemide helps prevent pulmonary edema, a high end of therapeutic range. (1) is incorrect because
complication of decreased cardiac output and heart fail- the PT is elevated and could cause bleeding. (3, 4) are
ure, and a potassium supplement is needed with incorrect because PT does not monitor heparin.
furosemide, a potassium-wasting diuretic. (2, 3, 4, 5) 21. (1, 5, 6) Bedrest is essential to prevent emboli develop-
help prevent complications that are not related to de- ment. It is OK to apply stocking to nonaffected leg to
creased cardiac output. prevent venous stasis. Heat provides pain relief and in-
10. (1) Determining the patient’s learning priorities helps creases circulation. (2, 3, 4) would encourage emboli
ensure that the patient is motivated to learn because the development if the affected leg is involved.
patient’s needs and not the nurses’ needs are being met. 22. (2) is above therapeutic range. (3) measures for heparin.
(2, 4) do not promote learning and may hinder it. (3) is (1) does not measure warfarin. (4) is therapeutic.
not correct. 23. (4) The patient is experiencing paroxysmal nocturnal
11. (1) Wearing Medical Alert identification is essential in dyspnea, which occurs from increased fluid returning to
case of a bleeding problem or loss of consciousness. the heart from reclining; the fluid then builds up in the
(2) An increased intake of green leafy vegetables can lungs. (1, 2, 3) are incorrect.
counteract the effects of warfarin (Coumadin) because 24. (2) Anorexia is a side effect of digoxin (Lanoxin). (1, 3, 4)
they contain vitamin K, the antidote for Coumadin. are incorrect.
(3) Blood test appointments are monthly. (4) An electric 25. (2)
razor is to be used when shaving. 45 mg 2 mL
= 1.5 mL (1, 3, 4) are incorrect
12. (1) If the patient understands to breathe normally when 60 mg
moving, Valsalva’s maneuver will not occur. (2, 3) are 26. (4) Pericardial friction rub indicates inflamed pericar-
incorrect. (4) results in Valsalva’s maneuver. dial tissue and would be the highest priority for this
13. (4) Dyspnea and coughing are indicators of heart failure patient. (1) Bronchovesicular sounds over the major
because of fluid congestion in the lungs, so you would airways are a normal finding. (2, 3) Chest soreness and
listen to lung sounds to see if crackles are present. tenderness and sternal bruising are expected with chest
(1, 2, 3) are not the current priority. trauma and are not the highest priority.
4069_Ans_Ch24_001-002 24/11/14 10:59 AM Page 1

Answers
muscle becomes damaged and no longer functions prop-
CHAPTER 24 erly. Ischemic injury takes several hours before complete
necrosis and infarction take place. The ischemic process
VOCABULARY affects the subendocardial layer, which is most sensitive
to hypoxia. Myocardial contractility is depressed, so the
1. (4) 11. (3) body attempts to compensate by triggering the autonomic
2. (9) 12. (1) nervous system. This causes an increase in myocardial
3. (13) 13. (8) oxygen demand, which further depresses the myocardium.
4. (10) 14. (11) After necrosis, the contractility function of the muscle is
5. (18) 15. (14) permanently lost. If treatment is initiated at the first sign
6. (16) 16. (19) of an MI, the area of damage can be minimized. If pro-
7. (12) 17. (15) longed ischemia occurs, the size of the infarction can be
8. (2) 18. (17) quite large.
9. (5) 19. (20) The area that is affected by an MI depends on which
10. (7) 20. (6) coronary artery is involved. The left anterior descending
(LAD) branch of the left main coronary artery is the area
ATHEROSCLEROSIS that feeds the anterior wall. The right coronary artery
1. A fatty streak appears on the lining of an artery. This (RCA) feeds the inferior wall and parts of the atrioventric-
buildup of fatty deposits is known as plaque. Plaque has ular node and the sinoatrial node. An occlusion of the
irregular, jagged edges that allow blood cells and other RCA leads to an inferior MI and to abnormalities of impulse
material to adhere to the wall of the artery. With time, conduction and formation. The left circumflex coronary ar-
this buildup can cause stenosis of the vessel, which leads tery feeds the lateral wall and part of the posterior wall of
to partial or total occlusion of the artery. When this oc- the heart.
curs, the area distal to it can become ischemic due to Pain is the most common symptom. The pain may radi-
lack of blood flow. This buildup will become calcified ate to one or both arms and shoulders, the neck, and the
and harden, leading to damage of the vessel with loss of jaw. The patient usually denies that an MI is occurring. Other
elasticity and compliance. symptoms may include restlessness, a feeling of impending
2. Cigarette smoking, hypertension, elevated serum choles- doom, nausea, diaphoresis, and cold, clammy, ashen skin.
terol, diabetes mellitus, obesity, stress, and sedentary The only symptom that might be present in the older adult
lifestyle. may be a sudden onset of shortness of breath. Women may
3. Determine readiness to learn. Example for smoking: have atypical symptoms of an MI.
Explain what occurs when one smokes, including The three strong indicators of an MI are patient history,
changes to vessels and effect on blood flow. Determine abnormal electrocardiographic (ECG) readings, and troponin
when patient craves cigarettes most, and teach patient I levels.
to try a different activity to distract from smoking. Teach Initially, patients are kept on bedrest to decrease myocar-
patient to avoid caffeine products—chocolate, cocoa, dial oxygen demand. Patients are medicated promptly when
and caffeinated soft drinks. Avoid stimulants. Increasing experiencing chest pain. Morphine sulfate is the most
fluid intake, especially during the first 3 days of quitting widely used narcotic for MI. It helps decrease anxiety, slows
smoking, will help wash nicotine out of the system. respirations, and vasodilates the coronary arteries. Oxygen
Have patients read books instead of magazines; maga- is given usually at 2 L/min via nasal cannula. Nitroglycerin
zines have many cigarette ads. sublingual, topical, or by intravenous (IV) drip can also be
administered. PCI is a frequent treatment option for an oc-
cluded coronary artery.
MYOCARDIAL INFARCTION A nursing care plan should include factors that may con-
Corrections are in boldface. tribute to increased cardiac workload. Changes in diet, stress
reduction, regular exercise program, cessation of smoking,
Myocardial infarction (MI) is the death of a portion of the and following a medication schedule require extensive
heart muscle caused by a blockage or spasm of a coronary patient and family teaching.
artery. When the patient has an MI, the affected part of the

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2 Answers

PHARMACOLOGICAL TREATMENT placed on it during exercise. The heart’s ability to con-

tinue adapting is related to the adequacy of blood sup-
1. (4) 6. (6) plied to the myocardium through the coronary arteries.
2. (3) 7. (9) If the patient develops chest pain, dangerous cardiac
3. (1) 8. (5) rhythm changes, or significantly elevated blood pres-
4. (7) 9. (8) sure, the diagnostic testing is stopped. (1, 2, 3) are
5. (2) 10. (10) incorrect.
7. (4) When a patient is apprehensive and afraid, the nurse
CRITICAL THINKING should listen and encourage patient expression of feel-
1. (1) is correct. Patient will exhibit signs of increased arte- ings. This can ease the mental burden and help the
rial blood flow and tissue perfusion. patient feel less overwhelmed, alone, and helpless. Lis-
2. Associated with arterial occlusive disease. This is pain in tening is an active process even if the patient does most
the calves of the lower extremities associated with activ- of the talking. (1) Learning is impaired during times of
ity or exercise. With poor blood supply to the muscles, anxiety. (2) Avoiding the subject may indicate to the
they are unable to receive increased oxygen to meet the patient that the nurse does not care. (3) How others
demand of increased activity. As ischemia increases, a have done ignores the fact that for this person, the
cramping-type pain develops. experience is unique.
3. When activity stops, the muscle does not have increased 8. (1) If nitroglycerin tablets are fresh, the patient should
oxygen demand, so the pain begins to subside with rest. feel a tingling or fizzing in the mouth. Tablets usually
4. Smoking contributes to loss of high-density lipoproteins need to be replaced about every 3 months. (2, 4) Nitro-
(HDL), which is the best type of cholesterol to have in glycerin tablets do not disintegrate or change color
order to decrease the risk of cardiovascular disorders. when old. (3) Aspirin smells like vinegar when it be-
The rate of progressive damage to vessels is increased comes old.
with smoking. Smoking also contributes to vasoconstric- 9. (2) Fresh vegetables without added salt are low in
tion, which reduces blood delivery to muscles and can sodium. (1, 3, 4) are high in sodium.
also lead to angina and cardiac dysrhythmias. 10. (1, 4, 5) Hypertension and diabetes can be controlled
with proper diet, exercise, and medications. Smoking
REVIEW QUESTIONS—CONTENT REVIEW can be stopped. (2, 3) cannot be changed.
11. (3, 5, 6) Saturated fats come primarily from animal
The correct answers are in boldface. products and some plants including the “tropical
1. (3) Iodine is the base for the radiopaque dye used for oils”—palm oil and coconut oil. Avocado, tuna, and
the arteriogram. Notify the health care provider if the olive oil have polyunsaturated fats. See the American
patient is allergic to it. The health care provider may Heart Association website.
cancel the procedure or take other precautions, such 12. (1, 2, 4) are all found with venous insufficiency. (3) is
as the administration of an antihistamine or other not correct because edema, moderate to severe, is a
emergency medication. (1, 2, 4) are not related to the manifestation of venous insufficiency. (5) is not a
test dyes used. sign of venous insufficiency but may indicate throm-
2. (3) Pulmonary edema. These symptoms are classic signs bophlebitis. (6) Hyperemia is an intense reddening of
of pulmonary edema. (1, 2, 4) Respiratory distress may the hands and is associated with arterial spasm/Ray-
be observed, but the frothy sputum is symptomatic of naud’s disease.
pulmonary edema. 13. (2, 3, 6) Pain is the outstanding symptom; cramping is
3. (2) Capillary refill is normally less than 3 seconds. (1, 3, 4) also a feature to a lesser extent; intermittent claudica-
are all symptomatic of atherosclerosis. tion and other symptoms of occlusive disease are com-
4. (3) 7% Kcal as saturated fat can help reduce LDL. (1, 2, 4) mon. (1, 4, 5) Numbness, swelling, and bounding
are incorrect and will likely raise LDL. pulses are not characteristic.
5. (3) Lack of sufficient oxygen to the myocardium is 14. (2) Arteriolar vasoconstriction. (1, 3, 4) are not descrip-
the cause of chest pain. (1) causes wasting of heart tive of Raynaud’s disease.
muscle. (2) causes dysrhythmias. (4) will not cause
chest pain unless oxygen supply is insufficient to meet
the workload.

REVIEW QUESTIONS—TEST PREPARATION

The correct answers are in boldface.
6. (4) A stress ECG demonstrates the extent to which the
heart tolerates and responds to the additional demands
4069_Ans_Ch25_001-002 24/11/14 10:59 AM Page 1

Answers
CARDIAC CONDUCTION
CHAPTER 25
1. (5) 13. (22)
2. (9) 14. (20)
VOCABULARY 3. (12) 15. (14)
1. (19) 12. (10) 4. (18) 16. (3)
2. (9) 13. (16) 5. (24) 17. (19)
3. (5) 14. (1) 6. (21) 18. (16)
4. (15) 15. (7) 7. (17) 19. (4)
5. (8) 16. (14) 8. (1) 20. (7)
6. (4) 17. (3) 9. (23) 21. (10)
7. (12) 18. (17) 10. (13) 22. (11)
8. (11) 19. (20) 11. (8) 23. (6)
9. (21) 20. (18) 12. (15) 24. (2)
10. (2) 21. (6)
11. (13) ELECTROCARDIOGRAM INTERPRETATION
A.
COMPONENTS OF A CARDIAC CYCLE 1. Rhythm: Regular
2. Heart rate: 39 beats per minute
R 3. P waves: Smoothly rounded and upright in lead II,
precede each QRS complex, alike
4. PR interval: 0.16 second
5. QRS interval: 0.10 second
6. QT interval: 0.40 second
7. Electrocardiogram (ECG) interpretation: Sinus
P wave T wave
bradycardia

B.
P T
8. Rhythm: Regular
9. Heart rate: 100 beats per minute
Q S
10. P waves: Smoothly rounded and upright in lead II,
ST segment precede each QRS complex, alike
PR interval 11. PR interval: 0.14 second
12. QRS interval: 0.06 second
13. QT interval: 0.34 second
QRS
complex 14. Electrocardiogram (ECG) interpretation: Normal sinus
rhythm

HEART RATE CRITICAL THINKING

1. 100 1. Assess patient: vital signs, heart sounds, note symptoms,
2. 110 place on heart monitor per agency protocol.
3. 80

1
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2 Answers

2. Report the patient findings to the registered nurse or health 9. (2) Digoxin (Lanoxin) slows the heart rate and in-
care provider. Elevate head of bed for comfort, monitor vital creases the force of contraction. (1) To decrease ectopic
signs, maintain oxygen per nasal cannula at 2 L/min per beats, an antiarrhythmic would be given. (3) To relieve
agency protocol, remain with patient to help alleviate anxiety. chest pain, nitroglycerin would be given sublingually or
3. Hypokalemia or ischemia causing irritability of the heart. intravenously. (4) To raise blood pressure, a vasopressor
4. Light-headedness, feel heart skipping, chest pain, or fatigue. such as dopamine would be given.
5. ECG, oxygen, administration of potassium, electrolyte lev- 10. (1) Atrial fibrillation can cause interruptions in the
els; may consider antidysrhythmic agent if symptomatic. movement of blood through the heart and the forma-
tion of a thrombus, with serious consequences. Aspirin
REVIEW QUESTIONS—CONTENT REVIEW or warfarin will be used to prevent thrombus forma-
tion and remain an important component of patient
The correct answers are in boldface.
care. (2) Swelling of feet, often an early sign of heart
1. (3) The complete heartbeat consisting of contraction, failure, could be a less serious result of atrial fibrilla-
or systole, and relaxation, or diastole, of the atria and tion. (3) is not contraindicated, although an exercise
ventricles. (1, 2) The circulation of the blood is a result routine should be carefully constructed for a patient
of the action of the cardiac cycle. (4) is the contraction with a cardiac history. (4) is a psychosocial concern
portion of the cardiac cycle. and not the highest priority for this patient.
2. (3) The superior and inferior vena cava. (1) delivers the 11. (1, 3, 4, 5) are appropriate treatments for atrial
blood back to the left side of the heart after oxygenation fibrillation. (2) Nitroglycerin is not an appropriate
in the lungs. (2) receives the blood pumped from the left treatment. (6) Epinephrine is not a treatment for atrial
ventricle into the systemic circulation. (4) is a part of the fibrillation.
heart’s own circulation. 12. (1) Three or more premature ventricular contractions
3. (4) is correct. (1) controls the flow of blood from one (PVCs) in a row constitute ventricular tachycardia.
heart chamber to another and into the pulmonary and (2) Bigeminy is a PVC every second beat. (3) Trigeminy
systemic circulations. (2) is the sac covering the heart. is a PVC every three beats. (4) Multifocal PVCs are
(3) collects blood that is then pumped out of the heart PVCs arising from different foci in the ventricle and
into the circulation. therefore vary in appearance.
4. (1) The left ventricle is the largest chamber. (2) The right 13. (4) In a hemodynamically stable patient, treatment with
ventricle is smaller. (3, 4) Both the right and the left atria medication is the first choice. (1) Cardioversion would
are smaller than either ventricle. be tried only if other measures did not work. (2) Pacing
5. (4) The T wave represents ventricular repolarization, is not an option for this. (3) Defibrillation is not appro-
or the resting state of the heart when the ventricles are priate treatment.
filling with blood and preparing to receive the next 14. (2) is the correct answer. (1) is the name of the rhythm
impulse. (1) The P wave represents atrial depolariza- of a dying heart with wide QRS complex and slowing
tion. (2) the QRS represents ventricular depolarization. irregular rate. (3) is the absence of a firing mechanism
(3) The U wave is frequently seen in patients with in the sinus node. (4) is a pattern with no ventricular
hypokalemia. activity.
6. (3) 60 to 100 beats per minute is the inherent rate for the 15. (3) Elevate the head of the bed and start oxygen by
sinoatrial node. (1) is the inherent rate for the ventricles. nasal cannula per agency policy to improve oxygena-
(2) is the normal rate for the atrioventricular node. (4) is tion because oxygen hunger is a common cause of
not a normal heart rate. heart irritability. (2) Call the health care provider
7. (3) Sinus rhythms identify the impulse as having origi- next. (1) Then with orders, an ECG is next. (4) is
nated in the sinoatrial node. (1) Escape beats are late not an appropriate action.
beats occurring when a more rapid focus fails to initiate 16. (4, 5) Third-degree heart block requires a permanent
a beat. (2) A block occurs when the normal conduction pacemaker, and symptomatic bradycardia may require
pathway of the heart is disturbed. (4) Ectopic rhythms it depending on the cause. (1, 2, 3, 6) do not require a
are abnormal beats. permanent pacemaker.

REVIEW QUESTIONS—TEST PREPARATION

The correct answers are in boldface.
8. (2) Examine patient. Monitored rhythms can be decep-
tive. Always “treat the patient, not the monitor.” (1, 3, 4)
may be appropriate actions after the patient is examined,
if indicated.
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Answers
Right-sided Heart Failure
CHAPTER 26 Right ventricle → right atrium → vena cavae → jugular vein
distention → hepatomegaly → splenomegaly → peripheral
VOCABULARY edema

1. Pulmonary edema (acute heart failure)

2. Cor pulmonale
3. splenomegaly, hepatomegaly
4. peripheral vascular resistance
5. Paroxysmal nocturnal dyspnea
6. preload
7. afterload
8. Orthopnea

FLUID ACCUMULATION PATTERNS

Left-sided Heart Failure
Left ventricle → left atrium → pulmonary veins → lungs

SIGNS AND SYMPTOMS OF HEART FAILURE

1. (1) 5. (2)
2. (2) 6. (1)
3. (1) 7. (2)
4. (2) 8. (1)

CRITICAL THINKING
1. Left-sided heart failure (HF) leading to backward fluid
accumulation in lung tissues and decreased cardiac
output.
2. Left: dyspnea, cough, crackles, orthopnea. Right: jugular
vein distention, peripheral edema.

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2 Answers

3. (a) Potent diuretic to reduce fluid congestion and fluid 5. (4) The heart is failing as a pump to move blood
returning to the heart (preload) to improve cardiac out- forward. (1) occurs in cardiac arrest, (2) occurs in
put. (b) Decreases afterload. Decreases cardiac hypertro- a myocardial infarction, (3) is the opposite of what
phy. (c) Restricting sodium may reduce fluid volume and occurs with heart failure.
aid in reducing edema. (d) Provides greater availability 6. (3) Fluid in the lungs is heard as crackles. (1, 2, 4) are
of oxygen to the tissues by increasing the percentage of related to right-sided heart failure.
oxygen in inhaled air. 7. (1) If fluid accumulates from heart failure, weight will
4. Mr. Donner is experiencing acute HF—pulmonary increase and is detectable by daily weights. (2) would
edema. Fluid accumulation in his lungs is severe and be monitored for problems with an adequate caloric in-
requires immediate treatment. take, not a fluid problem. (3) would be monitored for
5. (a) Decreases fluid returning to the heart (preload) to the effects of digitalis toxicity. (4) would be monitored
ease the heart’s workload and improve cardiac output. for ascites development.
(b) Provides greater availability of oxygen in inhaled air. 8. (2) Lanoxin increases the strength of the heart’s con-
(c) Potent diuretic; when given intravenously (IV) has a traction. This allows better emptying of the ventricle,
quicker onset of action to reduce the amount of fluid which improves cardiac output and increases blood
congestion and fluid returning to the heart to improve flow to the kidneys, so increased urine output occurs.
cardiac output. (d) Decrease preload, which reduces car- (1) If urine output decreases, the Lanoxin has not im-
diac workload. (e) Sedative action reduces anxiety, and proved cardiac output to increase blood flow to the
given IV, it has a quicker onset of action. kidneys. (3) Lanoxin slows the heart rate. A rapid heart
6. Excess Fluid Volume related to (r/t) pump failure; clear rate occurs to compensate for reduced cardiac output.
breath sounds and free of edema. Activity Intolerance (4) A slow heart rate is expected with Lanoxin, but
r/t fatigue; tolerates activity with appropriate increases below 50 beats per minute is slower than desired for
in heart rate, blood pressure, and respirations. Sleep effectiveness.
Pattern Disturbance r/t nocturnal dyspnea; awakens 9. (1) Poor appetite is a common sign of Lanoxin toxicity.
refreshed and is less fatigued during day. Impaired Gas (2) Diarrhea is a side effect of Lanoxin. (3) Yellow
Exchange r/t pump failure; maintains clear lung fields. lights, not halos, are a sign of toxicity. (4) Bradycardia
Anxiety r/t dyspnea; verbalizes decrease in anxiety. Self- occurs with toxicity.
Care Deficits (total) r/t fatigue and dyspnea; activities 10. (4) Furosemide is a loop diuretic that may deplete elec-
of daily living (ADLs) completed with assistance. Inef- trolytes, especially potassium, so ongoing monitoring of
fective Therapeutic Regimen Management r/t lack of potassium is necessary. (1, 2, 3) are not affected directly
knowledge; states understanding of treatment plan and by furosemide (Lasix) and are not monitored for this
willingness to follow it. therapy.
7. Signs and symptoms of heart failure; medications; pur- 11. (1, 5) Morphine sulfate is given to relieve the patient’s
pose, monitoring (heart rate, potassium), side effects; anxiety caused by the dyspnea of pulmonary edema. It
diet; energy conservation; daily weights. also reduces preload and afterload to decrease the work-
load of the failing heart. (2) Chest pain is usually asso-
REVIEW QUESTIONS—CONTENT REVIEW ciated with a myocardial infarction, not pulmonary
edema. (3) It does not strengthen the heart’s contrac-
The correct answers are in boldface.
tion. (4) It may decrease blood pressure.
1. (3) 0.25 mg by mouth (PO) is the usual adult daily dose 12. (3) is a common sign of pulmonary edema. (1, 2) are
of digoxin (Lanoxin). (1, 2) are less than the usual daily associated with right-sided heart failure. (4) Tachycar-
dose of Lanoxin. (4) is greater than the usual daily dose dia occurs in pulmonary edema as a compensatory
of Lanoxin. mechanism.
2. (1) Hypokalemia may predispose to Lanoxin toxicity. 13. (4) Inotropic agents strengthen the heart’s contractions.
(2, 3, 4) do not predispose to Lanoxin toxicity. (1) An agent that slows the heart rate is a chronotropic
3. (4) The right ventricle enlarges from the extra work- agent. (2) An inotropic agent does not increase heart
load that occurs from the increased pulmonary pres- rate. (3) Conduction time is not affected by the in-
sures while ejecting blood into the pulmonary artery. otropic property of a medication.
(1, 2, 3) are not directly affected by pulmonary 14. (1) Furosemide is a potent diuretic that works quickly
pressures. when given IV to increase urine output and subse-
quently pull fluid from extravascular spaces, thereby
REVIEW QUESTIONS—TEST PREPARATION reducing fluid in the lungs so bilateral crackles will di-
minish. (2, 3, 4) are not the reasons a diuretic is given.
The correct answers are in boldface.
15. (2) An anxious patient is comforted by the presence of
4. (2) Decreased cardiac output occurs with heart failure, the nurse and does not want to be left alone. (1) would
leading to reduced oxygenation of the tissues and there- increase oxygen needs and increase dyspnea and anxiety.
fore fatigue. (1, 3, 4) all result from heart failure, as does (3, 4) could make the dyspneic patient feel more
fatigue. They do not cause the fatigue. confined, increasing dyspnea and anxiety.
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Answers
4. Purpura
CHAPTER 27 5. Thrombocytopenia

VOCABULARY LYMPHATIC SYSTEM

1. Ecchymosis 1. (2) 4. (1)
2. Lymphedema 2. (4) 5. (3)
3. Petechiae 3. (5)

BREAKDOWN OF RED BLOOD CELLS

1 _______________
Liver
Spleen
2 _______________

Globin
3 __________________
+
Heme
4 __________________

Iron
6 __________________
Amino Acids
5 __________________ +
Bilirubin
7 __________________
Fe+

Proteins
8 __________________ Bone Marrow
9 _______________ Intestines
10 ________

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HEMATOLOGIC SYSTEM REVIEW QUESTIONS—TEST PREPARATION

1. (10) 6. (3) The correct answers are in boldface.
2. (6) 7. (4)
7. (2) is correct. The international normalized ratio (INR)
3. (2) 8. (1)
should be between 2 and 3; 1.6 is low. (1) The patient is
4. (7) 9. (8)
unlikely to bleed with a low INR. (3) The dose should
5. (9) 10. (5)
be altered only by the health care provider. (4) Vitamin
K might be given if the INR is prolonged.
CRITICAL THINKING 8. (3) is correct. The transfusion must be stopped immedi-
1. Fever may indicate a febrile or hemolytic reaction. Back ately because these are symptoms of a possible deadly
pain is an early symptom of hemolytic reaction. Respira- hemolytic reaction. (1) A head-to-toe examination
tory distress may signal circulatory overload or anaphy- would be nice, but this is an emergency and there is no
laxis. Crackles are a symptom of circulatory overload. time for that. (2) There is no time for a pain assessment.
Hives indicate an urticarial reaction. (4) An analgesic can be administered after emergency
2. Even though 20 breaths per minute may be normal, it is care has stabilized the patient.
an increase for Mr. Foster. A thorough assessment should 9. (2) is correct. A bone marrow biopsy is painful.
be done and the registered nurse notified in case this is (1) Explaining the procedure to the family should be
an early sign of a reaction. done, but it is not as important as pain control for the
3. The maximum time blood can hang is 4 hours from the patient. (3) The patient is observed for bleeding after,
time it is picked up from the blood bank. not before, the procedure. (4) The health care provider
can drape the site.
REVIEW QUESTIONS—CONTENT REVIEW 10. (4) is correct. Neutrophils comprise 54% to 75% of the
white blood cell count and are a critical component in
The correct answers are in boldface.
protecting patients from infection. (1) is a normal
1. (4) is correct. WBC, (2) is a low platelet count but increases risk for
2. (4) is correct. bleeding not for infection, (3) is a normal hematocrit
3. (2) is correct. and does not correlate with infection risk.
4. (3) is correct. The partial thromboplastin time (PTT) is
monitored for heparin therapy. (1, 2) are used to monitor
warfarin therapy. (4) indicates platelet function.
5. (4) is correct. Cryoprecipitate contains clotting factors.
(1, 2, 3) do not contain clotting factors.
6. (2, 3, 4, 5, 6)
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Answers
was confirmed in a laboratory test by the presence of Reed-
CHAPTER 28 Sternberg cells. He expresses his fears to his nurse, who tells
him that although Hodgkin’s disease is a cancer, it is often
VOCABULARY curable. Joe takes a leave from work and begins curative ra-
diation therapy. (At age 28, it would be very unusual for Joe
1. False 7. False to choose palliative therapy.)
2. True 8. False
3. True 9. True SICKLE CELL ANEMIA
4. True 10. False
5. False 11. True
6. True 12. True Brain:
Thrombosis
CRITICAL THINKING: LEUKEMIA Hemorrhage
Brain attack (stroke)
1. Mr. Frantzis is in the final stage of his disease, and he Eyes:
has opted for no treatment. Rehabilitation is no longer a Retinal or conjunctival
hemorrhage
goal. On days when he is feeling especially tired, it Blindness
would be appropriate to bring him his breakfast in bed.
A liquid supplement that is easy to drink might also be Lungs: Heart:
Atelectasis Failure
helpful.
Infarction
2. Do a complete pain assessment using the WHAT’S UP? Pneumonia
format. The pain might be sternal or rib tenderness from Abdominal organs: Kidney:
crowding of bone marrow. Administer analgesics as Hepatomegaly Dilute urine
Gallstones Diuresis
ordered. Hematuria
Splenic enlargement
3. Not all runny noses are infectious. Find out if the nursing Splenic infarction
assistant has a cold. If so, reassign Mr. Frantzis’s care to
another assistant because he is at risk for infection.
4. Mr. Frantzis may be developing confusion if the Penis:
Bones and joints: Priapism
leukemia has invaded the central nervous system. Clarify Hand and foot syndrome
with him who Jennifer is, and assess him for confusion.
(Keep in mind that you may look like someone named
Skin:
Jennifer, and he may not be confused at all.) If he is be- Stasis ulcers
coming confused, assess for other causes, such as med-
ication use or oxygen saturation, and institute measures
to keep him safe.
5. Provide good mouth care after each meal and as re-
quired. Use a soft toothbrush or a swab if irritation is
severe. Avoid giving him foods that are irritating, acidic,
or extremely hot or cold. If he has dentures, remove for REVIEW QUESTIONS—CONTENT REVIEW
cleaning and at bedtime. Inspect his mouth carefully
The correct answers are in boldface.
while dentures are out.
1. (2) is correct. Red meat is high in iron. (1, 3, 4) are not as
CRITICAL THINKING: HODGKIN’S DISEASE high in iron.
2. (4) is correct. The conjunctivae are pale in a patient with
Corrections are in boldface.
anemia. (1, 2, 3) are not necessarily pale in anemia, espe-
Joe is a 28-year-old construction worker diagnosed with stage cially in a dark-skinned patient.
I Hodgkin’s disease. He initially went to his health care 3. (1) is correct. The patient with anemia may experience
provider because of a painless lump in his neck. He is also palpitations as an early compensatory mechanism. (2, 3, 4)
experiencing low-grade fevers and weight loss. The diagnosis are later signs.

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2 Answers

4. (4) is correct. Multiple myeloma attacks bone, making it 12. (3) is correct. The best measure of effective teaching is
prone to fractures. (1, 2, 3) are not directly related to actual change in behavior, as evidenced by the patient
multiple myeloma. using an electric razor. (1, 2, 4) are all good measures of
5. (1) is correct. Fluids help dilute and promote excretion of learning, but they are not as convincing as the actual
calcium. (2) Respiratory problems are not related to hyper- change in behavior.
calcemia. (3) Activity should be encouraged to keep cal- 13. (2) is correct. Often the patient knows best when
cium in the bones. (4) Heat will not affect calcium levels. bleeding is occurring, and treatment should be initi-
6. (1) is correct. Vitamin K can help correct clotting prob- ated as soon as possible. (1) Deep palpation may in-
lems and prevent bleeding during surgery. (2, 3, 4) are jure tissue and worsen bleeding. (3) An x-ray will
not affected by vitamin K. waste valuable time when the patient could be receiv-
ing treatment. (4) Heat is a vasodilator and could in-
REVIEW QUESTIONS—TEST PREPARATION crease bleeding. Also, waiting before beginning
treatment is not recommended.
The correct answers are in boldface.
14. (4) is correct. Fatigue is subjective and is best described
7. (2) is correct. A high incision often discourages deep by the patient. (1, 2, 3) may be indirectly related to fa-
breathing and coughing because of the resulting pain. tigue, but they rely on the nurse’s interpretation.
This can result in infection. (1) Platelet count is not re- 15. (1) is correct. Crowds of people will increase risk of ex-
lated to infection. (3, 4) Early ambulation and discharge posure to infection, and lymphoma affects the immune
may help prevent infection. system. (2, 3, 4) do not expose the patient to infection.
8. (4) is correct. Fever is a sign of infection. (1, 2, 3) are 16. (3) is correct. This can assist the patient to identify sup-
not signs of infection. port systems that will help the patient cope. (1, 2) offer
9. (2) is correct. Hemoglobin carries oxygen to tissues; he- false reassurance. (4) is inappropriate because there is
moglobin level is reduced in anemia. (1) Oxygen trans- no evidence that the patient is terminal at this time, and
port to tissues is the problem. (3) Oxygen, not nutrients, it will not help coping. It may be addressed at a time
is the problem. (4) Anemia does not cause lung damage. when the patient is coping better.
10. (2) is correct. Chilling and exercise may both con- 17. (3) is correct. Vaccines will help guard against infection.
tribute to hypoxemia and a crisis. (1, 3, 4) do not (1, 2) do not help prevent infection; (4) is unnecessary.
cause hypoxemia.
11. (1) is correct. Infarction of small bones in the fingers
and toes causes unequal growth. (2, 3, 4) are not symp-
toms of hand-foot syndrome.
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Answers
CHEST DRAINAGE
CHAPTER 29
VOCABULARY
1. dyspnea
2. crepitus
3. thoracentesis
4. barrel
5. excursion
6. adventitious
7. tracheotomy
8. tidaling
9. apnea
10. tracheostomy

ANATOMY
1, 4, 6, 5, 7, 8, 3, 2

VENTILATION
1, 4, 3, 6, 2, 5, 7

ADVENTITIOUS LUNG SOUNDS

1. (5) 3. (6) 5. (3)
2. (1) 4. (4) 6. (2)

1
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THE RESPIRATORY SYSTEM

Larynx

Trachea

Carina
Left primary
bronchus

Left secondary
Bronchial tree bronchus

Secondary bronchi
Left tertiary
Tertiary bronchi bronchus

Bronchioles Bronchioles

Alveolar sacs

CRITICAL THINKING 3. A chest x-ray and sputum culture and sensitivity will
1. Mr. Howe’s cough should be assessed using the be ordered. Additional tests for TB are discussed in
WHAT’S UP? technique. He should be asked how it Chapter 31.
feels, how bad it is, what makes it better or worse, and 4. Mr. Howe should be kept NPO (nothing by mouth) ac-
when it started. In addition, he should be asked about cording to institution policy before the bronchoscopy. An
amount, color, odor, and consistency of sputum. injection of atropine may be ordered to dry secretions.
2. Night sweats, cough, and weight loss are symptoms of After the test, Mr. Howe’s vital signs and respiratory sta-
tuberculosis (TB). Bloody sputum is also common. tus should be closely monitored. Mr. Howe will remain
These symptoms should alert the nurse to ask the health NPO until his gag reflex returns. The nurse should con-
care provider about the likelihood of TB and the need for sult the health care provider’s orders for additional post-
isolation to protect staff and other patients. procedure instructions.
4069_Ans_Ch29_001-003 24/11/14 11:00 AM Page 3

Answers 3

REVIEW QUESTIONS—CONTENT REVIEW appropriate, but oxygen should be tried first. (4) Nor-
mal SpO2 is 95% to 100%.
The correct answers are in boldface. 10. (4) is correct. “Good lung down” has been shown
1. (4) is correct. to increase oxygenation. (1, 2, 3) do not increase
2. (2) is correct. oxygenation.
3. (4) is correct. 11. (1) is correct. Assistance with cleaning the catheter two
4. (2) is correct. to three times a day should be provided. (2) Transtra-
5. (3) is correct. cheal oxygen usually prevents the need for another oxy-
6. (3) is correct. Cilia help remove potential pathogens. gen source. (3) Removal of the catheter for this length
(1, 2, 4) are not affected by changes in cilia. of time may cause the tract into the trachea to close.
7. (2) is correct. Wheezes sound like a violin. (1) Crackles Also, if removed, another oxygen source would be
sound like Velcro being pulled apart. (3) A friction rub needed. (4) A transtracheal catheter is not hooked to
sounds like leather rubbing together. (4) Crepitus is not humidification.
an adventitious sound. 12. (4) is correct. Chest physiotherapy (CPT) helps mobi-
8. (1) is correct. Pursed-lip breathing helps excrete carbon lize secretions. (1) CPT does not affect chest muscles.
dioxide. (2, 3, 4) are not promoted by pursed-lip breathing. (2) CPT does not use humidification. (3) CPT does not
promote expansion.
REVIEW QUESTIONS—TEST PREPARATION 13. (3) is correct. Reducing the level of wall suction will re-
duce the bubbling. (1) Bubbling in the water-seal cham-
The correct answers are in boldface. ber, not the suction chamber, indicates a system leak.
9. (2) is correct. The first concern is increasing oxygena- (2) There is no need to replace the system. (4) Increas-
tion, and replacing the oxygen will help. (1, 3) may be ing the water level will increase the level of suction.
4069_Ans_Ch30_001-002 24/11/14 11:01 AM Page 1

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5. Older adults are more at risk for complications of in-
CHAPTER 30 fluenza, especially pneumonia. She should see her health
care provider. An antiviral agent might be helpful if
VOCABULARY given within 48 hours of exposure.

1. laryngectomy REVIEW QUESTIONS—CONTENT REVIEW

2. epistaxis
3. Exudate The correct answers are in boldface.
4. rhinoplasty 1. (4) is correct. Interventions were aimed at comfort. (1, 2, 3)
5. dysphagia do not evaluate effectiveness of comfort measures.
6. Rhinitis 2. (1) is correct. A patient with a laryngectomy does not
have a voice box and can’t vocalize by blocking the es-
CRITICAL THINKING: NASAL SURGERY cape of air through the stoma. (2, 3, 4) are all options for
1. Wake Mr. Jones and examine his throat. He may be swal- communication for a patient with a laryngectomy.
lowing blood. Vital signs should also be checked for 3. (1) is correct. Narcotics depress the respiratory rate and
signs of blood loss. Make sure that he is in semi- cough reflex, which would increase risk for postoperative
Fowler’s position to help prevent aspiration and reduce complications. (2) Narcotics do not increase secretions;
swelling. Notify the health care provider if indicated. (3) they do not cause stomal edema; and (4) narcotics
2. “You may need to ask your health care provider for an can be addicting but not when they are taken for legiti-
antihistamine or cough suppressant. If you must sneeze, mate pain.
be sure to do so with your mouth open. A stool softener 4. (4) is correct. Dysphagia and hoarseness are common
and plenty of liquids and fiber can help keep your symptoms of cancer of the larynx. (1, 2, 3) may possibly
stools soft.” develop later or as complications, but they are not early
3. “Aspirin and related drugs such as ibuprofen can in- symptoms.
crease your risk for bleeding and should be avoided.” 5. (1) is correct. Facial tenderness is a symptom of a sinus
Check with his health care provider to see if acetamino- infection. (2, 3, 4) are not symptoms of sinus infection.
phen can be recommended.
REVIEW QUESTIONS—TEST PREPARATION
CRITICAL THINKING: INFLUENZA 6. (3, 4, 6) are correct. Hot moist packs can help reduce in-
1. Influenza is caused by a virus. Antibiotics will not be ef- flammation, humidity will help loosen secretions, and
fective. Antibiotics must be used with discretion to pre- semi-Fowler’s position helps reduce pressure. (1, 5) are
vent the development of resistant strains of bacteria. effective for pulmonary, not sinus, secretions; (2) is not a
2. Fever and illness can lead to dehydration. Fluids will nursing intervention.
also help thin respiratory secretions so that they are more 7. (3, 4, 1, 2) A patent airway is always a priority. Remem-
easily expectorated. ber your ABCs (airway, breathing, circulation). Pain is
3. Fever may be beneficial if it is not too high. Ask the second, because it is physiological. Physiological needs
health care provider at what temperature acetaminophen are priorities according to Maslow. Ambulation is third,
should be taken. Some sources say to give it only if fever because it promotes recovery. A visit from someone who
reaches above 103°F (39.4°C) or if discomfort is severe. has had a laryngectomy is important, but acceptance of
4. Influenza is contagious, so if symptoms are the same, it the laryngectomy would come after physiological needs.
would be reasonable to provide the same care as was rec- 8. (3) is correct. Pollutants in the tracheostomy can cause
ommended for her husband. (If any medications were infection and irritation. (1) The patient will be taught to
prescribed, however, they should not be shared.) It is suction the tracheostomy as needed. (2) This is not a
probably not necessary to take her to the urgent care cen- therapeutic statement. (4) The patient, not the health
ter unless additional symptoms develop or symptoms care provider, will need to do routine tracheostomy care.
persist. A call to the center can always be placed to be 9. (4) is correct. A sitting position will help reduce bleed-
sure a visit is not recommended. ing. Leaning forward will allow the blood to drain out

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of the nose so that bleeding can be monitored. (1, 3) (2) It may dilate bronchioles, but this will not help
Lying down increases pressure in the nose and may in- bleeding. (3) Epinephrine does not enhance clotting.
crease bleeding, and (2) extending the neck will allow 11. (3) is correct. Swine flu is named for a virus that usu-
blood to drain down the back of the throat and be swal- ally occurs in pigs. Symptoms and prevention are simi-
lowed, making it impossible to monitor the severity of lar to other types of flu. (1) It cannot be caught by
the bleeding. eating cooked pork. (2) It is also transmitted to humans,
10. (4) is correct. Phenylephrine is a vasoconstrictor. and from human to human. (4) Antiviral agents may be
(1) Raising the blood pressure can increase bleeding. used, but no agent is specific to swine flu.
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3. Emphysema causes destruction of alveolar membranes
CHAPTER 31 and adjacent capillaries, reducing the surface area avail-
able for gas exchange. Reduced gas exchange results in
VOCABULARY hypoxia, which causes dyspnea.
4. Edith’s lung sounds will most likely sound diminished.
Across 5. Edith probably has a chronically high PCO2, making a low
3. ARDS (acute respiratory distress syndrome) PO2 her stimulus to breathe. If a high flow rate of oxygen
4. Paradoxical is administered, it can reduce her stimulus to breathe.
7. Hemoptysis 6. Emphysema increases the risk for occurrence of bullae
9. MDI (metered-dose inhaler) and blebs. Rupture of these can cause pneumothorax.
10. Mucous 7. Fowler’s, semi-Fowler’s, or orthopneic (leaning over
13. Thoracotomy bedside table) position increases room for lung expan-
18. NMT (nebulized mist treatment) sion and helps reduce dyspnea. Sitting in a chair may
20. Pleurodesis also help if it is not too tiring.
21. Bleb 8. Edith has probably had many lectures on the evils of
22. TB smoking. Determine her desire to quit and her knowl-
edge of the relationship between her illness and her
Down smoking. If she is willing, ask her health care provider
1. AP (anteroposterior) for an order for nicotine patches and medication, and she
2. Ectopic can be referred to a local stop-smoking program (check
3. Antitussive the Yellow Pages). Assist her to identify a friend who has
5. Adjuvant quit smoking for support.
6. ABG (arterial blood gases)
8. Anergy REVIEW QUESTIONS—CONTENT REVIEW
11. Status The correct answers are in boldface.
12. Exudate
14. Hemothorax 1. (4) is correct. Corticosteroids have potent anti-inflammatory
15. Tachypnea action. (1, 2, 3) are not affected by corticosteroids.
16. Induration 2. (1) is correct; 2 L/min is the maximum rate for patients
17. Risk with chronic respiratory disease, unless they are in a
19. SOB (short of breath) closely monitored environment or mechanically ventilated.
(2, 3, 4) are too high and may reduce respiratory drive.
RESPIRATORY MEDICATIONS 3. (3) is correct. Intravenous (IV) morphine can reduce
acute dyspnea. (1) Cortisone is slower acting. (2) Meperi-
1. (2) 5. (1) dine (Demerol) will not help. (4) A beta blocker may
2. (4) 6. (3) worsen dyspnea.
3. (5) 7. (7) 4. (1) is correct. Smoking is a major risk factor for many
4. (6) kinds of lung disease. (2, 3, 4) are risk factors for a vari-
ety of problems, but they are not as significant as smok-
CRITICAL THINKING ing in causing lung disease.
1. A complete respiratory assessment should be completed.
Edith’s respiratory symptoms can be assessed using the REVIEW QUESTIONS—TEST PREPARATION
WHAT’S UP? format. Have her rate her degree of dysp- The correct answers are in boldface.
nea on a scale of 0 to 10. Auscultate lung sounds and as-
sess activity tolerance. Collect vital signs and SpO2. Note 5. (1) is correct; 86% is low, and the patient would benefit
skin color and ask about cough and sputum. from supplemental oxygen. (2) 86% is not normal.
2. A 48-pack-year history can mean two packs a day for (3) 86% does not warrant emergency treatment unless
24 years, or three packs a day for 16 years, and so on. additional symptoms are present. (4) Walking in the hall
Multiply packs per day by number of years for pack-years. will further reduce the SpO2.
1
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2 Answers

6. (1) is correct. A bronchoscopy is an endoscopic proce- 10. (1) is correct. Airways are inflamed and spastic in
dure. (2, 3, 4) A bronchoscopy does not involve dyes or asthma. (2) Asthma does not cause fluid collection.
x-rays. (3) Asthma constricts rather than stretches airways.
7. (4) is correct. The patient’s throat will have been numbed (4) Asthma is not caused by infection, although infec-
and irritated by the scope. A gag reflex must be present tion may exacerbate it.
before the patient can safely eat. (1) Breakfast should be 11. (3) is correct. Emphysema destroys alveoli, causing loss
held until the gag reflex returns. (2) There is no dye. of elasticity and air trapping. (1) Inflammation and se-
(3) The patient did not receive a general anesthesia. Any cretions are more characteristic of bronchitis. (2) Capil-
sedation given should be gone before the patient is re- laries are damaged in emphysema, but the entire blood
turned to the room. supply is not destroyed. (4) Large sacs of sputum are
8. (2, 3, 4, 6) are correct; all have been shown to increase not present in emphysema.
risk. (1, 5) do not increase cancer risk. 12. (2) is correct. Auscultating lung sounds will help deter-
9. (2) is correct. Radiation for small cell lung cancer is mine whether the lung is reexpanding. (1, 3, 4) may
palliative. (1) Surgery is the treatment for cure. (3) The all be appropriate, but they do not monitor whether
patient will probably require oxygen eventually. the chest drainage system is effectively reducing the
(4) Treatment may slow the spread but will probably pneumothorax.
not totally prevent it.
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Answers
5. stomach
CHAPTER 32 6. large
7. small
FUNCTIONS OF THE GASTROINTESTINAL 8. esophagus
SYSTEM 9. external anal
10. salivary
1. lower esophageal 11. teeth, tongue
2. ileocecal 12. villi
3. pyloric 13. rectum
4. small 14. bile

STRUCTURES OF THE GASTROINTESTINAL SYSTEM

Tooth
Oral Cavity
Tongue
Sublingual gland
Submaxillary gland
Parotid gland
Esophagus

Lower
esophageal
sphincter
Liver
Stomach
Gallbladder
Common bile duct Transverse
Duodenum colon(cut)
Pyloric sphincter (cut) Pancreas

Ascending colon
Jejunum
Descending
colon
Ileum
Cecum Sigmoid colon
Appendix
Rectum

Anal canal

1
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2 Answers

VOCABULARY serum glucose levels to detect this and treat it

with insulin. If the patient becomes hyperglycemic,
1. endoscope it does not indicate that he or she is diabetic. When the
2. bowel sounds high dextrose percentage is stopped, the patient’s blood
3. colonoscopy glucose returns to baseline levels. If insulin
4. gavage is given, it is used only temporarily to control the
5. impaction hyperglycemia.
6. guaiac 3. (a) Dextrose of 12% or less may be given in peripheral
7. fluoroscope veins; (b) dextrose greater than 12% must be given in
8. steatorrhea a central vein such as the subclavian or jugular vein
9. gastric analysis because the high glucose concentration is irritating to
10. gastroscopy veins.
4. It is important to run parenteral nutrition on an infusion
LABORATORY TESTS pump to carefully control the rate. It is important not to
1. (5) 4. (1) allow the parenteral nutrition to go in too quickly, or hy-
2. (4) 5. (3) perglycemia and then dehydration from the high blood
3. (2) sugar can result. Dehydration occurs from the body’s at-
tempt to dilute and eliminate the high levels of blood
BOWEL PREPARATION sugar.
5. Maintain the ordered rate. Parenteral nutrition should
Corrections are in boldface. never be increased to catch it up if it is behind schedule
A bowel preparation is required for several procedures that because the patient would become hyperglycemic and
visualize the lower bowel. This preparation is important for dehydrated.
effective test results. An incomplete bowel preparation may 6. When parenteral nutrition is discontinued, the infusion
prevent the test from being done or cause the need for it to usually is slowly weaned off to prevent hypoglycemia
be repeated. This can result in the patient’s delayed discharge from occurring if the dextrose was abruptly stopped.
and increased costs. The patient usually receives a clear liq- This weaning can take several hours.
uid diet 24 hours before the test. A bowel preparation med- 7. When parenteral nutrition is ordered to be stopped, the
ication (liquid or pill) may be given. A warm tap-water patient is fed, if not contraindicated, to prevent hypo-
enema or Fleet enema may be given until returns are clear. glycemia from occurring when the dextrose is stopped.
Older or debilitated patients should be carefully assessed dur- 8. Possible nursing diagnosis: Imbalanced Nutrition: Less
ing the administration of multiple enemas, which can fatigue Than Body Requirements.
the patient and decrease electrolytes. In patients with bleed- Outcome: Patient will maintain ideal body weight or gain
ing or severe diarrhea, the bowel preparation may not be weight toward goal weight.
ordered by the health care provider. Interventions:
Obtain baseline patient weight and identify ideal body
PANCREAS weight.
Identify barriers to nutrient ingestion.
1. Trypsin Weigh patient weekly and report changes to health care
2. Lipase provider.
3. Amylase Administer and monitor parenteral nutrition as ordered
according to protocols.
LIVER Monitor lab values such as albumin and absolute lym-
1. clay phocyte levels.
2. clotting If patient is receiving parenteral nutrition, monitor blood
3. radioactive glucose levels.
4. 2 Teach patient about parenteral nutrition and necessary
5. bleeding management of it if it is used in the home setting.

CRITICAL THINKING REVIEW QUESTIONS—CONTENT REVIEW

1. The parenteral nutrition rate should be started at The correct answers are in boldface.
a lower rate and gradually increased until the 1. (2)
ordered rate is reached. This allows body systems 2. (2)
and the pancreas time to adjust to the high dextrose 3. (1)
concentration. 4. (3)
2. The high dextrose percentage can cause the patient 5. (4)
to become hyperglycemic, so it is necessary to monitor 6. (1)
4069_Ans_Ch32_001-002 24/11/14 11:01 AM Page 3

Answers 3

7. (3) Stool cultures must be collected using sterile tech- greater than 30 per minute. (4) The rate of 4 per minute
nique so as not to introduce any pathogens into the is less than normal.
specimen that would alter the test results. (1, 2, 4) can 12. (1, 3, 4, 5, 6) all require either clear visibility or they
be done using clean technique. have a risk of aspiration. (b) A flat plate x-ray can be
8. (3) The chalky barium will cause the patient’s stool to done with food in the stomach or feces in the bowel,
look white for 1 to 3 days after the procedure. (1) Stools which does not impair visibility of the structures and
usually gradually return to a brown color; (2, 4) are not has no risk for aspiration.
associated with the color of barium and are not normal 13. (1, 5) Barium can produce constipation if it is not di-
stool colors. luted; it is important the patient be taught to increase
9. (2) The gag reflex must return before the patient eats or fluid intake after the procedure and that stool is nor-
drinks to prevent aspiration. (1) Keeping the patient nil mally white for up to 3 days postprocedure. (2) is incor-
per os (NPO) does not rest the vocal cords. (3) There is rect because the barium can produce constipation, not
no reason to keep the throat dry after an esophagogas- diarrhea, if it is not diluted. (3) is incorrect because
troduodenoscopy (EGD). (4) An absent gag reflex does there is no pain during or after a barium swallow. (4) is
not stimulate vomiting. incorrect because nutritional intake is not excessive as a
10. (4) The patient sits upright to facilitate the tube moving result of the barium ingestion.
down into the stomach by gravity. (1, 2, 3) do not facili- 14. (3) Disturbed body image is expressed by how patients
tate insertion of the nasogastric (NG) tube by gravity see themselves and the pride they take in their appear-
and would inhibit the tube insertion. ance. (1, 2, 4) do not address the embarrassment the pa-
tient expresses.
REVIEW QUESTIONS—TEST PREPARATION 15. (2) Swallowing helps insertion by closing the epiglottis,
thus preventing the NG tube from slipping into the tra-
The correct answers are in boldface.
chea, which could obstruct the airway and be dangerous
11. (3) Hypoactive bowel sounds occur less than 5 to 30 per to the patient. (1, 3) close the throat, preventing passage
minute. (1) There are some bowel sounds, so they are of the tube into the esophagus. (4) has no effect on the
not absent. (2) Hyperactive bowel sounds occur at a rate insertion of the NG tube.
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Answers
GASTRITIS
CHAPTER 33
1. (1) 5. (2)
2. (2) 6. (1)
VOCABULARY 3. (1) 7. (3)
1. Helicobacter pylori 4. (3) 8. (1)
2. anorexia
3. gastritis PEPTIC ULCER DISEASE
4. aphthous stomatitis Corrections are in boldface.
5. bulimia nervosa
6. dumping syndrome Most peptic ulcers are caused by the bacterium Helicobacter
7. gastrectomy pylori. Peptic ulcers are commonly found in the duodenum.
8. obesity Symptoms of peptic ulcers include burning and a gnawing
9. hiatal hernia pain in the epigastric region. With a duodenal ulcer, there is
10. gastrojejunostomy pain and discomfort on an empty stomach, which may be
relieved by ingesting food. Peptic ulcers can be cured.
Medication treatment for most peptic ulcers should include
antibiotics as indicated.

GASTRECTOMY

Vagus nerve
Distal portion
resected

Stomach joined
to jejunum
Total resection of
cancerous stomach
Stomach joined
to duodenum
Esophagus
Diaphragm

Jejunum

Duodenum

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2 Answers

CRITICAL THINKING 5. (1) Anorexia is a symptom of chronic gastritis type B.

(2) Dysphagia is seen in gastroesophageal reflux dis-
1. The nurse’s first action is to prevent Mrs. Sheffield from ease. (3) Diarrhea is not a sign of chronic gastritis
aspirating. The nurse maintains her side-lying position type B. (4) A feeling of fullness can occur in patients
and reminds her to remain in this position, propping her with dumping syndrome.
with pillows so she does not aspirate. 6. (2, 4, 5) Diaphoresis and hypotension are common
2. The next action is to take her vital signs. signs of hypovolemic shock. Altered level of conscious-
3. The nurse believes that Mrs. Sheffield is in the early ness or confusion is an indication of altered oxygena-
stages of hypovolemic shock (increased pulse and respira- tion, which accompanies shock. (1) Hypotension, not
tions, decreased temperature and blood pressure, and hypertension, is a sign of hypovolemic shock. (3) The
diaphoresis) and that her gastric bleeding needs to be pulse would be weak and thready, not bounding.
stopped immediately. The nurse maintains her intermittent 7. (3) A low-fat diet is advised to decrease the fat content
low-wall suction to remove the gastric output and thus in the stool. (1) A bland diet may decrease irritation of
prevent further gastric distention. The nurse also main- the bowel, but the patient’s problem stems from inade-
tains her intravenous (IV) setting to compensate for her quate mixing of food with pancreatic and biliary se-
fluid loss. cretions to digest fats, and a low-fat diet would be
4. The nurse notifies the health care provider of more helpful for this. (2) A high-carbohydrate diet
Mrs. Sheffield’s condition. does not prevent fat from being introduced in the diet.
5. Report current vital signs; signs and symptoms— (4) A pureed diet would not be helpful because it
diaphoresis, nausea, slightly distended abdomen; intake could contain fat.
and output—vomitus (amount and color), nasogastric 8. (4) Diet management and exercise are the first interven-
output (amount and color), IV (solution and rate), urine tions used to promote weight loss in the obese patient
output since return to the unit; other data: the time because they are noninvasive. Also, monitoring the
Mrs. Sheffield returned from the perianesthesia care patient in a diet and exercise program gives the health
unit, her vital signs, and her general assessment data care provider information about the patient’s metabolism,
upon return to the unit. food preferences, food habits, rate of weight loss, and ac-
6. Apply oxygen at 2 L/min via nasal cannula and reassure tivity tolerances. (1) is a surgical procedure that would be
the patient that her condition is being closely monitored considered if noninvasive interventions were not success-
and that her HCP is taking her back to surgery to repair ful. (2, 3) are not surgical procedures used for treating
her abdomen. Request the laboratory work. Gather the obesity; they are used for diseases such as cancer.
equipment necessary to transport Mrs. Sheffield with 9. (1) Eating small, frequent meals that can pass easily
oxygen, an emesis basin, and some extra blankets. through the esophagus prevents the rapid filling of the
stomach and thus heartburn and regurgitation. (2) The
REVIEW QUESTIONS—CONTENT REVIEW patient should avoid reclining for 1 hour after eating
The correct answers are in boldface. because reclining would promote reflux, not prevent it.
(3) The patient should sleep in an elevated position to
1. (4) Gastrectomy is the only effective treatment for gas- prevent reflux by raising the head of the bed on 6-inch
tric cancer. (1) Gastroplasty reduces the size of the stom- blocks and using pillows. (4) Eating before bedtime
ach to treat morbid obesity. (2) Gastrorrhaphy is suturing should be avoided so the stomach is empty to prevent
of the stomach wall. (3) Gastric stapling is a surgical reflux.
treatment for obese patients. 10. (4) Start the oxygen first. Use Maslow’s hierarchy to
2. (1) A painless ulcer is common early in oral cancer. help prioritize interventions. Oxygen administration
(2) White painful ulcers describe aphthous stomatitis will increase the amount of oxygen in the vascular sys-
(canker sore). (3) Feeling of fullness occurs with hiatal tem, thus increasing the oxygen to the tissues. (1) The
hernia or esophageal cancer. (4) Heartburn occurs with IV should be hung next to help restore and maintain
hiatal hernia. volume. (2) The laboratory can be called to draw blood
3. (2) Esophageal dilation is performed to enlarge the for a complete blood cell count while other interven-
esophagus and allow food to pass the obstruction caused tions are occurring, which will give a hemoglobin level
by the tumor. (1) Gastrectomy is done for stomach can- that will indicate oxygen-carrying capacity. (3) While
cer. (3, 4) Radical or modified neck dissection is per- the patient’s blood is being drawn and processed, insert
formed for oral cancer that has metastasized to cervical the nasogastric tube, which will decompress the stom-
lymph nodes. ach, and keep the head of the bed up 30 to 45 degrees to
prevent aspiration of any emesis.
REVIEW QUESTIONS—TEST PREPARATION 11. (4) Foods that cause discomfort need to be identified so
The correct answers are in boldface. they can be avoided. (1) Large meals promote reflux, so
small meals should be eaten. (2) Sleeping flat without
4. (1) Confusion is a common side effect of cimetidine, es- pillows promotes reflux, so the patient should be ele-
pecially in the older adult. (2, 3, 4) are not side effects of vated. (3) Lying down after each meal would promote re-
cimetidine. flux, so the patient should sit up for 2 hours after a meal.
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Answers 3

12. (3) Fundoplication, in which the stomach fundus is tified right away because the repair may be too tight,
wrapped around the lower part of the esophagus, is the causing obstruction of the passage of food. (1, 2, 4) can
most common surgical procedure performed for a hiatal be common after surgery, are not of a serious nature,
hernia. If dysphagia occurs, the physician should be no- and should have postop orders in place for intervention.
4069_Ans_Ch34_001-002 24/11/14 11:02 AM Page 1

Answers
ever, the nurse should intervene to prevent the problem
CHAPTER 34 from becoming worse. Unrelieved constipation can lead
to fecal impaction, megacolon, and complications related
VOCABULARY to use of Valsalva’s maneuver.
4. Before giving Mrs. Hendricks more milk of magnesia,
1. (12) 7. (8) the nurse can try giving her some prune juice, have her
2. (10) 8. (9) ambulate in the halls if she is able, and have her sit on
3. (2) 9. (3) the toilet or bedside commode (avoid use of bedpan) to
4. (11) 10. (5) attempt to have a bowel movement. Placing her feet on a
5. (1) 11. (7) footstool while sitting on the toilet may also help.
6. (4) 12. (6) 5. Prevention is the best treatment for constipation. Place
Mrs. Hendricks on a regimen of 2 g bran with her cereal
OSTOMIES each morning. Include pureed fresh fruits and vegetables
Corrections are in boldface. as much as possible in her diet. Encourage fluids and as-
sist her to walk in the halls several times each day. Estab-
1. Michelle Braun is a 16-year-old with ulcerative colitis. lish a regular time each day (or two) for Mrs. Hendricks
She is taking cortisone. She is on a low-residue diet. to have the bathroom to herself for a bowel movement.
She has just been admitted to the hospital for a colec- Offer a warm drink such as a cup of coffee or tea or
tomy and permanent end ileostomy. The nurse moni- warm water before this time. If these measures do not
tors her intake and output (I&O), daily weights, and work, add Metamucil to her daily regimen. Avoid the
electrolytes. The nurse also monitors for signs of in- milk of magnesia, senna (Senokot), and use of enemas as
flammation in her joints, skin, and other parts of her much as possible.
body. The nurse teaches her to increase fluids follow-
ing surgery, but it is not feasible to limit the number of REVIEW QUESTIONS—CONTENT REVIEW
stools she has daily.
2. James Key is a 46-year-old with a new sigmoid The correct answers are in boldface.
colostomy. Following surgery the nurse monitors his 1. (3, 4) are correct because diverticulitis involves infection
stoma every shift for 3 days to ensure that it remains and inflammation of the outpouchings and is usually
pink and moist. The nurse explains that the stool will be symptomatic. (1, 2, 5) Diverticulosis and diverticulitis
formed and that irrigation is optional to establish reg- both have outpouchings of the bowel mucous mem-
ularity. The nurse contacts the dietitian to provide a list branes and weakness in the bowel wall and are found in
of the high-fiber foods that he should avoid. the large intestine.
2. (3) is correct. Inflammatory bowel syndrome is a disor-
CRITICAL THINKING der of altered intestinal mobility in which disorderly
1. Collect data on Mrs. Hendricks’ abdomen for normal contractions of the colon lead to a pattern of alternat-
bowel sounds, distention, tenderness, and other signs of ing diarrhea and constipation. It is a functional prob-
problems such as impaction; her diet, exercise, fluid in- lem, not a disease. (1, 2) Crohn’s disease and
take, and other possible factors that may have caused ulcerative colitis are both inflammatory bowel diseases
constipation. often characterized by diarrhea that may lead to com-
2. Because Mrs. Hendricks has arthritis, she may not be plications. (4) With a large-bowel obstruction constipa-
getting much exercise. Lack of teeth probably prevents tion usually occurs.
her from eating many fresh fruits or vegetables. Poor 3. (3) is correct. For some women with IBS and constipa-
fluid intake and certain medications may also be factors. tion, paroxetine HCl (Paxil) is used as antidepressants
Chronic laxative abuse can be a factor, but Mrs. Hendricks block the brain’s perception of abdominal pain. (1, 2, 4)
only takes milk of magnesia occasionally. The other three drugs listed are used to treat IBS with
3. Mrs. Hendricks is only 1 day behind her normal bowel diarrhea.
movement schedule. This is not a major concern. How-

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REVIEW QUESTIONS—TEST PREPARATION 9. (1) is correct. Fluids are needed to replace those lost in
liquid stools. (2, 3, 4) can all increase liquid stools and
The correct answers are in boldface. fluid loss.
4. (3) is correct. Parenteral nutrition (PN) is the only way to 10. (2) is correct. Pouches are made of odor-proof plastic.
adequately feed a person for an extended period without (1) Nothing will absorb all odor, (3) effluent does have
using the gut. (1, 2) both require a functional bowel; an odor, and (4) daily pouch changes are hard on skin
(4) provides inadequate nutrition for an extended period. and therefore not recommended.
5. (1) is correct. A low-fiber diet increases risk for divertic- 11. (2) is correct. Pain may be so severe that the patient
ulosis. (2, 3, 4) do not increase risk for diverticulosis. delays defecation, leading to further constipation and
6. (1) is correct. Foods with seeds may need to be avoided. worsening symptoms. (1) Treatment of anal fissures
(2, 3, 4) do not exacerbate diverticulosis. involves measures to ensure soft stools to allow fis-
7. (3) is correct. A bowel obstruction can cause nausea and sures time to heal. Sitz baths may be used to promote
vomiting. (1, 2) are not related to diverticulitis. There is circulation to the area to aid in healing. (3) Instruc-
no evidence that (4) is correct. tions to prevent constipation includes a high-fiber diet
8. (4) is correct. The loop can be returned to the abdomen and 2 to 3 L of fluid a day to promote regular bowel
after the resected area of bowel has healed. (1) Trans- movements. (4) A side effect of opioid analgesics is
verse ostomies do not usually drain constant liquid stool, constipation, which needs to be avoided; anesthetic
(2) there is no such thing as a looped bag, and suppositories and nonopioid analgesics may be
(3) the ostomy will drain stool. ordered for comfort.
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Answers
9. (A) Indicates neuromuscular irritability from decreased
CHAPTER 35 serum calcium levels.
10. (A) Indicates malabsorption of dietary fats from
VOCABULARY decreased lipase.

1. (4) 7. (12) CRITICAL THINKING

2. (3) 8. (1)
3. (10) 9. (9) 1. The data collected about Ms. Smythe that support the
4. (5) 10. (2) diagnosis of cirrhosis are a grossly distended abdomen,
5. (7) 11. (8) jaundiced sclerae and skin, multiple bruises, and pitting
6. (11) 12. (6) edema of the lower extremities. Ms. Smythe also scratches
her arms and legs frequently, indicating pruritus. Her labo-
LIVER ratory data indicate that her serum bilirubin, ammonia, and
prothrombin time are elevated and that her serum albumin,
Across Down total protein, and potassium are below normal.
2. HBV 1. Encephalopathy 2. The nurse notes that Ms. Smythe is irritable, has diffi-
6. Caput medusae 2. Hepatorenal culty answering questions, and appears to doze off often
9. TIPS 3. Portal during the interview. Other observations the nurse might
10. Asterixis 4. Hepatitis make include asterixis, increasing difficulty in arousing
11. HAV 5. RUQ the patient, muscle twitching, and fetor hepaticus.
6. Cirrhosis 3. The pitting edema and abdominal distention are due to the
7. Ascites decreased amount of serum albumin being produced by the
8. Varices impaired liver. Reduced levels of this protein permit fluid
to seep into the abdominal cavity and other body tissues.
GALLBLADDER 4. The nurse expects the physician to order a severely protein-
restricted diet for the hepatic encephalopathy. In addi-
1. (4) 6. (8) tion, the physician may order lactulose or neomycin to
2. (6) 7. (9) rid the patient’s body of excess ammonia.
3. (7) 8. (10) 5. The physician may order vasoconstrictors such as vaso-
4. (5) 9. (2) pressin, octreotide (Sandostatin), beta-blockers or ni-
5. (1) 10. (3) trates, and endoscopic variceal ligation (banding) or
sclerotherapy.
PANCREAS 6. Monitor the patient’s emesis, stool, and urine at least
1. (A) Serum glucose may elevate because damage to every 8 hours for blood. Observe for any increase in
the islets of Langerhans causes decreased insulin bruising or bleeding from the gums. Monitor blood clot-
production. ting laboratory studies such as the international normal-
2. (A) The digestive enzyme amylase is released in large ized ratio and prothrombin time, as well as the complete
quantities by an inflamed pancreas. blood count for excess blood loss.
3. (N) 7. Measure Ms. Smythe’s abdomen and weigh her daily;
4. (A) Pleural effusion is caused by a local inflammatory document results. Report any weight gain or increase in
reaction to the irritation from pancreatic enzymes. circumference promptly. Because Ms. Smythe will usu-
5. (N) ally be ordered a low-sodium diet and will have fluids
6. (A) Serum albumin is decreased, usually from decreased restricted, carefully monitor and record intake and out-
protein metabolism. put. Monitor Ms. Smythe’s vital signs and mental status
7. (A) A positive Cullen’s sign indicates hemorrhage from every 4 hours and report changes promptly. Administer
pancreatic destruction. diuretics as ordered.
8. (A) Urinary output of less than 30 mL/hr can indicate he- 8. Teach Ms. Smythe that acetaminophen (Tylenol) is to be
patorenal syndrome or shock from circulatory collapse. avoided because it is toxic to the liver and may cause fur-
ther damage.

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WORD SEARCH

Gallbladder

C W J V L S U P O M C Q R S M R W S M X

W D Q I Y W A W E W V H U L U I K W V S

O E Y L V X Z B S N L S W V F N V P Q R

W V S D N O U C T E A S X U W I F L U S

F T K T J G Z H H Q E C W P S B I N G V

L - Q Y B C D O H V U X R C H U P Z L X

A T K M K H D L G K W H Z K U R A Z B F

T U F U C C F E Q X P X C G O I C E M S

U B Y R Y P O C S O H C O D E L O H C Q

L E H P B E Y Y L Z M D M X O I P L L K

E G E H D K V S P O G M P Q D B O C S D

N N P Y V N X T B Q M B A J B R I S D L

C P S ‘ Y J T I G N A A P C E O V K N R

E I F S M T O T F L O E W T V I W H V J

U S L S O L B I Z P P X S C O D H N J X

S X O I O M E S G L S E W P Y M X U W O

R D J G S V Z M B B L R H J Z B C E A T

M R C N G Y A T H O R Z Z F V U I P Z Z

J O R L P Q F Q H N H Y B N O Y S T C W

L Q N L S U W C F S R V L O I D O S R U

1. Bilirubin is the yellow part of the breakdown hemoglo- 6. Flatulence is excess intestinal or stomach gas.
bin. Serum levels increase with liver disease as the liver 7. Murphy’s Sign is pain that occurs with palpation of the
is unable to use it to produce bile. right upper abdomen on inspiration. It can indicate acute
2. Choledochoscopy is viewing of the biliary tract with cholecystitis.
endoscope via incision into the common bile duct. 8. T-tube is a T-shaped external biliary drainage tube in-
3. Cholesterol is a lipid molecule necessary for cell mem- serted after gallbladder surgery.
branes; if the cholesterol level is elevated it is a risk 9. Ursodiol is a bile acid that decreases cholesterol pro-
factor for heart attack. duced by the liver. It is also used to dissolve gallstones.
4. Cholecystitis is inflammation of the gallbladder.
5. ESWL, extracorporeal shock wave lithotripsy, is a non-
invasive treatment of kidney stones using sound waves.
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Answers 3

REVIEW QUESTIONS—CONTENT REVIEW 6. (1) is correct. Patients describe their pain as dull, boring,
and beginning in the mid-epigastrium and radiating to
The correct answers are in boldface. the back. (2, 3, 4) are not characteristic of pancreatitis.
1. (2) is correct. Standard precautions protect the nurse
from exposure to disease. (1) Reverse isolation protects REVIEW QUESTIONS—TEST PREPARATION
the patient, not the nurse. (3, 4) do not protect from The correct answers are in boldface.
blood exposure.
2. (4) is correct. Acetaminophen is the most common cause. 7. (3) is correct. This is a low-sodium meal. (1, 2, 4) are
(1, 2, 3) are not the most common causes. all high in sodium.
3. (1, 2, 4) are correct. Banding of varices with rubber 8. (2, 3, 4, 5, 6) are correct. Females are more at risk for
bands during endoscopy stops bleeding. The synthetic gallbladder disease, so (1) is not a risk.
hormone octreotide (Sandostatin) IV may vasoconstrict; 9. (2, 3) are correct. Straining and heavy lifting will fur-
injection of a sclerosing agent causes thickening and ther increase pressure and may cause bleeding. (1, 4, 5)
closing of dilated vessels. (3) A soft diet does not treat are not appropriate. Coughing could rupture a varix (en-
the varices. With bleeding, the patient would be NPO. larged tortuous vein), increasing fluid intake can further
4. (4) is correct. Pro-Banthine is an anticholinergic agent increase pressure. Vitamin K supplements will not alter
that may help relieve biliary colic. (1) will worsen gall- portal hypertension.
bladder spasms, (2) will not help, and (3) is used to dis- 10. (1) is correct. These are symptoms of hepatic en-
solve stones. cephalopathy. They are not symptoms of (2, 3, 4).
5. (3) is correct. Excessive alcohol intake is associated with
pancreatitis. (1, 2, 4) are not associated with pancreatitis.
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Answers
SAMPLE URINALYSIS RESULTS
CHAPTER 36
Patient A: urinary tract infection
Patient B: dehydration, deficient fluid volume
VOCABULARY Patient C: liver disease
1. (3) 5. (8)
2. (1) 6. (6) RENAL DIAGNOSTIC TESTS
3. (4) 7. (5) 1. False—It is an intravenous (IV) pyelogram.
4. (2) 8. (7) 2. False—It is a renal ultrasound.

ANATOMY

Renal medulla

Papilla
Renal pelvis Renal cortex
Calyx
Renal artery

Renal vein

Ureter

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Proximal convoluted tubule Glomerulus

Bowman’s capsule (inner)
Bowman’s capsule (outer)
Distal convoluted tubule

Peritubular
capillaries
Efferent arteriole

Afferent arteriole

Blood flow

Loop of Henle
Collecting
tubule

3. False—It is a urine culture and sensitivity. could be helpful. A roommate might be able to turn on
4. True the call light for her, if needed.
5. False—Allergic reactions are possible; also can be 5. Fluids should not be restricted. Fluid restriction can re-
nephrotoxic. sult in concentrated urine, which is more irritating to the
urinary tract and can cause incontinence. Some people
CRITICAL THINKING become continent only by increasing their fluid intake
and setting up a regular pattern of voiding.
1. These are classic symptoms of stress incontinence.
2. Mrs. Bohke should be taught how to perform Kegel’s REVIEW QUESTIONS—CONTENT REVIEW
exercise. She also should be referred to a health care
provider such as a urologist or gynecologist who special- The correct answers are in boldface.
izes in incontinence. She may benefit from medications 1. (1)
or surgery. 2. (2)
3. Functional incontinence. Mrs. Simmon would have been 3. (3)
continent if she had been able to call the nurse for assis- 4. (2)
tance in time. 5. (4)
4. The patient should receive a call light that she can feel 6. (1)
and that is pinned to the front of her gown. It would also 7. (1, 2, 3, 4, 6)
be helpful to have the nurse make hourly rounds that in-
clude the need to toilet. A regular toileting schedule
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Answers 3

REVIEW QUESTIONS—TEST PREPARATION 12. (1) is correct. It is important that the nurse determine
whether the patient is able to urinate. There may be
The correct answers are in boldface. edema of the urethra after a cystoscopy, which can re-
8. (1) is correct. The perineum should be washed before sult in urinary retention. (2, 3, 4) are not necessary.
collecting a urine sample from a female to decrease 13. (1) is correct. Urge incontinence is associated with dif-
contamination of the specimen. (2, 3, 4) are not ficulty retaining urine once the urge to urinate is sensed.
necessary for a routine urine specimen. (2) is stress incontinence. (3) is not a specific type of in-
9. (1) is correct. The elevated specific gravity is seen with continence. (4) is total incontinence.
dehydration because the urine is more concentrated. 14. (3) is correct. It is important to keep the catheter taped
When a patient is dehydrated, the amount of urine that to prevent movement of the catheter, which increases
the patient makes is decreased, which makes the urine the chance of introducing bacteria into the urine and
more concentrated. A small amount of bacteria is nor- trauma to the urethra. (1) increases risk of infection and
mally found in the urinalysis. (2, 3) A small amount of (2) is not necessary. (4) A full bag increases risk of
bacteria does not indicate infection. (4) No blood was backflow and contamination.
noted on the results. 15. (4) is correct. With total incontinence, the patient is
10. (4, 5) are correct. The elevated creatinine level and unable to control urination, and an adult incontinence
blood urea nitrogen level reflect reduced kidney brief is appropriate. (1) Cranberry juice would be help-
function. (1, 2, 3, 5) are incorrect. ful to decrease onset of a urinary tract infection, but the
11. (2) is correct. The patient should be nil per os (NPO) patient would still be incontinent of urine. (2) A urinal
before undergoing an intravenous pyelogram (IVP) so will not help if the patient cannot tell when he or she
the dye is more concentrated for better visualization of has to go. (3) Kegel’s exercises will not help total
renal structures. After the IVP, the nurse should force incontinence.
fluids to clear the dye from the kidneys. (1, 3, 4) are
not restricted.
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URINARY TRACT OBSTRUCTIONS
CHAPTER 37
1. The most common symptom of cancer of the bladder is
hematuria because cancerous tissue readily bleeds.
VOCABULARY 2. The most common risk factor for cancer of the bladder is
1. Urethritis smoking because of continual exposure of the bladder
2. Cystitis mucosa to the carcinogenic byproducts of smoking.
3. Pyelonephritis 3. The most common symptom of cancer of the kidney is
4. urethroplasty bleeding, again because cancerous tissue bleeds readily,
5. calculi just as in cancer of the bladder.
6. Nephrolithotomy 4. The urine of a patient with an ileal conduit is cloudy
7. hydronephrosis because of the presence of mucus because a portion of
8. nephrostomy the small intestine is used and it continues to secrete
9. nephrectomy mucus.
10. nephrosclerosis 5. To care for a patient with an ileal conduit, an appliance is
kept on at all times that either holds urine or drains into a
URINARY TRACT INFECTIONS Foley bag. When the appliance needs changing, it is nec-
essary to use a wick to catch urine until the appliance can
1. The usual cause of urinary tract infections (UTIs) in be applied. See textbook for how to apply an appliance
women is contamination in the area from the proximity to a patient with an ileal conduit.
of the rectum to the urinary meatus. Women who void in- 6. The most important care of a patient with a kidney stone
frequently are predisposed to UTIs. is to strain all urine to catch the stone. Pain relief meas-
2. The usual cause of UTIs in men is the presence of pro- ures are also important.
static hypertrophy leading to obstruction of urinary flow 7. The patient with a calcium oxalate kidney stone should
predisposing to infection. avoid foods high in calcium, such as large quantities of
3. The patient should be advised to drink large amounts of milk, and sources of oxalate, such as colas and beer. It
water and a glass of cranberry juice daily. If the patient can also be helpful to keep the urine acidic. The patient
cannot void frequently, he or she should drink less water. with a uric acid kidney stone should avoid foods that are
4. The single most important thing a patient with a history high in purines, such as organ meats and sardines.
of UTIs should do is void frequently to prevent stasis of
urine and then infection. CRITICAL THINKING
5. Cystitis Pyelonephritis 1. Mrs. Zins is having incidences of hypoglycemia because
Symptoms Dysuria; frequency; Dysuria; frequency; her kidney function is declining. The kidney helps de-
urgency; cloudy, urgency; cloudy,
grade insulin and excrete it from the body. As the kidneys
foul-smelling urine; foul-smelling urine;
sometimes hematuria sometimes hematuria; also fail, smaller amounts of insulin are needed because it is
chills and fever, flank pain, not removed from the body.
and general malaise 2. It is important that Mrs. Zins not receive orange juice as
Urinalysis Increased bacteria, Increased bacteria, WBCs; would normally be given for a hypoglycemic patient be-
results white blood positive nitrites, positive
cause her potassium level is already high. Instead, cran-
cells (WBCs); positive leukocyte esterase; may
nitrites; positive also have casts in the urine berry juice or another low-potassium carbohydrate
leukocyte esterase source should be given.
Prognosis Good with treatment; Acute pyelonephritis has a 3. Diabetes causes atherosclerotic changes in the kidney
can become chronic good prognosis; with vessels. In addition, diabetes causes an abnormal
condition with repeat repeat infections the
thickening of the glomerulus, which damages it. The
infections patient can develop
chronic pyelonephritis patient with diabetes is predisposed to frequent
with scarring and eventual pyelonephritis (kidney infections), which can damage the
destruction of the kidneys kidney. Also, the patient with diabetes can develop a

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2 Answers

neurogenic bladder, which predisposes the patient to which stimulates the bone marrow to make red blood
both infection and obstruction of the urinary system. cells. It is also possible that she has slowly been bleeding
4. Good control of diabetes, that is, keeping blood sugars through her gastrointestinal tract, a common
within a defined range, can decrease the development occurrence in patients with kidney disease.
of diabetic complications including kidney disease. 8. The three most important areas to monitor when caring
5. Nursing diagnoses that would be relevant for Mrs. Zins for a patient with chronic kidney disease are daily
include Excess Fluid Volume (she has edema, weight weight, intake and output (with fluid restriction if pre-
gain, and jugular venous distention) and Fatigue (she scribed), and monitoring laboratory test for dangerous
states she feels exhausted and also has a hemoglobin levels of electrolytes.
level of 7.2). 9. Mrs. Zins would probably be on a defined diabetic diet
6. The serum creatinine of 5.4 is most diagnostic of kidney that was also low sodium, low potassium, decreased
disease. A 24-hour creatinine clearance is more diagnos- protein, and fluid restricted. If her phosphorus level was
tic, but this laboratory test is not available in this case elevated, she would also be put on a low-phosphorus
study. diet. This is one of the most restrictive diets possible
7. Mrs. Zins is anemic because her kidneys have decreased and is very difficult to follow.
or stopped production of a substance called erythropoietin,

CHRONIC KIDNEY DISEASE

Neurological system
Fatigue
Depression
Headache
Oral cavity Confusion
Stomatitis Seizures
Bad taste in mouth Coma

Cardiovascular system Respiratory system

Hypertension Pulmonary edema
Heart failure Pulmonary effusion
Dysrhythmias Dyspnea

Renal system
Gastrointestinal system Anemia
Anorexia Oliguria/anuria
Nausea
Vomiting
Gastrointestinal
bleeding
Ulcers

Skin
Reproductive system Pruritis
Sexual dysfunction Ecchymosis
Infertility Uremic frost
Dry skin
Yellowish skin
Musculoskeletal system
Prone to fractures

Fluid volume
Edema
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Answers 3

REVIEW QUESTIONS—CONTENT REVIEW are all relevant to other diagnostic tests of the urine but
are not relevant to a midstream culture.
The correct answers are in boldface. 9. (2) is the correct answer because the most serious com-
1. (4) is correct. Hematuria is the most common symptom plication of a high potassium level is cardiac dysrhyth-
of cancer of the bladder. (1) Nocturia or (2) dysuria may mias. (1, 3, 4) may be present in kidney disease but are
occur related to a resulting infection, or (3) retention may not associated with high potassium levels.
occur because of obstruction, but these are not the most 10. (3) is the correct answer because the daily weight is the
common symptoms. single best determinant of fluid balance in the body.
2. (2) is correct because a 24-hour creatinine clearance is most (1, 2, 4) are also important, but daily weight remains
diagnostic of acute kidney injury; a result of 5 mL/min most significant.
means that the patient has approximately 5% of normal 11. (2) is the correct answer because orange juice is high in
kidney function. (1, 3, 4) would be elevated in the patient potassium, and the patient’s potassium level is already
with acute kidney injury, but the creatinine clearance is high. (1, 3) would still give the patient too much potas-
most diagnostic. sium; (4) it would be important to check the kind of diet
3. (2) is correct. Beer is high in oxalate, which predisposes later, but the first priority is to protect the patient from a
the patient to calcium oxalate kidney stones. (1, 3, 4) are dangerously high potassium level.
not especially high in oxalate or calcium. 12. (1) is the correct answer because there is a larger blood
flow, and dialysis is more efficient. (2) All blood access
REVIEW QUESTIONS—TEST PREPARATION sites can clot. (3) It is harder to access a graft than a
two-tailed subclavian. (4) Either site can be damaged
The correct answers are in boldface. by trauma.
4. (4) is correct because mucus is normally found in the 13. (2, 4, 5) is correct because the patient must be weighed
urine of a patient with an ileal conduit. This is because a following dialysis to determine fluid balance after dialy-
portion of the small bowel is used to make the conduit, sis and vital signs are obtained to determine patient sta-
and that portion of bowel continues to secrete mucus. bility. After dialysis the patient is very tired and usually
(1, 2, 3) are not necessary. needs to sleep for a short time. (1, 3) are not relevant.
5. (3) is correct because often the first and most obvious 14. (2) is correct because this is the mechanism by which dial-
sign of acute kidney injury is a decrease in urine output. ysis works. (1, 3, 4) do not describe how dialysis works.
(1) The blood pressure may elevate later as the patient 15. (3) is correct because these are symptoms that are seen
continues into kidney disease, but the urine output is with fluid retention related to untreated kidney disease.
most significant. (2, 4) may occur in some patients, but (1, 2, 4) are not symptoms of fluid excess and kidney
they are not the most common. disease.
6. (4, 5) are correct because they are the only foods listed 16. (4) is correct because hematuria is the most common
that do not contain significant potassium. (1, 2, 3) are all symptom of trauma to the kidney because the kidney
high in potassium. has a very large blood supply. (1, 2, 3) are not symp-
7. (4) is correct because there is a sudden decrease in urine toms of trauma.
output, and the patient has symptoms of urinary reten- 17. (2) is correct because the patient has symptoms of too
tion, which are distention and pain in the suprapubic much fluid in the body, which is a fluid volume excess.
area. (1) Decreased renal perfusion would be an appro- (1, 3, 4) are not relevant. In certain situations, a nursing
priate answer if the patient had not had symptoms of uri- diagnosis of Noncompliance may have caused the
nary retention. (2, 3) would not cause the symptoms of symptoms, but there is not enough information in the
urinary retention. question to be able to support this diagnosis.
8. (3) is the correct answer because the patient should col-
lect the specimen partway through urination. (1, 2, 4)
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Answers
HORMONES
CHAPTER 38
1. (10) 10. (3)
2. (17) 11. (14)
VOCABULARY 3. (1) 12. (6)
1. glycogen 4. (8) 13. (7)
2. hyperglycemia 5. (5) 14. (4)
3. affect 6. (13) 15. (15)
4. exophthalmos 7. (16) 16. (2)
5. feedback 8. (11) 17. (12)
9. (9)
ENDOCRINE GLANDS AND HORMONES

Anterior pituitary gland Hypothalamus

Posterior pituitary gland

Thyroid gland Parathyroid glands

Thymus

Adrenal medulla Adrenal cortex

Pancreas

Ovaries

Testes

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REVIEW QUESTIONS—CONTENT REVIEW 7. (1) is correct. A history is appropriate. (2) could cause re-
lease of hormone and exacerbate symptoms. (3) evalu-
The correct answers are in boldface. ates diabetes, not thyroid function. (4) A buffalo hump
1. (2) is correct. is present when there is too much cortisol, not thyroid
2. (4) is correct. hormone.
3. (1) is correct. 8. (3) is correct. This answers her question. Further testing
4. (2) is correct. must be done to determine a definite diagnosis. (1) She
may have cancer of the thyroid, but she needs further
REVIEW QUESTIONS—TEST PREPARATION testing; also, the nurse does not make a medical diagno-
sis. (2) is not true. (4) A cold spot is not normal.
The correct answers are in boldface. 9. (1, 3, 4, 5) Cortisol stimulates gluconeogenesis (the con-
5. (3, 4, 5) are correct. ADH increases water reabsorption version of triglycerides, lactic acid, and some amino
by the kidney tubules while aldosterone and cortisol in- acids to glucose) in the liver. It also increases lipolysis
crease reabsorption of Na+ ions and therefore water by and protein breakdown to liberate fatty acids and amino
the kidneys to the blood. Both affect blood volume and acids, respectively, for gluconeogenesis. Cortisol also
blood pressure. (1) influences metabolic rate; (2 and 6) has an anti-inflammatory effect because it blocks the
affect glucose level. effects of histamine and stabilizes the lysosomes in cells.
6. (3) is correct. The final urine voided at 24 hours must be (2) is not correct. Cortisol does not stimulate storage of
added to the specimen. (1) The first, not the last, urine glucose. This would lower glucose levels, and cortisol
voided is discarded. (2) A separate container is not neces- raises glucose.
sary. (4) All urine produced in 24 hours is necessary for
the test.
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Answers
CHAPTER 39
VOCABULARY
1. euthyroid 6. dysphagia
2. goiter 7. myxedema
3. polydipsia 8. Nocturia
4. polyuria 9. amenorrhea
5. pheochromocytoma 10. ectopic

HORMONES
Disorder Hormone Problem Signs and Symptoms
Diabetes insipidus ADH deficiency Polyuria
SIADH ADH excess Water retention
Cushing’s syndrome Steroid excess Moon face
Addison’s disease Deficient steroids Hypotension
Graves’ disease High T3 and T4 Exophthalmos
Hypothyroidism Low T3 and T4 Weight gain and fatigue
Pheochromocytoma Epinephrine excess Labile hypertension
Hyperparathyroidism High serum calcium Muscle weakness, brittle bones
Short stature Growth hormone (GH) deficiency Failure to grow and develop
Acromegaly GH excess Growing hands and feet
Hypoparathyroidism Low serum calcium Tetany

CRITICAL THINKING 5. Mr. Samuels’s urine will be very concentrated because

he is not excreting much water.
1. Because Mr. Samuels has too much ADH, he will be 6. When Mr. Samuels is effectively treated, his urine will
retaining water. An appropriate nursing diagnosis would look more dilute because he will be excreting more water.
be Excess Fluid Volume. 7. A head injury can directly or indirectly damage the
2. The best way to monitor fluid balance is by daily pituitary gland, placing the patient at risk for reduced
weights, at the same time each day, on the same ADH secretion and DI.
scale, and in about the same clothes. In addition to 8. Polyuria and polydipsia are symptoms of both DI and DM.
daily weights, intake and output, vital signs, urine 9. Mrs. Jorgensen’s urine specific gravity will be low
specific gravity, lung sounds, and skin turgor can be because she is excreting too much water.
monitored. 10. Mrs. Jorgensen’s serum osmolality will be high because
3. Mr. Samuels will retain water, which will reduce the she is losing water and becoming dehydrated.
osmolality of his blood. This in turn can cause cerebral 11. Mrs. Jorgensen is at risk for Deficient Fluid Volume.
edema, increased intracranial pressure, and seizures. 12. Mrs. Jorgensen should watch for signs of fluid over-
4. Mr. Samuels’s side rails should be padded. If a seizure load, such as increasing weight and concentrated urine.
occurs, he should be protected from harming himself.

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THYROID DISORDERS 8. (1) is correct. Tachycardia can occur if she gets too
much Synthroid. (2, 3) are not side effects of Synthroid;
1. (O) 7. (R) and (4) she should lose weight, not gain weight, on
2. (O) 8. (R) Synthroid.
3. (R) 9. (O) 9. (2) is correct. Body fluids will be radioactive. (1, 3) are
4. (R) 10. (R) not necessary; and (4) exposure to even small doses of
5. (O) 11. (R) radioactivity should be minimized.
6. (O) 12. (O) 10. The correct order is (2, 3, 1, 4, 6, 5). Airway is always a
priority (remember your ABCs). Vital signs are second
REVIEW QUESTIONS—CONTENT REVIEW because the patient must be monitored for thyrotoxico-
The correct answers are in boldface. sis, which could be life threatening. Surgical site is
third, because physiological problems take priority, and
1. (1) is correct. Numb fingers and muscle cramps are excessive bleeding could also be life or health threaten-
symptoms of tetany. (2, 3, 4) are not symptoms of tetany. ing. An analgesic is next, so the patient will be comfort-
2. (3) is correct. Thyrotoxicosis causes blood pressure, able for range-of-motion exercises. Teaching is last;
pulse, temperature, and respiratory rate to rise. (1, 2, 4) although it is important, it does not maintain the
are not affected by thyrotoxicosis (peripheral pulses may immediate physiological integrity of the patient.
be indirectly affected). 11. (4) is correct. It is the only outcome that addresses pain.
3. (3) is correct. Fluids will help prevent kidney stones by (1, 2, 3) may all be appropriate, but they are not related
flushing excess calcium through the kidneys. (1, 2, 4) directly to the nursing diagnosis.
will not help. 12. (2) is correct. Buffalo hump and easy bruising are often
4. (3) is correct. Acromegaly is caused by an excess of GH. present in Cushing’s syndrome. (1, 3, 4) are not symp-
(1, 2, 4) do not cause acromegaly. toms of Cushing’s syndrome.
5. (3) is correct. Addison’s disease is associated with fluid 13. (1) is correct. Vital signs are important because the pa-
loss. (1, 2, 4) are not relevant. tient with pheochromocytoma has labile hypertension.
(2, 3, 4) are all part of a routine assessment, but they are
REVIEW QUESTIONS—TEST PREPARATION not as important as vital signs in this case.
The correct answers are in boldface.
6. (3) is correct. Negative feedback causes the pituitary
to produce more thyroid stimulating hormone (TSH).
(1) TSH does not take the place of T3 and T4, (2) TSH
will not directly affect the metabolic rate, and (4) fat
cells do not make TSH.
7. (3) is correct; the patient is experiencing fatigue.
(1) There is no evidence in the data that the patient is
overeating, (2) weight gain does not necessarily affect
gas exchange, and (4) there is no evidence that the
patient is experiencing depression.
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Answers
2. Jennie is exhibiting symptoms of hypoglycemia. You
CHAPTER 40 should follow hospital policy, which usually directs the
nurse to check the blood glucose level and provide a
VOCABULARY quick source of glucose such as juice or glucose tablets.
Notify the registered nurse according to policy.
1. glycosuria 3. It appears that the treatment has been effective; 80 mg/dL
2. Hyperglycemia is probably OK, especially if a meal tray is to be served
3. Hypoglycemia soon. Check to be sure her meal is on its way, and watch
4. Kussmaul’s her for further symptoms. Consult with the RN or physi-
5. Polyphagia cian before administering her supper dose of Humalog.
6. Polydipsia 4. Common causes of hypoglycemia include skipping or
7. nocturia delaying meals, eating less than prescribed at a meal, and
8. peak more exercise than usual.
9. duration 5. Because she is receiving regularly scheduled insulin, it
10. tight is important to eat regularly to prevent periods during
which there is insulin but not enough glucose in her
HYPOGLYCEMIA AND HYPERGLYCEMIA blood.
1. O 6. Obesity causes insulin resistance. Losing weight has
2. R probably decreased Jennie’s insulin resistance, making
3. R her insulin dose too effective. She now needs a lower
4. R dose, or it is possible that she will no longer need insulin
5. O to control her diabetes.
6. R 7. Metformin increases tissue sensitivity to insulin and
7. O reduces glucose production by the liver.
8. R 8. Jennie has type 2 diabetes. If she had type 1 diabetes, she
would not be able to take oral hypoglycemics. Obesity is
LONG-TERM COMPLICATIONS OF DIABETES also common in type 2 diabetes.

1. 5 REVIEW QUESTIONS—CONTENT REVIEW

2. 2
3. 4 The correct answers are in boldface.
4. 1 1. (2) is correct; 70 to 130 mg/dL is recommended by the
5. 7 ADA. (1) is too low. (3, 4) are too high.
6. 6 2. (2) is correct. Insulin should never be given without first
7. 3 evaluating the blood glucose level. (1, 3, 4) may all be
significant for the person with diabetes, but they are not
CRITICAL THINKING immediately necessary before administering insulin.
1. Keeping the blood glucose level too low can increase 3. (1) is correct. Insulin lispro is a rapid-acting insulin.
risk of hypoglycemia, especially in a patient who has (2, 3, 4) are incorrect.
had diabetes for some time. If autonomic neuropathy is 4. (3) is correct. These are symptoms of hypoglycemia.
present, symptoms of hypoglycemia may go unnoticed, (1, 2, 4) are not associated with hypoglycemia; in fact,
making hypoglycemia even more risky. Although most (2, 4) are symptoms of hyperglycemia.
people are advised to keep their premeal glucose read- 5. (3) is correct. Micronase increases tissue sensitivity to
ings between 70 and 130 mg/dL, the physician should insulin. (1, 2, 4) can all potentially raise blood glucose
always be consulted for desired glucose range. levels, an undesirable result.

1
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REVIEW QUESTIONS—TEST PREPARATION intramuscularly in urgent situations. (1, 2) are incorrect.

Insulin is never given orally because it would be di-
The correct answers are in boldface. gested; it is not currently given via a topical route.
6. (1) is correct. Ketones and DKA usually occur in type 9. (2) is correct. The peak action time of NPH is 6 to
1 diabetes, especially in a newly diagnosed patient. 12 hours after administration. (1) is the onset of NPH.
(2) Type 2 diabetes in not usually associated with ke- (3) is the duration of long-acting insulin. (4) is incorrect.
tones, except late in the disease. (3) A patient with predi- 10. (1) is correct. Raisins contain sugar, which will raise the
abetes would have a blood glucose closer to normal. blood glucose level. (2, 4) are protein foods and will affect
(4) Gestational diabetes occurs in pregnant women. the blood glucose level only very slowly. (3) is not a food.
7. (4) is correct. If a patient forgets a prescribed oral hypo- 11. (4) is correct. Glucagon stimulates the liver to convert
glycemic, blood sugar levels will go up. Fatigue, thirst, glycogen to glucose, which raises the blood glucose
and blurred vision are the only symptoms of hyper- level. (1, 2, 3) are all related to hyperglycemia, which
glycemia. (1, 2) are symptoms of hypoglycemia. (3) is would be worsened by glucagon.
not related to diabetes. 12. (4) is correct. Oatmeal and bread are both bread/starch
8. (3, 4, 5) are all correct. Insulin is given subcutaneously exchanges. (1, 2, 3) are not starch exchanges.
most of the time; it can be given intravenously or
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Answers
CHAPTER 41
VOCABULARY
1. hysteroscopy 6. hydrocele
2. insufflation 7. varicocele
3. digital rectal 8. libido
4. gynecomastia 9. menarche
5. hypospadias 10. mammography
ANATOMY AND PHYSIOLOGY
Fallopian tube
Ovary

Uterus

Cervix of uterus

Urethra Rectum
Labium minora

Labium majora
Vagina

Vas deferens Rectum

Urinary bladder
Seminal
vesicle
Corpus Prostate
cavernosum gland

Urethra

Epididymis

Glans penis
Prepuce
(foreskin) Corpus
spongiosum Bulbourethral
Testis gland
Ejaculatory
duct
Scrotum

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2 Answers

FEMALE REPRODUCTIVE STRUCTURES physical problems are preventing sexual activity, inform
him that there are many treatments available. If Mr.
1. (5) 5. (2) Brown wishes, talk with his physician about a consulta-
2. (7) 6. (1) tion with a urologist or other specialist.
3. (6) 7. (4)
4. (3) REVIEW QUESTIONS—CONTENT REVIEW
MALE REPRODUCTIVE SYSTEM The correct answers are in boldface.

4, 2, 5, 1, 3 1. (1)
2. (2)
DIAGNOSTIC TESTS 3. (1)
4. (4)
1. (2) 4. (6)
5. (3)
2. (1) 5. (4)
6. (3) is correct. A yearly mammogram and clinical breast
3. (3) 6. (5)
examination are recommended. Optional breast self-
examination can be done monthly.
CRITICAL THINKING 7. (4) is correct. Digital rectal examination (DRE) is done
1. “Even though you had prostate surgery, unless you had by a physician at a routine visit. (1, 2, 3) It is unreason-
your entire prostate gland removed, some of the tissue will able to expect such frequent physician visits; testicular
grow back, and a rectal examination is still important.” self-examination (TSE) can be done at home more often.
2. Examine her abdomen, and check her medical record for
the report of her procedure. Most likely she had carbon REVIEW QUESTIONS—TEST PREPARATION
dioxide (CO2) pumped into her abdomen as part of the
The correct answers are in boldface.
procedure to enhance visualization of structures. Explain
to her why her abdomen is distended and have her lie flat 8. (2) is correct. A cystourethrogram involves a catheter,
to decrease migration of CO2. If there is no record of dye, and x-rays. (1, 3, 4) are not correct.
CO2 insufflation, something may indeed be wrong, and 9. (2) is correct. The patient should empty her bladder
further assessment and reporting to the nurse or physi- before the Papanicolaou (Pap) smear. (1, 3, 4) are not
cian are indicated. necessary for Pap smears.
3. Prepare to assist with cultures to send to the laboratory. 10. (1) is correct. A portion of the BSE is done while lying
Ask if she uses protection during intercourse. Tell her she down. (2, 3, 4) are inappropriate.
may have to refrain from sexual activity until the source 11. (4) is correct. A mammogram shows a lesion, but it can-
and communicability of her discharge are determined. not diagnose specifically what the lesion is. Additional
4. Depending on how Mr. Brown shared this initial infor- tests are needed. (1, 2) are not true; (3) a mammogram
mation, you probably have a good idea how comfortable is not the best test but is a good screening tool.
he is sharing additional information. If not, you can ask 12. (4) is correct. Wet mounts must be viewed immediately.
if he would like to discuss the matter further. A good (1) There is no time to sit at this time, (2) is not thera-
question to ask might be why he is no longer sexually ac- peutic, (3) the wet mount needs to be delivered before
tive. If it is not by choice, he may be experiencing erec- spending time and recommending her partner be tested
tile dysfunction from complications of diabetes. If is premature.
4069_Ans_Ch42_001-002 24/11/14 12:28 PM Page 1

Answers
be elevated on a pillow to decrease swelling. Neither arm
CHAPTER 42 should be used for blood pressures after mastectomies; con-
sult with the physician about the advisability of using the left
VOCABULARY arm or possibly her legs. She should be taught to exercise her
arm using exercises recommended by the institution.
1. (3) 6. (7)
2. (4) 7. (1) CRITICAL THINKING
3. (2) 8. (6)
4. (10) 9. (8) 1. Some factors affecting her frequent yeast overgrowths
5. (5) 10. (9) may include poor nutrition, inadequate blood glucose
control, overly restrictive clothing, overheating of the
BREAST SURGERIES genital area from long periods of sitting, immune system
deficiency, a strain of yeast that is resistant to her usual
1. (5) 4. (2) treatment, and antibiotic use (many young people take
2. (1) 5. (4) antibiotics regularly for acne control).
3. (3) 2. Some suggestions to help her prevent this problem in the
future might include wearing loose-fitting skirts and light
MENSTRUAL DISORDERS cotton underwear for bus trips, changing positions fre-
1. (5) 4. (2) quently, and sitting with her legs apart under a skirt,
2. (3) 5. (4) getting out and walking (if this is practical) when the bus
3. (1) stops, mentioning any antibiotic use to the physician,
emphasizing the recurrent nature of this problem to her
MASTECTOMY CARE physician, and assessment for immune system problems
if other infections are also frequent. One main area to
Errors are in boldface. explore with her is her blood glucose control. Find out
You are assigned to care for Mrs. Joseph, who is 1 day post- why she is not testing often enough, and help her to plan
operative following a right radical mastectomy. You know that strategies to improve testing regularity. If she is finan-
she is not anxious because she had a left mastectomy a year cially unable to afford the test materials, find out if there
ago and knows everything to expect. You listen to her breath are support options available to her. (The local American
sounds and find them clear, so it is not necessary to have her Diabetes Association chapter or hospital diabetes clinic
cough and deep breathe. You encourage her to lie on her may be able to help you find this information.) Empha-
right side to prevent bleeding. You use her right arm for size the benefits of adequate blood glucose control for
blood pressures because both arms are affected and the right many body systems as well as this disorder.
one is more convenient. You also encourage her to avoid use
of her right arm to prevent injury to the surgical site. You pro- REVIEW QUESTIONS—CONTENT REVIEW
vide a balanced diet and plenty of fluids to aid in her recovery. The correct answers are in boldface.
It is impossible to know if Mrs. Joseph is anxious without
assessing her. Most likely she is anxious because a second 1. (3) is correct. A douche may wash away signs of the
mastectomy probably was done for a recurrence of cancer. pathogen. (1) Better visualization is nice, but it does not
She needs a lot of support. A referral to Reach to Recovery help identify the pathogen. (2, 4) are not true.
or another appropriate support group would be helpful. Also, 2. (3) is correct. Multiple sexual partners increase the risk
never assume that because a patient has had a procedure be- of cervical cancer. (1) There is no evidence that tight
fore, she knows everything to expect. Assess her knowledge underwear increases cancer risk. (2) Papanicolaou
level and teach accordingly. The incision on her chest may smears detect cancer early. (4) Late onset of sexual
hurt when she coughs and deep breathes, increasing her risk activity may reduce risk of some diseases.
of pulmonary complications. She should receive analgesics 3. (2) is correct. Women who eat a high-fat diet have higher
and encouragement to cough and deep breathe every hour. rates of breast cancer. (1, 3, 4) are all associated with
Lying on her right side may make elevation of her right arm reduced risk of breast cancer.
difficult. She should assume a position in which her arm can

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REVIEW QUESTIONS—TEST PREPARATION 7. (2) is correct. Elevation of the arm reduces swelling.
(1, 3, 4) may worsen swelling.
The correct answers are in boldface. 8. (1) is correct. Her reaction shows anger over her diag-
4. (1, 2, 3, 5) are correct. Restriction of alcohol, caffeine, nosis, a normal grieving response. (2, 3, 4) may be true,
nicotine, salt, and simple sugars; participation in regular but there is no evidence to support them in the question.
exercise; and development of stress management skills 9. (1) is correct. This therapy affects hormone function.
may help to reduce premenstrual syndrome symptoms. (2, 3, 4) do not work by affecting estrogen.
5. (2) is correct; it is not 100% effective. (1, 3, 4) are all 10. (4) is correct. These are signs of infection. Prompt report-
true and do not indicate a need for more teaching. ing is necessary so a culture can be done and antibiotics
6. (3, 1, 4, 2) Breathing pattern takes priority because inef- ordered. (1, 3) Another day or two allows time for the in-
fective respirations can be life threatening. Ineffective fection to spread. (2) May cause unnecessary concern in
tissue perfusion can be health threatening and is second. the patient. In addition, if she is receiving home care, it
Psychosocial problems, although important, are the last may be difficult for her to get to her physician’s office.
priority. Anxiety comes first because it is actual; coping
is a risk in this case.
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Answers
Benign prostatic hypertrophy and cancer of the prostate
CHAPTER 43 gland are two possibilities.
3. Be prepared to assist with Foley catheter insertion. It
VOCABULARY may be difficult to insert the catheter past an enlarged
prostate, so the physician may need to be involved. The
1. retrograde catheter can maintain urine flow until Mr. Washington is
2. priapism transferred to the hospital for further diagnostic tests and
3. Phimosis possible surgery. Find out how Mr. Washington got to the
4. Smegma urgent care center and arrange a ride to the hospital if
5. circumcision needed.
6. Cryptorchidism 4. If urine flow continues to be blocked, hydronephrosis,
7. orchitis infection, and rupture of the bladder can occur.
8. erectile dysfunction 5. “A special scope will be inserted into your penis that
9. varicocele will chip away the enlarged parts of your prostate gland.
10. vasectomy You will be anesthetized so you won’t feel it. Afterward
you can expect to have a catheter in your bladder for
DISORDERS OF THE MALE REPRODUCTIVE several days.”
SYSTEM 6. The catheter has several purposes. It allows urine to
1. (3) 6. (7) drain, places pressure on the resected gland to minimize
2. (5) 7. (4) bleeding, and provides a route to irrigate the bladder so
3. (1) 8. (6) blood clots can be removed. When totaling intake and
4. (2) 9. (8) output (I&O), irrigation solution should be included in
5. (10) 10. (9) the intake measurement because it is impossible to sepa-
rate urine from solution in the output.
ERECTILE DYSFUNCTION 7. Bladder spasms are very painful, and the patient will in-
form you if they are occurring. Spasms may also cause
1. Medication leakage of urine around the catheter. Anesthetics and an-
2. Stress tispasmodic medications such as belladonna and opium
3. Hypertension (B&O) suppositories can help the discomfort. Irrigation
4. TURP (transurethral resection of the prostate) of the catheter can flush out clots that can increase
5. Heart failure spasms. Relaxation exercises may also help.
6. Multiple sclerosis 8. Tell Mr. Washington that some episodes of incontinence
may occur, but that they should subside in a few weeks.
CRITICAL THINKING Teach him to do Kegel’s exercises to increase sphincter
1. Use the WHAT’S UP? format to assess Mr. Washington’s tone. He should not restrict fluids because this can in-
symptoms. The most important question is what he crease risk for urinary tract infection (UTI). A condom
means by “can’t pass water” and how long it has been catheter or penile pad may help catch urine until inconti-
since he last urinated. If he truly can pass no urine, the nence improves. His panic could have been prevented by
situation is an emergency. You can also observe for blad- careful discharge teaching, letting Mr. Washington know
der distention, but palpation may be best done by the what to expect and what to do about it.
physician because of the risk for injury. Ask if he has
ever been told he has prostate problems. If it has been REVIEW QUESTIONS—CONTENT REVIEW
a long time since he urinated last or the bladder appears The correct answers are in boldface.
distended, have the physician see the patient as soon
as possible. 1. (3) is correct. Always replace the foreskin to prevent
2. In an older man, prostate enlargement is a common impairment of circulation and the possibility of not
cause of urinary problems and inability to urinate. being able to replace it later. (1) Never leave the fore-

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2 Answers

skin retracted. (2) The foreskin should be retracted if 7. (2) is correct. Kegel exercises will help strengthen
possible to wash the area. (4) Mild soap, not alcohol, sphincter tone. (1) Restricting fluids increases risk of
should be used. infection, (3) reinserting the catheter will only delay the
2. (1) is correct. Monthly TSE is one method to detect tes- problem, and (4) incontinence may last several weeks.
ticular cancer. (2) DRE is used to detect prostate enlarge- 8. (4) is correct. Asking an open-ended question will help
ment. (3) An annual physical examination is advised, but the patient share his concerns at his level of comfort.
it does not take the place of monthly checks for early de- (1) The information provided does not support a diag-
tection. (4) Ultrasound is not done routinely to detect tes- nosis of impaired communication, (2) not all patients
ticular cancer. are helped by verbalizing concerns, and (3) this does
not allow the patient to identify his own concerns.
REVIEW QUESTIONS—TEST PREPARATION 9. (2) is correct. The scrotum will be painful and swollen.
(1, 3, 4) are not symptoms of epididymitis.
The correct answers are in boldface.
10. (2) is correct. A respiratory rate of 36 indicates respira-
3. (1, 3, 6) are all correct. (2) Erectile dysfunction is not a tory distress and is the first priority. (1, 3, 4) are all im-
symptom of BPH, and (4, 5) are signs of kidney disease portant and should be addressed once breathing has
or metastasized cancer. been stabilized.
4. (3) is correct. Sexual function is only occasionally 11. (1) is correct. Male hormones continue to be produced
affected. (1) does not answer his question, and (2, 4) after a vasectomy and levels do not need to be checked;
imply that dysfunction is expected, which is not true. this statement indicates need for further teaching.
5. (2) is correct. The B&O suppository will relieve bladder (2) The patient should be encouraged to continue using
spasms. (1) Demerol relieves pain but not spasms, another birth control method for about 3 months after
(3) warming the solution is not recommended, and surgery to be sure there are no sperm left in the tract
(4) notifying the physician stat is not necessary— above the surgical site. (3) There should be no major
bladder spasms are an expected occurrence. change in the way the ejaculate looks or feels following
6. (3) is correct. The catheter needs to be kept free of clots the procedure. (4) A semen sample should be sent to be
so that it drains the bladder. (1) Irrigation does not stop evaluated for the absence of sperm before the procedure
bleeding, (2) antibiotics are not normally in the irrigating is considered successful.
solution, and (4) irrigation does not affect urine
production.
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Answers
that male condoms may be split down one side and
CHAPTER 44 opened or rubber dental dam material may be taped over
areas that have lesions to avoid direct contact with blood
VOCABULARY and body fluid, especially during sadomasochistic sexual
activity, this very high-risk behavior is not recommended.
1. (4) 4. (5) 5. Anal intercourse is a very high-risk activity for transmis-
2. (2) 5. (1) sion of many types of STIs, as well as many intestinal
3. (3) 6. (2) organisms, and is not recommended. Homosexual net-
works advise wearing double condoms and using water-
INFLAMMATORY DISORDERS soluble lubricants, preferably containing nonoxynol-9,
1. (1) 4. (5) to decrease the risk somewhat if engaging in this type of
2. (3) 5. (4) sexual activity.
3. (2)
CRITICAL THINKING
BARRIER METHODS FOR SAFER SEX 1. Misunderstandings may include the following:
1. Latex condoms are less likely to break during intercourse 1. The mistaken idea that one blood test can diagnose
than other types. Lubrication decreases the chances of all STIs
breakage during use, but only water-soluble lubricants 2. Misunderstanding about the time that may be required
should be used because substances such as petroleum to treat STIs (if the disease is treatable)
jelly (Vaseline) may weaken the condom. Condoms 3. Lack of understanding of the importance of interview
should never be inflated to test them because this can information for diagnosing STIs
weaken them. Condoms should be applied only when the 4. Lack of understanding of the importance of physical
penis is erect. Either condoms with a reservoir tip or reg- examination for diagnosing STIs
ular condoms that have been applied while holding ap- 2. The woman is an adult and has the right to make her own
proximately 1/2 inch of the closed end flat between the decisions. Unless James is her legal guardian, he has no
fingertips allow room for expansion by the ejaculate legal right to information about her. He may be notified
without creating excessive pressure, which might break by a public health authority that he has been listed as a
the condom. The penis should be withdrawn after ejacu- sexual contact by someone (anonymous) who has tested
lation before the erection begins to subside while holding positive for a particular STI. However, if they have not
the top of the condom securely around the penis to avoid yet become sexually intimate, he is not actually a contact.
spillage. Condoms should never be reused and should be The only ethical and legal way that he can find out the in-
discarded properly after use so others will not come in formation is by her choice (without coercion) to tell him.
contact with the contents. 3. Before any testing is done, both people should see the
2. Female condoms should be applied before any penetra- physician separately, be interviewed, be examined, and,
tion occurs (even pre-ejaculation fluid can contain mi- if necessary, have samples taken for investigation. The
croorganisms). Lubrication decreases the chances of physician should then order the tests that he or she deems
breakage during use, but only water-soluble lubricants necessary and counsel each patient about the test proce-
should be used because substances such as petroleum dures, possible outcomes and treatments, and the ex-
jelly may weaken the condom. Female condoms should pected time frame for return of results. A return visit may
never be reused and should be discarded properly after be arranged for a time after the physician should have re-
use so others will not come in contact with the contents. ceived notification of results.
3. These may provide some protection for the cervix only. 4. No, James is not going to get his answer about whether
They are not effective barriers against sexually transmit- he has a contagious STI today. Even if he is a virgin, he
ted infections (STIs). may possibly have contracted an STI prenatally, so he
4. These may provide some barrier protection for manual must wait for test results. Recent exposure to some STI
and oral sexual activity. Although some groups suggest agents may not show positive results for a long period.

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REVIEW QUESTIONS—CONTENT REVIEW 6. (1) is correct. The ulcer should be examined for diagno-
sis and treatment. (2, 3) may be upsetting to the patient
The correct answers are in boldface. because the ulcer may be from something other than an
1. (4) is correct. Syphilis is associated with gummas. STI. (4) Gentle cleaning is important, but an STI can
2. (3) is correct. Human papillomavirus causes genital occur at any age.
warts. (1, 2, 4) cause other viral disorders. 7. (2) is correct. The girl is asking for information to
maintain health. (1, 3, 4) may be true but are not sup-
REVIEW QUESTIONS—TEST PREPARATION ported by the data provided.
8. (3) is correct. Urethritis causes painful, frequent urination
The correct answers are in boldface. and discharge. (1, 2, 4) are not symptoms of urethritis.
3. (1, 3, 4) are correct. Standard precautions are always ap- 9. (1) is correct. Her pain should be assessed before inter-
propriate, especially with possible herpes infection. Ce- vention takes place. (2, 3, 4) may also be appropriate
sarean delivery may protect the baby from exposure. The after assessment has taken place.
obstetrician or midwife must be informed so decisions can 10.
be made for a safe delivery. (2) is incorrect. Teaching is 2,400,000 units 8 mL
appropriate, but reprimanding is not. (5) An antibiotic will = 3.8 mL
5,000,000 units
not treat a viral infection, and would need a physician’s
order. (6) would protect a patient who is immune compro- 11. (4) is correct. An initial outbreak following infection
mised and is not appropriate in this case. with the herpes virus occurs 2 days to 2 weeks after ex-
4. (4) is correct. A history and physical examination with posure and may produce a flu-like condition. Urethritis,
diagnostic testing are the only way to diagnose an STI. cystitis, and mucopurulent cervicitis (MPC) with vagi-
(1) is untrue. (2, 3) Checking for lesions and using a condom nal discharge may also be evident. (1, 2) Assessing the
are good ideas, but will not prevent all STI transmission. partner’s history or symptoms is not as important as ed-
5. (4) is correct. Questioning a partner is only one small ucating the client on symptoms she may develop that
part of STI prevention, so if the student believes this is require medical evaluation. (3) Use of a diaphragm will
adequate protection, more teaching is necessary. (1, 2, 3) protect the cervix but will not reduce the risk of con-
are all correct statements and do not indicate a need for tracting a sexually transmitted infection.
further teaching.
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Answers
CHAPTER 45
STRUCTURE OF NEUROMUSCULAR JUNCTION AND SARCOMERES

Motor neuron

Vesicles of
acetylcholine
Sarcolemma T tubule
Synaptic
1
cleft

2 3
Sarcoplasmic
reticulum

Myofilaments
ACh receptors
Ca+

Sarcomere

NEUROMUSCULAR JUNCTION VOCABULARY

1. (3, 5) 1. (3) 6. (6)
2. (1, 6) 2. (1) 7. (8)
3. (2, 4) 3. (4) 8. (7)
4. (5) 9. (10)
SYNOVIAL JOINTS 5. (2) 10. (9)
1. (5)
DIAGNOSTIC TESTS
2. (3)
3. (1) 1. (3) 7. (6)
4. (2) 2. (1) 8. (8)
5. (4) 3. (2) 9. (10)
4. (5) 10. (9)
5. (4) 11. (11)
6. (7) 12. (12)

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CRITICAL THINKING REVIEW QUESTIONS—TEST PREPARATION

1. Allergies, past health, medications, surgeries, injury, The correct answers are in boldface.
cause and mechanism of injury (how injured will indi-
7. (2) Crepitation is the term used for a grating sound
cate other injuries to look for; mechanism of injury—
heard in a joint. (1) A friction rub is associated with
twisting, crushing, stretching).
either pleural or pericardial inflammation or fluid accu-
2. Inspection: injury, asymmetry, mobility and range of mo-
mulation. (3) An effusion is a collection of fluid in a
tion, swelling, deformity and limb length, ecchymosis. Pal-
space. (4) Subcutaneous emphysema is leaking air that
pation: skin temperature, crepitation, tenderness, sensation.
is felt under the skin.
3. X-rays of his leg and any other areas of potential injury
8. (3) Joint movement should immediately be stopped to
based on the history. Complete blood count (CBC) to
prevent further joint injury. (1, 2, 4) would move the
identify loss of blood. Additional tests may be ordered
joint, causing possible injury.
based on findings.
9. (2) Ability to prepare food is an instrumental activity
4. Any procedures to be done, tests to be done, need to re-
of daily living (ADL), which is part of a functional as-
port symptoms, pain relief issues, answer any questions.
sessment. (1, 3, 4) are not items assessed in a functional
assessment.
REVIEW QUESTIONS—CONTENT REVIEW 10. (4) A hematoma may develop after a biopsy. (1) does
The correct answers are in boldface. not occur from a biopsy; (2) crackles are heard in the
lungs; and (3) an infection would not develop immedi-
1. (3)
ately but would occur several days later.
2. (2)
11. (1) Bleeding into soft tissue is a complication of a
3. (1)
biopsy. (2, 3, 4) relate to pain control.
4. (3)
5. (2)
6. (3)
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Answers
PROSTHESIS CARE EDUCATION
CHAPTER 46
1. False—same 4. True
2. False—water 5. False—grease, prosthetist
VOCABULARY 3. True
1. Arthritis 7. Avascular necrosis
2. Arthroplasty 8. Replantation HEALTH PROMOTION FOR PATIENTS WITH
3. Synovitis 9. Hemipelvectomy GOUT
4. Arthrocentesis 10. Fasciotomy 1. purine, sardines 4. aspirin, aspirin
5. Hyperuricemia 11. Osteomyelitis 2. Avoid 5. Avoid
6. Vasculitis 12. Osteosarcoma 3. fluids 6. stress

FRACTURES
1. (10) 3. (9) 5. (7) 7. (5) 9. (3)
2. (1) 4. (8) 6. (6) 8. (4) 10. (2)

CRITICAL THINKING

NURSING DIAGNOSIS
Impaired Physical Mobility related to hip precautions and surgical pain

Interventions Rationale Evaluation

Reinforce transfer and ambulation Activity is restricted due to hip Does patient transfer and ambulate
techniques. precautions and weight-bearing as instructed by physical therapy?
limitations.

Place overhead frame and trapeze Patient mobility is increased Does patient use over-bed frame
on bed; teach patient how to use it. and pain decreased with use of and trapeze for movement?
trapeze for movement.

Assess the patient for and take Immobility complications can Is the patient free from complica-
measures to prevent complications occur if preventive measures tions of immobility?
of immobility: are not used.
Turn patient every 2 hours and
check skin.
Keep heels off of bed.
Teach patient to deep breathe and
cough every 2 hours; also teach
use of incentive spirometer.
Apply thigh-high elastic stockings.
Give anticoagulants as ordered.
Mobilize patient as soon as
possible as ordered.
Remind patient to practice leg
exercises.

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REVIEW QUESTIONS—CONTENT REVIEW 6. (4) The morphine should be prepared now so it is ready
promptly when 3 hours is up; 15 mg should be given
The correct answers are in boldface.
because the pain level is at the maximum and is occur-
1. (2) It should be wrapped in a cool moist cloth (sterile, if ring before the minimum ordered time interval. (1) Ap-
available) and sealed in a plastic bag. (1) It should be plying ice to the cast may be helpful, but because the
cool and moist. (3) It is not placed on dry ice, which is pain is at the maximum, it will not provide enough
also not readily available. (4) is not readily available relief. (2) There are no abnormalities to report to the
or moist. physician at this time. (3) Removing the pillow may
2. (3) Diagnosis of gout is based on an elevated serum uric increase pain if swelling increases.
acid level, which is a waste product resulting from the 7. (4) This is a sign of hip dislocation. (1, 2, 3) are incorrect.
breakdown of proteins. Urate crystals, formed because 8. (4) Liver is an organ meat that is high in purines. (1, 2, 3)
of excessive uric acid buildup, are deposited in joints and are not high-purine foods.
other connective tissues, causing severe inflammation. 9. (1) can cause an attack of gout. (2, 3, 4) are incorrect.
10. (3) The erythrocyte sedimentation rate is a general
REVIEW QUESTIONS—TEST PREPARATION screening test for systemic inflammation. (1, 2, 4) are
incorrect.
The correct answers are in boldface.
11. (4) A test dose is given to assess for an allergic reaction.
3. (2) Buck’s traction is skin traction. (1, 3, 4) are examples (1, 2, 3) are incorrect.
of skeletal traction. 12. (2) Stiff, sore joints are one of the early symptoms of
4. (2) Palming the cast to move it prevents indentations rheumatoid arthritis. (1, 4) are not early symptoms.
being made in the wet cast with fingertips. (1, 3, 4) are (3) is not a related symptom.
incorrect.
5. (3, 5) Giving a test dose of gold is important to assess for
an allergic reaction, and the patient is monitored after the
test dose for an allergic reaction. (1, 2, 4, 6) are incorrect.
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Answers
3. A lumbar puncture involves a needle into the spinal fluid to
CHAPTER 47 collect cerebrospinal fluid (CSF) for analysis. Before the
procedure you may ask the physician for an order for an
VOCABULARY analgesic or sedative if the patient is especially anxious.
Make sure that a consent form has been signed. Assist the
1. dysphagia patient into a side-lying position with knees flexed and
2. electroencephalogram back arched. Some physicians prefer the patient sitting on
3. paresthesia the edge of the bed leaning over a bedside table. Stay with
4. decorticate the patient to offer reassurance and assist the physician
5. decerebrate with specimens. Following the procedure check orders for
6. Anisocoria bedrest, and encourage fluids. Monitor the puncture site for
7. nystagmus leakage of CSF. Notify the physician if a headache occurs.
8. contractures 4. Magnetic resonance imaging (MRI) uses magnetic energy
9. dysarthria to produce images of tissues. It is not an x-ray. Ask patients
10. aphasia if they have any metal in their bodies (pacemakers, joint re-
placements, foreign bodies, tattoos)—if so they may not be
DIAGNOSTIC TESTS able to have an MRI. Instruct the patient that he or she will
1. A myelogram is an x-ray (or computed tomographic or be in a tunnel-like machine for 30 to 60 minutes, and that
magnetic resonance imaging scan) examination of the there will be banging noises. If the patient is claustropho-
spinal canal after injection of contrast material into the bic, notify the physician and obtain a sedative or alternative
subarachnoid space. Before the procedure ask the patient orders. If the patient is in pain, request analgesic orders for
about allergies to contrast media. Make sure that a con- use before the procedure. No special aftercare is necessary.
sent form has been signed. Check institution policy for 5. Computed tomography (CT) produces images of layers
NPO (nothing by mouth) guidelines. Following the pro- (“slices”) of tissue. It usually requires that the body or
cedure the patient is maintained on bedrest, positioned body part be within the scanner, which may be difficult for
with the head elevated or according to physician’s orders claustrophobic people. The physician may order contrast
(based on type of dye used). Fluids are encouraged to material. Find out if this is planned, and ensure the patient
help the kidneys excrete the dye. has no allergies to contrast material. The physician should
2. An electroencephalogram (EEG) uses electrodes at- be notified if kidney function is compromised because
tached to the scalp to monitor the electrical activity of kidneys excrete the dye. Check institution policy to deter-
the brain. Before the procedure, make sure the patient’s mine whether the patient should be kept NPO before the
hair is clean and dry. Check with the physician for any procedure. If dye is used, the patient should be prepared to
medications to hold. After the procedure, monitor for expect a feeling of warmth during the injection. Following
seizures, especially if seizure medications were held. any procedure using dye, fluids should be encouraged. If
Wash the adhesive from the hair as soon as possible dye is not used, no special aftercare is necessary.
before it becomes hard and difficult to remove.

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ANATOMY

Central sulcus
Precentral gyrus Postcentral gyrus

Parietal lobe

Frontal lobe

Occipital lobe

Lateral sulcus

Temporal lobe
4069_Ans_Ch47_001-004 24/11/14 12:31 PM Page 3

Answers 3

Nucleus

Cell body
or Soma

Dendrites

Axon

Myelin sheath

Nodes of Ranvier

Synaptic
knobs

ANATOMY REVIEW CRITICAL THINKING

1. (5) 4. (3) 1. After checking her transfer records for previous activity
2. (4) 5. (2) level, check muscle strength in her legs and feet. Ask
3. (1) how she got up to go to the bathroom at the hospital.
Then have a second nurse or aide help in dangling her at
ASSESSMENT OF CRANIAL NERVES the bedside and slowly standing before attempting to am-
bulate. If she is unable to dangle or stand, use a bedpan
1. (3) 4. (1)
or bedside commode until she can be evaluated by the
2. (4) 5. (5)
physical therapy department. Document how she did and
3. (2)
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4 Answers

how much assistance she needed in the plan of care. thus would be responsible for writing (arm movement)
Consider whether she needs an order for physical or oc- and nodding (head movement). Cranial nerves (facial
cupational therapy. nerve) are responsible for the contraction of facial mus-
2. Again, check her transfer records, and ask how she ate cles and (hypoglossal) the movement of the tongue.
at the hospital, keeping in mind that her answers may The first and second thoracic nerves also contribute to
not be reliable. Check for a gag reflex. Make sure she peripheral nerves in the arms. Other thoracic nerves
is sitting straight up to eat, preferably in a chair. Try supply the trunk of the body. Lumbar and sacral nerves
small sips and bites first. Stay with her for the first supply the hips, pelvic cavity, and legs.
meal to monitor her swallowing. Because she is weak 9. (3) is correct. The patient is positioned on his or her
on one side, check her mouth after each bite for pock- side to expose the spinal column for puncture. (1, 2, 4)
eting of food. are not necessary for a lumbar puncture (LP).
3. Ask questions to determine her orientation, such as the 10. (1) is correct. The patient lays flat for 6 to 8 hours to
month and year, where she is, and who familiar visitors prevent headache following LP. (2) The patient should
are. Check recent and remote memory. (What did you drink fluids, not be NPO. (3) Pedal pulses are not sig-
have for lunch? What is your mother’s name?) Clarify nificant following LP. (4) Deep breathing and coughing
her question. She may have a perfectly legitimate reason are not a priority.
to ask for the cookies. 11. (4) is correct. Metal of any kind can be attracted to the
4. Blood pressure is affected by muscle tone. A weak arm powerful magnets in the MRI. (1) refers to a lumbar
may have a lower pressure. puncture, (2) refers to an EEG, and (3) is not necessary.
12. (2, 3, 4, 5) are correct. During the CT scan, the patient
REVIEW QUESTIONS—CONTENT REVIEW must lie still on a movable table. Noncontrast scans take
approximately 10 minutes; contrast scans take between
The correct answers are in boldface.
20 and 30 minutes. Patients who are receiving dye
1. (2) should be warned that they may feel a sensation of
2. (2) warmth following the injection; warmth in the groin
3. (1) area may make them feel as though they have been in-
4. (2) continent of urine. Nausea, diaphoresis, itching, or dif-
5. (4) ficulty breathing may indicate allergy to the dye and
6. (1) should be reported immediately to the physician or
7. (3) nurse practitioner. Sedation may be required for
patients who are agitated or disoriented.
REVIEW QUESTIONS—TEST PREPARATION
The correct answers are in boldface.
8. (2, 4) The cervical nerves supply the back of the head,
the neck, shoulders and arms, and the diaphragm and
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Answers
3. (1) Cervical traction will keep his cervical spine immo-
CHAPTER 48 bile and prevent further damage to the spinal cord.
(2) Administration of vasopressors may be necessary to
VOCABULARY maintain blood pressure at a level that is adequate for tis-
sue perfusion. Intravenous (IV) fluids may be inadequate
1. (9) 6. (4) to maintain blood pressure and may result in fluid over-
2. (6) 7. (5) load. (3) Loss of innervation to the bladder may result in
3. (1) 8. (3) urine retention. An indwelling catheter is used to prevent
4. (7) 9. (8) bladder rupture or urinary reflux.
5. (2) 10. (10) 4. Edema of the spinal cord, fatigue of respiratory muscles,
or both are reducing Mr. Granger’s already compromised
DRUGS USED FOR CENTRAL NERVOUS respiratory function. As he feels more short of breath, he
SYSTEM DISORDERS becomes more anxious, fearing that his condition is
1. (2) 4. (5) worsening. Explain to him that this is a common short-
2. (3) 5. (4) term complication of spinal cord injury. Reassure him
3. (1) that if mechanical ventilation is required, it will not nec-
essarily be a permanent situation.
ALZHEIMER’S DISEASE 5. Expect that Mr. Granger will be intubated or have a tra-
cheostomy placed to allow for mechanical ventilation.
1. (3) 3. (4) Expect the ventilation to be necessary until the spinal
2. (2) 4. (1) cord edema has subsided.
6. Ineffective Breathing Pattern: The goal is that
CENTRAL NERVOUS SYSTEM DISORDERS Mr. Granger will not experience hypoxia or respiratory
1. (9) 6. (2) arrest. Monitor his pulse oximetry and respiratory
2. (6) 7. (8) pattern frequently. At the first sign of restlessness,
3. (1) 8. (10) anxiety, or shortness of breath, inform the physician.
4. (5) 9. (4) Impaired Physical Mobility: The goal is for all of
5. (7) 10. (3) Mr. Granger’s care needs to be met. He will be unable to
care for himself independently. Protect him from skin
SPINAL DISORDERS breakdown and other hazards of immobility. Whenever
possible, give Mr. Granger choices as to how and when
1. L care will be performed. Include his significant others as
2. C much as he and they wish.
3. C 7. Mr. Granger needs simple explanations of what has hap-
4. L pened to him and what his prognosis is. He also needs to
5. L begin to learn to direct his care. This will improve his
ability to function outside of the hospital. After he is
CRITICAL THINKING: SPINAL CORD INJURY stable, he will likely be transferred to a rehabilitation
1. These are the hallmark signs of spinal cord injury or facility to continue to learn self-care.
spinal shock. Loss of vasomotor control results in va-
sodilation. This causes hypotension. Dilated blood REVIEW QUESTIONS—CONTENT REVIEW
vessels allow more exposure of blood to the skin surface, The correct answers are in boldface.
thereby cooling the blood and causing hypothermia.
Bradycardia results from disruption of the autonomic 1. (2) A structured environment provides a quiet setting
nervous system. with minimal distractions. (1, 3, 4) could all potentiate
2. Mr. Granger no longer has full use of his respiratory the patient’s agitation.
muscles. Therefore, he is not able to take deep breaths. 2. (1) is correct. Decreasing level of consciousness (LOC)
is a symptom of increasing ICP. (2, 3) Sympathetic and

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2 Answers

parasympathetic responses and (d) increased cerebral physician. (1) Incisional pain and (4) muscle spasm are
blood flow do not cause decreased LOC. common temporary results of microdiskectomy.
3. (3) Widening pulse pressure warns of increasing ICP. (2) Bleeding should be monitored, but a small amount
(1, 2, 4) do not occur in increasing ICP. does not require immediate reporting unless it is rapidly
4. (2) is correct. Elevation of the head of the bed reduces increasing.
ICP. (1, 3, 4) all can potentially increase ICP. 9. (1) The patient with a brain tumor is at risk for seizures.
(2, 3) are important interventions once the patient’s
REVIEW QUESTIONS—TEST PREPARATION safety is assured. (4) There is no reason to place the
patient in isolation.
The correct answers are in boldface.
10. (1, 3, 4, 6) can all help avoid falls. (2) Restraints are not
5. (3) This addresses the patient’s feelings and is most recommended, and may increase agitation and risk of
likely to calm her. (1, 4) try to reason with a patient who falls. (5) Assisting the patient who is at risk of falls is
is unable to reason and may be threatening. (2) is mis- appropriate. Encouraging independence may be appro-
leading—the patient is not going to find her mother. priate for some patients but may not be appropriate if
6. (3) Drowsiness is a common side effect. (1, 2, 4) are not the patient is at risk for falling.
common side effects. 11. (1, 4) are correct. (2) Oral contraceptives are contraindi-
7. (4) Ambulation is the best evidence that the patient with cated because of the increased risk for DVT. (3) A di-
lumbar disk disease is mobile. (1, 3) are good outcomes aphragm may be too difficult for the woman to insert.
but are not related to mobility. (2) relates to cervical dis- (5) Patients may not feel an IUD move out of position
ease, not lumbar. or be aware of signs or symptoms of uterine perfora-
8. (3) Inability to move the affected leg would not be tion. (6) Fertility is not compromised by spinal cord
expected and should immediately be reported to the injury, so birth control is recommended.
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Answers
and possibly a sling to prevent harm to her weakened
CHAPTER 49 shoulder muscles.
10. Reposition every 1 to 2 hours, maintain good nutrition
VOCABULARY and fluid intake, apply a pressure-reduction mattress to
the bed, use a lift sheet, keep skin clean and dry, and
1. (7) 6. (6) check frequently for incontinence.
2. (3) 7. (9) 11. Because Mrs. Saunders understands spoken words, ask
3. (1) 8. (10) her if she has to go to the bathroom. Usually if a patient
4. (4) 9. (8) is attempting to get out of bed, there is a reason for it.
5. (5) 10. (2) See if she can nod yes or no in response. She may be
able to point to the bedside commode or bathroom. A
DRUGS USED FOR CEREBROVASCULAR picture board might also be helpful.
DISORDERS 12. Check swallowing. Ask for a consultation with the
1. (1) 3. (4) speech therapy department or other swallowing expert
2. (3) 4. (2) for recommendations specific to Mrs. Saunders.
13. Many patients do better with pureed foods and thick-
CRITICAL THINKING: STROKE ened liquids. Be sure she is sitting straight up, prefer-
ably in a chair, to eat. Have her tilt her head forward
1. A stroke is the infarction of brain tissue due to the while swallowing. Have her swallow each bite twice.
disruption of blood flow to the brain. Considering After each bite, remind her to check the right side of her
Mrs. Saunders’ history, the cause of her attack was mouth for food that is not noticed. Avoid straws. Check
most likely ischemic, the result of atherosclerosis. swallowing study recommendations for specific instruc-
2. Hemiplegia. tions for each patient.
3. Left, because her right side is paralyzed. 14. Involve her family in her care. Give them small tasks
4. She was a smoker, she has a history of atherosclerosis to do for her. Encourage them to attend physical and
and hypertension, and she is overweight. other therapies with her. Explain what will happen at
5. Expressive aphasia. the rehabilitation facility. Assist the family to identify
6. Her score on the Glasgow Coma Scale is 11. resources that can help when she is discharged to home.
7. Early symptoms of rising intracranial pressure include Consult with the social worker or discharge planner to
restlessness, irritability, and decreased level of con- provide them with additional information.
sciousness. Later signs include dilated pupils, increasing 15. Antiplatelet drugs such as aspirin or clopidogrel
systolic blood pressure and respiratory rate, and increas- (Plavix).
ing and then decreasing pulse rate.
8. A thrombolytic medication may have been used in the REVIEW QUESTIONS—CONTENT REVIEW
emergency department if Mrs. Saunders arrived within
3 hours of onset of her symptoms. The nurse would con- The correct answers are in boldface.
tinue to monitor for side effects. Heparin may be ordered 1. (1) is correct. A temporary impairment of cerebral circu-
as an anticoagulant; antiplatelet drugs may be ordered for lation that causes symptoms lasting minutes to hours is a
long-term prevention of recurrent stroke; antihyperten- transient ischemic attack (TIA). (2, 3, 4) A cerebrovascu-
sives may be ordered to control blood pressure; statins lar accident (CVA), stroke, or subarachnoid hemorrhage
may be ordered to lower cholesterol if needed. (SAH) cause permanent deficits.
9. Many diagnoses fit Mrs. Saunders’s situation. An ex- 2. (2) is correct. In atrial fibrillation, the blood is not ejected
ample is Impaired Physical Mobility related to flaccid normally and small clots may develop in the atria. If these
right side. Measures to prevent complications related to clots are ejected into the circulation as emboli and travel
immobility include repositioning every 1 to 2 hours, to the brain, an embolic stroke occurs. (1) A hemorrhagic
maintaining good body alignment with pillows, consult- stroke is caused by a rupture of a blood vessel that, in
ing physical therapy for exercise recommendations, turn, deprives the brain tissue beyond that vessel of
range-of-motion exercises, constraint therapy, needed oxygen and nutrients. (3) A thrombotic stroke is

1
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2 Answers

caused by a blood clot occluding an artery, causing de- 7.

creased perfusion to brain tissue; the bifurcation of the 62 mg 1 grain 1 tablet
= 1 tablet
carotid artery is the most common site of this type of 60 mg 1 grain
stroke. (4) A cerebral aneurysm places patients at risk for 8. (2) is correct—the stroke may be extending. (1, 3, 4) all
hemorrhagic stroke. delay treatment if the stroke is extending.
9. (2) is correct. Patients with stroke are prone to aspira-
REVIEW QUESTIONS—TEST PREPARATION tion and reducing the risk of aspiration is the highest
priority; patients should be turned to the side to reduce
The correct answers are in boldface.
this risk with vomiting. (1, 3) Setting up suction and
3. (1) is correct. The patient may be exhibiting unilateral giving medication will take too long—they are not pri-
neglect or homonymous hemianopsia. (2) is incorrect— orities. (4) Performing a test for blood is not indicated
there is no evidence that the patient is hard of hearing. with the information provided.
(3) Waving fingers is rude and unnecessary in this case. 10. (2, 4, 6) are correct. All increase risk of bleeding. (1, 3, 5)
(4) Using a picture board will not help if the patient can- do not increase risk of bleeding.
not perceive his left side. 11. (2, 4) are correct. Before giving a patient with a sus-
4. (2) is correct. A stroke can reduce inhibitions. (1) Punish- pected stroke anything to eat or drink, including medica-
ment is inappropriate—his actions are not on purpose. tions, the patient should pass a swallow, or dysphagia
(3, 4) may be true but do not address the problem. screen. If there is any apparent facial weakness or asym-
5. (4, 5, 6) are correct. These can help prevent aspiration. metry, do not give the patient anything by mouth (NPO).
(1) is incorrect—sitting upright is recommended. If everything appears normal, have the patient swallow
(2) Straws should be avoided. (3) Thin liquids are more about 30 oz of water. If the patient coughs, has difficulty
easily aspirated. swallowing or has a wet/gurgly voice afterwards, the pa-
6. (3) is correct. Allowing the patient to defecate on his tient should remain NPO. (1) Grip and (5) blood pres-
usual schedule can help prevent incontinence. (1) If the sure are not related to ability to swallow. (3) A positive
patient is unable to detect the need to have a bowel gag reflex would indicate that swallowing may be intact.
movement, asking him will not be helpful. (2, 4) Inconti- (6) Aspirin and clopidogrel are not related.
nence pads may be useful, and avoiding embarrassing
the patient is essential, but neither will help reduce
incontinence.