Answer Key  1  

Answer Key

CHAPTER 1—THE EVOLUTION OF NURSING Multiple Choice

17. Answer 2: One of the primary problems of the
Matching early nineteenth century hospitals was poor
1. b hygienic practices. Hospitals were dirty and
2. d overcrowded and care was mostly given by
3. e untrained persons.
4. a 18. Answer 4: The population is aging rapidly
5. f and there is an increased need for nursing ser-
6. h vices for this growing segment of the popula-
7. c tion.
8. g 19. Answer 3: “Nightingale Nurses” improved
9. j patient care and advanced the practice of
10. i nursing through good hygiene, sanitation,
patient observation, accurate recordkeeping,
Short Answer nutritional improvement, and the introduc-
11. The National League for Nursing (NLN) es- tion and use of new equipment.
tablished educational standards and criteria 20. Answer 1: The four major concepts are nurse,
and is involved in the voluntary accreditation patient, health, and environment.
of nursing programs. 21. Answer 4: Poverty, homelessness, and un-
12. The purposes of NAPNES and NFLPN are to: employment are factors in increased risk for
Set standards for practical/vocational nursing health problems.
programs. 22. Answer 2: Physiologic needs, such as eating
Promote and protect practical/vocational and oxygenation, are the first priority accord-
nursing. ing to Maslow.
Educate and inform the general public about 23. Answer 4: Adolescence is time when love and
practical/vocational nursing. belonging to a peer group are very important.
13. LPN/LVNs function to provide specific ser- Being part of a team is the best way to help
vices to patients under the direct supervision him meet this need.
of a licensed physician, dentist, or registered 24. Answer 1, 3, 5: Patient can participate in
nurse; assists individuals, sick or well, in the smoking cessation; stress, weight, and alcohol
performance of those activities contributing to intake reduction; and control over own body
health, to their recovery, and to gain indepen- and health. Giving information about technol-
dence as rapidly as possible or to have a peace- ogy, new medications, and costs may be of
ful death. The LPN/LVN is educated to be a interest to the patient, but these topics are less
responsible member of a health care team, per- useful in helping the patient take an active
forming basic therapeutic, rehabilitative, and role in her own health.
preventive care to assigned patients. LPN/ 25. Answer 4: While the UAP or unit secretary
LVNs are continuing to provide care in all can direct visitors, extreme caution should
types of settings, with the majority employed be used in giving out patient information.
in long-term care settings. (Note to student: Even acknowledging that a
patient has been admitted to the hospital can
Fill-in-the-Blank Sentences be viewed as a violation of confidentiality.)
14. state board of nursing Taking vital signs is acceptable; however, the
15. National Council of State Boards of Nursing pharmacist generally restocks medications.
16. Patient’s Bill of Rights Validating and interpreting are nursing re-
sponsibilities.
26. Answer 2: Economic use of time and materials
is the best way to contain costs for individual

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 Answer Key  2  

patients. Malpractice insurance does not help with care, caused hair loss, took too
to contain costs. While it is appropriate to much time for washing and starching,
question the health care provider about safety and were a source of bacteria. Health
issues, it is not appropriate to question use of care facilities and nursing schools typi-
diagnostic testing. Diagnosis is an extremely cally have dress codes for style of uniform
complicated process, which requires an exten- and/or color. Staff are generally required
sive depth of knowledge about pathology. Re- to wear nametags and identification badg-
ferring patients to another clinic just shifts the es. Many nurses do not approve of man-
financial burden to another part of the health datory dress codes. They argue that other
care system. health care professionals do not depend
27. Answer 1: Orem’s theory is based on helping on uniforms for their authority.
the patient to attain self-care. Nightingale’s b. It is likely that as a nursing student and a
theory uses manipulation of the environment soon-to-be nurse that looking professional
(i.e., patient’s pillows). Benner and Wrubel is important to you. You may feel anxious
demonstrate caring by assisting the patient to to be rid of your current student uniform
cope. Parse’s theory encourages the patient to for a variety of reasons. Freedom of choice,
participate in the health experience. unattractive style, and not being marked
28. Answer 1, 2, 3, 4, 6: Under the terms of this as a student are frequent reasons cited by
document, patients are assured that they can students. From patients’ point of view,
expect high-quality hospital care, a clean and they feel more comfortable and confident
safe environment, involvement in their care when they are easily able to distinguish
and the decision-making process, protection nurses from other staff members. Recent
of privacy, help when leaving the hospital, studies also suggest that patients believe
and help with billing concerns. Patients can- that nurses who wear white are better
not always expect to get a private room with nurses than those who do not wear white.
all amenities. 33. a. This patient has complex physical prob-
29. Answer 3: Health care workers are entitled to lems and he has some lifestyle, social, and
respect from patients and also expect patients financial issues that need extra attention.
to be responsible for their own behavior. Registered nurse (RN)—provides direct
30. Answer 3: LPN/LVNs never function inde- patient care in the hospital and an RN
pendently without the supervision of an RN from a home health agency could also be
or health care provider. involved in the care of this patient.
LPN/LVN—works under the supervision
Critical Thinking Activities of the RN in providing patient care.
31. Physician—provides diagnosis and pre-
Wellness X Illness scription of treatment and medications.
Social worker—provides counseling and
Highest level of Diminished or impaired
optimal health state of health referral to community resources.
Physical therapist—offers exercises and
This patient has some health problems and will assist this patient in learning tech-
some changes in her life, but she has a rela- niques for safe ambulation, bending, and
tively high level of wellness. Her blood pres- lifting.
sure is under control and she has adapted to a Dietitian—provides nutritional counsel-
major change (retirement), by taking on a new ing.
challenge of volunteering. Her positive out- Respiratory therapist—supervises oxygen
look on life allows her to find joy in the pros- administration and performs pulmonary
pect of sharing time with a new generation. assessments.
32. a. Originally, the white pleated cap and the Technologist—will obtain and analyze
apron signified respectability, cleanliness, specimens and perform other diagnostic
and servitude. Caps gradually became procedures.
symbolic of office and achievement and Pharmacist—prepares the medication in
were celebrated with capping ceremonies. the hospital. The community pharmacist
Uniforms became more informal and can help this patient monitor his home
nurses complained that caps interfered medications.

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 Answer Key  3  

(Note to student: Some hospitals will also Discuss this situation with your clinical in-
have a financial counselor to assist the structor for advice about visiting patients dur-
patient in understanding the hospital bill ing the preclinical preparation time.)
and to make arrangements in paying out- 17. Answer 4: A poor nurse-patient relationship
of-pocket costs.) increases the likelihood that the patient will
b. For primary prevention, the nurse would seek legal action and harm has to occur in or-
encourage wellness activities and pre- der for liability to be established. The family
emptive screening programs such colo- of the elderly patient could seek damages, but
noscopy or glucose screening. For second- that is less likely if they understand that the
ary prevention, to reduce the impact of nurse and facility will try their best to prevent
the chronic respiratory disease, the nurse falls, but are unable to physically restrain pa-
would encourage smoking cessation tients for the purpose of preventing falls. The
and weight loss. For tertiary prevention, angry patient may report the nurse to the su-
the nurse would get a referral for home pervisor, but if no harm is sustained then any
health assistance, including physical legal action against the nurse will not be suc-
therapy, which will improve quality of life cessful. The family who complained at 3:00 am
and reduce further loss of function. may also be very angry. The nurse’s decision
to wait must be based on comprehensive as-
sessment of the patient to ascertain that there
CHAPTER 2—LEGAL AND ETHICAL ASPECTS is nothing to warrant calling at 3:00 am. Care-
OF NURSING ful documentation is necessary. Making an
incident report in all of these situations would
Matching be a good idea.
1. e 18. Answer 1, 2, 3, 4, 6: The UAP’s personal
2. d health records are confidential and unrelated
3. b to the patient’s case.
4. h 19. Answer 2: Early discharge and high levels
5. f of patient acuity require excellent discharge
6. a teaching so patients can perform self-care and
7. c self-monitoring and are therefore less likely to
8. j suffer harm. Being able to take a limited num-
9. g ber of high-acuity patients would be ideal,
10. i but high acuity is the current trend. Having
malpractice coverage is good if litigation oc-
True or False curs; however, insurance payouts may actu-
11. True ally be contributing to the problem. Ensuring
12. True accountability of others is not possible.
13. False. Duty refers to the established relation- 20. Answer 1: Assess knowledge and readiness
ship between the patient and the nurse. to perform. Barriers may include knowledge
14. False. Assault is an intentional threat to cause deficit or feelings of anxiety or self-doubt. Go-
bodily harm to another; does not have to in- ing with her and observing performance and
clude actual bodily contact. The nurse would pulling her file would be appropriate after as-
be charged with battery, which is the unlawful sessment. Forcing someone to do a task that is
touching of another person without consent. beyond their ability and understanding is in-
15. True appropriate supervision and the nurse would
be liable for the UAP’s errors.
Multiple Choice 21. Answer 2: Locate the RN in charge so that
16. Answer 4: The student has initiated the nurse- the blood can be started. Health care provid-
patient relationship and therefore has the ers can supervise nurses and they know the
duty to act. All students are CPR-certified so potential adverse reactions of blood products;
the student has to perform the duty in a rea- however, they are generally less familiar with
sonable and prudent manner as would other the policies and procedures related to the ac-
nursing students. All of the other options are tual administration.
also likely to be necessary. (Note to student:

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 Answer Key  4  

22. Answer 1, 2, 3, 4: Do not include any informa- dressing may be necessary for continuity of
tion that identifies the patient. Information care and also for reimbursement. The other
such as the room number or the health care options are incorrect.
provider’s name may seem harmless, but 29. Answer 4: Disciplinary defense insurance
including those details could lead to specula- includes attorney; wage loss reimbursement;
tion about patient’s identity. A clinical report travel, food, and lodging expenses; and le-
must include information such as vital signs gal fees when the nurse has to go before the
and medical condition. If in doubt, the clinical board of nursing for disciplinary action. The
instructor should be consulted. other types of insurance are for malpractice
23. Answer 1: Patients must be at least 18 years protection.
old to give consent. If under 18, the exceptions 30. Answer a. 4, b. 3, c. 2, d. 5, e. 1: The nurse
are marriage; court-approved emancipation; hopes for dismissal of charges. The letter of
self-supporting and living apart from parents; reprimand may be formal or informal. Proba-
military service; or for STIs, alcohol or drug tion with stipulations means that the nurse can
abuse, sexual assault, or family planning. continue to work, but under conditions as
24. Answer 3: Policies about giving patient infor- determined by the board (e.g., monitored).
mation over the phone will vary. For example, Suspension with stipulations means that the
some facilities may not allow acknowledging nurse cannot continue to work, but there are
that the patient is or is not there. Other facili- conditions that must be fulfilled. Revocation
ties require that the patient have a list of peo- of license is loss of licensure.
ple who are allowed to call for information. 31. Answer 1: First, assess the patient’s feelings
Another variation is that selected callers are by encouraging expression. The patient may
given a phone code to reach the patient. The not understand the advance directives or may
nurse should be familiar with hospital policy, have issues that were triggered by the discus-
because the policies are designed to specifi- sion. The other options are also necessary.
cally comply with HIPAA. 32. Answer 2: The patient’s living will is the best
25. Answer 3: Alert the health care provider so protection, because it reflects the patient’s
the child can be examined for occult injury. wishes. Policies and procedures and the Joint
The other options may also be used to investi- Commission may contain general guidance
gate the possibility of child abuse. about giving excellent care to patients, but
26. Answer 3: Call for help first, because the will not offer any specific help in this situ-
health care team is not prepared to face armed ation. The Patient Self-Determination Act
assailants. Trying to reassure patients in the supports the use of living wills to define the
immediate area would be the second step. individual’s choices about care and treatment.
Stifle the impulse to run out and help. If 33. Answer 4: The nurse, the 13-year old girl, and
the emergency staff is killed or injured, this the mother all have very strong feelings about
makes the situation worse. Locking doors this emotional situation. First, the nurse must
in an emergency department is likely to be control her own responses. The other options
impractical and create additional safety prob- are likely to be necessary, but this will be a
lems. difficult process and other health care team
27. Answer 1: Being competent and compassion- members, such as a social worker, family
ate are the best defenses. Knowing the legal counselor, spiritual advisor, legal counsel, or
definition may be helpful, but definitions obstetrician are likely to be involved.
are abstractions and the nurse’s day is full of 34. Answer 1, 2, 3, 5: If the nurse observes an-
real-world events. Obtaining malpractice in- other nurse being rude toward a patient, the
surance is likely to make the nurse feel better, ethical thing to do would be to follow up so
but it does not decrease the chances of getting that patients are respected. Texting should not
sued. Validating nursing actions with another be used as an additional method of passing
is always beneficial, but this is not a realistic gossip among staff. The other options demon-
option for minute-to-minute care. strate ethical professional behavior.
28. Answer 2: The nurse is assessing the wound 35. Answer 3: The supervisor should be present-
during the dressing change and documenta- ed with the facts. Theft is unethical and el-
tion should reflect the nurse’s attention to the derly residents are in an especially vulnerable
standard of care. Documenting the type of position; thus the Nurse B is not giving good

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 Answer Key  5  

care. Talking to the residents or families will al and professional behavior, which is also
be part of the investigation that is conducted part of the code of ethics, Nurse B should
by the supervisor. The supervisor could rec- talk to Nurse A about the comment, rather
ommend that both nurses seek assistance for than ignoring it.
values clarification. b. Nurse B should initiate the process of val-
ues clarification, either by herself or with
Critical Thinking Activities assistance from a counselor or supervisor.
36. a. In regard to informed consent for a sur- This process includes thinking about a
gical or diagnostic procedure, the nurse belief or behavior, deciding its value and
may be responsible for witnessing that incorporating the value into a response.
the patient is signing the consent and is Nurse B could talk directly to Nurse A to
aware of the treatment, risks, alternatives, see if Nurse A is actually discriminating
and consequences of accepting or reject- against a certain type of patient or if there
ing care. The nurse should be careful not is some other problem, such as knowl-
to discuss with the patient the elements edge/skills deficit. Nurse B may also
of disclosure that the health care provider decide to report Nurse A’s unethical be-
is required to make, such as the risks or havior by following the appropriate chain
benefits involved with the treatment or of command, explaining the facts clearly,
procedure. and documenting the incident objectively
b. The nurse should go back to the charge and accurately.
nurse and clarify how nurses are getting 38. a. First, the nurse needs to involve other
informed consent signed. It is possible members of the health care team, such as
that health care providers are explaining the health care provider and the psychi-
the procedures and the nurses are later atric social worker. Physical causes for
assessing the patients’ understanding and depression or changes in cognition should
then contacting the provider if the patient be investigated, as well as psychological
has additional questions or needs clarifi- causes of depression. A psychiatrist or
cation; however, this is not the best situa- psychiatric clinical nurse specialist should
tion. Ideally, the nurse should accompany assess the patient for signs of suicide. If
the provider during the explanation and the patient is deemed of sound mind,
the form should be signed at that time. than he has the right to refuse care.
The nurse could ask the charge nurse to b. When a patient refuses care, the nurse
obtain the informed consent and then fur- may experience a personal feeling of re-
ther discuss this process with a supervi- jection. The nurse has to recognize that
sor, because the nurses in this facility are refusal of treatment is not a refusal of
at great risk for practicing outside scope interaction and human warmth. It may be
of practice and could be liable if the pa- difficult, but the nurse should continue
tient suffers harm from the procedure. to check on the patient as before and to
37. a. Further assessment is needed to deter- spend as much time as before, but the
mine the underlying motivation for the focus may shift from task orientation
action of these two nurses. It appears that to therapeutic communication. And of
Nurse A is reluctant to care for “those course the patient always has the option
kinds of people” and the code specifies of changing his mind and accepting se-
that the nurse should provide care with- lected elements of care.
out discrimination. Assessment of Nurse c. For nurses, the refusal of heroic measures
A’s behavior may reveal that she lacks the is often easier to accept, because many
confidence or skills to care for AIDS pa- nurses themselves do not want to be kept
tients; thus additional training is needed. “alive by machines.” However, it seems
Possibly the death of a close friend from cruel and inhuman if basic needs like
AIDS may have created an emotional bar- food or hygiene are not provided. Nurses
rier and thus she may need grief counsel- have worked for centuries trying to pre-
ing. Nurse B is attempting to help Nurse vent pressure ulcers and to improve pa-
A, which is a laudable action; however, in tient outcomes. Nurses may also believe
order to maintain a high degree of person- that immunization is partially for the pro-

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 Answer Key  6  

tection of the individual, but also for the teaching, and source for research and data col-
purpose of “herd immunity.” Nurses are lection.
trained to be problem-solvers and doers. 14. Focus charting uses the nursing process and
Doing nothing for the patient may seem the focus is sometimes a current patient con-
difficult, but remember that supporting cern or behavior, and sometimes a significant
the patient emotionally and psychologi- change in patient status or behavior or a sig-
cally is also a nursing function. nificant event in the patient’s therapy. In CBE,
39. The nurse has gone up the chain of command complete physical assessments, observations,
and reported her concerns to the supervisor. vital signs, intravenous (IV) site and rate, and
However, the nurse could still be involved in other pertinent data are charted at the begin-
a legal action if there is an occurrence where a ning of each shift. During the shift, the only
patient is harmed. The nurse could report the notes the nurse will make will be for addi-
conditions to the state board of nursing, but tional treatments done or planned treatments
change is likely to come slowly, if at all. The withheld, changes in patient condition, and
nurse may opt to make personal notes or inci- new concerns. Narrative charting is an ab-
dents reports related to working conditions or breviated story form of patient care. It is used
to discussions with supervisors. for both computerized and noncomputerized
The ethical implications are that the nurse nurse’s notes and includes subjective and/or
is employed in a situation that is constantly objective data, consultations, care and treat-
putting the patients at risk; however, in some ments, and response to therapy.
ways, if the nurse opts to quit and seek anoth- 15. Home health care and long-term care docu-
er job, then the patients have lost an advocate mentation are directly related to reimburse-
and a caregiver. In addition, this scenario is ment, because patients’ eligibility and services
not uncommon and the nurse could find that provided by the nurses must be documented
he/she has jumped from the frying pan into to justify payment by Medicare, Medicaid,
the fire. or private insurance companies. The chart-
If the nurse opts to stay, then teamwork is ing is not usually done on the same time
especially important under these conditions schedule or with the same frequency as that
and watching out for each other and all of the of the acute care facility. An interdisciplinary
patients becomes more important when ev- approach must be documented in the notes
eryone is tired and stressed. along with evidence of compliance with state
and federal regulations. For home health care,
nurses carry written records with them or use
CHAPTER 3—DOCUMENTATION a laptop computer to maintain patient docu-
mentation.
Matching
1. d Table Activity
2. k 16. See Table 3-1, Essential Elements of Documen-
3. f tation, page 39.
4. l
5. j Multiple Choice
6. h 17. Answer 4: Narrative notes should include a
7. b complete description of the patient’s response
8. c to any therapies. As a student, you write
9. a evaluation statements on a care plan, but in
10. e the hospital it is unlikely that you will see the
11. g actual care plan format that you use in school.
12. i The Kardex is tool that outlines therapies,
orders, and activities, but there is no space for
Short Answer documentation of outcomes. Medication ad-
13. The five basic purposes of patient records are ministration times are recorded on the MAR,
communication, permanent record of account- but usually there is no space for additional
ability, legal record of care, information for notation.

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 Answer Key  7  

18. Answer 3: Documentation can always be im- 23. Answer 3: The charge nurse can determine the
proved; however, it is particularly important corrective action, which may include referral
to document patient condition on discharge to the nurse educator. Coworkers do not have
and any follow-up instructions. If the patient time to teach basic spelling and grammar to
goes home and immediately dies, the nurse, other employees. All health care professionals
who is the last professional to see the patient, are obligated to watch out for each other and
has made no note to indicate that the patient the patients; therefore, doing nothing is incor-
was stable on leaving the hospital. rect. The nurse can correct (not change) his/
19. Answer 2: In a large hospital, there could be her own documentation, but not the docu-
many employees who would have a legiti- mentation of others.
mate reason to look at the patient’s chart; 24. Answer 3: Documenting the time that the pa-
however, for document security and patient tient is in x-ray explains why the medication
confidentiality the nurse is obligated to ques- was not given on time. Consult the charge
tion any unfamiliar person. If the person nurse, because there are certain medications
identifies self and the nurse is still not sure if that should not be held for prolonged time
access is appropriate, the charge nurse or se- periods. Interventions and therapies should
curity could be contacted for advice. be documented after they are completed, not
20. Answer 4: Computer access and time for doc- before. Calling the pharmacy is okay, but the
umentation can always be a problem, so mak- student will have to take additional steps after
ing notes for personal use is an alternative. talking to the pharmacist. An incident report
The student can always ask the instructor for is not needed at this time if steps are taken to
advice, but there is nothing the instructor can resolve the situation.
do about lack of functional computers. Hard- 25. Answer 1: Clinical (critical) pathways allow
copy charting is usually reserved for total sys- staff from all disciplines to develop stan-
tem shutdown for prolonged periods of time. dardized, integrated care plans for projected
Waiting until the end of the shift is never the length of stay for specific and predictable
best option. cases. Day-to-day elements of care such as
21. Answer 3: The nurse would meet the patient’s activity and pain control are laid out. Unusual
immediate need for the medication. Since events with potential for harm or those that
the vital sign data are missing, the nurse ap- cause actual harm are usually documented in
plies nursing process and assesses the blood an incident report. The pathway is a multidis-
pressure and pulse before administering the ciplinary care plan that replaces the nursing
medication. Then the nurse documents the BP care plan. The LPN/LVN has a role in moni-
and pulse and the administration of the medi- toring and documenting, but professional
cation. Next the nurse would find the UAP roles are not specifically written out in the
and ask about the vital signs (Ask about other pathway.
patients too; the UAP should have finished 26. Answer 3: The nurse manager will have
and recorded all am vitals by 10:00 am.) Giving knowledge of policies related to medical
the medication without knowing the BP is an records and leaving the hospital prior to dis-
incorrect action. If the UAP recorded the vitals charge. The records are hospital property, but
in the narrative notes, he/she may need ad- this explanation is likely to cause the patient
ditional training, because this is not the best to become more upset. Contacting the health
place to document routine vital signs. care provider may be appropriate to address
22. Answer 2: If the nurse is clear about the or- the patient’s desire to leave the hospital, but
ders, it would be appropriate to carry them the provider is not the best resource to contact
out. If there are questions, the nurse should for requesting records. Copying the chart for
call the health care provider for clarification. the patient is incorrect, because policies need
Later, consult a supervisor about provider’s to be reviewed and followed.
response; SBARR is a relatively new concept 27. Answer 4: Contact the nursing instructor for
and some providers may need some addition- guidance. Immediately shredding the Kardex
al instruction about the process. Documenting or checking for patient identifiers at this point
the incident in the patient’s chart is not appro- does not address the problem. Apologizing
priate. and explaining may seem like the best route,
but the student should seek out the instructor

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 Answer Key  8  

first. This is a serious HIPAA violation that performed and one nurse is the designated
could result in disciplinary action or even a recorder.) “SSE” and “CC” are not approved
lawsuit for the student and the instructor. abbreviations. There are two spelling errors:
28. Answer 1: For paper charting, draw a line adominal distencion should be corrected to ab-
through it and initial the error. Generally dominal distention.
there is no need to report this type of error to Sample #3: Time of entry is missing. Full
the charge nurse, unless there is some unusual assessment of pain is missing. Statement indi-
occurrence. Using correction fluid is incor- cating blame, “physician made error,” should
rect. Discarding the page is a possibility if the not be used. Inppropriate follow-up action is
nurse is the first and only person to make an recorded (i.e., the appropriate follow-up is to
entry on that page. call the provider for clarification). Patient’s
29. Answer 1, 2, 3, 4: Failure to completely docu- complaint about care and quoted remark
ment allergies puts the patient at risk for should not appear in nurses’ notes. Time of
severe allergic reactions that could result in pain medication is missing and there is no
death. Using patient quotes may be appropri- note about response to medication. Signature
ate for describing symptoms or conditions, of nurse is missing.
but complaints about care or caregivers 32. Both EHR and hardcopy systems provide a
would be documented in an incident report. permanent legal record of past and current
Documenting medication that is not given is medical and nursing problems, plans for
falsification. Failure to document assessment care, care given, and the patient’s responses
of the IV site indicates low quality of care to various treatments. Both are used for cost
(even if there was no actual problem with the reimbursement and quality assurance and im-
IV site). Clustering information is a common provement.
and acceptable method of documentation. EHR eliminates repetitive entries and it is
It would be better if the generic and brand easier to locate and retrieve the data. Gener-
names are written in orders; however, if the ally, EHR increases efficiency, consistency, ac-
meaning is clear, legible, and accurate, the or- curacy, and legibility and decreases cost. EHR
der is acceptable. has created new issues related to safeguarding
30. Answer 2: If the computer monitor is left patient confidentiality and additional training
open, anyone who walks by can look at the is needed for new employees and whenever
information. In addition, an active login al- the software is upgraded. Access to functional
lows anyone to go into the system under the computers can also be an issue.
nurse’s password. The other actions are ac- Hardcopy charting is less common, es-
ceptable ways to pass information to other pecially in large hospital settings; however,
health care team members. hardcopy can be easier to read than a com-
puter screen. The hardcopy system can also
Critical Thinking Activities be easier to navigate when documenting the
31. Sample #1: Day of month and time of entry atypical situation (i.e., patient’s situation or
are missing. “Good night” and “status un- the event does not seem to fit into the com-
changed” are empty, general phrases. There puter’s checkbox style of organization).
is one spelling error: escendially should be
corrected to essentially. Rather than charting
diamond ring and gold watch, use descrip- CHAPTER 4—COMMUNICATION
tive adjectives, such as clear, white, or yellow.
Also, documenting that expensive items are Fill-in-the-Blank Sentences
being stored in the bedside table creates li- 1. caring; sincerity; empathy; trustworthiness
ability for theft or loss. Patient’s condition, the 2. trust
time, and the method of transportation to the 3. anger; impatience; withdrawal
cafeteria are missing. 4. Impaired verbal communication
Sample #2: Generally charting for another 5. inability to speak
nurse is not done. (Note to student: Charting
the actions of another team member could Multiple Choice
potentially be done in an emergency situation 6. Answer 2: The best method is to give report
where many tasks are simultaneously being behind a closed door. Eliminating all passers-

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 Answer Key  9  

by is almost impossible in busy care settings. 12. Answer 4: Use of closed questions is the best
Negative language should be eliminated from strategy for this type of patient interview. The
reports, but even positive reports should not other techniques will only prolong the discus-
be broadcast to anyone not directly involved sion of irrelevant information. Focusing could
in the patient’s care. Written notes do not also be used.
guarantee confidentiality unless they are 13. Answer 2: In expressive aphasia, the patient
closely safeguarded and shredded appropri- understands, but can’t verbally respond;
ately. therefore, eye blinks are an alternative. En-
7. Answer 4: Open-ended questions and two- couraging the patient to speak is inappropri-
way communication are the best ways to elicit ate at this time. Referring to family members
feelings. Asking the patient if he is afraid is a is appropriate if they have knowledge of
closed question, this could also suggest to the details that the patient cannot describe; how-
patient that he should be afraid. Giving infor- ever, do not leave the patient out of the com-
mation or showing pictures creates a one-way munication loop. Hearing and understanding
information flow from nurse to patient and speech are not the issues.
this doesn’t encourage the patient to speak 14. Answer 1, 2, 3, 6: Method of addressing
out. people, interpretation of time, touch, and eye
8. Answer 1: The nurse acknowledges the pa- contact are culturally based. Facial expres-
tient’s desire to go home, while providing an sions and gestures such as hand-shaking and
opportunity to assess (patient must also as- tone of voice also have a cultural context, so
sess) ability to independently walk and func- the nurse should investigate cultural norms
tion. The other options indicate that the nurse before assuming that these are acceptable ap-
is agreeing with the patient’s verbal desire to proaches.
go home and is ignoring the nonverbal gri- 15. Answer 2: Older adults may need additional
mace. time to process information or formulate a
9. Answer 4: A notebook and a pen are typically response. Speaking loudly and slowly is not
associated with recording new material for necessary unless there is some hearing loss.
later use. However, an optimistic nurse will Well-lit environments are preferred. Discour-
remember that adolescents may demonstrate aging anecdotes or tangential communication
behaviors to get peer approval; thus all of may be necessary if there is an urgent need or
these students may be interested in the topic, if the nurse needs specific information.
and the cell phone or the bored expression 16. Answer 3: The nurse paraphrases the patient’s
may be less about the teacher or topic and statement. This indicates that nurse heard and
more about the peer group. Use of the Inter- interpreted the meaning. For the other behav-
net is questionable. The adolescent may be iors/responses, the nurse is using passive lis-
searching for some information that will con- tening and the patient is not sure if the nurse
tribute to the discussion; however, use of the understands what he/she is trying to say.
Internet can be a distraction to others in the 17. Answer 2: The nurse is reflecting patient’s
group. feelings and then invites the patient to elabo-
10. Answer 4: The nurse checks to understand the rate. Restating what the patient has said
patient’s concern. Option 1 is a closed ques- should be used sparingly; overuse sounds like
tion. Option 2 is giving information. Option 3 parroting. Offering to review the instructions
is a validating response. suggests that grasp of the knowledge will al-
11. Answer 3: An open-ended question allows leviate all problems. Suggesting that someone
the patient to take the lead and provides an stay with the patient is offering unsolicited
opportunity for the nurse to assess the pa- advice.
tient’s worries. A closed question that directs 18. Answer 1: Intimate space is from the face to 18
the patient’s worries back toward the health inches away; therefore, in assisting the patient
care provider does not elicit explanation. The to transfer, the nurse would have to touch the
second-best response: the nurse makes a good patient and should obtain permission first.
guess about the patient’s worries, but this is Sitting in a chair would be within the personal
also a closed question. Offering to make the space of 18 inches to 4 feet. Speaking to the
patient feel better is not realistic in this in- family or handling the patient’s belongings
stance. could also have cultural implications; how-

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 Answer Key  10  

ever, these are less directly related to intimate 24. Answer 4: The nurse is newly graduated and
space. wants to have good relationships with co-
19. Answer 1: Asking about type of surgeries workers and to see that the patients get good
invites the patient to give an exact answer. care. Honest praise is a good way to establish
“What kinds of problems?” and “How do trust in coworker relationships. Once trust
you feel?” are very broad questions. The pa- is established, the nurse could be more con-
tient may be unsure what the nurse is asking frontational with the UAP. Role modeling is
about. “Are you having any pain?” is a closed one way to gently redirect behavior. Gaining
question, which is okay, but requires several more experience is good, but don’t mimic
other follow-up questions to elicit relevant questionable behavior. Speaking to the RN is
details. a possibility, but true disrespect may not be
20. Answer 2: The nurse should assess the un- the issue, so assessment of behavior should
derlying meaning of the patient’s comment precede going to the RN. Everyone may seem
(i.e., UAP’s jokes might be hurtful, offensive, happy, but residents in long-term care facili-
or inappropriate to the patient. Or the patient ties frequently feel that they have to get along,
might like the UAP’s communication style.) because there is no other option.
Automatic superficial responses, making as- 25. Answer 2: First assess the patient to deter-
sumptions, or changing the subject are not mine if there is an issue with social isolation.
therapeutic. Also remember that hearing-impaired pa-
21. Answer 3: When talking to health care provid- tients may have problems if there is excessive
ers, the nurse uses assertive communication background noise, so he may actually hear
that conveys respect, but also communicates better in his own room. Based on the assess-
what is needed to safely care for the patient. ment, the other options could be considered.
The other responses are not in the best inter-
ests of the patient. Being aggressive towards Critical Thinking Activities
the health care provider may cause him/her 26. a. Problems—slurred words and unclear
to hang up. Being nonassertive puts the nurse speech
in the position of having no orders to address b. Goal—Patient will communicate needs
the change in condition. effectively with verbal and/or nonverbal
22. Answer 4: The nurse is acting like a physical communication.
bridge between the boy at the window and c. Nursing actions—Refer to Box 4-6 on p.
the two at the bedside. Using silence and be- 74. Determine the language spoken by the
ing physically present are good interventions patient, use simple communication, spend
when a patient has died. Talking to the boy time with the patient, and try alternative
about feelings or directing him to come to the methods of communication. Allow time
bedside may be premature. He may need a for responses; ask questions that can be
little time to process the death of his father. At answered “yes” or “no.” Anticipate pa-
the same time, do not leave him isolated by tient’s needs. Maintain eye contact. Watch
grouping with the two at the bedside. for frustration or fatigue.
23. Answer 2: The nurse must do a quick assess- d. Evaluation statement—Patient is able to
ment of her own feelings and decide whether convey needs to the nurse by nodding
she can be therapeutic with the patient. The head and using unaffected hand for sig-
patient’s nonchalance could mean many naling.
things and the young patient needs to feel e. Reassess the patient and the situation for
that health care personnel are available to confounding factors or changes in the
help. The nurse must care for a patient if there patient’s condition that may be interfer-
is no one else available, but asking another ing with goal achievement. For example,
nurse would be appropriate if the situation the patient may have pain that is distract-
is not urgent and the nurse continues to feel ing him. Possibly the patient may have
hostile towards the patient. Expressing con- a change in mental status that signals a
cern is a possibility, but the nurse and the new problem with cerebral perfusion. The
patient must have a well-established trusting patient could be too tired or frustrated
relationship, and when expressed, the concern to attempt communication. Based on the
should be patient-centered.

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 Answer Key  11  

new assessment data, the care plan may CHAPTER 5—NURSING PROCESS AND
have to be modified. CRITICAL THINKING
27. Environment—the nurse is experiencing
an overload of distraction from a variety of Crossword Puzzle
sources. The nurse’s posture and position 1. See Table 5-3, p. 82.
(crossing the arms over the chest) and the 1 2 3
F A P
space and territory (standing too far away 4 5
A U D Y S F U N C T I O N A L B E
and by the door) convey impatience. The N N I R
message to the patient is “I do not want to T C
6
I
7
D L C
8 9 10
communicate with you.” Any trust between I N T E R R U P T E D N E F F E C T I V E
C I I A F T I
the nurse and patient is destroyed. “Dear” is I O S B E Y V
used less by younger people and possibly the P N
11
S I T U A T I O N A L E
nurse may view “dear” as condescending. A A
12
B L
13
S D
T L O W L I I M P A I R E D
The patient may be experiencing unresolved
O I T V
grief over the loss of husband (recall that she R
14
D E L A Y E D N Y
15
E X C E S S I V E
is a widow) or stress related to hospitaliza- Y G
16
tion. The patient could also be having a physi- I N E F F E C T I V E

ologic problem such as fever or an electrolyte

imbalance which has triggered confusion or True or False
hallucinations. Cultural differences and use of 2. True
language could also be factors. For example, 3. False. Identification of problems occurs dur-
the patient may not be able to directly express ing the diagnosis phase.
fears and concerns, so repeatedly uses the call 4. False. A nursing intervention is created to
bell to get attention. provide specific written instructions for all
28. See Table 4-4, p. 73. caregivers.
We all use responses that block commu- 5. False. Advising patients about medications
nication, so do not judge yourself to be a poor for a health condition is the responsibility of
communicator if you have numerous exam- the health care provider.
ples. 6. False. Perceived constipation is defined as
On the other hand, if you cannot think of “self-diagnosis of constipation and abuse of
any examples where you used responses that laxatives, enemas, and/or suppositories to en-
blocked communication, you may need to in- sure a daily bowel movement.”
crease awareness of what you are saying and
how others are responding to you. Conscious Short Answer
use of communication responses and the ef- [Note to the student: For questions 7, 8, 9, and 10,
fect that responses have on others allow us to the answer key shows examples of nursing diagno-
intentionally improve our therapeutic com- ses, goals, interventions, or evaluation statements.
munication. Your answers may differ, so check your answers for
these questions against the following criteria. The
nursing diagnosis should include: (1) the nursing
diagnosis label from the NANDA-I list; (2) the
contributing, etiologic, or related factor; and (3)
the specific cues, signs, and symptoms from the
patient’s assessment. A patient outcome statement
provides a description of the specific, measurable
behavior (outcome criteria) that the patient will be
able to exhibit in a given time frame following the
interventions. Nursing actions should be directly
related to helping the patient achieve the goal
and evaluation statements should reflect achieve-
ment, partial achievement, or failure to achieve the
patient-centered outcome.]

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 Answer Key  12  

7. Fluid volume deficit related to severe vomit- questions would be done during the interven-
ing and diarrhea manifested by poor skin tion phase.
turgor, weight loss, and decreased blood pres- 15. Answer 3: There are a number of things that
sure could cause the patient to be pale, diaphoretic,
Patient will demonstrate fluid balance (in- and tachypneic. Based on the objective cues,
take approximates output) within 24 hours. the nurse would use critical thinking and con-
8. Impaired physical mobility related to right clude that respiratory (e.g., pulmonary em-
hemiparesis manifested by an inability to boli) and cardiac (e.g., myocardial infarction)
ambulate independently or perform selected causes would have priority over metabolic
activities of daily living. Patient will perform (e.g., hypoglycemia or infection) or renal (e.g.,
transfer techniques (e.g., moving from lying kidney stone) causes. Then the nurse will use
to sitting position) prior to discharge from re- a series of closed questions to try to determine
habilitation facility. the cause. In other words, chest pain suggests
9. Examples of possible nursing interventions cardiac or respiratory problems. Fever and
include: assess skin integrity every shift, en- chills are related to infection. Difficulty sitting
sure skin is clean and dry at all times, range could be related to neurologic dysfunction,
of motion to right side, turn every 2 hours if systemic weakness, or musculoskeletal prob-
unable to ambulate. lems. Asking about time of onset of symptoms
10. a. At 8:00 am, patient passed moderate helps to further clarify problem (e.g., onset
amount of formed brown stool without after exertion).
straining. 16. Answer 3: Prioritize the problems/nursing
b. At 8:00 am, patient reports passing very diagnoses, so that the patient’s health and
small amount of stool, but “feels better safety are maintained; immediately intervene
than I did yesterday.” if necessary. The other actions are also part of
c. At 8:00 am, patient straining for bowel a complete and comprehensive nursing care
movement; attempts x 2 for 30 minutes, plan.
but unable to pass stool. Is requesting an 17. Answer 4: The decision to use a PRN medica-
enema for relief. tion is based on nursing assessment; therefore,
11. Examples of how critical thinking is used by the nurse would obtain a baseline assessment
the nurse are (1) deciding when to do vital at the beginning of the shift and reassess pe-
signs, (2) deciding what temperature site riodically at least every 4 hours or more often
should be used, (3) deciding when to sit and if needed. The nurse could ask the charge
talk with a patient, and (4) determining the nurse if the order could be revised; for ex-
presence of hypoglycemia or hyperglycemia ample, “use inhaler for respiratory rate > 30/
in the unconscious diabetic patient. min with subjective feelings of air hunger.
12. a. Acute pain: Physiologic However, the charge nurse might also point
b. Decreased cardiac output: Physiologic out that all nurses should be familiar with
c. Situational low self-esteem: Esteem asthma symptoms. Asking the patient about
d. Risk for injury: Safety and security what triggers the asthma gives a clue as to
e. Ineffective relationship: Love and belong- when the inhaler might be needed. Leaving
ingness the inhaler at the bedside could be a strategy
f. Hopelessness: Self-actualization if the patient is very familiar with the onset
of asthma and how to use the inhaler, but this
Multiple Choice option leaves the decision-making up to the
13. Answer 4, 3, 1, 2, 5, 6: The six steps are as- patient.
sessment, diagnosis, outcomes identification, 18. Answer 1, 2, 4, 5, 6: All subjective, objective,
planning, implementation, and evaluation. historical (note to student: opioid medication
14. Answer 1: Observing the patient’s abilities is can cause constipation), and functional data
an assessment that will guide the type of in- related to bowel function are relevant for a
terventions that the nurse selects. Modifying diagnosis of Constipation. Flat, brown lesion
a standardized plan is part of the planning near umbilicus is noted during physical as-
phase. Taking the blood pressure after medi- sessment, but does not apply to bowel func-
cation is evaluating the efficacy of the inter- tion.
vention. Assisting the patient to make a list of

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 Answer Key  13  

19. Answer 2, 3, 5, 6: A focused assessment is charging hospital for the patient. Because of
advisable when the patient is critically ill, confidentiality, the family should not have
disoriented, or unable to respond. A focused this form, unless the patient gives permis-
assessment is also used to gather information sion. Health care providers and pharmacists
about a specific health problem or a patient’s will also rely on the medication reconciliation
report of a sign or a symptom. A complete form.
assessment involves a review and physical 25. Answer 2: Palpating the abdomen to locate
examination of all body systems and cogni- any rigidity or rebound tenderness would be
tive, psychosocial, emotional, cultural, and part of the focused physical assessment relat-
spiritual components and is appropriate for a ed to the patient’s report of abdominal pain.
patient who is stable and not in acute distress. The other assessments are appropriate for the
20. Answer 3: Biographic data assists the health head-to-toe assessment that would be done at
care team to identify potential risk factors. For the beginning of each shift.
example, the average 85-year-old man has dif- 26. Answer 2, 3, 4, 5: Patients with Alzheimer’s
ferent health issues than the average 3-year- disease will have multiple nursing diagnoses.
old child. The other options are also true. Acute confusion should not apply, unless the
21. Answer 2: The nurse must gather and analyze patient has delirium or a new injury/insult
data to make clinical judgments and deter- to the neurologic system. Chronic confusion
mine appropriate nursing diagnoses. In the would be selected.
past, nurses were not encouraged to make 27. Answer 3: All phases of the nursing process
judgments, but rather were expected to fol- are linked together. However, for this patient
low the physician’s orders without question. the problem is straightforward and the solu-
Health care providers identify disease and tion seems simple, but careful planning is
illness. Standardized care plans did evolve essential, because assisting this patient to the
from the use of nursing diagnoses; however, bathroom will be very time-consuming. El-
standardized plans must be carefully evalu- derly people may move slowly, require help
ated to make sure that they are appropriate to to stand, ambulate, sit, undo clothing, clean
the individual patient. Nursing diagnoses are perineal area, and wash hands. It is likely
not intended to limit, but rather to reflect, the that the nurse will make a short-term plan
types of problems that the nurse can treat. that includes assigning a UAP to assist the
22. Answer 4: Being underweight and having patient and an order should be obtained for
difficulty with independent position changes a bedside commode. Also some time must be
puts the patient at risk for developing prob- allocated to teach the patient to call for help.
lems with the skin. In the other options, a This patient will also need more frequent skin
problem with the skin already exists; there- assessments. Long-term, the plan may include
fore, Impaired skin integrity would be a better bowel/bladder training, or possibly a physi-
choice. cal therapy consult to help the patient gain
23. Answer 1: Edema would be a collaborative more independent movement.
problem, because the health care provider 28. Answer 4: If the goals are not being met, then
would identify the medical diagnosis that the nurse should evaluate the situation to
is causing or contributing to the edema and determine why they are not being met. After
then prescribe medication or other therapies. that, the nurse may opt to revise the goal or
The nurse would identify a nursing diagno- change interventions. Documentation of inter-
sis such as Excess fluid volume, and design ventions, results, and any revisions to the plan
interventions such as position change, review are always essential.
dietary aspects, and reinforce medication 29. Answer 2: Evidence-based practice is a
compliance. Assisting the patient with anxiety scholarly and systematic problem-solving
and coping would be nursing responsibilities. paradigm that draws from research, practice-
Making the diagnosis of cancer would be the generated data, clinical expertise, and health
responsibility of the health care provider. care consumer values and preferences. The
24. Answer 3: At discharge, patients should be committee will draw on many sources to cre-
given a copy of the medication reconciliation ate an evidence-based practice policy and
form. If the patient does not have the form, procedure manual, because it guides the
the nurse should obtain a copy from the dis- employees of an institution in the delivery of

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 Answer Key  14  

high-quality care. Directly applying research Evaluation—After intervention, reassess the

results to the clinical setting is rarely done. patient’s subjective reports of pain
While this is a criticism of research, results 33. a. The LPN/LVN assists the registered nurse
generally have to be replicated many times by performing ongoing complete and fo-
with large numbers of subjects. The Internet cused assessments of patients, depending
is a tool, but sources and information must on the facility and scope of practice in a
be validated. Asking for advice from clinical state. See Box 5-2, p. 90 for additional in-
experts is one of many sources used to build formation.
evidence-based practice. b. The RN is responsible for identifying and
30. Answer 4: The nurse applied critical thinking prioritizing nursing diagnoses; however,
skills and used assessment findings, knowl- patient care is a collaborative effort and
edge of pathophysiology, and knowledge of the goal is to provide quality care for the
equipment used for monitoring to identify patient. If the LPN/LVN feels that an er-
the irregular pattern of heart rhythm. Possibly ror has been made, he/she has a respon-
the nurse might visually identify patient risk sibility to point out the error to protect
factors, such as being overweight, smoking, the patient. When there is a disagreement,
or shortness of breath. In this case, the nurse use a diplomatic approach. Organize in-
would use questions to gather more data (e.g., formation, opinions, and rationales in a
“Do you ever have chest pain?” and “Do you clear and concise manner. Focus on the
have a personal or family history for heart patient and avoid making comments that
problems?”). A head-to-toe assessment and are personal or defensive. If two people
a complete evaluation can always give ben- cannot resolve their differences, it would
eficial information; however, because of time be appropriate to discuss the situation
constraints, these assessments are not always with a supervisor. This is very important
practical. when patient safety and well-being are
31. Answer 1, 2, 3, 4: Mentally rehearsing is a way involved.
to think about a problem before it happens.
Formulating questions is a way of actively
engaging the mind while receiving informa- CHAPTER 6—CULTURAL AND ETHNIC
tion. Knowing how others are making deci- CONSIDERATIONS
sions can guide the learner to understand
the linkage of events. Advocating for more Crossword Puzzle
clinical time is a reasonable suggestion, but 1.
most nursing programs are already providing
the maximum number of clinical hours and 1
S T
2
E R E O T Y P E
3

4
are constrained by clinical space and faculty. 5
R T E
Scanning nursing information is useful to R A C E H L
N N A
gather more information, but critical thinking 6
S
7
O C I E T Y O S
requires active application and practice. C U C T
U L E I
8
Critical Thinking Activities M L T N C
32. An example of a potential plan for this patient O T U T I
R U R R T
is: A R
9
E T H N I C I T Y
Nursing diagnosis—pain related to abdomi- L A S
nal surgery 10
S U B C U L T U R E M
Goal—reduction or relief of pain when treated
Assessment—check vital signs and do a com-
plete assessment of the patient’s pain, observe Fill-in-the-Blank Sentences
for signs or symptoms of potential complica- 2. Cultural competence
tions (e.g., hemorrhage or infection); observe 3. ethnic stereotype
for contributing factors (e.g., noxious stimuli) 4. Hispanic
Nursing interventions—Provide analgesic as 5. biomedical health belief system
ordered, position the patient for comfort, pro- 6. health care; care; discipline the children
vide distraction if desired (e.g., music)

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 Answer Key  15  

Multiple Choice suggestions. Religious beliefs can assist with

7. Answer 2: People who speak a little Eng- coping, but those who have no religious pref-
lish are more likely to understand simple erences may have alternative coping methods.
language; brevity is also important because Rituals and ceremonies should be allowed as
communicating in a second language is very long as there is no harm to patient or others.
tiring. Speaking loudly may be interpreted as 13. Answer 3: First the nurse controls own behav-
aggression and cause withdrawal or irritation. ior; this helps the family to decrease excite-
Use of an interpreter is necessary when ob- ment and anxiety. Identifying the leader is
taining an initial history or getting informed important, because the leader can control the
consent; however, getting an interpreter for family and the information flow. If the leader
every interaction is not possible. Provid- does not speak the best English, then the
ing detailed directions is not usually a good nurse can ask him/her to identify the member
strategy even for patients who speak English, to speak. Taking the patient to a private room
because details are frequently forgotten or be- may be counterproductive if the patient relies
come overwhelming. on family for support or translation. Physi-
8. Answer 2, 3, 5: While it is important to ap- cally assessing the patient would be appropri-
proach all patients as individuals, older adults ate if the patient arrives unresponsive or is in
are generally less tolerant of other cultures, apparent distress.
more likely to be rigid in practices, and use 14. Answer 3: Talk with the UAP first to assess
home remedies and traditional religious prac- the circumstances and the UAP’s behavior.
tices. Those with cognitive impairments may After assessing, the nurse can go back to
make thoughtless or hurtful comments. Older the patient and apologize or explain as ap-
age is not directly related to educational back- propriate. There is a chance that the patient
ground. did something that made the UAP feel very
9. Answer 2: Discuss the alternatives to blood uncomfortable, in which case the nurse can
transfusion with the health care provider and support the UAP to be professional and to
then perhaps the provider can make a plan problem-solve in difficult situations. Also, the
that will incorporate an acceptable alternative. UAP may be exhibiting behavior that would
Supporting the patient and documenting are be considered normal or even respectful, but
also appropriate after alternatives have been giving feedback about how patients are inter-
fully explored. The risk manager can advise preting her behavior can help her to work in
about problems that might occur if the patient cross-cultural situations.
feels coerced, but trying to change the pa- 15. Answer 2: If a nurse has very strong beliefs
tient’s mind about a blood transfusion is not or has certain behaviors that are very natural,
appropriate. finding a work environment that matches per-
10. Answer 1: There are special procedures for sonal strengths can be a better solution than
washing and shrouding the body, so contact trying to modify behavior for every patient
the family first. Staying with the body and situation. For example, pediatrics may be a
waiting 8-30 minutes before postmortem care good match for this nurse, whereas a clinic
would be in keeping with the Jewish religion. that serves older multicultural patients may
Organ donation may be a personal decision, not be a good match. Assessing and under-
but many religions forbid it. standing behavior is always a good start, but
11. Answer 1, 3, 6: Self-assessment and under- understanding origin of behavior does not
standing of self along with keeping an open ensure change. Learning about other cultures
mind will help the nurse. Trying to match broadens perspective, but patients still need
beliefs is not reasonable, because the nurse to be assessed and treated as individuals. Re-
is also influenced by his/her own culture. If questing certain types of patients is not ethical
trying to act the same or ignoring the differ- or fair to staff or patients.
ences, the nurse is not giving care based on 16. Answer 3: In group settings, people will
individual needs. normally gravitate to preferred areas with
12. Answer 2: Respect and protection of the soul preferred company; thereafter the same seat/
were indicated by all study participants. area is chosen over and over again. (Watch
Prayers at the bedside may be appropriate how a group of students enters and sits in a
for some, but not all; assess before making classroom.) Assigning seats is demeaning for

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 Answer Key  16  

adults and may inhibit natural development Critical Thinking Activities

of relationships. Asking every resident for 22. a. The nurse can explain that she under-
seating preference at every meal is impractical stands and speaks a little Spanish, but
for time management. (Some residents may be an interpreter is needed to ensure an
confused or very hard of hearing and others accurate history. When speaking to a pa-
may answer, but decide and move very slow- tient through an interpreter, look at the
ly.) Encouraging conversation with a variety patient (the way you normally would),
of people is not a bad idea, but this might be a rather than looking at the interpreter
better strategy during other social activities. while speaking. In caring for the patient,
17. Answer 1: To prevent delay for all the pa- the nurse can use her limited Spanish and
tients, leave this patient to the end. If there is should keep directions short and simple,
a medication that cannot be delayed, giving and use appropriate gestures or written
a 15-minute warning might work. Assessing cues.
the preoccupation may be useful; however, b. The advantages of having a family mem-
the patient may just have a number of rituals/ ber translate include not having to locate
behaviors that always fill the morning hours. and wait for a translator. The family
Starting at 8:00 am is impractical, there are becomes more involved in the patient’s
many things at the beginning of the shift that care and the nurse can build rapport with
the nurse must attend to. the family and observe the family inter-
18. Answer 1: Present orientation is action that actions. The patient may also feel more
is guided by patient’s “feeling okay” in the comfortable or reassured if the family is
moment. “What should I do if…?” indicates present during care or procedures.
future thinking and readiness to make con- The disadvantages are that family
tingency plans. “Can we share the pills?” is members may or may not be able to ac-
possibly present-oriented, but also there is no curately convey the nurse’s meaning to
understanding of even basic safety concepts. the patient or may intentionally or unin-
“Would you take…?” suggests that the patient tentionally withhold information from the
is ready to align himself with the future think- nurse or the patient. Potentially there is
ing of the nursing student. a violation of confidentiality; the patient
19. Answer 3: Use of herbal tea should be inves- has less opportunity to decide whether
tigated. Many herbs can interact with pre- the information is something that the
scribed medications or will be contraindicated family should know. There could also be
in certain disease conditions. The health care legal problems; for example, the services
provider should be informed and the phar- of a professional translator should always
macist can be consulted. The other practices be used for consent forms.
should be allowed, because they may be effec- c. i. Language—“What language is used
tive or ineffective, but are not harmful. in the home?”
20. Answer 4: First gather more information ii. Health—”How would you describe
about what the wife is feeding the husband, your health?”
then this information can be shared with the iii. Family structure—“Who will make
nutritionist. Revising the goal is necessary. the decisions about your care?”
The dietary plan can be changed, but the iv. Dietary practices—“What types of
change should incorporate compromises that food do you normally eat?”
support the patient’s health and meet the cul- v. Use of folk medicine—“Are there any
tural preferences. special remedies that you use? If so,
21. Answer 2, 3, 4, 5: These questions are de- what are they?”
signed to elicit what the patient thinks or 23. The nurses have tried to go up the chain of
believes about what is happening to the body. command and this has not been successful
Asking about onset or duration of sensations so far. Approaching the nurse manager again
are the standard assessment questions used to would be appropriate, because one person’s
identify the problem. behavior is affecting other staff members
and potentially patient care is being delayed
across the board. Talking to the nurse is an-

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 Answer Key  17  

other good attempt, but the day-shift nurse’s CHAPTER 7—ASEPSIS AND INFECTION
comment suggests that her time orientation is CONTROL
not the same as the other nurses on the staff.
There are many factors that may contribute True or False
to the nurse’s being late. Culture is one fac- 1. False. Hand hygiene is considered the most
tor, but family responsibilities, transportation important method.
problems, or health problems may also con- 2. True
tribute. The nurse who is late also needs to 3. True
hear feedback from coworkers about how her 4. False. Coccidioidomycosis (valley fever) and
behavior affects them. Respect has to be ex- histoplasmosis (a systemic fungal respiratory
tended both ways. The nurse manager should disease) are examples of systemic fungal in-
be involved to help all of the nurses make a fections. Protozoa are responsible for malaria,
personal and unit-wide action plan for the amebic dysentery, and African sleeping sick-
safe and efficient function of the unit. ness.
24. a. Answers will vary widely, because the 5. False. Accidental needlestick is an example of
US is a large country and Americans portal of entry.
are frequently influenced by worldwide 6. False. Microorganisms are present in all
ancestral backgrounds; however, Ameri- people, but infection will not develop unless
can nursing students frequently share a the host is susceptible to the microorganism’s
belief in equal access to health care and strength and number.
education. As a nursing student, you are 7. True
likely to place a high value on education, 8. False. Hepatitis B, or serum hepatitis, is the
achievement, and scientific principles. most commonly transmitted infection by con-
Nurses are also known as having high taminated needles.
standards of moral and ethical behavior 9. False. The acute stage is usually when the
and being champions of human rights. danger of contagion is the highest.
It is also likely that you aspire to be a 10. False. Intact multilayered skin surface is the
responsible citizen who is willing to be first line of defense.
happy on a modest income. You may also
identify strongly with one or several other Short Answer
American subcultures. 11. Refer to Table 7-1 on p. 120. The four major
b. As a nursing student who is originally categories of pathogens are bacteria, viruses,
from another country, you are likely to fungi, and protozoa.
share many of the values that American 12. Disinfection is used to destroy microorgan-
nursing students hold. If you are not orig- isms; however, it does not destroy spores.
inally from the United States, the impact Disinfectant solutions are too strong to use
of being in the American culture may be on human skin, but are appropriate to use on
(or perhaps used to be) very stressful for inanimate objects. If a disinfectant solution
you. Even if you are relatively comfort- comes in contact with human tissue, the tissue
able in your job/school, have friends, and may feel “slippery.” This is the first step of
speak English very well, it is likely that tissue breakdown. Use clean gloves to protect
there are many things about your country the skin.
that you miss very much. Sometimes you 13. Refer to Box 7-5 on p. 127. Standard precau-
may feel isolated, angry, or just exhausted tions include techniques for hand hygiene,
because of the challenges of being in a disposal of equipment/sharps; handling of
country that seems so different. In addi- specimens, supplies, and equipment; and use
tion to adapting to American culture, it is of private rooms for patients.
also likely that as a nursing student, you 14. Everyone (including health care providers) is
will meet many patients from other coun- responsible for disposing of sharps immediate-
tries. ly after using them. Sharps should be disposed
of in a puncture-proof container in the patient
area. Drop sharps into box; never push items
into the box or overfill it. Avoid leaving sharps
on procedure trays or among bed linens.

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 Answer Key  18  

15. Refer to Skill 7-3 on p. 133. 20. Answer 4: Rubella requires droplet precau-
16. Medical asepsis includes techniques that tions; thus mask and cough etiquette are
inhibit the growth and spread of pathogens. appropriate. Washing hands before the proce-
Surgical asepsis destroys all microorganisms. dure would be more useful to prevent spread
Sterile technique is required to prevent intro- of rubella to others. Calling x-ray is okay, but
duction of organisms. advise that patient should continuously wear
a. MA mask; mask should be changed if it becomes
b. MA wet. An isolation gown is not necessary in this
c. SA (Interior of syringe, tip and interior of case.
needless adapter, and interior of specimen 21. Answer 2: Shaking linens stirs up air currents
container are sterile.) that encourage transfer of microorganisms.
d. SA (Tip of cotton swab and interior of The other actions are all useful to control in-
specimen container are sterile.) fection.
e. SA (Requires sterile gloves, field, and 22. Answer 4: It is mandatory that health care
equipment.) workers wear an N-95 or higher particulate
f. MA respirator mask when caring for patients with
g. MA active tuberculosis.
h. SA (Interior of syringe, entire needle, and 23. Answer 1: If the closest flap is opened first,
interior of medication vial are sterile.) the nurse will have to cross the sterile field to
i. MA open the rest of the kit. The other options are
j. SA (Requires sterile gloves, field, and correct.
equipment.) 24. Answer 2: Antacids can alter the acidity of
k. SA (Requires sterile gloves, field, and gastric secretions which offers some defense
equipment.) against microorganisms that are ingested.
l. MA Cipro and Vibramycin are antibiotics that
17. 1. Perform hand hygiene. fight infectious organisms. Hibiclens is an an-
2. Place the wrapped sterile package in the tiseptic solution for cleaning the skin.
center of the work surface. 25. Answer 3: If the white blood cell count con-
3. Remove the tape or seal indicating the tinues to be elevated after antibiotic therapy,
sterilization date. then the health care provider may have to
4. Grasp the outer surface of the tip of the change antibiotics or do additional diagnostic
outermost flap; open the outer flap away testing. Positive sensitivity results indicate
from your body. that the antibiotic should be effective killing
5. Grasp the outside surface of the first side the organism. A positive blood titer for anti-
flap; open the side flap, allow it to lie flat bodies indicates possible previous exposure
on the table surface. to disease or vaccination. Negative growth on
6. Grasp the outside surface of the second blood cultures either means that insufficient
side flap and allow it to lie flat on the time has passed for bacterial growth to occur
table surface. or there are no pathogens in the sample.
7. Grasp the outer surface of the last and in- 26. Answer 3: An unusual cluster of infection
nermost flap; pull the flap back, allowing noted in the emergency department must be
it to fall flat. investigated because of the epidemiologic
implications for the community (e.g., bioter-
Multiple Choice rorism or epidemic). The laboratory should
18. Answer 4: A soiled dressing is an environ- be contacted for results of cultures. The nurse
ment that is suitable for growth of micro- should follow protocols for disposal of con-
organisms. Wearing gloves and masks and taminated waste and putting patients into
isolating personal items interrupts mode of isolation.
transmission. Having the patient cover mouth 27. Answer 2: All patients do not have infectious
and nose interrupts the portal of exit. disease; however, use of Standard Precautions
19. Answer 3: Herpes simplex virus is transmit- is based on the assumption that any of us
ted by contact; thus gloves and gowns are could have an infectious disease and not nec-
needed, but masks and negative airflow are essarily be aware of it. “Universal blood and
not necessary. body fluid precautions” is a term that was

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 Answer Key  19  

used in the past. Studies do show higher in- same room, this might help, but remember
fection rates if there are no precautions used. that all PPE still has to be changed and hand
Hand hygiene is always appropriate, but use hygiene performed when moving from one
of gloves, masks, etc., should be based on as- patient to the next. If a nurse is repeatedly
sessment, protocols, and nursing judgment. given all of the isolation cases day after day,
28. Answer 4: First talk to the patient about why talking to the charge nurse would be an op-
he feels the need to sneak out and smoke. tion. Caring for isolation patients is more
Smoking and/or getting out appear to have time-consuming.
a very high value for him. Educating the pa- 34. Answer 2: All of these patients are going to
tient is often a one-way information flow from take extra time and careful planning before
nurse to patient; thus education does not al- starting the procedure; however, the patient
ways take the patient’s feelings or needs into who is confused and obese presents two chal-
account. The other options might be used, lenges. Inserting a urinary catheter into an
based on assessment findings. obese female presents a challenge to visual-
29. Answer 1: Contact isolation is needed for in- ize the meatus. If she is confused and moves
fectious diseases that are passed by direct con- at the wrong time, sterility will be broken. A
tact with an infected person or item. Draining 4-month-old is small enough that an expe-
wounds fall into this category. Leukopenic rienced nurse can give the injection without
patients require isolation to protect them from assistance; for those who need help, a parent
exposure to pathogens. Neisseria meningitides or helper can stabilize the leg during the in-
meningitis and tuberculosis require droplet jection. The patient who is coughing can be
precautions. medicated with a cough suppressant or given
30. Answer 3, 4, 6: Exposure to oral secretions a cough lozenge. Also applying a mask to the
would be reason to wear gloves. Taking a his- patient is necessary. For the patient who is
tory and reviewing medications should not eager to help, give him a task that allows par-
require gloves (if bottles appear soiled, the ticipation, but one that does not interfere with
nurse may opt to wear gloves). Taking blood sterility. For example, he could hold the roll
pressure should not expose the nurse to any of tape and apply a piece of tape to the tubing
body fluids. (Note to student: Some nursing after the IV is inserted.
programs will require students to use gloves 35. Answer 2: Even though the tray was steril-
for a full set of vital signs. Following program ized, if moisture is present it should not be
and facility procedures is always recommend- used. The other options are incorrect.
ed.) 36. Answer 4: There is no point in putting on
31. Answer 2: Remove the gloves and flush the sterile gloves to open the bottle, because the
area freely with water to remove the allergens. gloves are immediately contaminated by the
After removing the immediate source, the outer surface of the bottle. In addition, the cap
other options would also apply. would never be placed on the sterile field be-
32. Answer 3: If coworkers are in the middle of cause the cap is contaminated; thus the entire
a task, help them finish unless there is an im- field would be considered contaminated. The
mediate patient safety issue and then try to other actions are correct.
problem-solve to prevent future occurrences. 37. Answer 2: All of these strategies are likely to
The nurse could allow the UAP to continue to help the patient gain control over fears and
drag the bag, but the UAP is at risk for injury. concerns associated with being HIV positive;
The UAP may or may not be responsible for however, the mode of transmission for HIV is
overfilling the bag; therefore, reporting or well-documented and reviewing this informa-
reminding are not fair until responsibility is tion will help the patient recognize that family
established. members are unlikely to contract HIV during
33. Answer 4: Isolation of patients is increasingly casual contact. The patient and sexual part-
more common, so learning to organize and ners can be referred for additional counseling
cluster care is the best strategy. If all patients about how to manage intimate contact.
are stable, then caring for nonisolation pa- 38. Answer 1: The health care provider demon-
tients first is a good idea; however, prioritize strates a bad habit that is placing all of her pa-
according to patients’ needs, not nurse’s con- tients at risk. Consulting the infection-control
venience. If similar cases can be housed in the nurse is a good strategy for a new nurse who

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 Answer Key  20  

may be unsure how to approach the provider. nated articles such as linen in designated
(Remember, if you are unsure about how to receptacles. Teach patients and visitors
do something, seek advice, especially when about hand hygiene and isolation proce-
you are new on the job.) Doing nothing is in- dures. Staff education, review of infection
correct. Health care providers are not directly procedures and policies, review of patient
accountable to nurses; however, nurses are records, and consultation with infection-
directly responsible to safeguard the health of control nurse contribute to decreased
patients. Checking on the patient is okay, but incidence of HAIs. Analyzing data and
the patient’s status is unrelated to the provid- consultation with public health depart-
er’s failure to correctly perform hand hygiene. ments helps alert staff about epidemio-
Writing up an incident report could be an al- logic trends.
ternative if there is no other mechanism avail- c. The patient with watery diarrhea should
able to deal with the problem at the systemic be placed on contact isolation. Clostridium
level. Offering a paper towel and assessing difficile (C. diff.) infection may be the
knowledge is a possibility, but the nurse must cause. C. diff. infection is more common
be prepared for the provider’s response. among elderly institutionalized people.
39. Answer 3: Advanced age, disease, chemo- The health care provider should be noti-
therapy, and radiation all affect the immune fied and an order for stool cultures should
system; thus the 73-year-old man has the be obtained.
most factors. The child needs to have immu- 42. a. “What is your typical breakfast, lunch,
nizations prior to entering school. Traveling and dinner?” (To determine nutritional
to Japan presents less risk than traveling to status and eating preferences)
other countries where water, sanitation, food “Do you have any health problems? Does
handling, and exposure to tropical diseases your immediate family have any health
would create greater risk. Stress and over- problems?” (Disease or hereditary factors)
weight increase likelihood for conditions such “Are you currently taking any kinds of
as diabetes or heart disease. prescribed, over-the-counter, or illicit
40. Answer 1: If the student has been taking anti- drugs?” (Some medications alter immune
biotics for at least 24 hours, it would be okay response.)
for him/her to care for patients in the clinical “Have you recently had chemotherapy or
area. The other options create opportunities to radiation therapy?” (Chemotherapy and
spread the infection. radiation lower immune response.)
“Do you smoke or use alcohol? If so, how
Critical Thinking Activities much and how frequently?” (Excessive
41. a. Any patient can develop a health care– use of tobacco and/or alcohol contributes
associated infection (HAI) if Standard to chronic illness. Both can alter immune
Precautions are not consistently used. response and healing.)
However, the patient with the hip fracture “Do you practice healthy habits, such as
and the patient with dehydration and di- exercise?” (Better baseline health contrib-
arrhea are at a greater risk because of age, utes to the immune response.)
debilitation, poor nutritional status, and “What do you do for work?” (Occupa-
decreased mobility. The patient who un- tional exposure to toxins, stress, or patho-
derwent the routine colonoscopy should gens affects immune status.)
be further assessed for underlying chronic “Are you currently experiencing stress at
health problems that may contribute to work, home, or otherwise?” (Stress ad-
risk for infection. versely affects immune response.)
b. HAIs are mostly transmitted by contact b. The inflammatory process begins in re-
between health care personnel and pa- sponse to injury or infection, with the
tients; thus hand hygiene is essential. cellular response and protective vascu-
Strict adherence to sterile technique is lar reaction. Fluid, blood products, and
required for invasive procedures. Provide nutrients are delivered to the interstitial
patients with items for personal care that tissues at the site of the injury. Pathogens
are not shared with other patients (e.g., are neutralized, allowing cell and tissue
urinal or water pitcher). Place contami- repair.

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 Answer Key  21  

c. Localized—edema, pain, erythema, heat, body and legs elevated was also historically
pain/tenderness, purulent drainage used for shock, but is used less frequently
d. Systemic—fever, leukocytosis, malaise, now. In the orthopneic position, the patient is
anorexia, nausea, vomiting, lymph node seated and chest is bent slightly forward over
enlargement (possibly change in mental a bedside table.
status, although more likely to occur in 12. Answer 3: Medications that are used to reduce
elderly patients) blood pressure may cause orthostatic hypo-
tension because of vasodilation or a reduction
of fluid volume (diuretics).
CHAPTER 8—BODY MECHANICS AND 13. Answer 1: Keeping the knees slightly bent
PATIENT MOBILITY helps the nurse maintain balance and maxi-
mizes the use of leg muscles, which are stron-
Word Scramble ger than the back or arms if the patient needs
1. Flexion: (b) movement of certain joints that support. Feet should be positioned apart, ap-
decreases angle between two adjoining bones proximately at shoulder-width. Contracting
2. Extension: (e) movement of certain joints that the stomach muscles protects the back. Keep-
increases angle between two adjoining bones ing the patient close prevents stretching or
3. Hyperextension: (h) extreme or abnormal ex- reaching.
tension 14. Answer 2: Immediately assisting the patient
4. Abduction: (a) movement of limb away from to the floor will prevent an uncontrolled fall
body that could cause injury. Leaning the patient
5. Adduction: (f) movement of limb toward axis against the wall might be helpful in some
of body circumstances, but there is still a risk of an
6. Supination: (g) kind of rotation that allows uncontrolled fall. Supporting the patient and
palm of hand to turn upward moving quickly back to the room would be
7. Pronation: (c) kind of rotation that allows ill-advised. This choice would require a rela-
palm of hand to turn downward tively strong patient who could move rapidly.
8. Dorsiflexion: (d) to bend or flex backward An assistant can be instructed to obtain a
9. Circumduction: (i) movement in a circular wheelchair or a stretcher as needed, but the
pattern nurse should not attempt to keep the patient
upright while waiting for a wheelchair to ar-
Multiple Choice rive.
10. Answer 4: Raising the head of the bed and 15. Answer 4: Deep-breathing and coughing help
assisting patients to sit upright or even to lean mobilize secretions and keep the alveoli open
slightly forward over an overbed table help and functional. Suctioning the airways is per-
facilitate respiratory efforts. Laying supine formed if the patient has an endotracheal or
is appropriate for patients who are in shock. tracheostomy tube, but the need for suction-
Trendelenburg or head downwards with body ing is based on assessment. Position should be
and legs elevated was also historically used changed a minimum of every 2 hours. Oxy-
for shock, but is used less frequently now. gen is only used if the oxygen saturation level
Lateral position with knee and leg drawn up is low or has potential to be too low. Nebu-
can be used for procedures, such as giving an lizers are used to open narrowed airways in
enema. pathologic conditions, such as asthma.
11. Answer 1: The Sims’ position is a lateral side- 16. Answer 3: The nurse must assess what the pa-
lying position with knee and leg drawn up tient normally does at home in order to design
towards the chest. Most patients can easily as- interventions that mimic or compensate for
sume this position. For the lithotomy position, routine activities. Limiting visitors may help
the patient lies supine with knees bent and some patients, but socially active patients may
hips and thighs are abducted. In order to easi- not benefit from restrictions. Independence is
ly access the rectum in the lithotomy position, always the goal; therefore, offering to do ev-
the patient’s feet have to be in stirrups on a erything for the patient is incorrect. A private
gynecology table or the hips have to be placed room may be appropriate, but this arrange-
on the flat side of a bedpan if the patient is in ment should be offered after assessing the
bed. Trendelenburg or head downwards with patient’s needs.

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 Answer Key  22  

17. Answer 1: Plantar flexion or foot drop can be were an additional person to assist on the
prevented if the feet are positioned so soles other side of the patient.
of the feet are resting against the footboard 24. Answer 2: According to NIOSH, health care
in dorsiflexion. A bedboard provides addi- staff should not attempt to lift more than 35
tional support to the mattress and improves pounds of the patient’s body weight.
vertebral alignment. A trapeze bar enables the 25. Answer 2: Sitting with legs crossed increases
patient to raise trunk by grasping the bar. A the risk for thrombophlebitis, so the patient
trochanter roll prevents external rotation of should be reminded to uncross legs. Forget-
legs when patient is in a supine position. ting slippers increases the risk for falls and
18. Answer 2: Pulses should be strong and easily injury to the feet. Rising too quickly can cause
palpated; this suggests good perfusion. Capil- orthostatic hypotension, which causes dizzi-
lary refill is usually 3 seconds (5 seconds for ness. Sitting in a slouched position will cause
older adults). Loss of sensation is not normal muscle fatigue and bad posture increases back
and may suggest pressure on surrounding strain.
nerves that could cause damage. Mild local- 26. Answer 1: Tissue damage can occur within 4
ized discomfort could occur with injury, sur- hours, so the minimum assessment should be
gery, or pathology, but if the patient does not every 4 hours. Assessment at the beginning
have any reasons for this to occur, it should be of the shift is appropriate to establish baseline
investigated. information, but once per shift is not ade-
19. Answer 1, 3, 4: Flexion, lateral flexion, or ro- quate. Pain is a later sign; thus early detection
tation are appropriate for ROM of the neck. is essential. Assessment immediately after cast
Hyperextending the neck is possible, but not application is to assess comfort and tolerance
advised, especially in older patients. Supina- of procedure. (Note to student: Compartment
tion is rotation of the forearm so that the palm syndrome can occur without a cast; for exam-
of the hand turns upwards. ple, crush injuries can cause swelling within
20. Answer 2: A contracture is a fixed joint with the fascial compartments.)
shortening (flexion) of muscles, ligaments, 27. Answer 2: Changes related to aging create
and tendons as a result of disuse. The other an increased risk for skin damage. CPM also
options are also abnormal conditions that may increases the risk for skin impairment, so
result from injury, disease, or improper body skin must be frequently assessed. Fire hazard
mechanics. is unlikely. CPM is not easy to use. CPM is
21. Answer 4: Shearing results when tissue layers frequently used in conjunction with physical
become torn and separated. This occurs as the therapy. Degree of flexion and speed must be
skin surface is pulled one way and the under- set correctly.
lying tissues do not move in the same direc-
tion or at the same speed. Pulling patients Critical Thinking Activities
across linens creates shearing force, as does 28. a. Before moving the patient, the nurse as-
slipping downwards in bed when the head sesses for the patient’s ability to assist in
of the bed is elevated. Dislocation, increased the move and the necessary safety mea-
stress, or hyperextension of joints can also oc- sures that should be taken (e.g., gait belt,
cur when moving patients if the joints are not additional people to assist).
properly supported when assisting the patient b. Position the chair on the patient’s stron-
to move. ger side. Stand in front of the patient and
22. Answer 1: Patients who are at risk for osteo- place hands at patient’s waist level or
porosis should be encouraged to exercise. This below, and allow the patient to use his or
strengthens bones and reduces the risk for her arms and shoulder muscles to push
fractures. The other complications are more down on the mattress to facilitate the
related to immobility. move.
23. Answer 3: Standing directly in front of the pa- Assist the patient to stand and swing
tient and placing hands on the patient’s waist around with back toward the seat of chair.
prevents reaching, which could cause injury Keep the strong side toward the chair.
to the nurse. Pulling on the patient’s joints Help the patient sit down as the nurse
could cause injury to the patient. Standing to bends his or her knees to assist the pro-
the side of patient could be an option if there cess.

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 Answer Key  23  

c. If the patient starts to fall during transfer, Fill-in-the-Blank Sentences

the goal is to ease the patient gently to the 6. physical assessment
floor. The nurse stands with feet a apart, 7. 68° to 74° F (20° to 23° C)
pulls the patient close to own body with 8. 2
patient’s buttocks on nurse’s hip. The 9. tympanic membrane (eardrum); cerumen
patient slides down the nurse’s leg. The (wax)
nurse bends knees and hips to lower the 10. skin integrity
patient to the floor.
d. First demonstrate passive range-of- Multiple Choice
motion exercises with use of left arm and 11. Answer 2: Patients with diabetes should be
leg. Encourage and support any small taught to visually inspect the feet because dia-
attempts at movement. Family members betes can cause changes in peripheral sensa-
can be very helpful with encouraging and tion. In addition, even small injuries are a risk
assisting with ROM exercises if the nurse because of poor wound healing. The other op-
teaches them how to do the exercises and tions are incorrect.
the underlying principles. 12. Answer 3: Dentures are cleaned with a soft
29. a. Complications of immobility include toothbrush and stored in a container with a
muscle atrophy, contractures, pressure solution of the patient’s choice.
ulcers, reduced peristalsis, and postural 13. Answer 4: Before-breakfast care includes as-
hypotension. Refer to Box 8-2 on p. 166 sisting to ambulate to the bathroom, washing
for additional information. face and hands, and oral hygiene if the patient
b. Nurses can prevent complications by desires it. The other tasks are typically per-
turning patients every 1-2 hours, provid- formed after breakfast, unless the patient has
ing range-of-motion exercises, obtaining procedures, treatments, or diagnostic testing.
an order for laboratory studies to assess 14. Answer 2: Patients who are paralyzed from
nutritional status (i.e., albumin), obtaining the waist down (paraplegic) should be taught
nutritional consult as needed, and obtain- to use arms to shift weight frequently. Chang-
ing an order for a specialized mattress or ing wet linens is always appropriate, but this
a sheepskin covering. intervention is more important for incontinent
c. For a reddened area on the sacrum, pro- patients. Paraplegic patients should be as-
vide skin care and turning and supportive sisted to master bowel and bladder training,
devices. Appearance of area and care so that incontinence is less of an issue. Donut
must be carefully documented. Consult a cushions are not recommended because they
wound care specialist as needed. can impair circulation. The skin should be
clean and dry.
15. Answer 4: The nurse would continue to assess
CHAPTER 9—HYGIENE AND CARE OF THE the patient for additional areas of redness.
PATIENT’S ENVIRONMENT Other potential areas include scapulae, ears,
elbows, heels, inner and outer malleoli, inner
True or False and outer knees, back of head, ischial tuberos-
1. True ities, trochanteric areas of the hips, and heels.
2. False. Incontinence is not an expected change 16. Answer 1: This patient will require frequent
that is associated with aging. gentle mouth care several times a day for a
3. False. As of October 2008, Medicare and Med- period of days to remove the crusting. Scrub-
icaid stopped covering the costs of treating bing is likely to cause bleeding. Hydrogen
pressure ulcers that developed during the pa- peroxide can impair wound healing and
tient’s hospitalization. would also create significant bubbling and
4. False. When the external pressure against the frothing for a patient who has no control over
skin is greater than the pressure in the capil- the gag reflex. Flushing with a bulb syringe
lary bed, blood flow decreases to the adjacent creates a potential for aspiration.
tissues. 17. Answer 1: Dried secretions can be gently
5. False. A male patient’s beard, mustache, or wiped with a moist gauze or cotton ball. If
sideburns are never removed without consent soap gets in the eye, it will cause pain and ir-
of the patient, except for emergency purposes. ritation. Eyes should be cleaned from inner

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 Answer Key  24  

canthus to outer. Paper towels can scratch among many that are required for skin integ-
plastic lenses. rity.
18. Answer 3: The hearing aid should not be 25. Answer 4: The nurse would assess the pa-
placed in the sun, by a heating element, or tient’s discomfort and solicit opinions about
near the stove. The other actions are correct. how to make the situation more tolerable. A
19. Answer 3: Most people prefer to do their own noisy staff could be the only problem, but the
pericare, so the nurse would first assess ability family member’s comment could also be the
and willingness. Next the nurse could assess “tip of the iceberg,” and thus the nurse would
secretions, wound site, and other symptoms. try to seek out other sources of irritation.
Then the patient can perform the hygiene or Based on the assessment of the patient, the
the nurse can perform it if the patient prefers. nurse may decide to use the other options.
20. Answer 1, 3, 4, 6: The patient has functional 26. Answer 4: Putting up all four side rails is con-
incontinence, so the staff must help the pa- sidered a form of restraint, which requires an
tient compensate for the difficulty in getting order.
to the toilet. Currently an indwelling catheter 27. Answer 3: If the patient is brushing his own
and restricting fluids are not appropriate in- teeth, this is a signal of actual independence
terventions for this patient. in accomplishing tasks. The patient may
21. Answer 1: The student would report the ab- or may not call for help when needed; the
normal clay color of the stool, which should nurse would have to assess the patient’s
be a brown color. Clay-colored stool suggests understanding and use of the call light. The
that the patient is having some problem in the position of the commode chair is typical; the
digestive tract. nurse should assess the patient’s ability to
22. Answer 3: Obese patients represent a chal- independently and safely get to the chair. The
lenge because it is difficult for one (some- UAP can tell the nurse that the patient is inde-
times two) person(s) to accomplish tasks that pendent, but the nurse should verify this in-
require moving the patient. It is faster and formation with the patient. (Note to student:
safer for everyone if the nurse and UAP work Observe that the nurse should have given bet-
together. The nurse can simultaneously assess ter instructions. An inexperienced UAP may
and perform hygienic care. After the initial as- not know how to encourage independence.)
sessment of skin and self-care, the nurse could 28. Answer 1, 2, 4, 5, 6: An upright position and
adapt the strategies; for example, ask a second oral suctioning are used to prevent aspiration.
UAP to help or instruct patient to do select (Facility policy may vary, but oral suction-
aspects of hygienic care. ing is not an invasive procedure and UAPs,
23. Answer 1: Patients with chronic pulmonary conscious patients, and family members can
disease will often request a cooler tempera- be taught to use this device.) The UAP can
ture or even a fan, because they have to work observe for and report conditions if the nurse
harder to obtain adequate oxygen. The patient specifies what to watch for. Brushing someone
with chills and fever could request that the else’s teeth should mimic the action that you
temperature be lowered, but may also request would use to brush your own teeth, unless
warm blankets for chilling. Patients with pe- the patient has special conditions, such hard,
ripheral vascular disease often report coldness dried secretions. Gloves and hand hygiene
of extremities. Critically ill patients are more are always part of oral care. Checking for gag
likely to need warmer room temperatures. reflex is a nursing responsibility.
24. Answer 2: Getting the residents out of bed is 29. Answer 1: Hot baths with water temperature
the most important intervention because im- of 113° to 115° F (45° to 46° C) provide relief
mobility and pressure on tissues will cause for sore muscles. A tepid bath of 98.6° F (37°
skin breakdown. Daily assessment would be C) can be used to lower elevated body tem-
ideal, but it is unlikely to occur in an assisted- peratures. Warm baths with temperatures of
living facility. A toileting schedule can help 109.4° F (43° C), help to relieve tension, al-
those with incontinence problems, but incon- though many people prefer to shower. A sitz
tinence is only one of many risk factors that bath is used primarily to reduce inflammation
elderly people will have. High-quality protein for patients who have had perineal or anal
is important, but protein is only one nutrient surgery.

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 Answer Key  25  

30. Answer 1, 3, 5, 6: Being relaxed, calm, and re- jacent tissue. The wound sometimes be-
assuring are useful. Using distraction is more comes covered with thin eschar.
useful than negotiating, and making demands d. Pressure ulcers can be prevented by re-
is likely to increase agitation. Demonstrating positioning the patient frequently in the
and explaining desired behavior is usually a bed or chair, providing good nutrition,
good strategy, but for safety and efficiency the keeping the skin clean and dry, and using
nurse is more likely to finish the bath without pressure-relieving surfaces.
trying to teach the patient with dementia how e. Refer to Box 9-5 on p. 202.
to accomplish the task. Repeating patterns is
a good general strategy, but for hygiene the
washing of body parts should be prioritized CHAPTER 10—SAFETY
on a daily basis. Having consistent caregivers
is the ideal. Abbreviations
1. Rescue patients, sound the Alarm, Confine the
Critical Thinking Activities fire, and Extinguish or Evacuate
31. Bathing may be affected as follows: 2. Center for Disease Control and Prevention
a. A fatigued patient—Perform only the care 3. Occupational Safety and Health Administra-
that is absolutely necessary for comfort tion
and safety. 4. P—Pull the pin to unlock the handle. A—Aim
b. Patient on complete bedrest—Assist as low at the base of the fire. S—Squeeze the
necessary with the bath and other hy- handle. S—Sweep the unit from side to side.
gienic measures such as oral care while 5. Safety reminder device
the patient is in bed.
c. Right-sided paralysis—Encourage the pa- True or False
tient to do as much hygienic care as pos- 6. True
sible with the left arm, assisting as neces- 7. True
sary. 8. False. Safety reminder devices (SRDs) can be
d. Inflammation of the perianal tissue—A used in any health care setting. Many long-
sitz bath is indicated. term care facilities are currently adopting a
e. East Indian Hindu patient—Hygiene is restraint-free environment.
extremely important and a daily bath is 9. False. There is a 0.03% chance of a health care
part of the patient’s religious duty; bath- worker becoming infected with HIV from a
ing after a meal or with water that is too sharps injury.
hot may be avoided. 10. True
f. Older adult who is incontinent—Special
care should be given to cleanse and dry Multiple Choice
the skin carefully; perineal care may be 11. Answer 1: Everyone should leave the room
done more frequently and a skin barrier where the thermometer has been broken.
cream can be applied. Close interior doors and open windows to
32. a. Risk factors for development of pressure increase ventilation to the outside. The area
ulcers include chronic illness, debilitation, should not be vacuumed, but should be mo-
limited mobility, incontinence, and poor ped with a mercury-specific cleansing agent.
nutrition. The home health nurse should refer to agency
b. Stage I is intact skin with nonblanchable policy for additional directions that relate to
redness. The wound characteristics vary: the home environment.
areas may be painful, firm, soft, warm, or 12. Answer 4: By delegating the UAP to move
cool compared to adjacent tissue. ambulatory patients, the nurse is rescuing the
c. During suspected deep tissue injury, the greatest number. Next, the nurse would call
wound appears as a localized purple or 911. Closing the door is appropriate because
maroon area of discolored, intact skin or the door will block the smoke and the fire.
a blood-filled blister. Characteristics of The nurse must then attend to the helpless
the area range from painful, firm, mushy, ventilator patient. Oxygen creates a good
boggy, or warm to cool compared to ad- environment for a hotter and faster fire, so
oxygen is turned off. The nurse now has to

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 Answer Key  26  

manually support respiration by delivering or choice of SRD. The other events may be
breaths with a bag-valve-mask or a pocket subject to an internal review by risk manage-
mask. Both methods will be delivering room ment, hospital administration, or the nurse
air. The nurse is aware that moving the pa- manager.
tient and equipment would take minimum of 19. Answer 1, 3, 4, 6: Previous history of falls and
two people and this action would also partial- unsteadiness increase the risk for falls. If assis-
ly block the hallways; thus the nurse would tance is required to walk from room to room,
use critical thinking to determine when (or if) the nurse must plan to assist the patient to the
to move the patient. bathroom and to meals. The nurse ensures
13. Answer 1, 3, 4: No one should smoke around that all assistive devices are close to the bed
oxygen. Fire alarms and other detectors or chair. Asking the patient if he can indepen-
should be properly installed and function dently get up after a fall is an assessment of
should be routinely checked. Family should strength and independence, but this also sug-
have escape routes planned and practiced. gests that the patient should independently
Use of candles should not be encouraged. Us- attempt to get up after a fall. (Patient should
ing one electrical circuit creates a potential be assessed for injury after a fall and encour-
for overload. Covering electrical cords may aged to regain balance and strength before
decrease falls, but the carpet will mask frayed attempting to get up.) Assessing for loss of
cords and offer a fuel source for fires. consciousness is usually performed when try-
14. Answer 1: A bed and chair alarm alert the ing to determine the etiology of the fall (e.g.,
nursing staff that the patient is getting up, so head injury, neurologic event, cardiac event).
someone knows to go to assist the patient. 20. Answer 3: The nurse gives specific measures
Keeping the light and television on would to prevent orthostatic hypotension (i.e., sit
add to confusion and disorientation. Side slowly and dangle legs before standing).
rails are considered a form of restraint and “Whenever she needs help” is a vague direc-
confused patients often attempt to crawl over tion that requires the patient to ask for help
the rails. Frequently checking on the patient and then the UAP must decide if help is ap-
is always a good idea, but the patient can still propriate, but there is no guidance about
wander off between times. Having family circumstance or execution. The nurse should
come in every night is unpractical and unreal- assess whether the use of the bedpan is ap-
istic in an extended-care situation. propriate for the patient. If the patient is able
15. Answer 3: The nurse stands on the weaker to get up, walking decreases the complica-
side and grasps the gait belt at the back. This tions of immobility. The UAP should not be
position allows the nurse to provide support expected to make a decision about “if she
and ease the patient to the floor if he begins to seems weak.” This decision should be based
fall. on nursing assessment.
16. Answer 1, 2, 3, 5: The use of SRDs requires an 21. Answer 3: The UAP can be instructed to as-
order, explanation to patient and family, and sist the patient to change position every two
is only used as a last resort after other meth- hours. Assessment of circulation and respira-
ods have been tried or considered. The entire tory effort should be performed by the nurse.
nursing staff does not have to be consulted The RN and the health care provider should
about the type of SRD. Type of SRD depends be consulted to determine the time for remov-
on provider’s orders, clinical judgment, and al of SRDs.
ongoing assessment. 22. Answer 4: Anyone involved in the care of a
17. Answer 2: The nurse remembers RACE and patient who is receiving internal radiation
first removes the patient from the room. As should wear their own dosimeter. This in-
they exit the room, the nurse closes the door cludes handling items such as linen and trash.
to confine the fire to that room and then Routine care must continue (e.g., vital signs
sounds the alarm. The nurse is not likely to and hygiene); thus staff will enter the room
turn off all electrical equipment in this case. whenever necessary, but care should be well-
18. Answer 3: A sentinel event is an occurrence organized so that minimal exposure occurs.
that causes death or serious injury. A broken Children under the age of 18 should not visit
arm suggests that there may have been im- the patient while there is a danger of radiation
proper assessment, application, monitoring, exposure. Wearing a mask, eye shield, and

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 Answer Key  27  

isolation gown do not offer sufficient protec- sary to pin or secure the SRD to the linen/
tion against radiation exposure. mattress if the child is very determined.)
23. Answer 2: If the patient is having uncontrol- Mummy wrap is more restrictive and usually
lable movements during a grand mal sei- used as a temporary restraint during pro-
zure, placing soft material against the side cedures. Bilateral wrist SRDs are also more
rails offers some protection. Checking the restrictive and the infant is likely to have skin
airway and suctioning secretions should be damage because he will continuously pull
performed by the nurse. Inserting an oral air- to get free. The wrap jacket allows free arm
way is not done during the seizure, but may movement.
be done after the seizure is over to keep the 29. Answer 3: In cases of overdose, it is essential
tongue from falling backward; also there is to determine quantity. The mother may need
always a possibility of a repeat seizure until help to remember that the bottle was half full,
medication or other therapy is given. or only had 2 or 3 pills. In the case of aspirin,
24. Answer 3: For infants who are just learning number of times of vomiting is less relevant,
to crawl, the mother should look at what’s because aspirin is readily dissolved and ab-
on the floor and within arm’s reach from a sorbed in the stomach. The health care team
crawling position. This would include electri- will contact Poison Control regardless of the
cal sockets and cords. Pot and pan handles mother’s report or the first aid given at home.
should be turned away from the child’s reach. In addition, Poison Control is likely to have
This becomes relevant when the child begins the mother’s call on file. Asking about previ-
to stand and walk. Pool safety is more related ous episodes of poisoning would be relevant
to toddlers and children. Children can be after current emergency care is given, if the
taught to recognize dangerous products, but health care team has reason to suspect child
this is for preschoolers who have developed neglect/abuse.
language skills. 30. Answer 2: Laryngeal edema puts the patient
25. Answer 2: Any new device or equipment at risk for an airway obstruction. The other
has some risks because of the learning curve; signs and symptoms could occur during a
however, new prescription lenses frequently type IV hypersensitivity allergic reaction
cause some distortion in depth perception and which is less serious.
they are less likely to be perceived by the pa- 31. Answer 2: Scrubbing and flushing the wound
tient or the staff as “new” or directly related with soap and water is the best first measure
to safe ambulation. A wheelchair, safety bar, to decrease risk of infection. The UAP should
and walker are designed to increase stability. contact the infection-control nurse. Sharps
In addition, the elderly adult is likely to ap- boxes should never be overfilled, but are dis-
proach these new items with caution. posed of before they are full and immediately
26. Answer 1: Postoperative patients have a risk replaced. The nurse and the UAP should both
for blood loss, and anemia can cause dizziness write an incident report which would include
and shortness of breath. An infection would the facts.
cause an increased white cell count; dizziness 32. Answer 3: The nurse would first review the
and shortness of breath may accompany in- facility’s emergency/fire policies and proce-
fection, but these would not be the most typi- dures to determine if contingency plans have
cal symptoms. Blood urea nitrogen (BUN) and been made for the blocked hallway. Based
creatinine reflect kidney function; however, on the review of the policies/procedures, the
changes in BUN and creatinine can occur and nurse may decide to use the other options.
the patient would not necessarily show imme- 33. Answer 4: Before any action is taken, some-
diate symptoms. one must recognize that an unusual biologic
27. Answer 2: Antihistamines cause drowsiness event is occurring. The nurse is one of the
and have mild sedative properties, so patients first health care professionals who will as-
should be cautioned about side effects. sess patients for flulike symptoms or other
28. Answer 4: The infant is using his right hand symptoms that mimic endemic disorders. The
to grab at the dressing on the left arm. If the nurse would isolate any suspected cases and
right elbow is secured in a straight position, immediately contact the supervisor, so that
he should not be able to reach the dressing. emergency/disaster plan can be activated.
(Note to student: Sometimes it may be neces- The plan should include notification of the lo-

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 Answer Key  28  

cal public health department and attention to b. Indications of a possible bioterrorist at-
public safety. tack include:
34. Answer 3: Severe respiratory distress is the A rapidly increasing incidence of disease
most prominent symptom of cyanide gas ex- Unusual increase in the number of people
posure. seeking care for fevers, respiratory prob-
35. Answer 2, 3, 4, 6: For nursing homes or long- lems, GI complaints
term care facilities, the plan must include An endemic disease rapidly emerging at
ways to keep track of residents and notifica- an uncharacteristic time or in an unusual
tion of families and health care providers. pattern
The goal would be to provide a safe environ- Lower attack rates for people who have
ment, which may include moving residents been indoors
to another location. Providing emergency Clusters of patients from a single area
treatment for critically injured patients or ini- Large numbers of rapidly fatal cases
tiating decontamination would be included in Presentation of diseases that are relatively
hospital disaster plans. uncommon
36. Answer 2: Botulism can be transmitted by 39. There is no right or wrong answer to this
contaminated food. Inhalation is the most question. Nurses must safeguard their own
likely form for anthrax as a bioterrorist weap- health in order to care for family and patients.
on. A bioterrorism-related outbreak of pneu- Some nurses may decide that the risk of expo-
monic plague is likely to be airborne and can sure is too high and will decide that the health
spread among people via large aerosol drop- of family will come first. Others will decide
lets. Smallpox can be transmitted by contact that the family is prepared and able to care for
or by the airborne route. themselves and these nurses will continue to
care for patients even in high-risk situations.
Critical Thinking Activities Having information about the disaster plan
37. a. Patient outcome: Patient will be free of and how to safeguard self, family, and pa-
injury and practice safety measures. tients is one strategy. Having discussions with
Nursing interventions: Assess patient’s coworkers and supervisors is another strategy
status and safety needs. to help prepare for such an event.
Provide instruction on use of call light.
Place patient near the nurse’s station,
orient patient to the surroundings, assist CHAPTER 11—VITAL SIGNS
with ambulation, have patient use rubber-
soled shoes or slippers, remove clutter Word Scramble
from walk spaces, use side rails as neces- Unscrambled Definition or
sary, and check equipment such as cane or Scrambled Term Term Characteristic
walker for disrepair. 1. cardiaydarb bradycardia b
b. Safe ambulation can be promoted by the
2. dysaenp dyspnea e
nurse using a gait belt for patient sup-
port, having the patient use hand rails 3. pertherhymia hyperthermia g
in hallways (if available), walking to the 4. pneabrady bradypnea f
patient’s side with the closest leg behind 5. eeafbril afebrile c
the patient’s knee, and having the patient
6. achypneat tachypnea d
walk using a wide base of support.
c. The safety of the older adult is influenced 7. yyhhdrstmia dysrhythmia a
by changes in sensory function (vi- 8. pohymiather hypothermia j
sion, hearing, touch), decreased muscle 9. diacartachy tachycardia h
strength, decreased circulation, medica- 10. sionperthenhy hypertension i
tions taken, and possible cognitive altera-
tions. Figure Labeling
38. a. Refer to Box 10-12, p. 246. The nurse’s role 11. See Figure 11-5, p. 266.
in a disaster is to know the necessary pro-
cedures and maintain personal safety and
patient safety.

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 Answer Key  29  

Fill-in-the-Blank Sentences Figure Labeling

12. 105.0° F (40.5° C) 19. The reading should be marked as 136/78 on
13. 97° F to 99.6° F (36.1° C to 37.5° C) the aneroid gauge; check your ability to read
14. 1½ inches an aneroid gauge with an instructor or a class-
15. thready mate.
16. medulla oblongata
17. alveoli
18. cardiac; arteries

Table Activity
20. See Table 11-1, p. 256.
Heart Rate Respiratory Rate
Age Group (per Minute) (per Minute) Blood Pressure (mm Hg)
Neonate 120-160 36-60 Systolic: 20-60
Infant 125-135 40-46 Systolic: 70-80
Toddler 90-120 20-30 Systolic: 80-100
School-age (6-10 years) 65-105 22-24 Systolic: 90-100
Diastolic: 60-64
Adolescent (10-18 years) 65-100 16-22 Systolic: 100-120
Diastolic: 70-80
Adult 60-100 12-20 Systolic: 100-120
Diastolic: 70-80
Older adult 60-100 12-18 Systolic: 130-140
Diastolic: 90-95

Multiple Choice 23. Answer 2: For teaching purposes and for

21. Answer 4: First determine if the experienced safety, the nurse would take the student back
UAP selected the axillary method for a specif- to the patient and teach assessment for other
ic reason; then teach the UAP about selection signs and symptoms that indicate danger-
of measurement sites if needed. Although the ous conditions, such as shock or sepsis. After
patient wants breakfast, the nurse may elect teaching the student that assessment is always
to assess the patient first to determine if there the first response, then the nurse could use
is a fever and identify a potential infection the other options to teach problem-solving for
source. Instructing the UAP to repeat the tem- abnormal vital signs.
perature using a more accurate method would 24. Answer 3: Hypothermia results in a decreased
be the second step after the nurse determines heart rate, because lowering body tempera-
that the axillary method was inappropriate. If ture lowers metabolism. Tachycardia is not
the UAP’s performance of vital signs appears expected for this patient; irregular tachycardia
to be a problem, observing technique would is a danger sign because hypothermia patients
be an option. have a risk for cardiac dysrhythmias. Palpat-
22. Answer 3: For stable medical-surgical pa- ing radial or dorsalis pedis pulses may be
tients, every 4 hours is typical; however, poli- difficult, but the carotid and femoral pulses
cies can vary. The nurse could take the vital should still be palpable, or the nurse could
signs more frequently, but this is likely to check an apical pulse.
interfere with accomplishing other tasks. The 25. Answer 1: Between 1:00 am and 4:00 am,
beginning and end of the shift are good times the body temperature is lower. Thanking
to take vital signs, but if the nurse works a 12- the UAP is appropriate because he/she has
hour shift there could be as much as 10 or 11 noted a change in the patient’s baseline. An
hours between vital signs, if these are the only explanation helps him/her to gain a greater
times that vital signs are taken.

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 Answer Key  30  

understanding that will contribute to future 35. Answer 4: The temporal arterial method is ap-
performance. propriate in virtually all situations. An infant
26. Answer: Pulse deficit is 9. cannot cooperate for an oral temperature. The
27. Answer 2: The apical pulse should be counted axillary is the least accurate and the rectal is
for a full minute. the most invasive.
28. Answer 1: The carotid pulses should not be 36. Answer 3: The earpieces should be cleaned
palpated bilaterally, because of the potential regularly. Draping the stethoscope around the
to interrupt blood flow to the brain. The other neck, rubbing the tubing frequently between
actions are correct. palms, or using alcohol for cleaning will cause
29. Answer 2: Patients who are having acute pain the tubing to dry and crack.
often demonstrate an increased respiratory 37. Answer 1, 2, 3, 4, 5: Any of these factors can
rate. Opioid medications, hypothermia, and cause tachycardia. (Note to student: Substance
brainstem injury are more likely to cause a abuse is not an expected event in the hospital;
decreased respiratory rate. however, patients have been known to go out
30. Answer 3: Patients can intentionally or unin- and smoke cigarettes or to use illicit drugs
tentionally alter rate if they know they are be- that are supplied by friends or family mem-
ing observed. The other options may also be bers. If substance abuse is suspected, explain
true or partially true. to the patient in a matter-of-fact tone that the
31. Answer 1: Using a cuff that is too small is like- health care team is merely seeking an expla-
ly to yield a blood pressure that shows a false nation for a change in vital signs.) Hypother-
high reading. The cuff is more likely to pop mia would cause a decrease in pulse rate.
off than to create discomfort for the patient. A 38. Answer 3: The sudden decompensation
large cuff on a small arm can yield a false low and accompanying symptoms suggest that
blood pressure. In order for blood pressure to cardiac output has been greatly decreased.
approximate baseline, conditions should be In this case, the blood flow to the periphery
repeated during measurement (e.g., appropri- will decrease so that the brain and heart are
ate cuff, same time of day, no exercise prior to preserved. The carotid is likely to be the stron-
measurement). gest. The femoral is often used during cardiac
32. Answer 4: The respiratory rate of 9 is low and arrest, because getting to the patient’s neck is
needs immediate attention. (Note to student: not always easy (too many staff members at
in the event of getting such a report, immedi- the head of the bed).
ately stop report and assess the patient. After 39. Answer 4: The report is a normal and expect-
attending to the patient, talk to the nurse who ed condition; thus the nurse plans to do the
gave report or to the charge nurse, because a routine assessment and observe as needed.
respiratory rate of 9 should be immediately 40. Answer 1, 2, 4, 5, 6: If the patient is having
addressed. The situation might need addi- alterations in respiration, the nurse would
tional investigation.) assess for additional symptoms. Pursed-lip
33. Answer 3: A 4+ pulse is considered a bound- breathing is seen among patients with chronic
ing pulse that feels full and springlike even respiratory disease, such as emphysema. Nos-
under moderate pressure. This indicates a tril flaring, especially when seen in small in-
hyperdynamic state that would be more con- fants, is an ominous sign. Retractions indicate
sistent with high blood pressure; whereas a that the patient is working very hard to draw
weak or thready pulse is associated with low air into the lungs. Worsening fatigue will oc-
blood pressure, decreased peripheral perfu- cur as the patient approaches the need for
sion, or pulse deficit. intubation. Subjective shortness of breath is
34. Answer 1: First, the nurse would check to see likely, but do not ask the patient for a detailed
if the pulse oximeter is correctly positioned. description; talking interferes with breathing.
The other options are also a possibility. If the Epistaxis is not expected.
fingers are cold because of environment or 41. Answer: Pulse pressure is 50. The usual pulse
poor circulation, the pulse oximeter may not pressure is around 40; consistently elevated
work correctly. Assuming that the nurse is pulse pressures may be a predictor of heart
healthy and a nonsmoker, applying the pulse disease, especially in the elderly.
oximeter to own finger is a quick way to test 42. Answer 4: In patients with hypertension, the
the function. sounds usually heard over the brachial artery

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 Answer Key  31  

disappear as pressure is reduced and then re- likely factor. While the patient is instinc-
appear at a lower level. This temporary disap- tively attempting to get into a sitting posi-
pearance of sound is the auscultatory gap. tion to facilitate breathing, the motion of
changing position is a form of exercise
Math and Conversion that creates an additional need for oxy-
43. a. 98.6° F gen. The nurse should also assess for fe-
b. 38.4° C ver, emotional stress, medication history,
c. 102.6° F smoking, and pain. See Box 11-11 on p.
d. 36.5° C 271 for additional information.
44. a. 20 kg b. If the patient’s respirations are rapid and
b. 94.45 rounded to 94 kg labored, the nurse should position the
45. a. 13.2 rounded to 13 lbs patient as upright as possible, check the
b. 35.2 rounded to 35 lbs vital signs, provide oxygen, remain with
46. a. 175.26 rounded to 175 cm the patient, and contact the health care
b. 68.58 rounded to 69 cm provider as needed. See Box 11-12 on p.
47. 2000 mL or 2 liters of fluid loss is equal to 2 kg 271 for additional information.
of weight c. “Sir, there is no need to apologize. You are
no bother. Right now, we need to focus on
Critical Thinking Activities helping you breathe, so you can explain
48. a. For this patient, menopause may be caus- everything to me later, after you are feel-
ing hormonal changes which would cause ing better. I want to help you sit upright,
the temperature to fluctuate. Physical or get you some oxygen and check your vital
emotional stress associated with illness signs.” (Note to the student: Usually you
and hospitalization may also be factors. would respectfully listen to a patient and
The nurse should also consider the am- encourage expression of feelings; how-
bient temperature of the room and the ever, with this patient the priority is oxy-
excessive layering of blankets or clothes. genation. His talking is interfering with
Also, assess the ingestion of hot liquids his breathing and oxygenation.)
or smoking that may have occurred 50. The nurse has to use knowledge of normal
immediately before the temperature daily fluctuations, normal variations, and nor-
measurement. See Box 11-4 on p. 258 for mal values (baseline) for the individual pa-
additional information. tient. Many factors, such as age, environment,
b. Signs and symptoms of an elevated tem- psychological state, and disease process can
perature include thirst, anorexia, warm affect vital signs. Other factors, such as equip-
skin, headache, elevated pulse and respi- ment malfunction, room temperature, and
ratory rates, restlessness, increased per- patient cooperation or condition can interfere
spiration, and disorientation. See Box 11-5 with the accuracy of vital signs. Medica-
on p. 258 for additional information. tions and treatments such as oxygen, dietary
c. For the patient with an elevated tem- therapies, or radiation treatments can influ-
perature, the nurse should recheck the ence outcomes. The nurse must know which
temperature, keep the linens dry, limit diagnostic tests and medical procedures will
activity, administer antipyretic medica- increase the risk for complications of hemor-
tion as ordered, and increase fluid intake. rhage, infection, or loss of function. Finally
The health care provider should be kept the nurse has to have knowledge of normal
informed about changes in the patient’s body response and changes in patient status
condition. Refer to Box 11-6 on p. 258 for that signal the need to intervene to maintain
additional information. the health and safety of the patient.
49. a. For this patient, the physical stress of
chronic respiratory disease is the most

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 Answer Key  32  

CHAPTER 12—PHYSICAL ASSESSMENT Fill-in-the-Blank Sentences

2. birth
Table Activity 3. lack of nutrients
1. 4. inspection
Term Description 5. introduce yourself
6. half
Anorexia Lack of appetite resulting in the
inability to eat
Multiple Choice
Constipation Difficulty passing stools or
7. Answer 2: Sickle cell anemia is a hereditary
infrequent passage of hard stools
disease; thus genetic counseling may be con-
Cyanosis Bluish discoloration of the skin and
sidered.
mucous membranes
8. Answer 2: Diabetes mellitus is a metabolic
Diaphoresis Profuse sweating disease. Ulcerative colitis is an autoimmune
Diarrhea Frequent passage of loose, liquid disorder. Cystic fibrosis is inherited. Heart
stools failure cannot be linked to any one cause, but
Dyspnea Shortness of breath or difficulty lifestyle modification is an important preven-
breathing tive measure.
Ecchymosis Extravasation of blood into the 9. Answer 4: High levels of cholesterol increase
subcutaneous tissues the risk for coronary artery disease.
Edema Abnormal accumulation of fluid in 10. Answer 3: All the options are recommended
interstitial spaces to patients for overall good health; however,
Erythema Redness or inflammation of the skin smoking cessation is the single most impor-
or mucous membranes tant intervention for lung disease. Participa-
Fetid Pertaining to something that has a tion in cancer screening is recommended, but
foul, putrid, or offensive odor currently there is no reliable screening test for
Inflammation The protective response of the lung cancer.
tissues of the body to irritation or 11. Answer 4: Diaphoresis and flushing can be
injury seen in a variety of disorders and circum-
Jaundice Yellow tinge to the skin stances, but are frequently associated with hy-
Lethargy or lethargic State or quality of being indifferent, permetabolic states, such as fever or exercise.
apathetic, or sluggish The other vital signs are lower than expected
Nausea Sensation often leading to the urge
for the average adult.
to vomit 12. Answer 2: Cyanosis and dyspnea indicate
Orthopnea Must sit upright or stand in order to
that oxygenation of tissues is inadequate and
breathe comfortably that the patient is having trouble breathing,
so frequent assessment of respiratory effort is
Pallor Unnatural paleness or absence of
color in the skin required.
13. Answer 3: In orthopnea, the patient has diffi-
Pruritus Itching and an uncomfortable
sensation leading to an urge to culty breathing in a flat position, so is likely to
scratch be more comfortable sitting in a chair or hav-
Purulent drainage Creamy, viscous, pale yellow or
ing the head of the bed elevated.
(pus) yellow-green exudate; liquefied 14. Answer 1: If the patient can identify other
necrosis of tissues symptoms, this helps the health care team
Sallow Unhealthy yellow color; usually to locate the source of the infection. For ex-
said of a complexion or skin ample, back pain or problems with urina-
Scleral icterus Yellow color of the sclera tion suggest a urinary tract infection. A sore
throat with difficulty swallowing suggests
Tachycardia Heart contracts at a rate greater
than 100 beats per minute.
pharyngitis. Allergies can cause some people
to have low-grade temperatures, but fever
Tachypnea Abnormally rapid rate of breathing
is not typically associated with allergic reac-
Vomit Expel the contents of the stomach tions. Asking about previous similar episodes
out of the mouth
could be a follow-up question to try to narrow
the search; for example, tuberculosis or AIDS
could cause episodes of respiratory infections

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 Answer Key  33  

that recur. Onset of fever is also a follow-up is working. However, subjective symptoms
question that could be used if a pattern of in- may improve after several days of antibiotic
fection is currently noted; for example, a num- therapy, but the infection can still be present
ber of people have developed febrile illness until antibiotic therapy is completed. Edema,
after attending the same event. redness, and elevated white count suggests
15. Answer 4: A patient who is anorexic has a that the antibiotic may need to be changed.
poor appetite with a subsequent poor intake 22. Answer 1: Watching the patient as he/she
of nutritious foods, so the nurse would assess performs an activity is the best method for as-
need for supplemental feedings, which could sessing abilities to accomplish ADLs. Asking
include high-calorie, high-protein oral supple- the patient who does the shopping and cook-
ments, tube feedings, or intravenous nutri- ing would be a better question than asking
tion. him what he eats. (He may rely on others to
16. Answer 2: The nurse recognizes that the pa- obtain and prepare the food.) A full set of vital
tient is tired. Shortness of breath is visible as signs gives some indirect information about
the patient’s respiratory rate increases and the the patient’s abilities; for example, a rapid
focus of attention is on breathing; usually the respiratory rate would suggest that activity
facial expression conveys anxiety. Licking lips intolerance would be a factor in performing
or dry lips would signal need for water. There ADLs. Level of consciousness and orienta-
many ways that pain manifests, but restless- tion are important, but a person can be fully
ness, shifting weight, or expiratory grunting conscious and oriented, yet be unable to get to
would be a few of the nonverbal behaviors the bathroom.
that the nurse might observe. 23. Answer 4: The nurse should use terminology
17. Answer 3: Fear activates the sympathetic ner- that is familiar to the average person.
vous system, so the blood pressure will rise 24. Answer 2: The Glasgow Coma Scale is used
and the pupils will dilated (fight or flight re- for patients who have potential for neurologic
sponse). Pain and nausea are subjective symp- abnormalities related to brain injury. The
toms. other patients have potential for brain injury
18. Answer 1: Patient is likely to have scratched related to poor tissue perfusion secondary to
self to relieve the sensation of itching. a disease state, but there are many other inter-
19. Answer 2: P stands for Precipitating- ventions that the nurse would use to prevent
Provocative-Palliative. Rating the pain is a coma from happening to patients with car-
query about Severity. Onset is determined by diac, infection, or respiratory problems.
asking when it started. Spread of symptoms 25. Answer 3: The most likely finding would be
to other body parts is used to determine Ra- dependent edema in the lower extremities.
diation and location. (See Box 12-6, p. 295 for 26. Answer 2: The preceptor would try to deter-
additional information.) mine what process the new nurse is using to
20. Answer 1: Crackles (produced by fluid in the assess and to document. There is a possibility
bronchioles and the alveoli) are short, discrete, that the new nurse knows what to do, but is
interrupted, crackling, or bubbling sounds that not able to describe the findings. Thus there
are most commonly heard during inspiration. is either a knowledge deficit or a communica-
Sibilant wheezes have a high-pitched, squeak- tion problem. There is also the possibility that
ing, musical quality and are produced by the new nurse copied the assessment from a
airflow through narrowed airways. Sonorous previous entry. This is falsification of docu-
wheezes have a lower-pitched, coarser, gur- mentation, but probably occurs more often
gling, snoring quality and usually indicate the than it should. After assessment, the precep-
presence of mucus in the trachea and the large tor could decide to use the other options.
airways. Pleural friction rubs are produced by 27. Answer 2: Press against one nostril and have
inflammation of the pleural sac; the nurse will patient breathe. If the nostril is patent, air
hear a rubbing, grating, or squeaky sound should flow freely; then switch and occlude
upon auscultation. the other nostril. Using a penlight only allows
21. Answer 3: A normal white cell count is the visualization of the opening of the nostril.
best indicator of the success of antibiotic ther- Having the patient blow the nose first would
apy. A decrease in pain and increase in func- be appropriate if the patient is having rhinor-
tion are good indicators that the medication rhea (runny nose). Having the patient breathe

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 Answer Key  34  

quietly is an opportunity to observe respira- 32. a. O Onset

tory effort, but air will enter the unobstructed When did the pain start?
nostril if the other is obstructed. P Precipitating-Provocative-Palliative
28. Answer 1: The UAP can observe and report What causes it? What makes it better?
on respiratory rate and depth, but the nurse What makes it worse?
should give the UAP parameters for report- Q Quality-Quantity
ing, especially if the patient is at risk for How does it feel, look, or sound, and
respiratory problems or if the UAP is inexpe- how much of it is there? How often,
rienced. The other tasks are nursing responsi- when, how long…?
bilities. R Region-Radiation
29. Answer 1: An inward curvature of the lumbo- Where is it? Does it spread?
sacral area is normal. An exaggerated posteri- S Severity scale
or curvature of the thoracic spine is kyphosis. Does it interfere with activities? How
An increased lumbar curvature is lordosis. A does it rate on a severity scale of 0 to
lateral curvature is scoliosis. 10?
30. Answer 2: The popliteal pulse is hard to find T Treatments
and the patient may have difficult assuming What helps? For how long?
the prone position which is optimal for this U Understanding
assessment. Prior to calling the health care What do you think is causing it? How
provider, the nurse would assess pulses and does it affect you?
tissues that are distal to the popliteal area; V Values
thus if the dorsalis pedis pulse and/or the Goals of care; on a scale of 1 to 10,
posterior tibial pulse are palpable, the blood is what would you consider a tolerable
flowing through the popliteal area to the dis- level of pain?
tal tissues. b. In assessing the abdomen, first inspect
for shape, contour, lesions, and skin color.
Critical Thinking Activities Listen for bowel sounds for 1 minute
31. a. Respiratory: “Do you have difficulty in all four quadrants. Next use light to
breathing?” “Have you ever been exposed moderate palpation and check for texture,
to TB?” “Do you smoke?” temperature, and moisture of the skin.
b. Endocrine: “Has your weight changed Also note distention, firmness, tender-
recently?” “Do you have a personal or ness, or guarding.
family history of diabetes?” “Have you 33. The nurse must have knowledge of normal
noticed any change in your tolerance to body function and pathophysiology in order
heat or cold?” to determine which questions to ask and in-
c. Gastrointestinal: “Do you have any trou- vestigate underlying physiologic disorders. If
ble swallowing?” “Is there any change in the patient has a headache, the logical place
your appetite?” “Have you had nausea, to start is to collect subjective data about the
vomiting, diarrhea, or constipation?” pain (e.g., “What does it feel like?” “Where
d. Cardiac: “Have you had any chest pain?” is the pain located?” “Are you having pain at
“Do you have a personal or family history any other location besides your head?”). Ask
of hypertension?” “Have you experienced about associated symptoms that are likely to
any palpitations?” accompany a severe headache (e.g., “Have
e. Neurologic: “Are you having headaches?” you felt nauseated?” “Have you felt dizzy?”
“Have you ever had a serious head injury “Are you experiencing any problems with
in the past?” “Have you experienced any your vision?”). Based on the nurse’s knowl-
changes in sensation or coordination?” edge of pathophysiology, the nurse would ob-
f. Genitourinary: “Do you have any dis- tain objective data; for example, hypertension
comfort when you urinate?” “Have you could cause headaches. Intracranial bleeding
noticed any changes in frequency of uri- could cause a change in pupil size and reac-
nation?” “Do you suspect that you may tion. Meningitis could cause an elevation of
have been exposed to a sexually transmit- body temperature.
ted infection?” 34. The patient might see the nurse as efficiently
using the time, but is more likely to think

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 Answer Key  35  

that the nurse is very busy and focused on form to the patient could be done, but the
completion of tasks. The nurse’s actions question is whether the patient can legally
have blocked communication and created assume responsibility for his own actions.
psychological distance between herself and Contacting the family is a possibility, but the
the patient. The patient is less likely to give hospital/nurse could still be held liable if the
complete information to this nurse, because patient were to injure himself or others in a
she doesn’t appear to be interested in hearing confused state. Calling the risk manager is an
what he has to say. option, but it is unlikely that the manager will
make the decision to detain the patient, be-
cause the decision has to be based on whether
CHAPTER 13—ADMISSION, TRANSFER, AND the patient is rational and able to make safe
DISCHARGE judgments.
8. Answer 1, 2, 3, 5, 6: When the admission is
Identifying Patients’ Reactions to conducted through the admissions depart-
Hospitalization ment, efforts are made to obtain demographic,
1. a. Reaction: Fear of the unknown. Patient is insurance, and emergency contact informa-
manifesting fear of the unknown, which tion. The ID band is immediately placed, so
causes insecurity, and relates to the need that all health care team members can cor-
for safety according to Maslow. rectly identify the patient for appropriate
b. Reaction: Separation anxiety. Separation care. HIPAA and Patient’s Bill of Rights can
anxiety is a reaction that reflect the needs be explained by the admissions representa-
Maslow identified as belongingness and tive. Discussions about medication and other
love. health-related matters should be done by the
c. Reaction: Loneliness. Patient is showing nursing staff.
loneliness, which is a reaction that reflects 9. Answer 3. While all patients benefit from an
the needs Maslow identified as belong- individualized approach, the farmer from ru-
ingness and love. ral China is most likely to be unfamiliar with
d. Reaction: Loss of identity. The adoles- plumbing conditions in a Western hospital.
cent feels that his clothes are a part of his The patient with Alzheimer’s disease is not
identity. His behavior reflects a need that going to remember any new information.
Maslow identified as self-esteem. Children who are just starting to toilet train
are likely to need diapers during hospitaliza-
Fill-in-the-Blank Sentences tion, because the stress may cause them to
2. The Patient Self-Determination Act revert to earlier behavior. The woman with
3. Joint Commission; Medicare; Medicaid stress incontinence needs interventions to
4. accepting facility; signed consent help tighten the pelvic musculature.
5. 24 10. Answer 2: Explaining that the band is for
safety reassures the patient that the band is
Multiple Choice for his/her benefit and not just a standard
6. Answer 1: The nurse should notify the health method of classification, and that he/she is
care provider, who ideally will come immedi- not viewed as just an assigned number. Joking
ately and talk to the patient and have the pa- with patients is often appropriate, but first the
tient sign the AMA form. The incident should nurse should establish rapport with the pa-
be documented in the nurse’s notes. An inci- tient; otherwise he/she may believe that there
dent report may also be completed as needed. is real possibility of getting lost or displaced.
It is inappropriate to detain a rational patient 11. Answer 4: First the nurse reflects the patient’s
if he/she wants to leave. feelings of anxiety and then directly invites
7. Answer 2: A patient with an old head injury the patient to ask questions. Indicating when
can be considered a chronic care case that to call and willingness to help is a good thing
could be assigned to LPN/LVN; however, to say after the patient appears to be comfort-
it would be appropriate for the LPN/LVN able and settled in his/her new surroundings.
to notify the supervising RN because the Telling the patient “not to worry” does not
patient’s change in status and needs should address his/her specific concerns. “I know I
be assessed by the RN. Explaining the AMA would” switches the focus to the nurse.

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 Answer Key  36  

12. Answer 4: This elderly patient is refusing The nurse would check respiratory rate,
information that the nurse believes is neces- get a pulse oximeter reading, and initiate
sary; however, the nurse can spend the time interventions such as assisting the patient
making the patient safe and comfortable and to sit in an upright position, encouraging
then return when the son arrives. At that time slow purse-lipped breathing, and discour-
the nurse can assess the family dynamics to aging excessive talking.
determine if the patient relies on the son for c. Ordinarily, the nurse would explain
decision-making or information retention and hospital routines such as visiting hours,
filtering. mealtime, and medication times; howev-
13. Answer 1, 2, 6: UAP can assist by making er, based on the assessment of the patient,
the room more comfortable and welcoming. the nurse may opt to temporarily delay
Needs should be assessed by the nurse and long explanations. The nurse might say,
then signs, equipment, or other items can be “Sir, when you are feeling more relaxed
obtained. Items of value should not be stored and breathing easier, I can explain more
in the bedside table. about the hospital routines and what you
14. Answer 4: A transfer requires an order from can expect.”
the provider, and the provider must speak d. The information that is generally included
directly to accepting provider at the receiving in the orientation for the patient includes
hospital. The receiving hospital must be con- location of the room (proximity to nurses’
tacted and accept the transfer and the nurse station), location of bathroom, how to
must give a report to the nurse who will be call for assistance, how to adjust the bed
caring for the patient. and lights, how to operate the phone and
15. Answer 2: For any patient who has change television, and policies that apply to the
of mental status, knowing baseline behavior patient (e.g., smoking, visiting hours).
is important. For a patient with dementia, For this patient, the nurse may decide to
knowledge of baseline behavior is especially explain how to call for assistance and how
important, because delirium and dementia to adjust the bed, but delay all additional
can have some similarities. The other infor- information. The nurse should make a
mation is also relevant, but not as critical as plan, inform the patient, and then follow
meeting the patient’s immediate physical through. For example, the nurse might
needs. say, “Sir, I am going to let you rest for
16. Answer 1: An older patient with chronic dis- about an hour. Use the call button before
ease and fewer personal resources is likely then if you need anything, but in an hour
to have the most complex discharge plan, I will come back and finish telling you
which may include social services, nursing, about hospital procedures.”
physical therapy, and home health aides. He 19. a. Other health care providers involved in
is more likely to need help with issues such the discharge process include:
as transportation, shopping, preparing food, Social worker—counseling, determination
and assistance with ADLs. He is also likely to of community and financial resources
be taking more medications and have more Wound care specialist—advice about
ongoing health problems. cleaning wound and changing dressings
17. Answer 4: The nurse would first attempt to Physical therapist—rehabilitation plan of
assess the caregiver’s attitude. Based on the exercise
assessment findings, the nurse could use the Occupational therapist—ADLs, vocation-
other options. al skills
b. Rationale for nursing interventions for
Critical Thinking Activities patient discharge:
18. a. There are certain responsibilities that i. Verifies health care provider’s
must be performed. Checking and verify- decision to discharge patient
ing ID band to ensure identification must ii. Prevents waiting when patient
be performed. is leaving and allows for initial
b. Immediate needs must be assessed and determination of insurance coverage
addressed. In this case, the patient’s res- iii. Avoids delays in the process and
pirations and breathing are the priority. allows for family members to prepare

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 Answer Key  37  

iv. Ensures that the patient has all provide good nutrition, but do not offer all of
personal items and assists the family the required nutrients.
v. Conserves the patient’s strength 13. Answer 4: The goal for the patient (assuming
no fluid contraindications) is 2000-2400 mL.
He drank a total of 1460 mL, so he if he drinks
CHAPTER 14—SURGICAL WOUND CARE two or three additional 8-ounce servings, he
will be closer to the recommended amount.
Matching 16 ounces = 480 mL
See Table 14-3, p. 347. 10 ounces = 300 mL
1. e 6 ounces= 180 mL
2. c Half a liter =500 mL
3. a Total intake =1460 mL
4. g 14. Answer 2: The nurse helps the patient learn
5. b to move independently and safely. This is ac-
6. d complished in steps: rolling, leverage, and
7. f pushing. The patient should not be encour-
aged to just lay in bed. Holding a pillow to
Short Answer the abdomen is appropriate during coughing
8. a. Inflammatory phase—24-48 hours, blood and deep-breathing. Calling for assistance is
elements leak into the tissues, leukocytes okay, but this limits independence.
appear 15. Answer 1, 2, 3: Initially, the nurse inspects
b. Reconstruction phase—2-3 weeks, fibro- the dressing for intactness and for any signs
blasts are present, collagen formation be- of hemorrhage. The skin surface around the
gins, wound strength begins to increase dressing is also noted for baseline compari-
c. Maturation phase—after 3 weeks, fibro- son. Exudate will drain downwards, so the
blasts exit, wound becomes stronger nurse must look underneath the patient to
9. a. Primary—surgical wound, clean edges ensure that there is no drainage present. The
b. Secondary—wound edges not close to- initial dressing is generally removed by the
gether, may have purulent drainage health care provider. Sanguineous drainage is
c. Tertiary—infected wound left open, de- expected at first; serous drainage occurs later
layed suturing as wound healing progresses.
10. a. Gauze—to permit air to reach wound 16. Answer 2: The nurse suspects that an infec-
b. Semiocclusive—to permit oxygen to reach tious process is occurring and knows that an
wound, but not the impurities in the air elevated white blood cell count is likely to
c. Occlusive—to prevent air or oxygen from validate this suspicion.
reaching the wound to keep the wound 17. Answer 2: The triangular binder (sling) will
moist and promote healing provide support for the possible fractured
d. Dry dressing— nondraining wounds, pro- forearm.
tects the wound from injury, prevents in- 18. Answer 1: The nurse would not remove
troduction of bacteria, reduces discomfort, staples or sutures if the wound edges ap-
and speeds healing peared to be separating. Serous drainage is a
e. Transparent—able to visualize wound, sign of healing and should be cleaned away.
contain exudates, and decrease wound The patient’s anxiety can be addressed before
contamination the procedure. Staple removal should feel
11. a. Finger or wrist—circular like a tug or a pinch, but should not cause
b. Calf or thigh—spiral reverse great pain. The site can be reinforced with
c. Joints—figure 8 SteriStrips, so this should decrease worries
d. Scalp—recurrent about the incision coming apart. Keloid for-
mation and scarring could be aggravated by
Multiple Choice leaving the staples in too long.
12. Answer 3: Seafood supplies protein and zinc. 19. Answer 4: If the dressing is moistened with
The salad provides vitamin A and the tomato saline, this will help loosen the crusty exu-
juice provide vitamin C. The other meals also date.

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 Answer Key  38  

20. Answer 3: The nurse should first reinforce the 27. Answer 1: The primary concern is that respi-
dressing, because this may help stop or slow ratory function could be restricted if the bind-
the bleeding. Next, the nurse would assess er is too tight. Vomiting and nausea are not
for signs of shock. The charge nurse and the contraindications, but the patient may need
health care provider should be notified about assistance in positioning the emesis basin.
the saturated/reinforced dressing and the Binders can be used for obese patients, but
vital signs and pain symptoms. The dressing the appropriate size is needed. Older patients
should not be removed at the 3-hour point by do have more fragile skin, so the skin must be
anyone except the health care provider. assessed frequently, or the nurse may decide
21. Answer 4: The wound should be covered with that the binder should not be used because of
sterile dressings moistened with saline. The the fragile skin.
patient should be placed in a low Fowler’s 28. Answer 3: The transparent dressing is cur-
position with the knees slightly flexed. The rently the dressing of choice.
health care provider should be notified. A pat-
ent IV is needed because the patient is likely Critical Thinking Activities
to need a surgical repair. 29. a. Factors that impair wound healing in-
22. Answer 1: For a postoperative patient, the clude age, malnutrition, smoking, drugs,
nurse is likely to first suspect hemorrhage, and diabetes mellitus. Patient’s ability to
so taking the pulse and blood pressure and care for himself is also not optimal.
checking for pain would be the best actions. b. The nurse would assess his ability to
The nurse would check for wound approxi- perform self-care, to reach the wound,
mation if dehiscence or evisceration were ex- and to manipulate the wound dressings.
pected. The patient is more likely to report a He has trouble with his vision, so the
pop or release sensation if the incision comes nurse would adapt the teaching (e.g., us-
apart. Infection is also a possibility. The symp- ing color-coding of dressing materials).
toms in the scenario could accompany septic The nurse will increase time allowed for
shock, but the goal is to identify infection the skills and repetition of teaching and
signs prior to the onset of septic shock. (Note give small amounts of information at a
to the student: The patient’s symptoms could time. This patient will have a decrease in
also be related to other disorders such as pul- sensory receptors and a decrease in pain
monary emboli or hypoglycemia.) sensation; therefore, he will need to have
23. Answer 2: An expected output ranges from someone to help him visually inspect
250-500 mL. the wound on a routine basis. The nurse
24. Answer 2: Clean gloves are adequate to re- should ask the patient about his resources
move old dressings. The other options are cor- and arrange for home health if necessary.
rect. This patient needs assistance to increase
25. Answer 3: The student has performed the cor- fluid intake and nutrition. Social services
rect action. Telling the patient that the student could be contacted about having meals
is doing a great job gives the student positive delivered to his house.
reinforcement, while reassuring the patient 30. a. Wound irrigation is used to clean the
that the student’s technique is correct. The wound and remove debris and eschar.
other options are incorrect. b. Equipment needed: 35-mL syringe,
26. Answer 2: The amount of drainage is exces- 19-gauge catheter, sterile solution.
sive, so the nurse would take vital signs and c. Syringe is held 1 inch above the wound
assess for other symptoms of hemorrhage or for irrigation.
shock and inform the health care provider. d. Direction of cleansing is from least to
Documenting is always necessary and com- most contaminated.
fort measures are always welcome once the e. Report evidence of fresh bleeding, sharp
immediate problem is addressed. The nurse increase in pain, retention of irrigant, or
should not apply a pressure dressing, but the signs of shock.
supine position would be appropriate if the
nurse determines that the patient is hypovole-
mic.

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 Answer Key  39  

CHAPTER 15—SPECIMEN COLLECTION AND useful in anticipating the patient’s response to

DIAGNOSTIC TESTING the procedure. For many tests, baseline vital
signs, mental status, or peripheral perfusion
Matching should be obtained. If a contrast medium is to
1. d bronchoscopy be used, assess for allergies.
2. c mammogram 17. For the older adult, there may be physical
3. b arteriography difficulty in manipulating equipment for
4. a paracentesis specimen collection or achieving necessary
For additional examples of diagnostic tests, positions. Hearing or vision may add to prob-
see Table 15-1, pp. 369-383. lems in understanding instructions. Altera-
tions in circulation and respiratory function
Fill-in-the-Blank Sentences may interfere with obtaining specimens. NPO
5. health care provider; supplies or equipment; status may lead to dehydration. Contrast
patient media such as barium can cause constipation,
6. informed verbal consent which is a chronic problem for many older
7. human immunodeficiency virus (HIV); hepa- adults. Decreased kidney function can be fur-
titis B ther compromised by contrast media that are
8. recap; puncture-resistant containers excreted by the kidneys. Multiple medications
9. interpreters may alter results.
10. confidentiality 18. Proper labeling of specimens requires date
11. abnormal and time, patient’s full name, ID number
12. psychological preparation and/or room number, age and sex, health care
provider’s name, test ordered to be completed
Figure Labeling on the specimen, and collector’s name and
13. See Figure 15-7, p. 401. initials.

Short Answer Figure Labeling

14. Assess patient’s ability and concerns. Ensure 19. See Skill 15-14, figure in Step 9b(1), p. 410.
proper preparation. Give explanations that
are appropriate to developmental age and cul- Delegation
tural background. Wear gloves and perform 20. The UAP must be trained in the procedure of
hand hygiene. Collect and label using correct specimen collection. The nurse must assess
techniques. Ensure that specimens are trans- the patient before directing the UAP to collect
ported to the laboratory in a timely manner. the specimen. If assessment findings indicate
See Box 15-4, p. 385. that the patient’s condition is unstable or if
15. Refer to Box 15-1, p. 368 and Skill 15-1, p. 367. the patient’s condition hinders specimen col-
General preparation of the patient before di- lection, it is not appropriate to direct the UAP
agnostic testing includes checking the medical to do the task.
record for the order, making sure the consent a. Yes
is signed (if necessary), gathering equipment b. No
and supplies, teaching and preparing the pa- c. No (Note to student: drawing blood is
tient, providing privacy, maintaining asepsis, frequently done by the phlebotomist. In
assisting the health care provider, labeling some cases, the LPN/LVN may draw the
and sending the specimen to the laboratory, blood, but this can be based on facility
and documenting the procedure. policy.)
16. Assess for pain, infection, and the ability to d. No
understand the procedure and directions. e. Yes
Also note any physical problems that may in- f. No
terfere with the procedure; for example, abil- g. Yes
ity to maintain the position (e.g., remaining h. No
quiet and still) or using equipment (e.g., open- i. No
ing a sterile wipe). Assess for anxiety, fear, or j. No
concerns about the procedure. Assessing for k. Yes
past experiences (negative or positive) is also l. No

Copyright © 2015, 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, an imprint of Elsevier Inc. All rights reserved.
 Answer Key  40  

m. No care provider. However, a low platelet count

n. Yes will result in prolonged bleeding at the punc-
o. Yes—If the patient has had the colostomy ture site, because platelets are involved in the
for a long period of time and is familiar clotting process.
with the care, it is appropriate to direct 30. Answer 2: The tourniquet is left in place no
the UAP to collect the specimen. If the more than 1-2 minutes because of discomfort
patient is still trying to learn about colos- and possible alteration of test results. One
tomy care, then the nurse should collect end is crossed tightly over the other, then the
the specimen and take the opportunity to upper end is tucked under the band to form
teach the patient more about self-care. a half bow. The tourniquet is generally posi-
tioned 4 to 6 inches above the selected site.
Multiple Choice Tourniquets serve to prevent venous blood
21. Answer 4: See Skill 15-11, p. 395. The inner flow but not arterial blood flow. Make sure
ampule is crushed so that the medium for or- the tourniquet is tight enough that the veins
ganism growth coats the swab tip. Closing the distend; however, pulse should be palpable.
lid tightly would apply to any specimen. Liq- 31. Answer 4: The patient may not be aware that
uid culture medium or color change reagents different bacteria can cause UTI; therefore,
apply to different types of specimens. explaining the rationale helps the patient un-
22. Answer 4: Flat, supine position or head not el- derstand the need for the test. Routine testing
evated more than 30 degrees is for prevention or health care provider’s desire to order the
of spinal headaches. Fluid intake would be test are both true, but these are vague answers
encouraged. The health care provider would that do not help the patient understand why
be notified if the pain is unrelenting. the test is ordered. Possibly, the patient could
23. Answer 3: See Table 15-1, figure under sub- convince the provider to prescribe antibiotics
heading “Thoracentesis,” p. 382. without doing the test, but most providers are
24. Answer 2: Sounds will be heard during the very reluctant to do this and inappropriate
test. There are no food or fluid restrictions. No prescribing does contribute to resistant strains
discomfort should occur and the patient must of bacteria.
remain motionless. 32. Answer 1: Stool is taken from two separate
25. Answer 1: Blood is allowed to drop onto the areas to demonstrate that blood is throughout
test strip rather than smearing it, which could stool and not localized. Specimen should not
alter results. The side of the finger is used be- be taken from toilet bowl. The control should
cause it is less painful than the center. Gently be tested at the same time as the specimen.
squeezing the finger and holding it down- Hemolysis and urgent delivery to the labora-
wards will encourage the blood flow. tory are not relevant for this test.
26. Answer 3: Voiding at least 30 mL is thought 33. Answer 2: During bronchoscopy, a flexible
to flush organisms that remain on the skin. tube enters the airway; therefore, impaired
The cup must be sterile, only about 10 mL is respirations, aspiration, laryngospasms, bron-
needed. Betadine was used in the past, but chospasms, or effects of anesthesia could be
chlorhexidine is now more commonly used to causing hypoxia. The nurse should assess
clean the skin. respiratory rate and effort; pulse oximeter is
27. Answer 2: Clamping the tube allows fresh used to check oxygenation. The other assess-
urine to collect. Clean gloves are needed, ments may also be relevant in contributing to
not sterile gloves. Disconnecting the catheter the overall status of the patient, but airway is
increases the risk for HAI. Inserting a needle the priority.
directly into the catheter will cause leakage; 34. Answer 3: Elderly patients have a greater
specimen should be drawn from the port. risk for dehydration and fluid and electrolyte
28. Answer 3: The purpose of catheterizing for imbalance. The patient has had the prepara-
residual is to determine how much urine re- tion twice and repeating the preparation for
mains in the bladder after voiding. The other a third time increases the risks. After assess-
options are incorrect. ment is completed, calling the health care
29. Answer 2: All of these values are of concern provider and technician and explaining to the
and would be evaluated in terms of the pa- patient can be done.
tient’s condition and reported to the health

Copyright © 2015, 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, an imprint of Elsevier Inc. All rights reserved.
 Answer Key  41  

35. Answer 2: Extra fluids, especially water, will 40. Answer 1, 2, 3, 4: Symptoms of systemic in-
help thin the mucus and make it easier to ex- fection and localized infection should be as-
pectorate. Mouth care should be performed sessed. Possibly the infection control nurse or
after expectoration, not before. Avoidance of the charge nurse could review past records to
red meat and caffeine are relevant to other di- identify quality of care issues. If the dressings
agnostic tests, not to sputum specimens. Col- are not being changed, this could contrib-
lecting saliva is not the goal. ute to the development of infection, but this
36. Answer 4: If the test is totally unfamiliar to investigation should not delay reporting or
the nurse, checking facility manuals that are treating the immediate problem.
related to diagnostic testing will guide the 41. Answer 2: It is likely that the phlebotomist
nurse in assessing the patient for specific will draw the blood cultures and the blood
symptoms, and in knowing normal values chemistries at the same time; however, from
versus slightly abnormal or critical values. a treatment standpoint the blood cultures
The laboratory technician may be able to help, should be done immediately so that the anti-
but frequently technicians are not familiar biotics can be started as soon as possible.
with how a test might relate to patient circum- 42. Answer 1: The nurse would remind the stu-
stances. dent that venipunctures (and other proce-
37. Answer 4: All of these patients represent dif- dures such as taking a blood pressure) should
ferent challenges in obtaining a voided urine not be performed on the side of mastectomy
specimen. The patient who is comatose is not or a shunt. The other actions are correct.
going to be able to understand or cooperate. 43. Answer 1: The patient is having a delayed al-
For women who are menstruating, if flow is lergic reaction as evidenced by the signs and
finished or nearly finished, then extra clean- symptoms of swelling and itching, dyspnea,
ing can sometimes overcome the interference and tachycardia. The treatment is to admin-
of menstrual blood. The overweight patient ister prn diphenhydramine (Benadryl) and
may need assistance in cleaning and holding contact the health care provider for additional
labia apart to prevent contamination (a bed- orders, such as steroid medication. The nurse
pan might be considered). Patients with pros- would watch for worsening. If the patient is
tate problems can have various flow problems worsening, alerting the rapid response team
(i.e., some difficulty starting stream or com- and preparing emergency equipment would
plete blockage). be appropriate. Contacting the health care
38. Answer 1: Patients who travel to foreign team member who administered the contrast
countries and develop GI symptoms are at medium might be done later by risk manage-
risk for ova and parasites. The stool must ment or hospital administration to investigate
be examined when it is fresh, because these issues of patient safety. Applying a cool com-
organisms are easier to detect when they are press and suggesting rest are comfort mea-
alive. Dark stool suggests blood, normal- sures that could be offered in addition to the
colored stool can still be tested for occult Benadryl.
blood. Stool is frequently examined if foreign 44. Answer 1, 2, 3, 5, 6: If the environmental
body ingestion is suspected; small, smooth, temperature is cool, peripheral blood flow
rounded objects will usually pass. Floating decreases. Likewise if the arm is lowered, it is
stool is usually associated with fat in the stool easier to draw blood and gravity will facilitate
and signals problems with digestion of fats. the flow once the skin is punctured. Tech-
39. Answer 4: Recall that vagal stimulation can nique includes many factors, the position of
result in bradycardia and the overall de- the arm, the depth and site of puncture, and
creased perfusion will cause diaphoresis. This the gentle squeezing or milking to encourage
can result even when the correct technique the drop to flow. Certain disease conditions
is used. Five to ten seconds for suctioning (e.g., Raynaud’s disease) can cause problems
is considered acceptable. Anxiety can cause with peripheral circulation. Calluses or skin
diaphoresis, but tachycardia is more likely injury or disease (e.g., burns) can alter the
than bradycardia. The nurse would monitor condition of the skin and make piercing the
the patient and notify the health care provider skin more difficult. Improper calibration of
about the incident. the glucometer can alter the accuracy of the

Copyright © 2015, 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, an imprint of Elsevier Inc. All rights reserved.
 Answer Key  42  

results, but this does not affect the difficulty because chest pain suggests inadequate oxy-
in obtaining the blood sample. genation of heart muscle. Time of pain should
45. Answer 1: The NG tube is not designed or in- be indicated on the ECG strip or request slip
tended to be pierced with a needle. The other (it is possible that the pain will correlate to a
options are correct. dysrhythmia on the ECG tracing). Chest pain
46. Answer 2: The cough reflex is stimulated by should be reported to the health care provider
the catheter. The other occurrences are not and treated, but the target of the medication
normal or expected. will be the oxygen deficit that is causing the
47. Answer 3: Having the patient say “ahhh” pain. A crash cart should not be needed, un-
facilitates visualization, minimizes the gag less the health care team fails to notice and
reflex, and gives the patient something to treat the chest pain.
focus on. Using a tongue blade can make
visualization more difficult if the patient is Critical Thinking Activities
already prone to gagging. The blade can trig- 51. a. Assess the patient’s baseline vital signs
ger the reflex and the patient will tense up as and pain, lung sounds, presence of cough,
the blade is inserted. Also, if the nurse uses level of knowledge about and prior ex-
the tongue blade, both hands have to be per- perience with the procedure, ability to
forming; tongue blade requires steady even understand and follow directions, and
pressure, but no pushing backwards; whereas overall physical and emotional status.
the culture swab needs a light quick sweep b. Lungs should be auscultated before the
backwards towards the tonsillar wall. It is im- procedure so that the nurse can compare
possible for the patient to obtain a good throat lung sounds after the procedure. Dimin-
culture on himself. The health care provider ished or absent breath sounds after the
should be notified if the specimen cannot be procedure are a sign of possible pneumo-
obtained. There are mild topical anesthetic thorax. If the patient has an uncontrol-
preparations that could be used, but these are lable cough, the nurse should obtain an
not typically used for this procedure. order for a cough suppressant, because
48. Answer 1, 2, 4: For elderly patients and chil- excessive coughing or moving can result
dren, the nurse should select 23- to 25-gauge in damage to the lung if the needle moves
needles. For most adults 20- to 21-gauge is during the procedure.
selected. Butterfly needles are frequently used c. Refer to Skill 15-1 on p. 367. Check the
for children or older adults because they are medical record for the order and make
easier to hold during insertion. If a vacuum sure the consent is signed. Teach the pa-
tube is used, sterile double-ended needles are tient that a sitting position must be main-
desirable. The nurse may be tempted to grab tained and coughing and moving could
equipment that is familiar, but it is the nurse’s potentially cause damage to the lungs.
responsibility to become familiar with equip- Explain that a local anesthetic is used and
ment that best suits the needs of patients. there is a pressure-like pain as the needle
The collection tube does not affect the nurse’s passes through the pleura and the fluid is
choice of needle, nor the type of blood chem- removed. Gather equipment and supplies.
istry that is ordered. Provide privacy and assist the patient to
49. Answer 4: Nurse A should go up the chain of a sitting position. Maintain asepsis, assist
command to address this problem. Report- the health care provider, label and send
ing to the nurse manager is an option if the the specimen to the laboratory, and docu-
charge nurse is not willing or able to deal ment the procedure.
with the problem. If Nurse A was a preceptor d. Monitor vital signs and observe for
for Nurse B, then assessing skill in perfor- cough, hemoptysis, dyspnea, tachypnea,
mance would be appropriate. Offering to help diminished or absent breath sounds, anxi-
is always good for morale and teamwork, but ety, restlessness, fever, or subcutaneous
Nurse B needs help with knowledge/skills emphysema. Turn patient to unaffected
deficit and stepping in and taking over does side for 1 hour. Obtain a chest x-ray if or-
not help Nurse B improve. dered. Resume normal activity in 1 hour
50. Answer 2: Continue the procedure, but con- if patient is asymptomatic.
tinuously monitor the patient for worsening,

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 Answer Key  43  

52. For this patient, there may be physical dif- time taken, any medications patient has taken,
ficulty manipulating the specimen cup or and current status of patient.
cleaning the perineal area. Explain the pro- 9. The teaching plan should include keeping
cess of a midstream urine collection and do emergency first aid supplies and instructions
additional assessments on fine motor skills. available. Maintaining a list of emergency
Obtain an order for a straight catheterization phone numbers. Accident-proofing the home:
specimen if she is unable to manipulate the Keep poisons locked away from children, use
wipes and the specimen cup while holding handrails, use nonskid surfaces, have good
the labia apart. Older adults are likely to have lighting, and practice electrical safety (e.g.
fragile veins; consider doing the venipuncture check electrical appliances for frayed cords).
without a tourniquet; also consider getting the 10. 54%
most experienced person to draw the blood.
NPO status and bowel cleaning procedures Multiple Choice
may lead to dehydration. This patient reports 11. Answer 1: First, the nurse assesses level of
poor appetite and fluid intake, so she has an consciousness. Based on the assessment, the
increased risk for fluid and electrolyte imbal- nurse may decide to question the person, start
ance. Older adults have decreased renal func- CPR, call 911, or check for injuries.
tion and the contrast media can contribute 12. Answer 4: Health care professionals, includ-
to additional decreased kidney function. The ing nurses, should check for a carotid pulse,
BUN and creatinine results must be checked but spend no longer than 10 seconds.
before the IVP. Fluids should be encouraged 13. Answer 4: A high-pitched inspiratory noise
after the test and urine output should be mon- suggests that there is an object in the airway
itored, because decreased urine output can be that is allowing a small amount of air to go
a sign of renal failure. around the object. This is an emergency, be-
cause the object could become lodged and al-
low no air movement. If the person can speak,
CHAPTER 16—CARE OF PATIENTS this means that air is passing over the vocal
EXPERIENCING URGENT ALTERATIONS IN cords and into the airway. Forceful coughing
HEALTH is a good sign because it is the most effective
means for the person to independently rid
Word Scramble the airway of a foreign body. If the person is
See Box 16-3, p. 423. coughing, rescuer would not interfere, even if
1. anaphylactic (b) some wheezing is heard.
2. cardiogenic (e) 14. Answer 3: Placing the fist just above the navel
3. hypovolemic (a) is the position to create enough force to expel
4. neurogenic (f) the foreign body, and to avoid fracturing un-
5. psychogenic (c) derlying bone structures.
6. septic (d) 15. Answer 4: The nurse would visually inspect
the mouth for an object, open the airway, and
Short Answer attempt to ventilate. If ventilation is not possi-
7. The caller should identity self and location. ble, deliver five abdominal thrusts; then look
State that structure collapsed and several in the mouth for foreign object and repeat
people were injured. State possibility of ongo- sequence until object is dislodged and breath-
ing danger related to the unstable structure. ing resumes, or if no spontaneous breathing,
Currently there are ____ adults and ____ chil- initiate CPR.
dren with ____ injuries. First aid measures: 16. Answer 1, 2, 4: Immediate measures are to
____, ____, and ____ have been provided. One establish an airway and control bleeding.
victim has chronic ____. The parking lot is Body temperature should be maintained, so
congested with cars and people who are try- covering the person helps minimize heat loss.
ing to leave. Best access is on the south side of The head should not be elevated, because this
the community center. See Box 16-1, p. 415 for will decrease perfusion to the cerebrum. Also,
additional information. spinal precautions would be applied if head
8. Patient’s weight, age, substance ingested, in- or neck injuries are suspected. Oral fluids are
haled, or injected, amount of substance taken, typically withheld. Intravenous fluids would

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 Answer Key  44  

be started if available. No medication should heart. It is possible for respirations to cease

be given at the scene of the accident. while the heart continues to beat (e.g., chok-
17. Answer 3: A person with a known allergy to ing or drowning); however; cardiac arrest will
bee stings is supposed to carry an epinephrine quickly follow respiratory arrest. There are
pen and the pen should be immediately avail- many reasons for decreased responsiveness
able in case the person has an anaphylactic (e.g., diabetic coma, stroke, drug overdose,
reaction or becomes unconscious or unable to electrolyte imbalance) where the heart will
speak. If a pen is not available, taking diphen- continue to beat.
hydramine and immediately seeking medical 22. Answer 3: The goal of CPR is to mimic the
assistance would be the next best thing. Dis- pumping action of the heart and if compres-
cussions about past episodes of allergic reac- sions are too rapid and the heart is not al-
tion should not delay treatment or seeking lowed to fill with blood, there is nothing to
medical assistance. Allergic reactions can be pump out. The rescuer will become fatigued
progressively worse with repeated exposures even if the proper rate is maintained; altering
to allergens. the speed of compressions is not the solution.
18. Answer 2: The person should not be moved, Lacerations or fractures are more associated
but since he is conscious it would be appro- with proper hand position than speed of com-
priate for the nurse to identify self and ask pressions. A smooth motion is more related to
for permission to help. Resist the impulse to proper position of arms and hands in relation
assist the person into a sitting or standing to the victim’s body. Rescuer fatigue could
position. (Person may also be attempting to also contribute to smoothness of movements.
get up.) Initiating spinal precautions is cor- 23. Answer 2: For infants, gastric distention is
rect; however, failure to ask permission or common because an excessive amount of air
explain actions could be interpreted as an at- is delivered during rescue breathing. To pre-
tack, especially if the person is confused and vent this, the amount of air that is held in the
the nurse is a stranger to him/her. Asking the nurse’s cheeks is given during each rescue
person about pain, symptoms, and events is breath.
appropriate after he is calm, immobile, and 24. Answer 4: For infants, use five back blows,
help has been summoned. turn him over and deliver five chest thrusts.
19. Answer 2, 4, 5: CPR can be stopped to apply For back blows and chest thrusts, head should
the AED, and for trained personnel to take be lower than the trunk. See Figure 16-9, p.
over. If the person is spontaneously breathing 423. If the object is expelled during blows or
and has a pulse, CPR should be discontinued thrusts and the head is downward, gravity
even if the person remains unconscious. Pulse will help. Using a flashlight and looking in
and breathing should be continuously moni- the mouth will delay the intervention of clear-
tored. The nurses should not trade off with ing the airway. The child is likely to struggle
a layperson unless they are exhausted and out of fear and respiratory distress and visual-
unable to continue with CPR. Trading causes izing the back of the mouth will be very dif-
delay. In addition, the nurses are more likely ficult.
to have experience, recent training, and better 25. Answer 2: Oliguria is urine output less than
compression technique than a lay rescuer. The 500 mL in 24 hours. During shock, blood flow
nurses should not be distracted by the relative to the kidneys is decreased. This can result in
or the crowd. CPR requires intense effort and damage to the kidneys. Paralytic ileus is de-
timing. The nurses could stop if the relative or creased or absent motility of the bowel, which
crowd were threatening their personal safety. can also occur with shock; however, the ap-
20. Answer 3: The wife is acknowledging that it is propriate assessment would be bowel sounds,
time to say goodbye. It is not uncommon for abdominal pain, or failure to pass gas or stool.
families to need additional time at the bedside Shock can also produce electrolyte imbalance,
when someone dies. The other statements in- but assessment of laboratory values would be
dicate a belief or hope that he can still recover. more appropriate than observing amount of
21. Answer 2: Absence of a carotid pulse is indic- urine output. Heart failure is the least likely
ative of cardiac arrest. The peripheral pulses complication of shock. Right-sided heart fail-
are not as strong and blood flow to extremi- ure is more associated with long-term respira-
ties will decrease to preserve the brain and tory or circulation problems.

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 Answer Key  45  

26. Answer 3: The patient has an arterial bleed, so of a pneumothorax or hemothorax. A patient
the nurse would not waste time seeking out could be unconscious and responsive if exces-
sterile supplies. Clean gloves and a clean tow- sive blood is lost or decreased oxygenation of
el are adequate. Elevation above the level of tissues has occurred; however, patients with a
the heart will also help control the bleeding. hemothorax or pneumothorax are frequently
Wrapping the area with layers of sterile gauze conscious and experiencing pain, anxiety, and
would be done after initial bleeding is con- severe respiratory distress.
trolled. Pressure to the brachial artery would 31. Answer 1: The nurse cannot immediately de-
only be done if direct pressure and elevation termine if the patient has been overcome by
were not controlling bleeding. gas or heat, or by something else; however,
27. Answer 4: If direct pressure, elevation, and for the nurse’s safety, he/she steps out of the
indirect pressure have failed to control bleed- house and calls 911. If the nurse is overcome
ing and the patient’s life is in danger, the by gas and help has not been summoned first,
nurse would use a tourniquet. Use of a tourni- the nurse and the patient could die. If the
quet should not be considered part of general nurse can remove the patient from the house,
first aid or the Good Samaritan principles. A this would be the best thing for the patient;
health care provider could order the applica- however, if the nurse cannot safely move the
tion of a tourniquet over the phone or the patient, the nurse should use critical thinking.
victim could request it; however, as with other (Windows could be broken from the outside.
procedures that are not within the scope of Two strong neighbors could assist the nurse
practice, the nurse should decline unless he/ to drag the patient from the house.) Cooling
she deems that the patient’s life is in jeopardy. measures and contacting Poison Control can
28. Answer 1: The nurse should assess for all of be done once the victim is out of the hot and
these options; however, for elderly patients toxic environment.
hypertension is a primary risk factor. If hy- 32. Answer 4: Loss of bowel and bladder func-
pertension is the underlying cause, the blood tion, rapid and weak pulse, labored breathing,
pressure is likely to be very high. Because seizures, nausea, vomiting, diarrhea, loss of
the bleeding was easily controlled, the nurse memory, lack of coordination, and depressed
suspects that the patient did not know how muscle reflexes are signs of serious intoxica-
or could not perform the self-care measures tion. The other adolescents are demonstrating
to stop the bleeding, so knowledge and skill signs and symptoms of mild intoxication.
must be assessed. Infections can also contrib- 33. Answer 4: Victims are first moved into a cool
ute to nosebleeds, so checking the tempera- environment. Next, the nurse would assist
ture would also be appropriate. to remove constrictive clothing, offer cool
29. Answer 2: All of these patients are at risk drinks, and give cool compresses. A circulat-
for internal bleeding; however, Coumadin ing fan will also help.
(warfarin) is an anticoagulant and fractures 34. Answer 3: No creams, ointments, sprays, or
of hip or femur can result in 500-1500 mL of other topical applications should be put on
blood loss. Small children with bumps to the the skin. The skin will have to be assessed and
forehead usually do well and are generally cleaned at the hospital and topical applica-
discharged to parents with a careful explana- tions can create complications. The other ac-
tion of what to watch for. Blunt trauma to the tions are correct.
abdomen can cause rapid or slow internal
bleeding. This patient should receive serial Critical Thinking Activities
abdominal assessments and complaints of 35. a. Good Samaritan laws stipulate legal
increasing pain are immediately reported to protection for those who give first aid
the RN or health care provider. Women with in emergency situations if they follow a
postpartum hemorrhage can die if the bleed- reasonable and prudent course of action.
ing is excessive or if there are complications, Once the nurse initiates any action, there
(e.g., disseminated intravascular coagulation), is a moral and legal obligation to continue
but generally a dilation and curettage and IV until qualified help arrives.
fluid replacement are sufficient treatment. b. Use simple language and remain calm.
30. Answer 1, 2, 3, 5, 6: Respiratory distress, pain, Direct a bystander to call 911. Ask the
and decreased perfusion are signs/symptoms woman for permission to help her and tell

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 Answer Key  46  

her to remain in a supine position. Check remember how to do CPR on young chil-
the airway, breathing, and circulation. dren? What were the children doing when the
Identify the source of bleeding and apply drowning occurred? Could the incident have
direct pressure (use the cleanest material been prevented?
available). Once bleeding is controlled The event could relate to your job in an
continue observations of skin color, tem- assisted-living center. Who discovered the res-
perature, pupil reaction, and neuromus- ident? What actions did you take first? Where
cular status. is the AED located? Do you remember how
c. A victim in shock may have a change in to use the AED? Does the facility have a bag-
the level of consciousness, skin tempera- valve-mask or is mouth-to-mouth the method
ture and color changes, decreased blood that you would use?
pressure, increased pulse rate and respira-
tions, diminished urinary output, muscle
weakness or tremors, pupil dilation, nau- CHAPTER 17—COMPLEMENTARY AND
sea, and vomiting. ALTERNATIVE THERAPIES
d. Appropriate interventions for this victim
in shock include: establish airway, control Fill-in-the-Blank Sentences
bleeding, maintain supine body position, 1. Complementary therapies
and avoid hyperextension of the neck to 2. Alternative therapies
protect against potential neck or spine 3. mind-body-spirit
injuries. Cover the patient. Do not allow 4. allopathic medicine
anyone to administer food or fluids. Give 5. Integrative medicine
emotional support.
36. a. The weather is cool and windy. The man’s True or False
clothes are wet. He is shivering, confused, 6. False. Chiropractors do not prescribe medica-
and his speech is slurred. The absence of tion.
shoes suggests that he has discarded them 7. True
in his confusion, and that loss of the shoes 8. False. Reflexologists are not qualified to diag-
is contributing to heat loss. nose.
b. Hypothermia is demonstrated by uncon- 9. True
trollable shivering; low body tempera- 10. False. Acute infectious conditions such as ap-
ture; slow, slurred speech; disorientation; pendicitis should be assessed by an allopathic
and uncoordinated or decreased muscle health care provider.
movement. The skin may appear mottled
and edematous, with general numb- Multiple Choice
ness. Pulse is weak and irregular, with 11. Answer 1: Many people use CAM therapies,
depressed respiratory rate. The victim but will not report the usage. Reasons for
becomes more lethargic, with decreasing not reporting include fear of disapproval by
level of consciousness, until reflexes are health care team, belief that natural products
also lost. are not harmful, or assumption that supple-
c. Victim should be moved to a warm en- ments are not worth mentioning. Practices
vironment if possible and wet clothes may seem so “normal” or routine that the
should be removed and the victim should patient would overlook them as health care
be covered with warm blankets. For a issues; thus direct questions are needed to
conscious victim, warm nonalcoholic flu- elicit information, rather than waiting for
ids should be provided. The victim needs the patient to offer the information. Taking a
medical help as soon as possible. complete history and advocating are expected
37. Your selection of event could be related to routine nursing behaviors. Some CAM thera-
your family. For example, you have young pies may be covered by insurance, but usually
children and a neighbor has a swimming pool a health care provider’s order is required for
where the children are frequently invited for coverage.
play dates. In your mental rehearsal, where 12. Answer 3: National Center for Complemen-
was the nearest phone to call 911? Who was tary and Alternative Medicine serves as a
most likely to be there to assist you? Did you clearinghouse to distribute information to

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 Answer Key  47  

the public, the media, and professionals. ing on the face will help reestablish rapport
Supporting, coordinating, and conducting and the patient’s face is more familiar to the
research, and research training in the area student than the wrinkled landscape of the
of alternative medicine are also performed. patient’s body. Safety is the primary concern
Textbooks include much basic and valuable at the moment, so leaving to step out into the
information, but the information will be out- hall or find the instructor is incorrect. Not
dated compared to other sources. Use of the looking directly at the patient will increase the
Internet is likely to yield much information, patient’s feelings of rejection.
but sources may not be validated. American 20. Answer 2: “Skin hunger” refers to lack of be-
Cancer Society is the second best option. ing touched; therefore, the nurse would assess
13. Answer 1, 2, 3, 4, 5: Lack of research, ac- who is amenable to receiving touch and hugs
countability, consistency, and standardization from staff members.
contribute to safety and quality problems. An 21. Answer 1: Inhalation of substances can trigger
herbal preparation usually includes an un- or worsen asthma symptoms. Aromatherapy
purified extract of the whole plant. One herb may help decrease depression, stress, or pain.
may be used for a variety of purposes, and its 22. Answer 3: Myasthenia gravis causes muscle
action is usually gentler than those of phar- weakness and possibly the magnet’s action
maceuticals. could cause relaxation of muscles; thus mag-
14. Answer 4: Herbal preparations should be dis- net therapy is contraindicated for patients
continued at least 2 weeks before a surgical with myasthenia gravis. Magnet therapy is
procedure to prevent interactions with drugs also thought to cause vasodilation and anti-
and to avoid complications such as hemor- inflammatory action. So checking vital signs
rhage. Over-the-counter products can have and being vigilant for occult signs of infection
dangerous side effects, especially if there are would also be relevant for anyone who is us-
interactions. Following the package instruc- ing magnet therapy. Memory and cognition
tions is correct, but this is just one aspect of should not be affected.
using the product correctly. 23. Answer 1: Guided imagery helps the person
15. Answer 2: See Table 17-1, p. 447 for herb-drug gain control over responses to stress or stimuli
interactions. by modifying perceptions. Deep-breathing,
16. Answer 4: Studies support the use of T’ai chi accessing all senses, and using images such as
in preventing osteoporosis. Acupuncture is warmth or success are part of the technique.
used in the treatment of osteoarthritis. Osteo- 24. Answer 1, 2, 6: Research indicates that
porosis is a contraindication for chiropractic animals have a calming effect and reduce
treatments. Reflexology decreases stress, blood pressure and anxiety. Interaction can
enhances circulation, and normalizes metabo- stimulate mental activity. Family pets do not
lism. necessarily make good therapy animals. Not
17. Answer 2: Acupuncture has been used in all patients will want to get involved with
smoking cessation and to treat other addic- therapy animals; conversely, some may like
tions. Exchanging tobacco leaf for another animals but allergies or autoimmune condi-
type of plant leaf could be dangerous and is tions prevent interaction.
ill-advised. Inhalation of lavender oil does 25. Answer 1: Repressed emotions may surface
reduce stress; possibly stress could be one during the biofeedback sessions; thus, the
reason that a person reaches for a cigarette, therapist would have to give support or refer
but nicotine is highly addictive and the crav- the patient to an appropriate counselor.
ing would persist. Biofeedback could also be
useful for increasing awareness of physiologic Critical Thinking Activities
changes associated with wanting a cigarette 26. a. Obtain information on the patient’s use
and/or withdrawal from nicotine. of complementary and alternative treat-
18. Answer 2: Patients who are at risk for throm- ments. Try to avoid using the term “alter-
bophlebitis should not have the legs mas- native medicine” because the patient may
saged. The other patients could all benefit. not view the use of herbs or other thera-
19. Answer 4: It is likely that the student’s initial pies as alternative or as medicine. Assess
reaction on seeing the patient was already the patient’s belief system about health
manifest through nonverbal behavior. Focus- and treatment. Add findings to the pa-

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 Answer Key  48  

tient’s record and inform the health care appears that he is not receptive to the
provider because some therapies could nurse’s help at this time. The nurse could
cause an interaction with medical treat- consider teaching the techniques to the
ment or be contraindicated for certain wife. It is likely that his tension is affect-
medical conditions. ing her.
b. Refer to Cultural Considerations: Provid-
ing Culturally Appropriate Complemen-
tary and Alternative Therapy on p. 460. CHAPTER 18—PAIN MANAGEMENT,
The nurse’s beliefs may be very different COMFORT, REST AND SLEEP
than the patient’s; therefore, the nurse
may have trouble supporting the patient’s Fill-in-the-Blank Sentences
choices because of potential dangers of 1. noxious
interaction or delay in seeking standard 2. chronic nonmalignant
medical treatment. Another potential is- 3. 6
sue is that the patient may intentionally 4. perception
withhold disclosure for fear of censure or 5. endorphins
criticism by the nurse or health care pro-
vider or the information may be uninten- True or False
tionally withheld because the use of the 6. False. There is no predictable relationship be-
therapy may be a longstanding routine tween tissue injury and pain.
part of the patient’s life and would there- 7. False. Approximately 50% of people who suf-
fore not be reported. fer moderate to severe pain will continue to
c. When teaching patients about CAM, the suffer, primarily because nurses fail to assess
nurse may include information on the pain.
safe use of therapies, positive and nega- 8. False. Acetaminophen and nonsteroidal anti-
tive effects, contraindications to use, repu- inflammatory drugs (NSAIDs)—the nonopi-
table sources for purchase, interactions oid analgesics—are the most widely available
with medical therapy, and when to seek and frequently used analgesic group.
medical treatment. 9. True
27. a. None of these patients are currently good 10. False. Older adults require about the same
candidates for relaxation therapy. The pa- amount of sleep as younger people, but are
tient with dementia will have trouble fo- more likely to achieve it in separate episodes.
cusing. It is unlikely that she would have
the ability to concentrate on the stimuli or Multiple Choice
understand the instructions. It is possible 11. Answer 2: Respiratory rate is already low and
that an advanced nurse specialist could respiratory depression is a side effect of opi-
design a specialized relaxation program oid medication.
for her, but the standard techniques in- 12. Answer 3: For chronic pain, such as the pain
cluded in Box 17-1, p. 456 are not likely to that accompanies arthritis, NSAIDs are most
work, and may actually increase her agi- commonly used. Their better-characterized
tation. actions are peripheral, where they are thought
b. The college student is concentrating on to exert analgesic effects.
studying and solving current math prob- 13. Answer 3: The epidural opioids have side
lems; therefore, his mind is not passive effects including urinary retention, postural
enough to turn away from his goal. It is hypotension, pruritus, nausea, vomiting, and
likely that he lacks the ability to focus respiratory depression.
on your instructions or to attend to the 14. Answer 1, 3, 4, 5: Meperidine is used much
stimuli because he is under the influence less frequently for any patients, but older
of “uppers.” This patient would be a good adults are even more prone to have side ef-
candidate for relaxation therapy once his fects because of reduced kidney function.
system is clear of the drugs. Morphine sulfate is generally not used for
c. The retired military officer demonstrates chronic pain. NSAIDs are not the first choice
some rigidity in his way of dealing with for older adults, because of the risk for gastric
the world and his personal issues. It and renal toxicity. Combinations of opioid

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 Answer Key  49  

drugs would not be a good choice of therapy the other routes. In addition, the child is more
for older adults because of drug-drug interac- likely to be opiate-naïve.
tions and additive effects. 23. Answer 2: Normeperidine is eliminated by
15. Answer 1: The nurse implements measures the kidneys and is a particularly poor choice
to alter the sensory impulses, which help for patients with sickle cell disease because
close the gate and block pain impulses, by most have some degree of renal insufficiency.
providing back rubs, applying warm or cool 24. Answer 4: Cancer patients require long-term
compresses, and using auditory and visual repeated doses of opioids for pain manage-
distractions. ment and this results in accumulation of the
16. Answer 3: Assessing and reassessing the pa- metabolite in meperidine, normeperidine. The
tient’s pain is one of the key concepts under active metabolite in meperidine, normeperi-
the new TJC standards. The other actions are dine, sometimes produces irritability, trem-
also important nursing responsibilities that ors, muscle twitching, jerking, agitation, and
the nurse would routinely perform. seizures. Meperidine (Demerol) is used much
17. Answer 2: The nurse should help the student less frequently than in the past, because there
recognize that an assessment of pain should are other opioid medications that are safer. At
precede any interventions. Based on the stu- home, patients cannot be monitored as closely
dent’s report of the patient’s description of as they are in an acute care facility, so those
pain, the nurse may decide to ask the other who need long-term therapy must be offered
questions or they may need to return to the treatments that they can manage in the home
patient’s room and conduct additional assess- setting. Young healthy patients have also had
ment. adverse reactions to meperidine (Demerol).
18. Answer 3: Guided imagery is the process of 25. Answer 4: Duloxetine (Cymbalta), an anti-
helping a patient recreate a time and place depressant, is used for control of the pain as-
where he/she felt relaxed, happy, and peace- sociated with diabetic neuropathy. NSAIDs,
ful. The nurse must be skilled in this process such as ketorolac tromethamine (Toradol),
to help the patient activate memories of tramadol (Ultram), and acetaminophen (Tyle-
sights, sounds, smells, and emotions. Firm nol) are considered as good pain relievers for
and light strokes are used during massage. mild to moderate pain, but are not as effective
Electrical stimulation of the skin is used in for neuropathic pain, which can be difficult to
transcutaneous electric nerve stimulation. treat.
Biofeedback uses specialized equipment to 26. Answer 1: Physical tolerance and physical
help the patient identify and learn to control dependence do occur in many patients after
responses to stress and stimuli. 1-4 weeks of regular opioid administration.
19. Answer 4: The biggest advantage is that the Recognize that these effects are expected
patient gains some feelings of control over with long-term opioid treatment, but do not
his/her own pain and many of the therapies confuse them with addiction. Chronic pain is
can be performed at home once the patient defined as lasting longer than 6 months.
learns to master the techniques. The other op- 27. Answer 3: Diuretics should be taken early in
tions are also relevant to the noninvasive tech- the day. Otherwise, the patient will have to
niques. rise frequently at night to go to the bathroom.
20. Answer 1: There is a possibility that the TENS Patients can have varied success with differ-
unit could interfere with a cardiac pacemaker, ent NSAID medications, but sleep disturbance
so the health care provider should be alerted is not a typical complaint. A recent increase
to discuss the possibility with the patient. in opioid medication should actually help the
21. Answer 3: The maximum dose for acetamino- patient to get more rest and sleep. Antiemetics
phen is 4000 mg in 24 hours, so if the patient are usually taken before meals. Some anti-
receives the medication every 4 hours over the emetics cause drowsiness and should help the
course of 24 hours, he/she will get 6 doses or patient rest and sleep.
6000 mg. So the nurse should call the health 28. Answer 2: Rotating days to nights creates the
care provider to clarify the order. biggest disruption because the body will con-
22. Answer 3: The intramuscular route is more tinuously try to adapt to the biologic rhythm
likely to cause respiratory depression than of sleep. Night shift work is also associated
with health problems.

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 Answer Key  50  

29. Answer 4: An automatic blood pressure b. Patient will sleep at least _____ hours per
cuff can be applied to an extremity and left night while in the hospital.
in place. This allows the nurse to check the c. Nursing interventions to promote sleep
blood pressure and pulse without having to include determining the patient’s usual
wake the patient to apply and remove the sleep patterns, limiting interruptions dur-
cuff. The machine does not replace the nurse. ing the night, providing a quiet darkened
The nurse must still enter the room every 2 room, maintaining comfort, emptying
hours, read the machine, count the respira- trash and removing dietary trays prompt-
tions, and ensure that the cuff has fully deflat- ly, offering a back rub, changing linens or
ed. If the provider has ordered q2h vital signs, dressings, administering medication as
it is likely that the patient is unstable or that ordered, and offering noncaffeinated bev-
the provider anticipates that the patient may erages.
develop a problem. Explaining the procedure 33. a. Many factors contribute to a patient’s
to the patient is appropriate; however, do not lack of comfort, which manifests in many
suggest to the patient that the process will forms, including anxiety, constipation,
end after 12 hours. It would be better to tell constricting edema, depression, diapho-
him that the provider will evaluate the pat- resis, diarrhea, abdominal distention, dry
tern of vital signs at the end of 12 hours and mouth, dyspnea, fatigue, fear, flatus, grief,
then make a decision based on that data. Tell- headache, hopelessness, hyperthermia,
ing the UAP to be quiet and quick is an option hypothermia, hypoxia, incontinence, mus-
if there is no automatic cuff or if the patient cle cramping, nausea, pain, powerless-
cannot tolerate the continuous presence of the ness, pruritus, sadness, singultus, thirst,
cuff. urinary retention, or vomiting.
30. Answer 4: First the nurse assesses patient’s b. Helping the patient cope with the cause
usual methods for dealing with difficulty of discomfort may have been as simple as
sleeping. Based on assessment findings, the changing the wet linen, offering a glass of
nurse may elect to use the other options. water, or obtaining a warm blanket. You
may have used therapeutic communica-
Critical Thinking Activities tion to help the patient deal with anxiety,
31. a. To fully assess the patient’s pain, the depression, fear, grief, hopelessness, or
nurse should follow up with questions powerlessness. You may have adminis-
about the severity, location, duration, pos- tered pain medication or other medication
sible cause, relief measures, exacerbating to relieve noxious symptoms such as nau-
factors, prior history, and degree of inter- sea and vomiting.
ference with ADLs.
b. If the nurse does not respond to the pa-
tient’s pain, the patient’s trust may be CHAPTER 19—NUTRITIONAL CONCEPTS AND
eroded and there could be physical set- RELATED THERAPIES
backs, such as delayed healing.
c. To reduce the patient’s pain, the nurse can Matching
provide comfort measures (e.g., applica- 1. b
tion of heat or cold), administer medica- 2. d
tions as ordered, encourage the patient to 3. a
report the pain, provide emotional sup- 4. g
port, maintain a clean and quiet environ- 5. i
ment, and reduce stress. 6. c
32. a. NREM sleep is necessary for body tissue 7. f
restoration and healthy cardiac function. 8. e
REM sleep is important for brain and 9. j
cognitive function; therefore, interruption 10. h
of REM sleep will interfere with memory
and learning. See Box 18-5, p. 480 for ad- Short Answer
ditional information. 11. The six classes of nutrients are carbohydrates,
fats, proteins, vitamins, minerals, and water.

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 Answer Key  51  

They function in the body to provide energy, tion: Nerve conduction; muscle contrac-
build and repair tissue, and regulate body tion, including the heart; fluid and acid-
processes. base balance. Symptoms of deficiency:
12. a. Protein: 4 kcal/g, 10% to 35% Severe: cardiac dysrhythmias, muscle
b. Carbohydrate: 4 kcal/g, 45% to 65% weakness, glucose intolerance. Moderate:
c. Fats: 9 kcal/g, 20% to 35% increased blood pressure, risk of kidney
13. a. Food source: Egg yolks, liver, milk, car- stones, increased bone loss. Symptoms of
rots, winter squash, sweet potatoes, toxicity: Cardiac arrest.
spinach, collards, kale, broccoli, apricots, c. Food source: Salt, processed foods, small
cantaloupe. Function: Vision, epithelial amounts in whole unprocessed foods.
tissue integrity, growth, reproduction, em- Function: Fluid and acid-base balance,
bryonic development, immune function. nerve conduction, muscle contraction.
Symptoms of deficiency: Night blindness, Symptoms of deficiency: Cramps, mental
xerophthalmia, increased infections, fol- confusion, apathy, appetite loss (usually
licular hyperkeratosis. Symptoms of toxic- secondary to diarrhea or disease). Symp-
ity: Fatigue, headache, nausea, vomiting, toms of toxicity: Hypertension in suscep-
blurred vision, liver abnormalities, bone tible individuals, increased calcium excre-
and skin changes. tion.
b. Food source: Fortified milk, fortified mar-
garine, egg yolks, liver, fish. Function: True or False
Maintain blood calcium and phosphorus 15. False. As adipose tissue, fat helps insulate the
balance. Symptoms of deficiency: Rickets body from temperature extremes and serves
(children)—abnormal shape and structure as a cushion to protect organs and other tis-
of bones. Symptoms of toxicity: Calcifica- sues from being bumped or jarred.
tion of soft tissues. 16. True
c. Food source: Green leafy vegetables, milk, 17. False. Increased fluid intake is a common
dairy products, liver, meat, egg yolks, dietary treatment for renal calculi (kidney
green tea (synthesis by intestinal bacteria). stones) and urinary tract infection.
Function: Formation of blood clotting fac- 18. True
tors. Symptoms of deficiency: Increased 19. True
prothrombin time; in severe cases, hem- 20. False. Current American Heart Association
orrhaging. Symptoms of toxicity: None recommendations for healthy individuals
exhibited. older than 2 years are to obtain 25% to 35%
14. a. Food source: Milk, cheese, milk products, of total calories from fat, with less than 7% of
green leafy vegetables, broccoli, legumes, total calories from saturated fats and less than
fish with bones, fortified cereals. Func- 1% of total calories from trans-fatty acids.
tion: Formation and maintenance of bones 21. False. In the United States, nearly 35% of
and teeth, blood clotting, nerve conduc- adults and over 16% of children and adoles-
tion, muscle contraction. Symptoms of cents are obese.
deficiency: Osteoporosis (adults)—weak, 22. False. If unable to aspirate, first try looking for
more porous bones. Stunted growth in kinks or occlusions and attempt to flush the
children. Symptoms of toxicity: Constipa- tube with 30 mL of water.
tion, increased risk in males for urinary 23. True
stone formation, reduced absorption of
iron and zinc.
b. Food source: Sweet potatoes, fruits, veg-
etables, fresh meat, legumes, milk. Func-

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 Answer Key  52  

Table Activity 29. Answer 1, 2, 5: Animal products, eggs, meat,

24. See Table 19-3, p. 492. fish, and milk supply complete proteins.
Peanuts and beans are good sources of incom-
Interpretation of
plete proteins.
Numerical Value Numerical Value
30. Answer 1: Vitamin A is a fat-soluble vitamin
LDL Cholesterol and can be stored in the body; potentially it
<100 Optimal can cause death. The others are water-soluble.
Vitamin C could cause diarrhea and abdomi-
100-129 Near or above optimal nal cramping.
130-159 Borderline high 31. Answer 2: Sources of zinc include red meat,
160-189 High liver, eggs, seafood, cereal, whole grains, and
legumes.
≥190 Very high 32. Answer 2: Any liquid that can by seen
Total Cholesterol through is considered okay for a clear liquid
diet.
<200 Desirable
33. Answer 4: In diabetes, the body does not pro-
200-239 Borderline high duce or properly use insulin. Insulin is a hor-
≥240 High mone needed to convert sugar, starches, and
other carbohydrates into the energy for daily
HDL Cholesterol life. Fat and sodium restrictions are frequently
<40 men; <50 Low used for patients who are at risk for cardio-
women vascular disorders. Protein restrictions are
used mostly for patients with kidney or liver
Figure Labeling problems.
25. See Figure 19-7, p. 522. 34. Answer 3: The patient is describing symptoms
of lactose intolerance and there is a higher
Multiple Choice incidence among Asian-, African-, and His-
26. Answer 1: Vitamin K can affect clotting times; panic-Americans and American Indians. Food
thus the patient should be assessed for inges- allergies are more likely to cause itching or
tion of typical amounts of vitamin K sources swelling of the mucous membranes. MyPlate
and be advised to keep consumption at a guidelines generally direct people to eat a
consistent rate so that the medication can be variety of foods in modest portions. Asking if
adjusted accordingly. others are having similar symptoms is a good
27. Answer 2: Bleeding gums is one sign of vi- question if food poisoning is suspected.
tamin C deficiency; citrus fruits, broccoli, 35. Answer 4: The nasogastric tube pressing
tomatoes, and peppers are some sources for against the eustachian tube causes obstruction
vitamin C. Milk, egg yolks, and liver supply and edema. It is best prevented by turning the
vitamins A, D, and K. Cereals, legumes, and patient from side to side frequently, at least
nuts supply vitamin B1 (thiamine). Poultry, every 2 hours.
fish, and brown rice supply vitamin B6. See 36. Answer 2: Patients should be assisted to a sit-
Table 19-4, p. 495 for additional information. ting or high Fowler’s position to prevent aspi-
28. Answer 4: Vitamin B12 is primarily found in ration. The other actions are correct.
foods of animal origin; therefore, the person 37. Answer 1, 2, 3, 5, 6: Ability to chew, swallow,
eating the vegan diet is most likely to need and take fluids should be assessed. Dietary
vitamin B12 supplements. The patient who is intake related to health problems or culture
trying weight loss plans should be assessed should also be assessed. Ability to obtain and
for weight loss goals and advised to see the prepare own food would be relevant for a
health care provider. The patient who eats community-dwelling patient, but meals are
very few fruits and vegetables needs counsel- typically prepared in long-term care facilities.
ing about healthy diet. Eating small amounts 38. Answer 3: The nurse must assess how the pa-
of a wide variety of foods is a good strategy to tient is tolerating the liquid diet before offer-
meet nutritional needs without taking supple- ing soft foods. This would include assessing
ments. bowel function and subjective sensations. The
patient is likely to be hungry for something

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 Answer Key  53  

besides liquids, but desire for food does not honey, table sugar, and chocolate are simple
necessarily correlate with what the bowel can sugars that supply quick energy because
tolerate. Assessments should be made before they require less digestion. Electrolyte drinks
calling the provider or the nutritionist. would be important on hot days during pro-
39. Answer 2: At approximately 4-6 months of longed periods of exercise.
age, depending on the infant’s development, 47. Answer 4: Water-soluble fiber foods help to
it is possible to introduce solid foods into the bind the cholesterol in the digestive tract.
diet. The child is usually started on iron-for- Insoluble fiber found in wheat bran, celery,
tified rice cereal. Fruits are added next, then lettuce, and pears helps to soften stool and
vegetables, and then meats. speed transit of foods through the digestive
40. Answer 4: Diuretics, such as furosemide, chlo- tract. Oranges provide more fiber than orange
rothiazide, and hydrochlorothiazide can con- juice. White rice will slow movement of solid
tribute to depletion of potassium, magnesium, material through the digestive tract.
and calcium. 48. Answer 2: Sudden increase in dietary fiber
41. Answer 1, 3, 4, 5, 6: Assisting, recording, ob- can cause bloating, gas, and constipation, so
serving, communicating, and monitoring are patients should be advised to add fiber foods
nursing responsibilities related to nutrition. slowly and to drink a lot of water. Contact-
Designing dietary plans for chronic health ing the health care provider is always good
problems should be done by a dietitian be- advice when starting a new dietary change,
cause many health problems require a balance but returning to old dietary habits should not
of calories and nutrients with disease condi- be encouraged in this case. Osteoporosis and
tion and patient preferences. anemia can be caused by excessive fiber, but
42. Answer 1: Ten ounces of chicken breast is an there are many benefits of a reasonable fiber
excessively large portion according to My- intake, so the nurse should not scare the pa-
Plate. tient by making statements that do not neces-
43. Answer 2: Helping the patient understand the sarily apply to the patient’s situation.
application of the DRIs to personal health is a 49. Answer 4: Saturated fats increase the risk
strategy to help him remember the informa- for atherosclerosis. However, none of these
tion. DRIs do replace RDAs, but are not ex- chronic health problems is improved by eat-
actly the same because DRIs combine RDAs, ing too much fat.
Adequate Intake (AI), Tolerable Upper Intake 50. Answer 2: Monounsaturated fats are thought
Level (UL), and the Estimated Average Re- to lower LDL (bad) cholesterol. The other
quirement (EAR) of each nutrient. RDAs did options are incorrect. Avocadoes are high in
target the adult American; however, RDAs fat, so the nurse should remind the patient to
were also made for other age groups (e.g., limit total fat intake to 20% to 35%.
children and elderly) and for pregnant/lactat- 51. Answer 2: If the patient is able to describe a
ing women. plan of self-management, it means that he/
44. Answer: 225 g carbohydrates; 75 g for protein; she understands the sources of cholesterol
33.3 g for fat and is ready for self-care; thus the nurse can
1500 ÷ 0.60 = 900 kcal in carbohydrates reinforce the plan. Asking the patient to de-
1500 ÷ 0.20 = 300 kcal in protein scribe a typical 24-hour period is the second
1500 ÷ 0.20 = 300 kcal in fat best option, because it provides assessment
900 kcal for carbohydrates ÷ 4 kcal/g = 225 g data as to areas the patient needs to “watch.”
for carbohydrates Offering a food list is a good option if the
300 kcal for protein ÷ 4 kcal/g = 75 g for pro- patient is unsure how to proceed. “Do you
tein understand?” is a closed question. The patient
300 kcal for fat ÷ 9 kcal/g = 33.3 g for fat may be embarrassed and just say yes.
45. Answer 4: Protein is the single most im- 52. Answer 2: Albumin is a plasma protein. Albu-
portant nutrient for building and repairing min level is lowered in poor nutritional states
tissue; however, the patient will need a well- and should improve with nutritional therapy.
balanced diet in order to recover. Hemoglobin and electrolyte values are also
46. Answer 1: Corn and potatoes are complex car- associated with nutritional status of various
bohydrates that break down more slowly and minerals. White blood cell counts reflect im-
provide energy for a longer time. Milk, fruits, mune system reaction.

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 Answer Key  54  

53. Answer: 67 g 60. Answer 4: Children under age 2 should not be

First convert pounds to kilograms given low-fat milk because they need the fat
185 ÷ 2.2 = 84 kg content. For the other patients, low-fat milk
84 kg × 0.8 g/kg = 67 g would be preferred over whole milk.
54. Answer 3: Iron deficiency anemia is the most 61. Answer 3: If the child helps prepare the food
prevalent nutrition problem in the world. it gives him a role and helps him increase feel-
In addition, adolescence, menstruation, and ings of control. Meal and snack times should
a lack of animal products in the diet will be set times. Children’s servings should be
increase the risk for iron deficiency anemia. smaller than adult servings. Offering the fam-
There is a higher incidence of anorexia ner- ily food is not a bad strategy, but if every meal
vosa among teenage girls; however, choosing is a struggle, then offering nutritious foods
a vegan diet is considered a healthy choice, that the child likes will meet nutritional needs
whereas anorexia nervosa is a mental health and make mealtimes more pleasant. In addi-
disorder. Rickets is caused by a vitamin D de- tion, children often have a very narrow range
ficiency. Marasmus is a protein deficiency. of preferences and introducing new foods
55. Answer 3: Patients with severe illness or in- should be done slowly.
jury or with prolonged starvation will have 62. Answer 4: If the information is relevant to
negative nitrogen balance and manifest mus- current interests, the recipient is more likely
cle atrophy. Being NPO and fasting do create to pay attention. In this case, most adolescent
a negative nitrogen balance state, but tem- girls are interested in their appearance. Delay-
porary protein deficiency should not cause ing the discussion would be ideal for teaching
obvious physical changes. Pregnancy creates a purposes, but this is not always realistic or
positive nitrogen balance as tissues are built. possible. Explaining the science of physiol-
56. Answer 4: Kwashiorkor is a severe protein de- ogy and nutrition is more likely to appeal to
ficiency. The swelling is caused by fluid shift- a nursing, medical, or nutrition student. As-
ing related to hypoalbuminemia. It is likely sessing interest in other health topics is okay,
that the children have many other nutritional but this is just another means for delaying the
deficiencies. discussion about nutrition.
57. Answer 3: Citrus fruits supply vitamin C 63. Answer 3: The UAP’s intentions were good
and an additional 35 mg/day of vitamin C is and long-term care facilities are trying to
encouraged because smoking increases oxida- liberalize the diet for residents. In addition,
tive stress. acknowledging holidays with special foods
58. Answer 1: Stomach acidity decreases with age helps residents to maintain cultural and social
and with antacid use. This decreased acid- norms. The meals could be adjusted for the re-
ity blocks the absorption of vitamin B12 from mainder of the day to allow for the cupcakes
foods. Intrinsic factor is required for vitamin to be part of the total intake. Collecting the
B12 absorption, and may be missing after cupcakes would be demeaning and demoral-
stomach surgery. Both vitamin B12 and intrin- izing for the residents and the staff. However,
sic factor are required to prevent pernicious reminding the UAP to check first before hand-
anemia. Heme iron prevents iron deficiency ing out food is appropriate.
anemia. Antacids do interfere with the ab- 64. Answer: Weight in kilograms divided by
sorption of many medications and nutrients; height in meters squared. See Figure 19-5, p.
advise patients to follow directions of health 511.
care provider. 65. Answer 4: Encouraging the patient to set
59. Answer 3: Iron poisoning can be fatal and small and realistic goals is the most impor-
many children’s supplements will contain tant thing for successful weight loss. Strict
iron. Vitamin C can cause some gastrointes- adherence to diet or exercise goals can seem
tinal disturbances. Poison Control will ask overwhelming at first and it is unlikely that
the child’s weight, amount ingested, time, the patient can start with 60 minutes of exer-
and product name. Inducing vomiting in this cise or strictly adhere to 1500 kcal every day.
case is not harmful, but probably not helpful Supplements may be needed, but taking these
either, because the chewable form is readily is the easier part of the weight loss program,
digested and absorbed. so emphasizing this point is usually not nec-
essary.

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 Answer Key  55  

66. Answer 1: Body mass index of ≥40 is consid- trauma or oral surgery. Anorexia from
ered morbidly obese and would be considered physical causes such as cancer. Psychiatric
valid reason for bariatric surgery. If BMI is causes such as anorexia nervosa where
35 or higher, the patient might be considered the patient refuses food. The patient has
if medical conditions such as diabetes are a severe nutritional need, such as severe
present. BMI of 23 is considered normal, so if burns.
weight loss of a few pounds was part of the b. Nursing assessments and interventions
treatment, diet and exercise would be pre- for enteral feedings:
scribed. BMI of 17 is underweight; therefore, i. Assessment—Need for teaching,
weight loss for this patient is not part of the presence of abdominal distention, and
therapeutic regimen. bowel sounds
67. Answer 4: Erosion of tooth enamel and the ii. Gastric aspirate—pH = 0-4, appearing
calloused knuckles are from frequent self- green, brown, or tan
induced vomiting, which is a behavior associ- iii. Gastric residual above 150 mL—
ated with bulimia nervosa. Hiding the food, Return the residual, hold the feeding,
throwing it away, or pushing it around the wait 1 hour and reassess
plate are behaviors exhibited in anorexia ner- iv. Formula is cold—Warm the formula
vosa. Eating extraordinarily large amounts of to prevent cramping
food is a feature of binge eating. v. Occlusion of tubing—Flush with 30
68. Answer 4: Consistent mealtimes make the co- mL of warm water
ordination of carbohydrate intake, insulin, or vi. After the feeding—Flush the tubing
oral medication and exercise more controlled with 30-60 mL water and recap and
and predictable. Diabetic meal planning secure the tube
should be individualized. Fish is good, but vii. Documentation—Amount and type
should be baked or grilled, not fried. Monitor- of feeding, status of tube, patient
ing and control of total carbohydrate intake is tolerance, adverse effects, and
emphasized. Sugars and desserts are consid- teaching provided
ered part of the total. c. Irritation of mucous membranes, diar-
69. Answer 2: Milk has lactose, which is a sugar, rhea, nausea, bloating, delayed gastric
and also supplies protein. Weakness, perspira- emptying, contamination, otitis media
tion, and disorientation could be signs of heat infection, aspiration, overhydration, fluid
related dehydration, in which case encourag- and electrolyte imbalance, and hyper-
ing water would be appropriate. IV glucose is glycemia. Clogged tubing or accidental
given if patients are unresponsive. Sucking on removal can also be problematic.
hard candy would be appropriate if no other 73. a. There is an increased need for nutrients
source of glucose was readily available. during pregnancy because of rapid fetal
70. Answer 4: Steatorrhea is fat in the stool and growth and increased maternal metabolic
occurs when there is incomplete digestion of needs, tissue growth, and blood volume.
fats. Carbohydrate-modified diets are pre- Optimal nutrition during pregnancy
scribed for patients with diabetes. Protein- reduces the risk of complications, prema-
restricted diets are used for patients with ture deliveries, and low birth weight.
kidney or liver problems. Sodium-restricted b. For the pregnant woman, supplements
diets are used for heart failure or hyperten- of vitamin A for embryonic development
sion. and breast milk production and content;
71. Answer 2, 3, 4, 5, 6: Explaining, offering sug- vitamin C for tissue formation and iron
gestions to relieve subjective thirst, and mak- absorption; vitamin B6 for protein me-
ing sure that others know about restrictions tabolism and fetal growth; and folic acid
are important interventions. Help the patient for prevention of neural tube defect and
divide fluid over the 24-hour period to de- macrocytic anemia are recommended. Vi-
crease subjective sensation of thirst. tamin A is found in milk, egg yolks, green
and yellow vegetables, and organ meats.
Critical Thinking Activities Vitamin C is found in citrus fruits, straw-
72. a. Patients who cannot chew or swallow; berries, broccoli, tomatoes, and green
for example, in cases of coma, facial leafy vegetables. Vitamin B6 is found in

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 Answer Key  56  

milk, wheat, corn, liver, and meat. Folic Table Activity

acid is found in green leafy vegetables, 15.
oranges, liver, broccoli, asparagus, and
fortified grain products. Electrolyte Normal Value Range
c. This woman is slightly underweight; Sodium a. 125-145 mEq/L
therefore, it is likely that she would be en-
couraged by her OB-GYN to gain between Potassium b. 3.5-5.0 mEq/L
28-40 pounds. The idea of nutrient-dense Chloride c. 96-106 mEq/L
foods should be discussed and encour- Calcium d. 4.5-5.6 mEq/dL
aged, rather than empty-calorie foods.
d. Things to be avoided by the pregnant Phosphorus e. 2.4-4.1 mEq/dL
woman are alcohol, caffeine, smoking, Magnesium f. 1.5-2.5 mEq/L
and drugs other than those prescribed by
Bicarbonate g. 22-24 mEq/L
the health care provider.
Multiple Choice
16. Answer 4: Potassium is excreted through the
CHAPTER 20—FLUIDS AND ELECTROLYTES
urine; therefore, increasing urine output helps
the body rid itself of excess potassium. IV cal-
Matching
cium is given to patients with hypocalcemia.
1. b
Fluid restrictions are used for patients with
2. e
hyponatremia. Foods high in potassium are
3. f
given when the patient has hypokalemia.
4. a
17. Answer 4: Infusion of excess amounts of
5. h
citrated blood (citrates bind to the calcium)
6. i
causes hypocalcemia, and Chvostek’s sign is
7. c
one of the signs.
8. g
18. Answer 1: Dairy products are the best source
9. d
of calcium. Calcium is also found in some
10. j
green leafy vegetables, but these sources are
harder for the body to use.
Short Answer
19. Answer 2: When metabolic acidosis occurs,
11. The intracellular fluid compartment is com-
one of the compensatory mechanisms is an
prised of all the fluid inside the cells within
increased respiratory rate to rid the body of
the body and contains dissolved particles
carbon dioxide. Removing carbon dioxide
called solutes.
from the blood lowers the carbonic acid level
12. The extracellular fluid compartment contains
and raises pH to create a more alkaline envi-
any fluid outside the cells. It contains large
ronment. Diaphoresis is not expected, because
amounts of oxygen and carbon dioxide as
the patient is dehydrated. Urine output is
well as glucose, amino acids, fatty acids, so-
likely to be decreased because of fluid deficit
dium, calcium, chloride, and bicarbonate.
from diarrhea. The heart rate is likely to be
13. Interstitial fluid is found between the cells or
increased also because of dehydration second-
in the tissues. Examples of interstitial fluid
ary to diarrhea.
include lymph, cerebrospinal fluid, and gas-
20. Answer 3: Normal ph is 7.35; thus acidosis is
trointestinal (GI) secretions.
identified. Paco2 greater than 45 is typical of
14. Intravascular fluid is the plasma within the
chronic obstructive pulmonary disease.
vessels. This fluid contains serum, proteins,
21. Answer 3: Breathing into a paper bag helps
and other substances necessary to sustain life.
the father to “rebreathe” some of the carbon
The intravascular fluid usually carries nutri-
dioxide that he is losing because he is hyper-
ents and waste products between cells and tis-
ventilating. This will help correct the blood
sues and makes up the remaining 7% of fluid
pH.
volume.
22. Answer 1: Aspirin is chemically acetylsalicylic
acid. This medication will result in excessive
acid in the body, resulting in metabolic aci-

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 Answer Key  57  

dosis. Respiratory alkalosis is also likely as 28. Answer 4: Fresh vegetables contain minimal
the body attempts to compensate for the acid amounts of sodium. Minimizing or elimi-
overload. nating table salt is encouraged. Cheese and
23. Answer 1: Suctioning removes acids from the canned vegetables are high in sodium. Eating
stomach and this is reflected in an elevated out is not necessarily discouraged, but the
pH which indicates alkalosis. The Paco2 is nurse should review the menu with the pa-
normal or maybe slightly elevated if the body tient to make sure that selections are reason-
is attempting to retain CO2 and increase acid. able.
The HCO3– is elevated because the kidneys 29. Answer 4: Patients who take loop diuretics
are attempting to excrete bicarbonate, but the must be cautioned about the signs of low po-
kidneys are slower than the other response tassium and advised about foods that provide
systems. potassium. Patients with small bowel obstruc-
24. Answer 2: Weighing the patient daily is the tion are more at risk for hyponatremia. Renal
best method to track trends of fluid gain or failure often results in hyperkalemia. Exces-
loss. It is essential that the patient be weighed sive alcohol consumption is associated with
the same time every day with the same hypocalcemia and hypomagnesemia.
amount of clothing. Assessing blood pressure 30. Answer: 2 liters. One liter of fluid equals 2.2
and pulse can reflect changes in intravascular pounds (1 kg); therefore, a weight loss of 2.2
volume (i.e., hemorrhage). IV fluid intake pro- pounds will reflect loss of one liter of fluid.
vides insufficient information. Laboratory val- 150 – 145.5 = 4.5 pounds
ues are intended to reflect body elements such 2.2 pounds × 4.5 pounds = 2.045 rounded to 2
as electrolytes, proteins, or cell structures. 1 liter x liters
Therefore looking at laboratory values in 31. Answer 1: High levels of potassium (normal
context of the patient’s condition can contrib- range 3.5-5.0 mEq/L) cause cardiac dysrhyth-
ute to understanding the pathology of fluid mias and cardiac arrest. The nurse would im-
status, but this is not the best method to track mediately begin to monitor the heart. Foods
trends of fluid increase or decrease. and fluids with potassium would be with-
25. Answer 1: Hypernatremia (sodium levels over held. Checking for medications that influence
145 mEq/L) causes intracellular dehydration potassium level would be appropriate once
as fluid is pulled from the cells. Hypotonic the immediate danger has been resolved. IV
solutions move into the cells, causing them calcium gluconate is given to patients who
to enlarge. The health care provider could have hyperkalemia so the nurse would ensure
order a hypertonic solution which pulls fluid that this is available, but the medication can-
from the cells if the patient had hyponatremia. not be given until an order from the provider
Isotonic solutions expand the body’s fluid is obtained.
volume without causing a fluid shift from one 32. Answer 2: The patient’s calcium level is low
compartment to another and are given when and this increases her risk for bone weakness
the intravascular volume is low (i.e., hemor- and other problems associated with osteopo-
rhage). rosis. The other values are within normal lim-
26. Answer 3: Isotonic solutions expand the its.
body’s fluid volume without causing a fluid 33. Answer 1: Amphojel is given to patients with
shift from one compartment to another. These high phosphorus levels. The normal range is
solutions are the most commonly used when 2.4-4.1 mEq/dL; therefore, the value shows
the electrolyte balance is not the issue, but therapy has corrected the imbalance to the
fluid replacement is needed. Hypotonic solu- normal range. The other levels are also within
tions move into the cells, causing them to en- normal limits.
large. Hypertonic solutions pull fluid from the 34. Answer 1: All of these levels are on the lower
cells. end of the normal range and should be ob-
27. Answer 1, 2, 3, 4: Electrolytes serve in body served for continued downward trends; how-
metabolism, water and electrolyte balance, ever, because the patient had surgery on the
and regulation and formation of hydrochloric parathyroid glands, the nurse should be con-
acid. Transportation of nutrients and wastes cerned about the calcium level in particular.
relies on the fluid component. Loss of parathyroid hormone (parathormone)
interferes with the absorption and utilization

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 Answer Key  58  

of calcium. Calcium levels below 4.5 mEq/dL administering supplements (diet, medica-
can result in tetany and laryngeal spasms that tions, IV).
could block the airway. e. The normal range of sodium is 125-145
35. Answer 2: The blood buffer responds in a mEq/L. Therefore, the patient has a so-
fraction of a second in an attempt to cor- dium level that is still within the normal
rect acid-base imbalance. When that system range; however, the value is on the low
is exhausted, the lungs are the second line end and the patient is losing sodium
of defense and respiratory rate increases to because of vomiting and diarrhea. The
compensate for metabolic acidosis. The kid- health care provider is likely to order in-
neys are the third line of defense, but will travenous solution that provides sodium
take hours or days to correct the imbalance. such as normal saline or 45% saline. The
In DKA, urinary output is usually decreased nurse should monitor laboratory values
because the patient is in a state of dehydration and be alert for signs of hyponatremia.
and the patient is generally tachycardic. If all f. Refer to Box 20-1 on p. 542. Common
systems fail, the pH will decrease. signs and symptoms of hyponatremia
36. Answer 3: Respiratory alkalosis can be re- include headache, fatigue, and postural
lated to rapid respiratory rates. The nurse hypotension. Interventions include mea-
would check the ventilator settings to ensure suring I&O, replacing sodium and fluids,
that they match the orders. If the ventila- and monitoring fluid losses.
tor settings are incorrect, the nurse would g. Output includes urine, diarrhea, nasogas-
reset them. The RN and health care provider tric suction, drainage, and emesis.
should be notified about the blood gas results 38. a. The nurse anticipates that the patient
and any action that was taken. Excessive needs treatment for respiratory acidosis.
secretions or a mucus plug are more likely b. Refer to Box 20-10 on p. 551. Signs and
to cause respiratory acidosis. Using the bag- symptoms of respiratory acidosis include
valve-mask would be appropriate as a tempo- lethargy, disorientation, headache, de-
rary measure if the nurse determines that the creased level of consciousness, dyspnea,
ventilator is malfunctioning. tachycardia, and increased blood pres-
sure.
Critical Thinking Activities c. Treatment for respiratory acidosis in-
37. a. Older adults have changes in their body cludes intermittent positive pressure
fluid amount, reduced kidney function, breathing (IPPB), low-flow oxygen, anti-
and may have increased sodium in their biotics (for underlying infections, if pres-
diet and decreased fluid intake. These in- ent), bronchodilators, hydration, and cor-
dividuals are at greater risk for dehydra- rection of the underlying problem.
tion and postural hypotension.
b. Serum potassium of 3.4 mEq/L is low
(normal range 3.5-5.0 mEq/L). The pa- CHAPTER 21—DOSAGE CALCULATION AND
tient will need replacement potassium. MEDICATION ADMINISTRATION
The patient should be closely monitored
for signs of hypokalemia and laboratory Basic Math Review
values should be closely monitored dur- 1. 13⁄5
ing the replacement therapy. 2. 61
⁄8
c. The following factors contribute to hypo- 3. 1
⁄4
kalemia: vomiting (a), diarrhea (b), and 4. 7 7⁄12
diuretics (c). 5. 1
⁄6
d. Refer to Box 20-4 on p. 544. Common 6. 1
⁄12
signs and symptoms of hypokalemia 7. 11⁄2
include muscle weakness, leg cramps, 8. 71.849
nausea, vomiting, and reduced gastroin- 9. 0.0833
testinal function. Interventions include 10. 5.750 5.8
measuring I&O, monitoring patients on 11. 1482.7750
digoxin and diuretics, monitoring cardiac 12. 13.3
status, checking laboratory results, and 13. 0.50

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 Answer Key  59  

14. 75% 30. 3460 mL

15. 2.5 31. Intake 3910 mL Output 3150 mL
32. 2 tablets
Table Activity 33. 2 tablets
16. 34. 12.5 mL
35. 0.4 mL
Metric Apothecary
36. 0.5 mL
60 milligrams 1 grain 37. 0.8 mL
0.45 kilogram 1 pound 38. 15 mg
39. 10 mg
1 kilogram 2.2 pounds
40. 6.7 mg rounded to 7 mg (Note to student: You
30 milliliters 1 fluid ounce may observe some pediatric nurses or health
500 milliliters 1 pint care providers who do not round up for drug
calculations. Also some drugs such as Lanoxin
1000 milliliters 1 quart are very potent and require more precision;
therefore, rounding is less appropriate.)
17. a. 1 ounce 41. 6.36 mg rounded to 6 mg
b. 1 liter 42. 13 gtt/min
c. 1 quart 43. 21 gtt/min
d. 1 pint 44. 30 gtt/min
e. 1 grain 45. 42 gtt/min
f. 2.2 pounds 46. 125 mL/hour
g. 0.4 liters 47. 125 mL/hour
h. 0.002 milligrams 48. Answer: 200 mL/hour (Note to student: In the
i. 0.004 grams clinical setting, you may see that some pumps
j. 20 kilograms will only go up to 199/hour.)
k. 5000 micrograms 49. 167 mL/hour
l. 2.5 centimeters 50.
m. 62.5 centimeters
n. 102 kilograms
o. 240 milliliters
p. 720 milliliters
q. 0.25 milligrams
r. 15 milliliters 10

s. 30 milliliters 20

30
Matching
18. d 40

19. a 50

20. c 60

21. e 80
22. b
90

Clinical Application of Math 100

23. 62.5 centimeters

24. 90 centimeters
25. 95 centimeters
26. 72 kilograms
27. 26 kilograms
28. 27 pounds
29. 720 mL

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 Answer Key  60  

51. 125 mL × 15 gtt/min = 31.25 round to 31 mL/

min
.20
60 min
59. Answer 2: Greater trochanter of the femur, the
.40 anterosuperior iliac spine, and the iliac crest
are the landmarks for the ventrogluteal site.
.60 See Figures 21-14, p. 601 and 21-15, p. 602 for
additional information.
.80 60. Answer 2: ID bands should show the patients’
full name and generally will have an ad-
1.00 ditional identifier, such as a patient number
mL
or birthdate. Asking patient to state his/her
name is also recommended. Occasionally,
mental status, language, or cognitive status
will prevent use of this method. Asking an-
other nurse about identity is a method that
could be used in some cases, such as with
Short Answer long-term care residents who do not wear ID
52. See Box 21-5, p. 575. bands, but it is not a preferred method. Ask-
53. See Box 21-6, p. 575. ing family members to verify names is also
54. A medication order should include patient’s occasionally done, but again is not the pre-
name, date and time of the order, name of ferred method.
drug, dosage of drug, route of administration, 61. Answer 4: For infants younger than 12
time or frequency of administration, signature months, vastus lateralis is the preferred site.
of health care provider, and any special in- 62. Answer 4: A witness is required whenever a
structions regarding the administration. an opioid is wasted. Usually the pharmacy
55. Factors that influence a patient’s response to will not have to be notified, because opioids
a medication include age, weight, physical are stored on the unit. The medication cannot
health, psychological status, environmental be “wiped off” and should not be adminis-
temperature, gender, amount of food in the tered.
stomach, and dosage form. 63. Answer 3: The purpose of the Z-track tech-
nique is to prevent seepage of the medication
Multiple Choice back through the track of the needle. This
56. Answer: a. 4, b. 2, c. 1, d. 3 method is preferred for medications that are
“STAT” has the highest priority. This type of irritating to the tissues.
order indicates an urgent or emergency situ- 64. Answer 2: The anterior aspect of the forearm
ation. “Now” has a relative urgency; for ex- is the most common site for tuberculin testing.
ample, the health care provider may want the The upper outer aspect of the arm and the
nurse to give pain medication prior to starting area around the umbilicus are common sites
a procedure, but the patient is not in critical for subcutaneous injections. Middle third of
danger. “One time only” is used for medica- the anterior thigh is an IM injection site.
tions that are only given once; for example, 65. Answer 4: Drip factors will vary by manu-
medication that is given just before going facturer, so looking at the package label and
to the operating room. The frequency of a instructions is the best way to find the drip
“PRN” medication is based on the assessment factor.
of the patient’s condition. 66. Answer 3: Inhaler medication is meant to be
57. Answer 4: One grain is equal to 60 mg; there- inhaled into the lungs. Spraying would result
fore, half of a grain is 30 mg. in a topical application to the mucous mem-
58. Answer 3: branes of the mouth and throat.
Amount × Drip factor = gtt/min 67. Answer 1, 3, 4, 5: The extended-release and
Time (in minutes) sustained-release beads are designed to dis-
500 mL ÷ 4 hours = 125 mL/hour solve and release the medication at different
times; thus crushing the beads destroys the

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 Answer Key  61  

mechanism. Sublingual tablets are meant to ule, but generally infusing the fluid to “catch
be placed under the tongue and the medica- up” is not recommended.
tion is absorbed directly into the bloodstream. 73. Answer 3: A precipitate indicates that the
Enteric-coated tablets are intentionally coated medications are incompatible, so the drug
to delay absorption. should be discarded. The nurse should have
68. Answer 1: An idiosyncratic reaction is an un- called the pharmacy prior to mixing the
expected reaction that seems to be unique to drugs. Administering the drug or verifying
that individual, sometimes the opposite effect the order is incorrect, because incompatible
of what the medication is supposed to do. drugs should not be given together. Rotating
Medications that augment action are syn- the syringe does apply in some cases, but not
ergistic. Need for higher dosage is evidence of for incompatible drugs.
tolerance to a drug. Development of a rash is 74. Answer 3: Patients are usually very familiar
likely to be an allergic reaction. with the medications they have to take at
69. Answer 2: In the buccal route, medication is home, so if there is a comment that suggests
absorbed through the mucous membranes a difference it is best for the nurse to stop and
and into the circulatory system. find out why the medication looks different.
70. Answer 2: Most facilities allow a 30-minute After checking, the nurse might consider us-
window on either side of the designated time, ing some of the other options. If there is a new
so the nurse has from 8:30 am to 9:30 am. Start- medication, the nurse should take the oppor-
ing with the most cooperative patients en- tunity to do patient teaching.
sures that many of the patients will get their 75. Answer 3: The RN or charge nurse should
medication on time. If the nurse starts with assume care of this patient because there is a
a patient who needs a lot of help, then all of risk for the patient to have a serious adverse
the medications will be delayed. Five patients reaction. During the first dose, the RN/charge
with many medications is not an atypical nurse will frequently assess the patient’s reac-
load; however, if the nurse feels that the as- tion and if the patient remains stable, it would
signment exceeds abilities, the charge nurse/ be appropriate for the LPN/LVN to give the
RN should be notified at the beginning of the subsequent doses. Refusing to give the medi-
shift, not at the start of medication time. The cation is an option, but delays can be danger-
nurse should alert the RN about the potential ous. For example, delaying antibiotics greatly
delay and then report back if the medications increases the morbidity and mortality related
were delayed. Starting at 9:00 am is too late. to sepsis. The pharmacy is unlikely to have
Many facilities require an incident report if access to any records beyond what the nurse
the medications are delayed. can access.
71. Answer 2: The total IV volume, 1000 mL, 76. Answer 4: Fifteen tablets is an “unreason-
should infuse in 8 hours; therefore, the patient able” number. Most medications come in a
should be receiving 125 mL/hour. If it was strength that approximates the typical dose
started at 0800 hours (8:00 am), at 1400 hours for the typical adult patient; therefore, if the
(2:00 pm) the patient should have been receiv- calculation exceeds 3 tablets, capsules, pills,
ing IV fluid for 6 hours; 125 mL/hour × 6 etc., the nurse should automatically question
hours = 750 mL. the order. A reliable drug source will cite the
72. Answer 4: First, the nurse would recalculate typical dose range. Based on information of
the gravity rate (gtt/min) and then reset the the typical drug dose, the nurse can contact
flow rate so that 125 mL/hr is being deliv- the provider or the pharmacy as needed.
ered. The charge nurse should be consulted 77. Answer 2: Inform the charge nurse, so that
if the nurse is unsure about how to proceed. he/she is aware of events that are affecting a
In some facilities, this type of error requires group of patients. The charge nurse may elect
an incident report. The charge nurse may also to give the medication her- or himself or may
decide that someone should talk to the night- opt to delegate the duty to Nurse B. Giving
shift nurse, because it appears the IV was not medications to someone else’s patients is nev-
checked after the fluid was started. In other er ideal; however, delaying medication is also
situations, the health care provider would not good for the patients. If Nurse B is asked
have to be notified, because the patient could to give the medications, she would have to
suffer ill effects. The IV flow is behind sched-

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 Answer Key  62  

use the six rights and quickly familiarize her- gency. The other findings are less urgent, but
self with the patient’s health conditions. still require the nurse’s attention.
78. Answer 1: Suppositories will melt at body 84. Answer 2: Older patients have reduced kid-
temperature and a soft suppository is more ney function and an increased risk for neph-
difficult to insert. The other actions are appro- rotoxicity. If urinary output is reduced, this
priate. further damages the kidneys. Nephrotoxic
79. Answer 2: Inhalers usually deliver medication effects will eventually affect mental status,
to the lungs; therefore, patients with asthma, but this would be a late sign. Vomiting could
emphysema, or chronic bronchitis are more contribute to nephrotoxicity if fluid loss is not
likely to have this type of mediation order. corrected. High blood pressure is associated
Patients with acute respiratory problems are with kidney problems; however, this is more
also treated with inhalers until symptoms im- associated with pathophysiology that devel-
prove. ops over time.
80. Answer 1: If the solution is viscous, the nurse
would select a Luer-Lok tip, because greater Critical Thinking Activities
pressure will have to be applied during the 85. Home health safety for drug administration
injection of solution. Higher syringe pressures should include instructing the patient/family
will cause the slip tip to separate from the on proper storage and labeling, disposal of
needle and the solution will spray out. The outdated drugs, compliance with prescribed
other factors are less important, although the dosage and schedule, not sharing drugs, and
physics of longer needles also requires higher side effects that require notification of the
syringe pressures. health care provider.
81. Answer 3: If an existing IV has stopped, this 86. Listen to the patient. Include the pharmacist
suggests that something is wrong. The first as a resource to prevent errors. Prepare only
thing that the nurse checks is the patient’s one patient’s medications at a time and leave
subjective sensation of pain, also assessing for drugs in their labeled packages. Have another
infiltration. (Note to student: Infiltration does nurse calculate the dose and the rate, and
not always cause pain. Pain results from the compare your answers. High-risk drugs such
type of solution or large infiltrations can put as insulin and heparin warrant a second nurse
pressure on nerves.) The RN or health care to verify the accuracy of the dose prepared.
provider should be notified if an infiltration is The need to quickly administer drugs does
present. Before the nurse discontinues the IV, not outweigh safe practices. Always report
the nurse should troubleshoot the problem. errors. Review the literature for error reports
Repositioning the arm or the IV bag may help. from other facilities. See Box 21-7, p. 579 for
If the flow resumes, then it would be correct safety tips.
to recalculate drip rate and count the drops to 87. Missing information: Date and time that order
regulate the flow. was written, route of administration, frequen-
82. Answer 3: There are no major blood vessels cy of administration.
in the intradermal tissues. The purpose of 88. Whenever a medication is not supplied in the
aspirating is to determine if the needle has desired dose, the nurse must make a calcula-
punctured a vessel. If the needle is within a tion. Any calculation is open to error; thus car-
vessel, the medication will be injected directly rying a calculator is important. Working the
into the bloodstream. This technique is likely problem out on paper helps the nurse to spot
to be included in the procedure manual, but errors and is a way of recalculating the same
the nurse should understand the rationale problem. In addition, the new nurse is in
that underlies nursing action. An intradermal training, so he/she is automatically less famil-
needle is fine and short, but if the nurse has iar with what the answer is “supposed to look
not selected an appropriate site, or improper like.” In this scenario, no one double-checked
technique is used, the needle could puncture a the calculation. Finally, it is apparent that this
blood vessel. nurse was very distracted. Medication admin-
83. Answer 2: Dyspnea and a weak thready pulse istration time is always hectic, but the nurse
are possible signs of pulmonary embolus or should develop habits that will sustain him/
anaphylactic reaction. This is a medical emer- her through chaotic times. Double-checking

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 Answer Key  63  

calculations and having a nurse recheck calcu- Short Answer

lations should be automatic behaviors. 23. (a) Right Task, (b) Right Circumstance, (c)
Right Person, (d) Right Direction, and (e)
Right Supervision/Evaluation, See Box 22-1,
CHAPTER 22—CARE OF PATIENTS WITH p. 614 for additional information.
ALTERATIONS IN HEALTH 24. (a) To maintain fluid volume if a patient is
not taking in fluid or nutrients orally, (b) for
Word Scramble fluid replacement if the patient is losing fluid
through prolonged nausea or vomiting, (c) for
Unscrambled Correct
medications, (d) for blood or blood products,
Scrambled Term Term Clue
and (e) for nutritional support.
1. zationcatheri catheterization b 25. IV therapy poses the risk of (a) infiltration,
2. ymotso ostomy​ h (b) phlebitis, (c) infection at the IV site or sys-
temic infection, (d) fluid volume excess, and
3. secef feces ​ f
(e) bleeding at the IV site.
4. lencetualf flatulence ​ d
5. tionimpac impaction ​ i Clinical Application of Math and Conversion
26. Answer 870 mL
6. continencein incontinence  ​ e 350 mL + 20 mL + 500 mL = 870 mL
7. ationinfiltr infiltration ​ c 27. Answer 500 mL
8. venintraous intravenous j 200 mL + 100 mL + 50mL + 150 mL = 500 mL
28. Answer 90 mL
9. vagela lavage g 30 mL/hour × 3 hours = 90 mL
10. ssionpredecom decompression a 29. Answer 250 mL
125 mL/hour × 2 hours = 250 mL
Fill-in-the-Blank Sentences 30. Answer 125 mL
11. infection; occlusion 475 mL – 350 mL = 125 mL
12. 3-5
13. 750-1000 mL Multiple Choice
14. 60-80 mm Hg 31. Answer 4: This procedure requires an order
15. 2-4 from the health care provider. The student
should check order for purpose, type of
True or False equipment, medications, or other specifics
16. False. Teaching the patient effective coughing that apply to this patient.
techniques and the implementation of suc- 32. Answer 3: Standard Precautions are based on
tioning will help to keep the patient’s airway the assumption that every patient is a source
patent. of infectious organisms, so hand hygiene be-
17. True fore and after every patient encounter contrib-
18. False. Internal vaginal irrigation or douching utes to safety and infection control. The other
should not be performed routinely as it tends options are important aspects of performing
to wash away protective agents. any procedure.
19. True 33. Answer 2: Raising the bed and lowering the
20. False. It is imperative for the nurse to check side rail are primarily done so that the nurse
for proper nasogastric tube placement before does not have to stoop or reach. Raising the
an irrigation or tube feeding; the tube can al- bed and lowering the side rail does not pro-
ways be dislodged after x-ray verification. vide patient safety or contribute to patient
21. False. Patients with urostomies are at high comfort. Visualization is likely to be slightly
risk for skin impairment at the site due to better and most procedure manuals would
nearly continuous urine drainage. recommend raising the bed, but nurse per-
22. False. Oxygen does not explode or burn, but forms the action based on knowledge of body
it does support combustion so flammable ma- mechanics.
terial combined with sparks or open flames 34. Answer 3: If a caustic substance enters the
increase the risk for fires. eye, the correct action is to immediately flush
the eye with the cleanest fluid available. At

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 Answer Key  64  

home this would be tap water. The nurse is 42. Answer 1: The patient should not lie directly
also likely to perform the other actions at the on the pad, because it increases the risk for
appropriate time. burns. The other actions are correct.
35. Answer 2: The pepper spray will cause severe 43. Answer 3: The tourniquet is applied to im-
pain and copious flushing is easier for the pede venous flow, but still allow arterial flow.
patient and the nurse if a Morgan lens is used. The other options are incorrect.
Conjunctivitis is usually not irrigated unless 44. Answer 2: Phlebitis is an inflammation of the
allergens were applied directly to the eye vein and as it progresses, the redness will
area. Prolonged use of contact lenses would travel up the vein. Edema can accompany
not be a reason for eye irrigation. Eye irriga- phlebitis, but will also be seen in infiltration.
tions at home are more likely to be performed Cool skin and sluggish flow are more typical
with an eye cup, or possibly a small syringe. of infiltration.
36. Answer 4: The elderly patient is reporting a 45. Answer 1: Normal saline is always used to
symptom of cerumen impaction and this is a flush the tubing and to hang concurrently in
common reason for ear irrigation. The other the Y-tubing setup. Other solutions can cause
patients have conditions that are contraindica- the blood cells to lyse.
tions for ear irrigation. 46. Answer 4: Although the patient needs fluid
37. Answer 3: Cold applications will cause vaso- and could benefit from a larger gauge, the pa-
constriction and should not be used for pa- tient’s veins are more likely to accept a small-
tients with preexisting circulation problems. er-gauge catheter. (Note to student: Giving
Slight swelling immediately after an injury the patient some fluid will often increase the
is not a contraindication for cold application. circulating volume and the veins will “plump
The cold application is an adjunct to pain up,” then a larger catheter could be inserted. )
medication. If the patient believes that 20 min- 47. Answer a, e, d, b, c: The nurse selects the tub-
utes is too long, then the nurse would assess ing based on the needs of the patient and the
his rationale and help him adapt the therapy type of infusion to be initiated. He/she re-
according to his preferences or document that moves the tubing from the sterile packaging,
he refused it, as appropriate. inspects it for kinks, and makes sure the roller
38. Answer 2: The benefit of cold application is or slide clamp is functional and closed.
local anesthesia. Vasodilation and increased 48. Answer a, i, d, e, g, b, c, h, f: The nurse re-
metabolism occur with heat applications. The moves the correct solution from the sterile
viscosity of blood should not be affected. The packaging; inspects for expiration date, leaks,
decreased flow is due to vasoconstriction. or contamination. The tubing is removed
39. Answer 1: Generally the application lasts from the package and inspected; then the
10-20 minutes. The patient should not adjust clamp is closed. The nurse inverts the bag
the temperature because the skin will adapt (holds it upside down) to allow easy access to
to temperatures; increasing or decreasing for the tubing insertion port. The insertion port
comfort could result in skin damage. The pa- cover and the cover from the tubing spike are
tient should not move the application because removed. The spike is inserted into the port
the purpose of therapy is to target structures until the plastic diaphragm covering the port
that are directly beneath the application. The is pierced. The bag is positioned upright and
nurse must observe the area, but purpose of the tubing drip chamber is partially filled. The
the application overrides the convenience of clamp is controlled during priming. As the
the nurse. fluid fills the tubing, invert injection ports to
40. Answer 3: Heat causes vasodilation, so the fill them with fluid as well. Finally the clamp
distribution of blood is changing and the is closed.
heart is having to work faster and harder to 49. Answer 2: The nurse would search for ad-
move blood. ditional signs of fluid overload: dyspnea; a
41. Answer 1, 2, 3, 4: The nurse specifies the tem- rapid, weak pulse; cough; disorientation; in-
perature, time, what to report, and asks to creased or decreased blood pressure; crackles;
be notified about completion of therapy. The pitting edema; and decreased urine output.
nurse would then evaluate the patient’s re- If overload is suspected, slow the infusion
sponse. This cannot be delegated to the UAP. and contact the RN and health care provider.
Weight gain is usually a good indicator or flu-

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 Answer Key  65  

id overload; however, because the patient is 57. Answer 4: A compress is a moist dressing. The
having sudden-onset respiratory symptoms, waterproof heating pad (e.g., Aquathermia) is
this indicator is not as useful. used to retain the warmth.
50. Answer 2, 4, 5, 6: The nurse inspects the IV 58. Answer 2, 4, 5: Swelling and coolness occur
site because signs of progressive local infec- because the fluid is flowing directly into the
tion would suggest systemic infection. The IV tissues. At some point, the fluid will become
can be discontinued and the tubing and cath- sluggish and stop, but for patients who have
eter are saved for culture. The nurse looks for loose skin (e.g., some older patients), a sig-
other sources of infection; recall that pneumo- nificant amount of fluid will enter the tissues
nia and urosepsis are two major HAIs. While before the pressure within the tissues exceeds
it is appropriate to review white cell count the pressure created by the IV flow. Warmth
and temperature, these are generalized body and redness are more associated with phlebi-
responses that do not point to the specific tis.
source of infection. 59. Answer 2, 3, 6: Leaving the stabilization de-
51. Answer 4: Secretions are obstructing the air vice (or tape that secures the device) in place
passages; suctioning will clear the airway. decreases the risk of accidentally dislodging
52. Answer 4: Semi-Fowler’s position allows the the catheter. Discontinuing the infusion and
patient to breathe easier and allows easy ac- changing the IV site are correct if erythema
cess for nurse. Sterile technique is required. or edema are present. Labeling allows other
The outer cannula is not removed. Cotton nurses to see when the dressing was last
balls should not be inserted into the tracheos- changed. The site is not palpated or covered
tomy. with tape because that would increase the
53. Answer 3: If the balloon is inflated while it risk for infection. Putting tape over the trans-
is in the urethra, it is possible to rupture the parent dressing obscures observation and it
urethra, so the fluid is withdrawn and the makes removal difficult.
catheter is advanced. If the catheter cannot 60. Answer 3: The nurse hangs a new bag. Fre-
be advanced, then it is withdrawn and the quently, shift-change activities can take an
health care provider is notified of a possible hour or two for the oncoming shift. This is a
obstruction. The catheter should not be pulled courtesy for the next shift and is better for the
back without withdrawing the fluid. Inflation patient.
of the balloon should not cause discomfort;
therefore, if discomfort occurs, the inflation Critical Thinking Activities
must stop and the fluid must be withdrawn. 61. Before, during, and after the skill, the nurse
54. Answer 4: The meatus is cleansed and 2 implements the following:
inches of the catheter from the point where a. To identify the patient—Check the name
it enters the meatus is cleansed. The catheter band and ask the patient his/her name.
should not have tension. The bag needs to b. To reduce the spread of microorganisms—
be emptied at least once every 8 hours. The Use Standard Precautions, especially
drainage bag should be below the level of the hand hygiene, and surgical asepsis as in-
bladder, and never attached to the side rails. dicated.
55. Answer 2: Urine specimens are never ob- c. To provide privacy—Close the door of the
tained from the drainage bag. They should room and pull the curtain around the bed
be obtained from the port. (Note to student: or table.
Even when the catheter is first inserted, if d. To ensure patient safety—Monitor the pa-
you obtain urine from the bag it would not be tient carefully, keep the patient informed
considered “midstream” because the first bit of his/her participation, return the bed
of urine would go directly into the bag.) The to low position, place the call bell within
other actions are correct. reach.
56. Answer 1: Digital stimulation can stimulate 62. If intravenous (IV) apparatus is positional,
the vagus nerve which can cause bradycardia instruct the patient how to properly position
and hypotension, so a previous history of car- arm to maintain flow. Teach to notify about
diac disease is of particular concern. redness, swelling, or discomfort at the site
or if flow slows or stops, or if blood is seen

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 Answer Key  66  

in the tubing. Instruct how to ambulate with CHAPTER 23—LIFESPAN DEVELOPMENT

IV pole or stand. It is best to take tub bath,
but showering may be allowed if the IV site Matching
is completely covered. Teach that IV pump 1. b
alarms should not be silenced and the flow 2. e
rate should not be stopped or changed. Re- 3. a
mind patient not to lie on tubing or kink it. 4. g
63. Changes in cardiac and renal function related 5. c
to the aging process or chronic conditions 6. f
create the need for extreme accuracy in flow 7. d
control and thus make the use of electronic 8. j
infusion devices necessary. Older adults are 9. h
more prone to fluid imbalances and fluid 10. i
overload. If the patient is not able to tolerate
the infusion of whole blood or red blood cells True or False
in 4 hours, it may be necessary for the blood 11. True
bank to split the unit into two bags. Make 12. False. Interaction with the environment pro-
sure to refrigerate the second bag during the vides a means for them to acquire language
infusion of the first. skills.
Fragility of veins in the older adult pa- 13. False. The adolescent often requires increased
tient increases risk of infiltration; use extra hours of sleep to restore energy levels.
care in injecting bolus of medications; tourni- 14. False. According to the Activity Theory, older
quet may cause ruptured veins and/or bruis- people who are more socially active adjust
ing to occur. Opt to perform the venipuncture better to aging.
without the use of a tourniquet or use a blood 15. True
pressure cuff to provide enough pressure for
vein dilation. Use the smallest gauge catheter Short Answer
or needle possible. Avoid the back of the older 16. Factors contributing to the changed family
adult’s hand or the dominant arm for veni- include economic changes, feminist move-
puncture, because any problems at these sites ment, better birth control, legalized abortion,
greatly interfere with the older adult’s inde- postponement of marriage and childbearing,
pendence. With decreased subcutaneous tis- and increased divorce rate. Refer to Box 23-1
sue, the veins lose stability and may roll away on p. 700.
from the needle. To stabilize the vein, apply 17. A functional family is able to adapt to change,
traction to the skin below the projected inser- has coping techniques in place, and demon-
tion site. An angle of 5-15 degrees on insertion strates a sense of commitment and purpose.
is helpful, because the veins are more super- See Box 23-3, p. 702.
ficial. Minimal use of nonporous tapes and 18. Family stress may be caused by chronic ill-
skin protectant solutions is recommended. ness, working mothers, abuse, and divorce.
Face the patient while speaking clearly and 19. a. Engagement stage: couple considers mar-
calmly to compensate for visual and hearing riage
deficits. Short-term memory loss, depression, b. Establishment stage: adjusts to married
and confusion sometimes lead patients to re- and interdependent state
move the IV catheter or change their attitude c. Expectant stage: makes decisions sur-
or decisions about care. The adult patient who rounding pregnancy
is competent and is properly taught about the d. Parenthood stage: begins at the birth or
benefits and risks of IV therapy has the right adoption of the first child
to refuse. e. Disengagement stage: grown children
leave home
f. Senescence stage: older adult must cope
with changes

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 Answer Key  67  

Table Activity
20.

Respirations
Age Group Temperature Pulse (at Rest) Blood Pressure
Infants at 12 Wide variation 120/min 30/min 90/60 mm Hg
months
Toddler 98° and 99° F (36.6° 90-120/min 20-30/min 80-100 mm Hg sys-
1-3 years and 37.2° C) tolic and 64 mm Hg
diastolic
Preschooler 97° to 99° F (36.1° to 70-110/min 23/min 110/60 mm Hg
3-5 years 37.2° C)

School age 97° to 99° F (36.1° to 55-90/min 22-24/min 110/65 mm Hg

6-12 years 37.2° C)
Adolescent 97° to 99° F (36.1° to 70/min 20/min 120/70 mm Hg
12-19 years 37.2° C)

Multiple Choice 25. Answer: 27 pounds. By the time the baby is 1

21. Answer 2, 3, 4, 6: Administering medication year of age, the birth weight has tripled.
on time and showing respect to elderly pa- 26. Answer 1: The infant’s body is using nutrients
tients are important to being a good nurse; according to a system of growth and devel-
however, Healthy People 2020 Health Indica- opment; thus fat reserves are accumulated
tors are more about improving the overall in the first several months for insulation
health of the general population. For addi- and a reserve of nutrition. Muscle and bone
tional information, see Table 23-1 on p. 698. are expected to develop around 8 months.
22. Answer 2: The nurse would continue the in- Cephalocaudal growth is defined as growth and
terview and assess the interaction between the development that proceeds from the head to-
wife and husband and how they are respond- ward the feet. Breast milk and formula supply
ing to each other. After additional assessment, the appropriate nutrients for the growth of
the nurse might ask the husband to leave if young infants.
the wife seems fearful to speak in front of 27. Answer 2: The signs and symptoms reported
him. The nurse could seek advice about cul- by the mother are the first expected evidence
tural norms, but discontinuing the interview of teething. Massaging the gums and giving
may be impractical. Directing the questions water are recommended for infant dental
towards the husband is likely to feel awk- hygiene. Brushing the teeth is recommended
ward, but it is possible that the wife prefers after the first tooth has erupted. The nurse
that he provide the answers. would advise the mother to contact the health
23. Answer 2: In the autocratic family pattern, care provider if the nurse believes that infant
the relationships are unequal. The parents acetaminophen is needed to relieve discom-
attempt to control the children with strict, fort. The nurse would not recommend medi-
rigid rules and expectations. Mother assum- cation to the mother.
ing dominance would be a matriarchal fam- 28. Answer 2: Persistent crying during a usual
ily pattern. Uncle controlling finances would sleep period indicates illness or some other
be the patriarchal family pattern. Children type of discomfort. Whenever the infant is
participating would be the democratic family inconsolable with usual measures, the health
pattern. care provider should be contacted. The other
24. Answer 2: Height (length) increases by about behaviors are normal and expected.
1 inch per month for the first 6 months. 29. Answer 2: Infants use sensory impressions
and motor activities to learn about the envi-

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 Answer Key  68  

ronment; thus reaching for, tasting, and feel- developed to use if the child is not hurt, but is
ing objects with the mouth gives the child not getting his own way.
information. Clinging to parents is an intel- 33. Answer 2: The toddler prefers ritualistic be-
lectual function that occurs as the child learns haviors; therefore, the nurse would assess
to distinguish parents from others. Shoulder nighttime rituals and try to approximate them
control prior to hand control is an example of as much as possible (e.g., favorite bedtime
proximodistal growth and development that story). Night bottles with milk or juice should
originates in the center and moves toward the not be encouraged because they contribute to
outside. Saying “me” and “no” is a toddler dental caries. Amount of sleep is a relevant
behavior. question, but it is more likely that he will have
30. Answer 1: An 8-month-old child is likely to trouble falling asleep in a strange environ-
demonstrate separation anxiety. This is a trau- ment. Once he is asleep, he is likely to sleep
matic time for the parent and the child, but for the accustomed period of hours. Keep ex-
knowing that this is a normal behavior will planations simple and honest.
help the mother feel less anxious and guilty. 34. Answer 3: Small hard foods have a greater
An 8-month-old should have an established potential for aspiration and choking. Reassure
sleep/rest pattern; ideally the daycare staff the mother that her nutritional logic is sound,
will interact with the child so that nap pattern but carrot sticks can be served when the child
is maintained. Parallel play is a form of play gets older.
used by toddlers. Assess mother’s feelings 35. Answer 4: Three-year-olds are usually able to
before validating guilt. It is likely that the carry on a conversation. Children do grow at
mother will feel some guilt, but the mother their own pace, but if expected milestones are
may also want to return to work and it would not being met, then consulting a health care
be inappropriate to imply that she should feel provider is recommended. Reading and play-
guilty. ing do help to expand vocabulary once the
31. Answer 3, 4, 5: Introducing cereals first and child is talking.
then slowly introducing other foods allow the 36. Answer 2: Preschoolers use imagination and
child and the parent to have new experiences are developing fine motor skills, and draw-
and evaluate the outcomes. There is a pos- ing is a way to communicate. The nurse
sibility that the child could have a bad physi- should not offer the child a snack without the
cal reaction or a dislike for a certain food, so mother’s permission and advice because of
the foods should not be mixed or introduced potential allergies or food restrictions. Desire
simultaneously. Early introduction of citrus to “help” is more related to the school-age
fruits may contribute to the development of child. Talking to a child is always beneficial;
allergies; waiting until after 6 months is rec- however a 4-year-old is less likely to be able
ommended. to independently entertain himself with a
32. Answer 3: Toddlers are unable to share book.
because of their egocentric nature, so this 37. Answer 2: The nurse should ask the age of
mother is demonstrating expectations beyond the child because complaints of “growing
the ability of the child. Harsh discipline tech- pains” related to rapid growth are reported by
niques can be evidence of how the mother school-aged children. Obvious growth in the
was treated as a child. The nurse would care- long bones and increase in height of approxi-
fully assess for other risks factors, behaviors, mately 2 inches per year for both boys and
and signs and symptoms before making any girls are physical characteristics of the school-
conclusions. Continuously retrieving a tod- age child. The other questions could help to
dler will cause frustration for the child, but identify contributing factors.
this mother is demonstrating anxiety about 38. Answer 3: The school-age child is able to
his safety. Rather than allowing the child to think logically and apply principles to specific
climb onto eating surfaces, the nurse could cases. Using a helper is recommended for
suggest that the mother redirect the child to younger children, especially toddlers who are
climb on equipment that is designed for the strong-willed. Magical thinking is also more
purpose of climbing. Ignoring a fussy toddler relevant to younger children. Modesty and
is probably a strategy that this mother has privacy are more important for adolescents.

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 Answer Key  69  

39. Answer 1, 2, 4: Vision, dentition, and signs of 46. Answer 3: Generativity is accepting respon-
scoliosis are recommended for routine screen- sibility for and offering guidance to the next
ing. Hearing would be tested if the child generation. Focusing on fears, concerns, and
showed some signs such as inattentiveness failures is evidence of stagnation, which is the
while being spoken to, speaking very loudly, opposite of generativity. Reviewing a personal
or failing to attend to instructions. Cancer will and belongings is more typical of late
screening is recommended by the American adulthood.
Cancer Society for adults. HIV testing is not 47. Answer 2: Visualization of half the field is a
routinely done on children. pathologic condition that is usually associated
40. Answer 2: Give the child a role as a helper. with stroke or damage to the brain. The other
This increases feelings of control and appeals options are part of the normal aging process.
to the developmental task of industry. Praise 48. Answer 2: Reminiscing or reviewing one’s
is an important reinforcer of desired behavior. life and past accomplishments validates the
Demonstrating on a doll is a method used for meaning and importance of life. The other ac-
preschoolers. Coaching the parent would be a tivities are important for the socialization and
good choice if the child had to have ongoing health of the elderly residents.
dressing changes at home. 49. Answer 3: The nurse can see several of the
41. Answer 4: The child’s nonverbal behavior problems, but additional assessment should
indicates to the nurse that something has hap- be made for contributing factors, such as
pened that causes the child to feel fear, em- loneliness, poor dentition, poverty, food intol-
barrassment, or possibly anger. The child has erances, and constipation. The nurse should
to trust the nurse before sharing the events also assess the patient’s ability to maintain a
associated with the strong feelings. The nurse household and live independently. Based on
should not promise confidentiality. Parents assessment findings, the nurse may decide to
have to be informed about injuries and ill- use the other options.
nesses that occur at school and if there is some 50. Answer 1: Low-fat, low-sodium diet help de-
violence, bullying, or safety issue, the princi- crease the risk of atherosclerotic heart disease
pal must be informed. and hypertension. Streptococcal pneumonia
42. Answer 1, 2, 3: It is normal for the school-age vaccine and coughing and deep-breathing
child to have gradual gains in height and are interventions for expected changes in the
weight, although the full growth potential is respiratory system. Frequent position changes
yet to come during the adolescent and young help protect the skin.
adult periods. Nutrients and genetics could
be contributing to the child’s shorter stature, Critical Thinking Activities
but it would be inappropriate for the nurse 51. See Safety Alert, Safety Rules for Infants and
to say this to the mother without first doing a Young Children, p. 711. Generally parents
dietary assessment and referring her to a ge- or those who care for young children will
netic counselor. welcome suggestions about how to improve
43. Answer 4: The more concrete the plan, the safety, so if you find areas that need improve-
greater the risk for committing suicide. The ment, remember to first give positive feed-
other questions are relevant because these are back about what they are doing correctly, then
indicators of depression. give suggestions for how to improve, then
44. Answer 3: The nurse should follow up on the reinforce the positive again. Your assessments,
statement about sex education and reinforce suggestions, and teaching points could pre-
that sex education has to be provided by vent an accident.
someone. If they prefer to give the informa- 52. a. Some children are ready for toilet training
tion at home, the nurse can offer to help with at 18 months, but readiness may not oc-
resources and communication methods. The cur in others until 24 months. The mother
other statements indicate that parents are may need to wait several months and
helping teenagers by setting boundaries. then try again. Bowel control precedes
45. Answer 1, 2, 3, 4: Developing own value sys- bladder control. Nighttime control is
tem should occur during adolescence. The achieved after daytime control is accom-
other tasks are part of development during plished.
early adulthood.

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 Answer Key  70  

b. The developmental task according to person has a good life and seems satisfied
Erikson is autonomy versus shame; and well-adjusted. Elders who self-impose a
therefore, parents should give praise for homebound lifestyle seem to be withdrawing
accomplishments which help the child from society as explained by the Disengage-
to build self-control and pride in accom- ment theory.
plishments. Scolding and punishing state-
ments create shame and doubt.
c. While temper tantrums are difficult for CHAPTER 24—LOSS, GRIEF, DYING, AND
parents, help the mother understand DEATH
that her child is expressing frustration.
Encourage the mother to try to maintain Fill-in-the-Blank Sentences
a matter-of-fact attitude and reassure her 1. loss
that the tantrums will pass as the child 2. grief work
learns other verbal and nonverbal ways to 3. Grief therapy
express feelings. 4. Bereavement
53. Refer to Table 23-4 on p. 729. Examples of 5. Mourning
changes that occur in the aging individual in- 6. confidence
clude: 7. pain; respiratory distress; confusion
a. Sensory—presbyopia, presbycusis 8. Euthanasia
b. Integumentary—thinner skin, decreased 9. Autopsies
moisture 10. year
c. Cardiovascular—arteriosclerosis, in-
creased blood pressure Multiple Choice
d. Respiratory—decreased gas exchange and 11. Answer 2: The college student is experienc-
ciliary action ing a change related to growing up and going
e. Gastrointestinal—decreased saliva, re- out on his own. He is losing the security and
duced peristalsis safety of home as he transitions to becoming
f. Genitourinary—prostate enlargement, more independent. The other people are fac-
drier vaginal tissue ing situational losses.
g. Musculoskeletal system—bones become 12. Answer 4: A situational loss presents an op-
porous, joint stiffness portunity to grow and develop. Evaluation
h. Neurologic—slowed reaction time, de- of strengths and weaknesses is a way for the
creased pain perception student to correct the negatives and repeat
54. a. Ability to cope may increase with aging positives. The student has recognized that
because of successful experiences and meeting criteria is a way to ensure future suc-
strengths that have developed and ma- cess. The other actions indicate that the “C”
tured over time; however, a decreased grade is still a threat to self-esteem and the
ability to cope may also be the result of student is continuing to emotionally struggle
perceived failures, multiple losses, and a with that loss.
sense of dissatisfaction. 13. Answer 3: The nurse should assess the pa-
b. Intelligence and learning—The capacity to tient’s feelings about the experiences. Sense
understand and learn can be maintained. of presence is a normal grief response and can
c. Memory—Some loss of short-term memo- be comforting if the person sees the deceased
ry may occur; past events are recalled. as safe and at rest. The other options might
55. Answers will vary according to your experi- be considered once further assessment is con-
ence with that older person and your selec- ducted.
tion of a theory. For example, if a person 14. Answer 4: In this uncomfortable situation, the
has a long history of alcohol abuse, then the nurse recognizes that each family member is
Wear-and-Tear theory may seem to apply. The expressing such intense grief that they are not
person may physically look older than his/ able to help or consider the feelings of each
her chronological age and have many health other. Rather than separate them, the nurse
problems. If you selected someone you know would stay with them as a bonding force and
who is very social and active, the Activity allow expression of emotions. Once the yell-
Theory could help explain how that active

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 Answer Key  71  

ing, screaming, and sobbing begin to ebb, the ses are too complex. Reviewing the care plan
nurse may decide to use the other options. is appropriate after assessment is performed.
15. Answer 3: Talking about things they used to 21. Answer 1, 3, 4: When the patient nears death
enjoy is the best indicator of the four, because there are changes in vital signs, including (1)
reminiscence is a healthy way to think about slow, weak, and thready pulse; (2) lowered
the past. The other activities suggest that she blood pressure; and (3) rapid, shallow, irregu-
is trying to keep him with her in the present lar, or abnormally slow respirations. Mouth
environment. breathing occurs, which leads to dry oral
16. Answer 4: First, the nurse acknowledges the mucous membranes. The patient often has a
pain and loss associated with the triggering detached look in the eyes.
factor. Taking the medication on a routine ba- 22. Answer 4: The nurse should consult the nurs-
sis would be particularly difficult for the pa- ing supervisor. Active euthanasia is still ille-
tient because the blame and guilt would recur. gal; even though the staff, the patient, and the
The nurse would then perform an assessment family may all agree. If the provider gives the
and use appropriate interventions. Options 1 dose, there is still a possibility that the nurse
and 2 are false reassurances. In option 3, the could be liable for failure to intervene.
nurse acknowledges feelings, but then offers a 23. Answer 2: If the patient is DNR, the nurse
platitude. would stay with the patient and perform com-
17. Answer 3: A grief attack is an unexpected fort measures. All attempts should be made to
emotional or behavioral response to a routine bring the family to be with the patient. CPR
event or behavior. It is even possible that see- or an IV fluid bolus would be inappropriate
ing the hospice nurse reminded the son about because of the DNR order.
the deceased patient. The nurse would calmly 24. Answer 4: The nurse has a responsibility to
reassure the patient that over time, his emo- make sure that the family has the opportunity
tions will become more balanced. to talk to a qualified health care professional
18. Answer 4: The nurse must assess on a fre- about organ donation. This is the law in most
quent basis whether the family wants to states, but also some families are comforted
participate in the patient’s care. The family by being able to help other patients and fami-
members may have helped yesterday, but to- lies. The health care provider who certified
day they could be tired, upset, or distracted. death should not be involved in the removal
They may have fears related to actual or per- or transplant of organs. The nurse is not re-
ceived change in the patient’s status, or re- sponsible or qualified to certify death or to
peatedly asking for assistance could be a sign explain the organ donation and transplant
of stress. Based on the initial assessment, the process.
nurse may decide to use the other options. 25. Answer 1, 2, 5, 6: Alleviating pain, meeting
19. Answer 2: For the dying patient and the fam- spiritual needs, giving comfort measures, and
ily, short-term goals are encouraged as being allowing decision-making are within the Dy-
more realistic and achievable; however, the ing Persons’ Bill of Rights. The patient should
nurse would not discourage expression of the be consulted first about how much informa-
other statements. The family and patient are tion he/she wants and if he/she wants to be
going through a process and some denial at included in the decision-making. The patient
certain points would be considered a coping may seem indecisive, but this is normal un-
mechanism. der stressful circumstances and extra time
20. Answer 3: The patient is overwhelmed by should be allowed. The nurse may find that
all of the problems, so the nurse will have to patients/families from different cultures have
use therapeutic communication and listen to a different approach to information flow and
what the patient has to say about each issue. decision-making. But in the United States, the
This will help determine which problem is the health care team generally takes the approach
priority. Addressing pain is a logical place to that the patient will be included in the infor-
start; however, there is a possibility that the mation and decision-making. The health care
other problems are more important to the pa- team can assist the patient with information
tient. There is a possibility that the nurse may about a living will or advance directives, but
decide to ask the RN to take charge of the case these decisions should be made by the patient
because the issues and analysis of the diagno-

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 Answer Key  72  

and the family. (See Box 24-8 on p. 751 for ad- of the loss, financial impact, availability
ditional information.) of resources, cultural factors, personal at-
26. Answer 3: Advance directives are signed tributes, and relationship to the object or
and witnessed documents providing specific person.
instructions for health care treatment in the d. This patient shows that the grieving pro-
event that a person is unable to make these cess is influenced by physical function-
decisions personally at the time they are need- ing—the attainment of basic needs (food,
ed. Cardiac arrest, respiratory arrest, or other air), sleeping patterns, discomfort, and
conditions that cause loss of consciousness or overall general health state are being af-
change in mental status would apply. fected. Social aspects include the patient’s
27. Answer 3: Children ages 5-9 years believe that support systems. The family members
wishes and actions can cause outcomes. (See should be available to help, but she is
Table 24-1 on p. 740 for additional informa- isolating herself. Members of the health
tion.) care team can offer support; some patients
28. Answer 1: The name and contact information need temporary distance from the family
of the person who will make health care deci- because of past relationships. Professional
sions if the patient becomes unable to make counseling is always an option.
those decisions should be on file. Generally, e. Assess such areas as sleeping patterns,
the facility likes to have a copy of the power body image, activities of daily living
of attorney on file. That person could be next (ADLs), mobility, general health, medica-
of kin (e.g., spouse), but could be a sibling or tion use, and pain. Additional areas of
adult child if the spouse is not able to make concern include the basic needs of nutri-
the decisions. The nurse should direct the pa- tion, elimination, oxygenation, activity,
tient and family to discuss and record wishes rest, sleep, and safety
about death in a living will. 31. a. Nurse B may be experiencing bereave-
29. b, e, a, c, d, f (See Skill 24-1 on p. 755 for addi- ment overload because of multiple losses
tional information.) in the course of work with failure to ade-
quately process them. On the other hand,
Critical Thinking Activities Nurse B may be experiencing personal
30. a. Goals—Patient will establish new rela- grief. Perhaps the dying patient reminds
tionships. the nurse of a beloved grandparent and
Patient will engage in activities with fam- family’s response reminds her of how her
ily and/or friends. own family responds.
Interventions—Establish trust. Use active b. Nurse A can use effective listening skills,
listening. Encourage verbalization of feel- and help Nurse B to acknowledge per-
ings. sonal limits and recognize when there
Provide opportunities for interaction. is a need to get away and take care of
b. Loss is when someone or something can herself. Nurse B might also need time
no longer be seen. The patient is expe- and assistance to grieve over personal or
riencing an actual loss. The severity of professional losses. Although Nurse B is
response varies, but the patient’s grief likely to be intellectually familiar with the
would be considered a natural response grieving process, nurses frequently find
to the loss of her husband. Her feelings themselves in the position of always hav-
and behaviors would be considered a ing to give. Nurse A can help Nurse B to
normal part of grieving unless they were realize that receiving is also necessary to
prolonged (>2 years). The goal of grief is be effective. Nurses can cope with grief
to resolve hurt and reestablish one’s life. by identifying their own beliefs, trading
c. Factors that influence loss include child- off patients when overwhelmed, avoiding
hood experiences, significance of the loss, the “savior” complex, and setting limits.
physical and emotional state, total loss (See Box 24-2 on p. 739 for additional in-
experiences, view of loss as a crisis, dura- formation.)
tion and timing of the loss, suddenness

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 Answer Key  73  

CHAPTER 25—HEALTH PROMOTION AND 18. Answer 4: At week 16, all organs and struc-
PREGNANCY ture are formed; at week 24, the fetus weighs
about 27 ounces; at week 19, head hair devel-
Matching ops; and at week 20, the fetus has settled into
1. i a favorite position.
2. g 19. Answer 3: Swelling of the face is one of the
3. b danger signs that should be reported to the
4. d health care provider. Increased blood flow
5. c from high estrogen levels causes reddened
6. e palms or spider nevi. Increased blood vol-
7. j ume is expected, but this alone does not
8. a cause water retention. Increased amounts of
9. h melanocyte-stimulating hormone cause be-
10. f nign changes in skin coloration.
20. Answer 2: Ptyalism is excessive salivation;
Fill-in-the-Blank Sentences sucking hard candy provides symptom relief.
11. mechanical injury; temperature; musculoskel- The other options are strategies for dealing
etal with heartburn.
12. 10 21. Answer 3: Prolonged or repeated fetal tem-
13. purplish discoloration of the vagina, vulva, perature elevation may result in birth defects.
and cervix The other options may also occur, but are less
14. biochemical or chromosomal abnormalities associated with the first trimester and the
15. 8; fetus problem of heat and humidity.
22. Answer 3: The goal is to experience 10 move-
Table Activity ments in a 1-2 hour period. Counting all of
16. See Table 25-5, p. 786. the movements in a 24-hour period would be
Heart rate Increases 10-15 bpm very impractical. Mother’s activities such as
eating or exercise could possibly influence the
Blood pressure Remains at prepregnancy levels fetus, but ideally the mother should choose
in first trimester (systolic) a quiet time to sit or lie down to count the
Slight decrease in second movements.
trimester (systolic and 23. Answer 1: Ten times in a row; three times a
diastolic) day is the recommendation. The other options
Returns to prepregnancy levels are incorrect.
in third trimester (diastolic) 24. Answer 4: Note the intactness of the placenta;
Blood volume Increases by 1500 mL or 40% to bleeding and infection can occur if fragments
50% above prepregnancy level of the placenta are retained in the uterus. The
Red blood cell Increases 18% placenta should be weighed and the presenta-
mass tion of the fetal side (Shiny Schultz) versus
uterine wall (Dirty Duncan) should be noted.
Hemoglobin Decreases Placental barrier refers to the ability of the
Hematocrit Decreases placenta to filter bacteria and some other sub-
stances.
White blood Increases in second and third
25. Answer 1: Ordinarily the cord would have
cell count trimesters
three vessels: two arteries and one vein. One
Cardiac Increases 30% to 50% artery and one vein may be associated with
output fetal anomalies and requires follow-up. The
other findings are expected.
Multiple Choice 26. Answer 2: At 12 weeks, the Doppler should
17. Answer 1: Blurring and diplopia (double be used to detect heart tones. The stethoscope
vision) can be associated with pregnancy- can be used between 16 and 19 weeks. Trans-
induced hypertension. The blood pressure vaginal and abdominal ultrasound are usually
and the symptoms should be immediately not performed by nurses; however, transvagi-
reported to the health care provider. nal ultrasound is used in the first trimester,

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 Answer Key  74  

and abdominal ultrasound is used later in the 34. Answer 3: In the initial health history, infor-
pregnancy. Ultrasound is used for examining mation about chronic diseases, infectious
additional factors beyond heart rate. disease, use of substances such as alcohol,
27. Answer 4: Remind the student that the patient or exposure to substances such as industrial
should be sent to the bathroom to empty the waste should be obtained. Genetic counsel-
bladder before she assumes a supine position. ing is a very involved process that should not
The other steps are appropriate. be initiated until all of the relevant data have
28. Answer 1: A stable or decreased fundal height been collected and risk factors are evaluated.
may indicate intrauterine growth restriction 35. Answer: The EDB is May 25, 2015. According
(IUGR); an excessive increase could indicate to Nägele’s rule, start with the first day of the
multifetal gestation or hydramnios (excessive woman’s last normal menstrual period and
amniotic fluid). count back 3 months, then add 7 days.
29. Answer 2: Declining levels of human cho- 36. Answer: The parity of the woman is 4-3-0-0-3.
rionic gonadotropin suggest a miscarriage. G: Gravidity, T: Term births, P: Preterm births,
Maternal serum alpha-fetoprotein is used to A: Abortions, L: Living children.
predict certain types of birth defects. A small 37. Answer 3: Hyperemesis gravidarum, which is
sample of amniotic fluid could be tested for excessive vomiting, can lead to dehydration,
genetic factors such as sex and chromosomal fluid and electrolyte imbalance, acid-base im-
abnormalities, health status, and maturity of balance, altered kidney and cardiac function,
the fetus. Chorionic villus sampling is used to and even fetal death. Small frequent meals
detect genetic disorders. are suggested for morning sickness and heart-
30. Answer 4: The woman and partner can watch burn. Salivating and heartburn are gastroin-
the imaging if they desire to do so. The blad- testinal problems that may occur, but presence
der should be filled prior to the procedure to of these conditions does not help identify hy-
allow for better imaging. The lithotomy posi- peremesis gravidarum.
tion is used during transvaginal ultrasound. 38. Answer 2: Maternal smoking is associated
The procedure should not cause any pain or with preterm delivery, low birth weight, and
discomfort. decreased intrauterine growth. Respiratory
31. Answer 3: At least 2 fetal movements ac- distress, infection, or fetal distress are serious
companied by 2 increases of 15 bpm in a problems that may occur, but are not neces-
20-minute period indicate a healthy fetus. The sarily associated with maternal smoking. No
mother is likely to express feelings of relief change in fetal heart rate during contractions
if she knows that the baby will not be at risk is a sign of a healthy fetus; this is detected
during the delivery. If the fetal heart rate does during the contraction stress test.
not increase with fetal movement, additional 39. Answer 4: Pain and burning with urination
testing is needed and anxiety and uncertainty signal a urinary tract infection. Infection is
will continue. one of the dangers that require evaluation.
32. Answer 4: Colostrum flow in the second The other symptoms are likely as the preg-
trimester is considered normal. Suggest use nancy advances.
of breast pads to control excessive flow. The 40. Answer 1: Increases in platelets and fibrino-
premilk would be given to the infant because gen will contribute to clot formation. De-
it contains antibodies, carbohydrates, and creases in hematocrit are mainly dilution due
protein and has a mild laxative effect. to increased circulating volume. The stressors
33. Answer 3: The nurse should be ready to assist placed on the kidneys during pregnancy may
the family with coping strategies if there are result in protein and glucose in the urine. This
financial issues by offering referrals, emotion- finding suggests gestational diabetes. Women
al support, and networking to find additional with a history of cholelithiasis may experience
resources. Ideally, the lack of insurance should increased cholesterol level, which is common
not affect quality of care; however, the family during pregnancy.
may avoid prenatal care or refuse diagnostic 41. Answer 1, 3, 5, 6: Traveling to areas with un-
testing if they are trying to save money. The treated water should be avoided if possible.
nurse can activate the health care team to help Airline policies regarding pregnancy vary.
the family make a plan that provides maxi- Insurance coverage may not extend to foreign
mum quality of care at the minimum price. countries and there is additional anxiety if

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 Answer Key  75  

preterm labor starts when far from home. Use tient to problem-solve by helping her to clear-
of seatbelt is always advisable. It is illegal to ly define problems, delimit problems as much
terminate someone because of pregnancy. as possible, set small goals, and develop an
Magnetometers do not harm the fetus. action plan. Encourage the patient to engage
in self-care activities that will boost her spirit
Critical Thinking Activities and appearance, such as buying an attractive
42. a. Refer to Box 25-7 on p. 781. Areas for new blouse or getting a haircut. Encourage
counseling are adaptation and discom- the patient to find things that she likes about
forts that may be experienced, safety herself and then help her to enhance those
measures, exercise and rest, nutrition, qualities, such as wearing a pair of earrings
sexuality, personal hygiene, danger signs, that bring out the blue color of her eyes.
fetal growth and development, prepara- Educate her about the bodily changes that
tion for labor, preparation for baby, and are occurring and reassure her that some of
diagnostic tests. the changes, such as the hyperpigmentation,
b. Refer to Table 25-1 on p. 785. There are a will resolve after delivery. Finally, encourage
number of drugs that should be avoided her through the first trimester, because as the
during pregnancy, including antiemet- pregnancy progresses it is likely that she will
ics, salicylates, stimulants, tranquilizers, start to feel better about herself and the preg-
opioids, antihistamines, vaginal antiinfec- nancy.
tives, alcohol, caffeine, and tetracycline.
c. The nurse instructs the woman to avoid
smoking, alcohol, medications (unless CHAPTER 26—LABOR AND DELIVERY
prescribed), too much sitting or stand-
ing, heavy lifting, hot tubs, saunas, and Matching
spas. Also, sports or activities that require 1. d
balance to maintain safety are not recom- 2. e
mended; for example, surfing or skiing. 3. b
43. a. Presumptive signs of pregnancy are sub- 4. c
jective in nature. These signs are frequent- 5. a
ly attributed to pregnancy, but they may
also indicate other conditions not related Fill-in-the-Blank Sentences
to pregnancy. Probable signs indicate a 6. first trimester
high likelihood that the woman is preg- 7. hospital; birthing center; home
nant. These findings are objective in nature 8. availability of trained personnel
and can be confirmed by an examiner. Still, 9. midwives
these signs are not 100% reliable indica- 10. matured and ready for birth
tors. Positive signs occur only with preg- 11. oxytocin stimulation; progesterone withdraw-
nancy and cannot be attributed to other al; estrogen stimulation; fetal cortisol
physiologic occurrences. Positive signs de- 12. progressive cervical dilation and effacement
finitively identify the presence of the fetus. 13. passageway; passenger; powers; position of
b. Presumptive signs—amenorrhea, breast mother; psyche
changes, quickening, nausea and vomit- 14. molding
ing
Probable signs—Hegar’s and Goodell’s True or False
signs, uterine enlargement, positive preg- 15. True
nancy test 16. False. The mechanical theory is based on
Positive signs—visualization of the fetus the principle that once a hollow-body organ
44. First encourage expression of feelings and reaches a certain state of distention, it will
validate feelings by using verbal and non- spontaneously contract and empty; therefore,
verbal responses. Assess methods of coping one woman giving birth to large and small in-
that worked in the past and help the patient fants contradicts the principle of the mechani-
recognize that she has experience in overcom- cal theory.
ing obstacles and that past methods can be 17. True
applied to the current situation. Assist the pa- 18. True

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 Answer Key  76  

19. False. No pushing until the cervix has dilated 27. Answer 4: The health care provider can re-
because this may result in swelling or tear- lieve pressure on the cord by putting on a
ing of the cervix and may ultimately slow the sterile glove and holding the presenting part
birthing process. off of the umbilical cord. Mother could be as-
sisted into a modified Sims, Trendelenburg, or
Figure Labeling knee-chest position. Cesarean birth and moni-
20. See Figure 26-5, p. 803, toring for fetal distress are also likely.
28. Answer 3: Massaging the fundus is done to
Multiple Choice restore muscle tone. Atony (relaxation) can be
21. Answer 1: Lightening refers to when the fe- caused by overstimulation. This is not desir-
tus settles into the pelvis. This places more able, because a firm fundus is less likely to
weight on the urinary bladder, so urinary bleed. Separation and expulsion of placenta
frequency is expected. The space in the chest complete the third stage of labor and the
cavity actually opens up, so breathing should health care provider will assist as needed.
improve. Decreased fetal movement should Massaging will help expel clots, but observa-
not occur and leakage of amniotic fluid is not tion is used to determine number and size.
expected to accompany lightening. 29. Answer 2: Upright positions (walking, sit-
22. Answer 3: The nitrazine test is positive for ting, kneeling, or squatting) promote cardiac
amniotic fluid; labor should start within a few output and reduce pressure on the great ves-
hours. If not, the health care provider is likely sels, thereby promoting placental perfusion.
to induce labor. Precipitous labor is rapid la- Left lateral side-lying is the position of choice
bor that lasts less than 3 hours. She could go if the mother is tired and wants to lie down.
home, but she should be preparing to activate Knee-chest position is used if there is sus-
the birth plan. pected cord compression. Lithotomy position
23. Answer 2: Braxton Hicks will increase in fre- is usually used for hospital deliveries.
quency, duration, and intensity as the preg- 30. Answer a. 5, b. 3, c. 2, d. 4, e. 7, f. 1, g. 6: Fig-
nancy progresses. Backache is expected, but ure 26-14, p. 811.
headache is not expected and could be a sign Engagement occurs when the biparietal
of hypertension. diameter of the fetal head crosses the pelvic
24. Answer 4: Renewed energy for nesting be- inlet. Descent is the downward progress of
haviors can occur. Nausea and diarrhea are the presenting part. Flexion occurs as the chin
not uncommon and weight loss of 1-3 pounds tucks and the occiput presents to the maternal
may occur. Depression is not expected at this pelvis. Internal rotation enables the fetal head
time. to progress through the maternal pelvis. Ex-
25. Answer 2: Pelvimetry involves the use of x- tension occurs when the occiput passes under
ray films and would be used for nonpregnant the symphysis pubis. External rotation occurs
patients who are planning to conceive, but as the shoulders and body move through the
have a history (injury or rickets) that could birth canal. The delivery ends with expulsion,
affect the shape of the pelvis. Palpation could in which the body of the infant leaves the pel-
be used for the patient in the first trimester. vis.
For multiple pregnancies or other soft-tissue 31. Answer 4: The transitional phase is the last
evaluations, ultrasound would be used. phase of the first stage of labor. Mother
26. Answer 1: While transverse lie only occurs should be alert and talkative in the latent
in 1% of pregnancies, multiple pregnan- phase and less talkative in the active phase.
cies weaken the abdominal wall and thus Confusion and disorientation is not expected
transverse lie is more likely to occur in these and may signal problems with oxygenation
patients. Pelvic contracture or placenta pre- and perfusion.
via also increases the risk. When the fetus 32. Answer 2: Contractions are expected every 3-5
is small, position changes are frequent and minutes. With 4- to 7-cm dilation. Pain will
lie seldom changes towards term because of be manageable, but is intensified compared
space. Longitudinal is spine parallel to spine to earlier. Desire to walk is more likely in the
and is the most common lie. Breech presenta- latent phase.
tion is affected by lie. 33. Answer 2: Early, or latent, phase: slow, deep
chest or abdominal breathing, 6-9 breaths/

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 Answer Key  77  

min; inhale through nose and out through ean delivery, breech presentation, medical
pursed lips. Middle, or active, phase: Slow conditions that would endanger the mother’s
acceleration then deceleration of breaths health such as cardiac complications, abnor-
through contraction; breaths shallow; approxi- mal conditions of the placenta such as placen-
mately 16-20 breaths/min. Transitional phase: ta previa, infections of the vaginal canal, and
4-6 pants followed by a blow for duration pelvic abnormalities. Major fetal indicators
of contraction. Remind patient to take deep, are fetal oxygen deprivation, prolapse of the
cleansing breath before and after contraction umbilical cord, breech presentation, malpre-
to increase oxygen intake. sentations such as transverse, and congenital
34. Answer: 7 (See Table 26-5, p. 819.) anomalies.
35. Answer 3: Ambulation before rupture of
membranes is encouraged because it provides Critical Thinking Activities
distraction and tends to strengthen the effec- 42. a. The admission assessment includes his-
tiveness of labor. Full bladder can slow labor. tory of pregnancy, medical history, review
Supine position is more uncomfortable and of the prenatal record, interview of the
can compress the vena cava. Enemas are not patient (progress of labor, preparation),
given if vaginal bleeding is present. physical examination, and performance of
36. Answer 1: Stop the infusion and contact diagnostic tests (urinalysis, blood work).
the health care provider if there are signs or See Box 26-5, p. 821.
symptoms of complications, such as changes b. Assessment includes contractions, fetal
in FHR; bradycardia; tachycardia; arrhyth- heart rate, cervical changes, vaginal dis-
mias; or excessive frequency, duration, or charge, degree of discomfort, and psycho-
pressure of contractions. social reaction.
37. Answer 2: Yellow-stain is associated with fetal c. Monitoring includes vital signs, uterine
hemolytic disease or intrauterine infection. tone, vaginal drainage, and status of peri-
Hydramnios is an excessive amount of fluid. neal tissues every 15 minutes for the first
Port wine color is associated with abruptio hour and then every 30 minutes for the
placentae. Greenish-brown is associated with second hour.
a breech birth. 43. External monitoring uses external transduc-
38. Answer 2, 3, 4, 5: Birth plan includes informa- ers on the maternal abdominal wall to assess
tion about the pregnancy-related changes the FHR and uterine activity. It does not require
mother will experience, fetal development, rupture of membranes or cervical dilation. An
labor, delivery, and the postpartum period. intrauterine catheter is used to monitor fre-
Ideally, discussions of when to get pregnant or quency, duration, intensity, and resting tone
genetic counseling are included in the precon- of uterine contractions. Fetal distress resulting
ception counseling. from hypoxia is indicated by nonreassuring
39. Answer 3: Uterine relaxation could result FHR patterns. These patterns can include a
in postpartum hemorrhage. Glycopyrrolate progressive increase or decrease in the base-
(Robinul) is given to reduce secretions and line FHR, progressive decrease in baseline
decrease the risk of aspiration. Citric acid (Bic- variability, tachycardia (more than 160 bpm),
tra) is given to reduce the acidity of secretions. severe bradycardia (less than 100 bpm),
Abdominal pain is likely to be associated with persistent late decelerations, and severe vari-
the procedure, not the anesthetic. able decelerations with slow return to base-
40. Answer 2, 3, 4: Hypertension, diabetes, and line. Another indication of fetal distress is
history of stillbirth or fetal demise are reasons greenish-stained amniotic fluid in a cephalic
for induction. For rupture of membranes 2 presentation.
hours ago, the patient is likely to be advised 44. Birth is a time when nurses and other health
to walk and wait to see if contractions will be- care providers are exposed to a great deal
gin. Placenta previa and herpes simplex infec- of maternal and newborn blood and body
tion are contraindications for induction. fluids. Wash hands before donning gloves
41. Answer 1, 3, 4, 5: Indications for cesarean and after performing procedures and remov-
birth can be maternal or fetal. The major ma- ing gloves. Wear gloves (clean or sterile, as
ternal indications for cesarean delivery are appropriate) when performing procedures
cephalopelvic disproportion, previous cesar- that require contact with the woman’s geni-

Copyright © 2015, 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, an imprint of Elsevier Inc. All rights reserved.
 Answer Key  78  

talia and body fluids, including bloody show Table Activity

(e.g., during vaginal examination, amniotomy, 10.
hygienic care of the perineum, insertion of an
internal scalp electrode and intrauterine pres-
Assessment of Newborn Normal Value
sure monitor, and catheterization). When as-
sisting with a birth, wear a cover gown and a Head circumference 13-14 inches
mask with a shield or protective eyewear. Cap Relationship of head to Head circumference is
and shoe covers are worn for cesarean birth chest circumference 1 inch larger than the
but are optional for vaginal birth in a birthing chest
room. Drape the woman with sterile towels
Temperature 97.6° F to 98.6° F
and sheets as appropriate. Help the partner
put on coverings appropriate for the type of Pulse 120-160/min
birth, such as cap, mask, gown, and shoe cov- Respirations 30-60/min
ers. Wear gloves and gown when handling
Blood pressure 60-80/40-50 mm Hg
the newborn immediately after birth. Use an
appropriate method to suction the newborn’s
airway. Multiple Choice
45. a. Memories of sexual abuse can be trig- 11. Answer 4: Shock results in generalized de-
gered by intrusive procedures such as creased oxygenation of tissues; thus giving
vaginal examination; losing control; be- supplemental oxygen is a priority interven-
ing confined to bed and “restrained” by tion. Raising the head of the bed is not ad-
monitors, intravenous lines, and epidur- vised, because this decreases perfusion of the
als; being watched by students; and expe- cerebrum. Oxytocin may be increased rather
riencing intense sensations in the uterus than decreased if uterine atony is contributing
and genital area. Survivors of abuse may to the blood loss. Over-massaging the fundus
react in panic or anger, may take control can contribute to uterine atony.
of everyone and everything related to 12. Answer 1: The mother should perform sponge
childbirth, may be submissive and depen- baths for 7-10 days, until the cord comes off.
dent, or may retreat by mentally dissociat- The other options are correct cord care.
ing. 13. Answer 2: The diaper is applied loosely.
b. Increase sense of control by explaining Health care providers may also recommend
all procedures and why they are needed, cloth diapers for the first week. The yellow
validating needs and requests, asking crust is not removed and may persist for 2-3
permission to touch, accepting her reac- days. Bleeding is assessed every hour for 12
tions to labor, and protecting privacy by hours. Petroleum gauze is not needed when
covering body and limiting the number of a Plastibell is used because the plastic bell
people involved in her care. covers the glans and prevents the tissue from
sticking to the diaper.
14. Answer 4: The bathwater should be approxi-
CHAPTER 27—CARE OF THE MOTHER AND mately 100° F (37.7° C) and the infant’s heat
NEWBORN loss should be controlled because infants
have a relatively large ratio of skin surface
Fill-in-the-Blank Sentences to body mass. The vernix caseosa should not
1. puerperium be vigorously removed because it is attached
2. involution to the protective layer of the skin. Mild soap
3. distensible and water are recommended for cleaning the
4. bathing; activity; dietary perineum in conjunction with every diaper
5. placenta change. Bathing every other day is usually
6. 48; 96 sufficient.
7. depression 15. Answer 4: The first postpartum visit is usually
8. attachment (bonding) scheduled around 6 weeks. Menses resume at
9. learned 6 weeks in about 45% of nonnursing mothers.
Breastfeeding should not be considered a reli-
able method of contraception. Discomfort and

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 Answer Key  79  

bleeding will occur if the episiotomy is not dice is not normal and may be the result of a
healed. maternal-fetal blood incompatibility. Further
16. Answer 3: The infant can latch on more read- assessment of jaundice is required.
ily if the mouth surrounds the areolar tissue. 22. Answer 2: Lochia serosa, a pinkish to brown
Alternate breasts with each feeding and allow drainage, is a sign of placental healing. Lochia
suckling for 10-15 minutes for each breast. serosa follows lochia rubra (bright-red drain-
To break suction, the finger is placed under age with small clots) that occurs immediately
nipple, rather than pulling child away from after delivery. After day 7, there is progression
breast. to slight yellow to white drainage. Lochia
17. Answer 3: Tenderness and redness of the should always have a fleshy odor, never a foul
breast may indicate mastitis; thus this symp- odor.
tom should be reported. Temperatures greater 23. Answer 4: Retroperitoneal hematomas are the
than 100.4° F (38° C) and lochia that has a foul least common, but are the most dangerous
odor or a bright-red color should also be re- because they are caused by laceration of ves-
ported. The fundus should feel very firm, like sels near the hypogastric artery, secondary to
a softball. rupture of a cesarean scar.
18. Answer 2: For mothers who are bottle- 24. Answer 3: Enemas and suppositories are con-
feeding, applications of covered ice packs traindicated for women who have third- or
are recommended for relief of engorgement. fourth-degree perineal lacerations. The other
The mother should not manually pump the treatments would be appropriate
breasts, because this will stimulate milk pro- 25. Answer 2: The bottle should be filled with
duction. Engorgement usually occurs about 3 warm tap water about 100.4° F (38° C). The
days after giving birth and mothers who se- contents of the whole bottle should be used
lect bottle-feeding still have to take measures for each cleaning. Cleaning with toilet tissue
to suppress milk production in the first part of is not recommended, but the area should be
the postpartum period. patted dry with tissue after flushing with the
19. Answer 1, 2, 4, 5: At birth, the skin is covered Peri bottle. Twice a day for 20 minutes is the
with a yellowish-white, cream cheese–like recommended time for a sitz bath.
substance called vernix caseosa. Another com- 26. Answer 3: Elevated platelet count increases
mon finding is lanugo (downy, fine hair the risk for thrombus formation. Early and
characteristic of the fetus, between 20 weeks frequent ambulation is key in preventing this
of gestation and birth). Good skin turgor and problem. Patients who have had excessive
tissue elasticity are expected. Desquamation blood loss (low hematocrit and hemoglobin)
at birth is considered a sign of postmaturity. can have fatigue. Elevated white blood cell
20. Answer 3: Have the mother hold the baby to count is typical with infection. A low platelet
minimize stress and take vital signs. Immedi- count would potentiate hemorrhage.
ately report assessment findings to the health 27. Answer 1: A full bladder places pressure on
care provider, because a weak, high-pitched the uterus and can prevent normal contrac-
cry can signal health problems such as infec- tion, which controls bleeding, especially in the
tion or neurologic disorders. early postpartum period. In the late postpar-
21. Answer 1, 2, 4, 5: Acrocyanosis can last for tum period, continued distention results in
7-10 days. It is most commonly observed urinary stasis, which contributes to infection.
when the infant becomes cold. Mottling, a Rectocele and uterine prolapse can be compli-
lacy pattern with dilated vessels on pale skin, cations from perineal lacerations that are not
is also common. Another normal variation properly repaired. Kidney dysfunction is not
is called the harlequin sign; half of the new- expected. Painful intercourse can be the result
born’s body appears deep red and the other of not waiting for the episiotomy to heal or for
half appears pale as a result of vasomotor normal vaginal lubrication to resume. Patients
disturbance. This looks alarming, but is not should be taught Kegel exercises to prevent
harmful. Epstein’s pearls on the hard palate future episodes of urinary incontinence.
are a result of epithelial cells and disappear 28. Answer 3: Patients can experience gestational
spontaneously within a few weeks. Jaundice hypertension, so check the blood pressure
occurring sooner than 48 hours after birth is and compare it to previous measurements.
termed pathologic jaundice. This type of jaun- The nurse reports findings to the health care

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 Answer Key  80  

provider. Leakage of cerebrospinal fluid can position change. The other options are also
create a headache after epidural or spinal an- good safety measures.
esthesia. The health care provider may decide 34. Answer 1: An epidural causes regional anes-
to order an analgesic. The nurse should not thesia, so loss of sensation in the lower part of
indicate to the patient that headaches are nor- the body is expected. Change of mental status
mal or likely to spontaneously resolve. is not an expected side effect of an epidural
29. Answer 1: In postpartum patients, profuse block, but may be the result of medications
diaphoresis is expected in the first week, espe- such as morphine. Blood pressure is more
cially at night. Low blood sugar, fever, and re- likely to decrease rather than increase, but all
spiratory distress can also cause patients to be changes should be reported. Low-grade fever
very diaphoretic. If the patient has a history of is not expected, although some women may
any chronic health problems or if the patient experience shivering or chills.
appears to be in distress, the nurse could use 35. Answer 2: First the nurse would check for
the other options. signs of dehydration, because the patient
30. Answer 2: It is a normal part of development is likely to be dehydrated from blood loss,
for a 15-year-old to be concerned about her perspiration, and being NPO. Giving fluids
appearance and to be concerned about her may resolve the slight temperature eleva-
relationship with her boyfriend. Support tion. Checking lochia and urine and looking
her sense of self-esteem first. If she is secure for other sources of infection would be more
about herself and her relationship with her likely after the first 24 hours, particularly if
boyfriend, she will be able to care for the in- the temperature is greater than 100.4° F (38°
fant. If she is not interested in learning about C). Checking the fundus is part of the routine
swaddling, the lesson can be postponed. She assessment, but is less related to temperature
should not be badgered into holding the baby elevation at this point.
or judged for wanting to look nice. 36. Answer 3: Discharge will pool in the vaginal
31. Answer 4: The nurse assesses bowel func- vault and when the patient stands there is a
tion by auscultating for bowel sounds; asking sudden increase of flow; however, the nurse
about passage of gas; and assessing for pain, should always do a firsthand assessment of
distention, or discomfort. Protocols or clini- the lochia and the patient’s response. Expla-
cal pathways give guidance, but they do not nations to the patient are always appropriate.
eliminate the nurse’s clinical judgment. Di- Reinforce to the UAP that reporting symp-
etary is not responsible for selecting or with- toms is always correct; although in this case,
holding foods related to medical therapies. the symptoms are benign and expected.
The nursing staff must ensure that the patient 37. Answer 4: If the baby grasps only the nipple,
consumes foods and fluids that are appro- there is insufficient pressure on the lactiferous
priate to the diet therapy. The health care glands. If the baby is unable to suckle, then
provider relies on the nursing staff to assess manually pumping the breasts is an alterna-
the patient’s readiness to advance foods and tive. Bottle feedings are also a possibility,
fluids. but decreased frequency and regularity of
32. Answer 1: Weight-loss diets are not encour- breastfeeding may suppress milk production.
aged. Breastfeeding mothers should follow Engorgement usually resolves in 48 hours and
the same diet as they followed while pregnant manual expression of milk should help relieve
(i.e., an additional 300-500 kcal/day with 2-3 the discomfort.
L of fluid). Non-breastfeeding mothers are ex- 38. Answer 3: First assess the father’s feelings
pected to return to their prepregnant weight and knowledge; then based on the assess-
in about 6-8 weeks. ment, a plan can be developed to include him
33. Answer 2: Patient is likely to experience some in the care of his wife and infant. The domi-
dizziness and orthostatic hypotension be- nant grandmother seems to be interfering, but
cause of blood loss, anesthesia medications, there may be cultural or familial issues that
splanchnic engorgement, and pain. Assisting affect her behavior. This family may benefit
her to a sitting position and pausing allows from counseling, but roles may become more
the nurse and patient to assess whether stand- clear as the initial excitement wears off. If the
ing is possible and also allows the body a few father desires to be more active in child care,
minutes to physiologically compensate for the teaching should begin as soon as possible.

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 Answer Key  81  

39. Answer 2: For mild pain, acetaminophen is 45. Answer 1: Neonates will have high levels of
usually sufficient. Morphine and codeine insulin, which can cause hypoglycemia. If
cause constipation; however, codeine may be the blood glucose level is 40 mg/dL or lower,
combined with acetaminophen preparations sterile glucose water is given. Oral feedings
to create a strong analgesic. If so, the nurse of sterile water are given to bottle-fed babies
should preemptively assist the patient with to assess for ability to swallow and anomalies
measures to avoid constipation. Aspirin can of the digestive tract. Breastfeeding would be
interfere with clotting. the second best option if sterile glucose water
40. Answer 1: Whenever there is an increased was not immediately available (delivery in
number of unfamiliar faces on the unit, the the field). Intravenous dextrose is given to
staff must be extra-vigilant because of the patients who are unresponsive and unable to
increased movement in and out of the unit. swallow.
The infant must be protected at all times and 46. Answer 3: If stool is not passed within 24
the nursing staff must always be aware that hours after birth, the health care provider
abduction could happen at any time. should be notified. The other stool conditions
41. Answer 3: Low-set ears may indicate a chro- are considered normal.
mosomal disorder. This finding should be
reported. Molding is related to compression Critical Thinking Activities
of the malleable cranium during birth and this 47. The postpartum nurse should be advised
should resolve within 1-2 days. Strabismus is about the name of the primary care provider;
crossed eyes and nystagmus is an abnormal gravidity and parity; age; anesthetic used;
lateral movement of the eyes. Both are com- medications given; duration of labor and time
monly seen because of the immaturity of the of rupture of membranes; oxytocin induction
newborn’s nervous system. or augmentation; type of birth and repair;
42. Answer 4: Hair tufts, dimples, and masses blood type and Rh status; rubella immunity
should be reported to the health care provider status; syphilis and hepatitis serology test re-
so that an abnormality of the spinal column sults; intravenous (IV) infusion of any fluids;
can be ruled out. Lanugo is the fine hair that physiologic status since birth; description
covers the baby, but the hair tuft is not an of fundus, lochia, bladder, and perineum;
expected feature of lanugo. Vernix caseosa is infant’s sex and weight; time of birth; pe-
the white cheesy substance that covers new- diatrician; chosen method of feeding; any
borns. It is attached to the skin, so it is usually abnormalities noted; and assessment of initial
left in place for 48 hours, then gently washed parent-infant interaction.
off. Skin and hair discolorations are related 48. Changes that occur in body systems after de-
to genetic factors, so the nurse must increase livery:
awareness of normal variations for different a. Cardiovascular—decrease in blood vol-
groups. ume and cardiac output
43. Answer 2: Vitamin K (AquaMEPHYTON) is b. Urinary—initial diuresis, possible reten-
routinely administered to compensate for the tion
temporary lack of intestinal flora. Prothrom- c. Gastrointestinal—hemorrhoids, constipa-
bin levels are low at birth, which increases the tion
risk for bleeding, but vitamin K should cor- d. Endocrine—reduction in estrogen and
rect this. Rho(D) immune globulin (RhoGAM) progesterone levels
is given to mothers for Rh incompatibilities. e. Integumentary—reduction of hyperpig-
Bowel movements are monitored, but not for mentation, increased elasticity
the purpose of measuring blood clotting fac-
tors.
44. Answer: 420-480 mL/day
Fluid needs are high: 140-160 mL/kg/day
6.6 pounds ÷ 2.2 kg/pound = 3 kg
140 mL/kg/day × 3 kg = 420 mL/day
160 mL/kg/day × 3 kg = 480 mL/day

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 Answer Key  82  

CHAPTER 28—CARE OF THE HIGH-RISK c. Sociodemographic—low income, lack of

MOTHER, NEWBORN, AND FAMILY WITH prenatal care, age, parity, marital status,
SPECIAL NEEDS residence, ethnicity
d. Environmental—exposure to infections,
Crossword Puzzle radiation, chemicals
1. 13. Refer to Box 28-2 on p. 877. Examples of fac-
tors that place the postpartum patient and
1 2 3
M G D M newborn at risk:
O O
N R
Mother—hemorrhage, traumatic labor and
O
4
D B delivery, infection, psychosocial factors, ab-
Z
5
H Y P E R B I L I R U B I N E M I A normal vital signs, previous medical condi-
Y Z D tions
6 7
G H K Y I
O
8
C E R C L A G E T
Infant—respiratory distress, poor Apgar
T R O Y score, cardiovascular disease, congenital
9
B I L I B L A N K E T
10
T O R C H abnormalities, neuromuscular dysfunction,
C I I hypo- or hyperglycemia, hyperbilirubinemia,
11 12
C E C L A M P S I A
T T
preterm, low birth weight, feeding problems
13 14
P H O T O T H E
15
R A P Y
16
M O R T A L I T Y 14. A preterm infant usually demonstrates frog-
E R N
17
N like/flaccid posture; ruddy color; head ap-
L U A H Y D R A M N I O S pearing large in comparison to body; pliable
L S S
P A bones of skull with large, flat fontanelles; thin,
18
P R E E C L A M P S I A translucent skin; lots of lanugo; pliable ear
C cartilage; small genitals; weak cry; and imma-
A
ture or absent reflexes.

Fill-in-the-Blank Sentences Multiple Choice

2. prematurity; low birth weight 15. Answer 3: Missed: The fetus dies and growth
3. choriocarcinoma ceases, but the fetus remains in utero. Amen-
4. fallopian tube orrhea continues, but no uterine growth is
5. uterine measurable. In fact, the uterus may decrease
6. respiratory distress syndrome in size. Septic: Malodorous bleeding, elevated
temperature, and cramping may be present;
True or False cervical os is opened; and abdominal tender-
7. True ness is typical. Incomplete: Some, but not all,
8. True of the products of conception are expelled.
9. False. Use of oral contraceptives is controver- Inevitable: Bleeding increases and the cervical
sial because of the increased risk of thrombo- os begins to dilate. Membranes may rupture.
embolic disease in the immediate postpartum 16. Answer 4: In hyperemesis gravidarum, exces-
period (first 4 weeks). sive nausea and vomiting may result in elec-
10. False. A prominent feature of postpartum de- trolyte, metabolic, and nutritional imbalances.
pression is rejection of the infant, often caused Relief of painful uterine contractions would
by abnormal jealousy. be a goal for abruptio placentae. Absence of
11. False. The woman who is addicted to opioids fetal withdrawal symptoms is relevant for
may have infections that compound the risk infants of mothers who abused alcohol or
to the infant, including hepatitis; septicemia; drugs. Prothrombin times, partial thrombo-
and STIs, including AIDS. plastin times, and platelet counts are moni-
tored for patients who develop disseminated
Short Answer intravascular coagulation.
12. Refer to Box 28-1 on p. 876. Examples of high- 17. Answer 2, 4, 6: UAP can measure and report
risk factors in pregnancy: amount and frequency of emesis, assist with
a. Biophysical—genetic, nutritional, medi- oral hygiene, and can weigh the patient. Ini-
cal, and obstetric disorders tially, patients are NPO until the vomiting
b. Psychosocial—smoking, caffeine, alcohol, subsides; IV fluid is used for hydration and
drugs, psychological status electrolyte replacement. The nurse must as-

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 Answer Key  83  

sess for dehydration; this cannot be delegated. 27. Answer 4: Exposure to cat feces is a source of
Bedrest is usually not ordered for this condi- Toxoplasma gondii, a protozoan that can cause
tion. toxoplasmosis.
18. Answer 2: Patients with placenta previa are 28. Answer 1: One of the main features of PPD
treated conservatively with bedrest to include is a seeming lack of interest in the baby. The
bathroom privileges. The rationale being that mother may demonstrate annoyance at hav-
the placenta could migrate upwards before ing to care for the baby or exhibit a lack of
delivery. Patients with hyperemesis gravi- maternal feelings. The mother may also have
darum are given clear liquids after the vomit- thoughts about harming self and child.
ing subsides. Painless bright-red bleeding is a 29. Answer 3: Disseminated intravascular coagu-
sign of placenta previa, but continued bleed- lation (DIC) is a potentially life-threatening
ing is not expected and will lower the hemo- disorder that results from alterations in the
globin and hematocrit. Tocolytic drugs are normal clotting mechanism.
used for patients with cervical incompetence. 30. Answer 3: Fundal massage is a measure to
19. Answer 4: Continuous headache, upset stom- counteract uterine atony. One nurse can per-
ach, and blurred vision are associated with form the massage and check for response. If
eclampsia and an upset stomach is a warning bleeding continues, another nurse calls the
sign of impending seizure activity. provider about suspected hemorrhage and for
20. Answer 3: Hyperglycemia in the fasting por- an order to start oxytocic medications.
tion of the test is blood sugar > 92 mg/dL. 31. Answer 2: To detect a hematoma, the nurse
Frequent urination would accompany high would examine the perineal area. Taking
blood sugar. The other signs/symptoms are the blood pressure and saving linens is ap-
typical of hypoglycemia. propriate if blood loss is suspected, but these
21. Answer 2: The nurse knows that vaginal ex- measures do not help to locate the source. Pal-
aminations can increase the bleeding, so she pating the abdomen would be appropriate to
would stop the inexperienced provider and assess internal bleeding, but not for suspected
take him/her aside and remind of the poten- hematoma.
tial complication. The other actions are cor- 32. Answer 2: The nurse would call the health
rect. care provider and ask for clarification. Blood
22. Answer 4: Abruptio placentae is considered pressures under 160/100 mm Hg may not be
an obstetric emergency. The patient is likely to medicated because of impaired perfusion to
have lost a significant amount of blood and is the fetus.
considered unstable while being prepared for 33. Answer 2: Abdominal palpation could
a cesarean birth. traumatize the liver and cause subcapsular
23. Answer 2: If the mother and the father are bleeding. The other assessments should be
both Rh negative, than the newborn will also performed.
be Rh negative. 34. Answer 3: Although mastitis can occur at any
24. Answer 1: Excessive or rapid weight gain, par- time, engorgement and milk stasis frequently
ticularly when accompanied by edema, should precede mastitis, when feedings are skipped
be reported promptly. Edema is typically de- or when breastfeeding is suddenly stopped.
scribed using a scale of 1+ to 4+. Antibiotics and cold packs are used if the con-
25. Answer 4: In cases of severe preeclampsia or dition occurs. Increasing fluid intake is recom-
eclampsia, medication therapies including mended to facilitate milk production.
magnesium sulfate (MgSO4) may be pre- 35. Answer 2: Perinatal infection is rare, so the
scribed parenterally to prevent seizure activ- mother would usually be treated and cleared,
ity. and then according to federal guidelines the
26. Answer 1: The pregnancy is likely to be un- danger to the infant will have passed. Infants
planned; thus the self-care measures and are tested at birth and treated with medica-
the physical and hormonal changes that ac- tions for preventive therapy. The infant’s
company pregnancy have probably not been medication can be stopped when the mother
considered. In addition, the adolescent has to and relatives are treated and show no evi-
combine developmental tasks with the new dence of disease.
role of becoming a mother or may face the de- 36. Answer 3: The process of labor would be
cision about adoption. stressful to the mother’s cardiac system, but

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 Answer Key  84  

oxygen therapy seems to have been sufficient 1+ to 2+ albumin readings. The nurse
in this case. The second stressful period to the should also ask about accompanying
mother’s heart will be the 48 hours after birth symptoms such as headache, visual dis-
as the extravascular fluid returns to the blood turbance, or upset stomach. The infant’s
system, so the nurse would be vigilant dur- status is also monitored.
ing that period to watch for cardiac decom- b. Treatment includes bedrest and a bal-
pensation. Based on findings from frequent anced diet with protein and moderate
assessments, the nurse may decide to talk to sodium intake.
the provider about PRN oxygen, telemetry, or 41. a. Diagnostic tests include 1-hour diabetes
transfer to the CCU. screening, glucose tolerance, glycosylated
37. Answer 4: Early ambulation is encouraged for hemoglobin, finger sticks, and fetal sur-
all patients to prevent thrombotic problems. veillance (biophysical profile, stress tests,
If DVT occurs, the affected leg is elevated. alpha-fetoprotein, ultrasound).
The legs are never massaged, because of po- b. The complications of gestational diabetes
tentially dislodging the thrombus. Oral an- are:
ticoagulants are given as part of the therapy Maternal—infections, difficult labor, vas-
for patients who develop DVT or those who cular problems, azotemia, ketoacidosis,
continue to have high risk for DVT. During pregnancy-induced hypertension
hospitalization, the patient may receive sub- Fetal—stillbirth, spontaneous abortion,
cutaneous injections of anticoagulant medica- hydramnios, large placenta, alteration in
tions such as enoxaparin or heparin. size for gestational age, neonatal hypo-
38. Answer 2: If the father is Rh negative, the glycemia, hyperbilirubinemia, respiratory
neonate will also be Rh negative. If the father distress
is Rh positive, the nurse will ask the mother
about other pregnancies and occasions for re-
ceiving RhoGAM. Amniocentesis would war- CHAPTER 29—HEALTH PROMOTION FOR THE
rant RhoGAM if the father is Rh positive. INFANT, CHILD, AND ADOLESCENT
39. 5. Provide oxygen by mask at 8-10 L/min.
7. Notify the health care provider that a con- Short Answer
vulsion has occurred. 1. Strategies to promote dental health include:
3. Note the time and sequence of the convul- a. Infant—The nurse instructs parents to
sion. clean the oral cavity by wiping the teeth
4. Insert an airway after the convulsion, and and gums with a damp washcloth; use a
suction mouth and nose. small, soft-bristled toothbrush when more
1. Remain with the woman and press the teeth come in; avoid toothpaste; initiate
emergency bell for assistance. fluoride supplementation after 6 months;
6. Observe fetal monitor patterns for brady- ensure proper nutrition; prevent bottle
cardia, tachycardia, or decreased variabil- caries (no propping of bottle at bedtime).
ity. b. Preschooler—Parents must assist with
2. If the mother is not on her side already, dental hygiene, provide professional den-
turn her onto her side when the tonic tal care, continue fluoride supplementa-
phase begins. tion, screen for malocclusion problems.
c. Adolescent—Continue good dental prac-
Critical Thinking Activities tices, correct malocclusions.
40. a. Ideally, the blood pressure readings are 2. a. Infant—Encourage breastfeeding, intro-
taken 2 times 6 hours apart. The readings duce baby foods as recommended, begin
should be taken with the woman seated with rice cereal, use prescribed baby for-
and ensure the cuff size is appropriate. mula.
The nurse would observe for generalized b. Preschooler—Encourage high-nutrient
edema of the face, hands, and ankles. foods such as fruits, vegetables, whole
Periorbital edema may mark a more omi- grains, and low-fat dairy and protein
nous finding. The nurse should weigh the products.
patient and test the urine. In mild pre- c. Adolescent—Provide nutritionally dense
eclampsia, urine testing frequently shows foods and snacks.

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 Answer Key  85  

3. Barriers to proper immunization include lack 11. Answer 3: Rice cereal is recommended as the
of insurance and funding, lack of transporta- introductory food.
tion, lack of education about the importance 12. Answer 3: Because the toddler is working
of immunizations, and personal and cultural through autonomy and initiative, give choices
beliefs. about nutritionally dense food. Bargaining is
more likely to set up a power struggle. Com-
True or False petitive or game-like approaches will appeal
4. True more to school-agers. Presenting cause and
5. True long-term effects will have little meaning for
6. False. Fluoride supplementation is recom- the toddler who lives in the now.
mended at age 6 months if the water supply is 13. Answer 4: Developmentally, the adolescent
not fluoridated. wants to be accepted by the peer group and
appearance is very important. It’s impractical
Multiple Choice to tell the daughter that she can’t go out with-
7. Answer 1: Asking about plans is a way for out sunscreen and unilateral pronouncements
the nurse to assess the adolescent’s knowl- are likely to create a climate of defiance. Infor-
edge and thoughts about sexual relations. mation about the risks for skin cancer are not
This question is a segue into the discussion of particularly meaningful to adolescents who
sexual relations as an event that is coming and believe they are invulnerable. Comparing the
how to prepare for it. The other questions are child’s characteristics to another child puts
also useful, but they are closed questions and the child in a powerless position.
offer less opportunity for the adolescent to 14. Answer 2: Children age 6-12 months have the
take the lead in what he/she wants to know greatest risk for aspiration, because they put
about sexual behavior. everything in the mouth as a way to investi-
8. Answer 2: The Healthy People 2020 goals are gate the properties of objects.
designed to target the whole population and 15. Answer 1, 3: The American Heart Associa-
they cover a wide range of topics. All of the tion recommends a maximum of 7% of daily
options contribute to the achievement; how- calories to be fats. Fat-free or 2% milk would
ever, teaching groups of people about general be recommended. Physical exercise for 60
health promotion for children is a way to have min/day is also recommended. Grains should
greater impact compared to helping individu- not be excluded from the diet. Children will
al patients with single issues. have bodily changes during adolescence, but
9. Answer 4: A child is more likely to develop overweight children often grow up to become
good health habits if adults, particularly overweight adults.
parents and close family members, practice 16. Answer 4: The child understands that parked
healthy habits on a routine basis. The other cars and curbsides are not good areas for
options are also recommended as health pro- playing. Parents should help the child review
motion points. when he can play outside and who must ac-
10. Answer 2: All of these children have risk fac- company him. The helmet should always be
tors, but the 9-year-old has a daily routine worn, regardless of anticipated distance. Run-
of eating high-calorie, high-fat foods. This ning out into the street to get a ball should
increases the risk for developing poor eating be discouraged, even if the child does “stop,
habits. The 13-year-old also has risk for obe- look, and listen.” Drivers anticipate people at
sity because of inactivity, but 2-4 hours may crosswalks, but are less aware of children who
be acceptable if the child is eating healthy are running out into the middle of the street.
food and spending at least an hour per day in 17. Answer 2: The toddler is going to use his/
physical activity. If parents have to work full- her new motor skills to investigate grand-
time, there is less time for meal preparation or ma’s house. Grandma is more likely to have
other health promotion activities; however, a drawers and cabinets that contain danger-
3-year-old is likely to prefer finger foods and ous household substances and prescription
this type of food requires less preparation. A drugs that are easily accessible. The infant
17-year-old boy is likely to eat large amounts will potentially ingest anything on the floor.
and still feel very hungry because of the The school-age child and adolescent could
growth spurt that occurs during adolescence. potentially be exposed to toxic fumes, but are

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 Answer Key  86  

unlikely to consume materials that they are particularly asthma and bronchitis in chil-
working with. dren. The nurse should be aware of available
resources and promote their use. For example,
Critical Thinking Activities the American Cancer Society (ACS) offers pro-
18. Regular physical activity lowers the death grams and resource materials aimed at educat-
rates for adults and reduces the risk for devel- ing children and adolescents concerning the
oping heart disease, high blood pressure, dia- dangers involved in tobacco use. These pro-
betes, and colon cancer. In children, physical grams are available at no cost to schools, civic
activity increases bone and muscle strength organizations, and health care professionals.
and helps decrease body fat. Psychological
benefits include improvement in self-esteem
and reduction of stress and depression. The CHAPTER 30—BASIC PEDIATRIC NURSING
nurse can promote physical activity in chil- CARE
dren by educating parents, teachers, school
administrators, and daycare providers and by Fill-in-the-Blank Sentences
being a good role model. 1. pure milk
19. a. Interventions for this nursing diagnosis 2. Women, Infants, and Children (WIC)
include counseling parents to store medi- 3. respect; collaboration; support
cines in containers with childproof caps, 4. are able; are not able
store harmful substances out of reach or 5. 5
in locked cabinets. Educate parents about
calling the Poison Control center. Remind True or False
that syrup of ipecac is no longer recom- 6. True
mended. 7. True
b. Examples of strategies that may be imple- 8. False. The American Academy of Pediatrics
mented to prevent accidental poisonings recommends breastfeeding exclusively for 6
include: months; then after 12 months, discontinuation
Never referring to medication as candy of breastfeeding is a personal choice.
and keeping it out of the reach of children 9. True
(childproof containers) 10. False. Children, like adults, will engage in
Storing harmful substances (e.g., cleaning activities for distraction as a method of coping
supplies) out of reach or locked away with pain.
Inspecting the home for possible sources 11. False. Newborns have the most rapid metabo-
of lead contamination lism and a fracture at birth could unite in as
Keeping toxic plants out of reach little as 3 weeks compared to 8 weeks for an
Keeping emergency phone numbers 8-year-old.
available 12. True
Educating older children about safety
hazards Short Answer
20. Behaviors associated with teen smoking in- 13. (a) Preventing disease or injury; (b) assisting
clude use and approval of smoking by peers children, including those with a permanent
or siblings, smoking parents, accessibility of disability or health problem, to achieve and
tobacco products, low self-esteem, and expo- maintain an optimum level of health and de-
sure to advertising for tobacco products. velopment; and (c) treating or rehabilitating
Nurses should support legislation that re- children who have deviations from an optimal
stricts the sale of tobacco products to minors. state of health.
Nurses should help adolescents under- 14. (a) Admission, (b) blood tests, (c) the after-
stand the risks involved in smokeless to- noon of the day before surgery, (d) injection
bacco: lip, gum, throat, and stomach cancers. of preoperative medication, (e) the moments
People who smoke should be advised that the before and during transport to the operating
damaging smoke is often trapped in cloth- room, and (f) return from the postanesthesia
ing, drapes, and household furnishings and care unit (PACU).
that environmental tobacco smoke results 15. Gain the trust of the parents by (a) review-
in increased risk for heart and lung disease, ing and interpreting information from the

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 Answer Key  87  

health care provider as needed, (b) asking the incorporated into the plan of care. This action
parents whether they have any questions, (c) demonstrates respect for the mother as an
conveying concern for the parents’ well-being, equal in the decision-making. Making sugges-
(d) listening and being available, and (e) re- tions, teaching, and projecting warmth are all
specting them as experts on their child and important, but note the directionality of these
soliciting their input. actions is from nurse to parent. Asking for
advice refocuses the direction from mother to
Figure Labeling nurse.
16. See Figure 30-8, p. 955. Each face is for a per- 26. Answer 1, 2, 3, 5, 6: The selected method is
son who has some pain. The nurse points to based on the child’s ability to cooperate; for
each face and says, “This face has no hurt. example, infants cannot hold an oral ther-
This one hurts a little bit. This one hurts a lit- mometer under the tongue. Parents may or
tle more. This one hurts even more. This one may not object to rectal temperatures, but
hurts a whole lot. This one hurts the worst. their wishes are considered. Adolescents will
Now you pick which face matches your pain.” object to rectal temperatures because of mod-
esty, whereas the preschooler does not like
Table Activity intrusion of objects. If there is a possibility of
17. Vital Signs (Averages) (See Table 30-3, p. 940.) sepsis or acute infection, the need for accurate
temperature overrides other considerations.
Heart Rate/ Respirations/ Blood The chosen route should be the least traumat-
Age min min Pressure ic and still fulfill the purpose. Parents’ lack
Newborn 120 35 70/50 of familiarity with the route would not be a
1-11 120 30 90/60
deciding factor because the nurse will explain
months procedures and equipment as a routine action.
27. Answer 1: See Table 30-3, p. 940 for additional
2 years 110 25 96/68
information.
4 years 100 23 100/70 28. Answer 1: A 1-year-old has a three- or four-
6 years 100 21 105/70 word vocabulary. It usually includes “mama”
and “dada.” Infants babble, coo, and mimic
10 years 90 20 108/70
sounds. In toddlerhood, more words are un-
12 years 88 20 110/70 derstood than expressed. Children usually
16 years 70 20 120/70 know 25-50 words by 18 months, but by 2
years they often know more than 250 words.
Clinical Application of Math and Equivalents 29. Answer 1: For a 12-year-old, P 88, R 20, BP
18. Three inches is approximately 8 cm and his 110/70 are considered average for the age. P
growth is within the normal range. 124, R 32, BP 126/66 indicates a hypermeta-
19. 280 mL bolic state such as fever or stress. The nurse
20. 95 mm Hg; formula for children age 1-7 years: should conduct additional assessment.
90 + the age in years 30. Answer 2: Infant likes toys that bang, shake,
21. 20 mL; 1 gram equals 1 mL of urine or can be pulled; enjoys playing “peek-a-boo.”
22. 240 mL; 1 ounce is equal to 30 mL At birth, visual acuity is normally 20/300 to
23. 4 mL is equal to 4 cc 20/400. Bladder control may not be achieved
until age 3. Doubles weight by 6 months;
Multiple Choice triples weight by 1 year.
24. Answer 3: The nurse empowers the mother by 31. Answer 1: The experience of the injection is
pointing out correct actions during a stressful best compared to a familiar sensation. “Don’t
event. This reinforces the mother’s confidence move” is a negative way to phrase the instruc-
and encourages her efforts. The other respons- tions. Rephrase in a positive way: “You can
es are also okay if used at the correct time, but help me by holding very still,” or “Mommy
responding to the mother’s source of distress is going to give you a big hug.” Don’t offer a
(fear of incompetence) is the first action to em- choice when there is no choice. Try to avoid
power her. the word “shot.”
25. Answer 3: The parent is the expert on the 32. Answer 3: Tell the child that the medicine
child’s behavior and her advice should be tastes a little strong and the sweet juice will

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 Answer Key  88  

wash away the taste. The syringe method is 39. Answer 2: Around 9 or 10 months, the child
usually used for infants or resistant toddlers. will start crawling. The parents should be
The ice pop could also be used in conjunc- encouraged to look around their house to see
tion with the sweetened juice, but requires a what the infant will encounter as he crawls
little more preparation for correct timing. If around; thus they can prepare the environ-
the child is allowed to sip the liquid at will, it ment in anticipation of this new milestone.
decreases the chance that he/she is going to 40. Answer 2: The nurse would first give the
willingly consume the entire dose. stethoscope to the child, so that he/she can
33. Answer 1, 2, 6: Only water should be used handle it and play with it. Assistance of a
around the eyes. Cotton-tipped swabs should helper will not be useful in this procedure,
not be inserted into the ear canal. The foreskin because resistance and screaming will make
is not retracted because of potential for bleed- auscultation impossible. If the assessment is
ing and damage. The other actions are correct. not possible, the nurse would ask about func-
34. Answer 4: If the school-age child has been tions and symptoms related to bowel function
told that he will be asleep for the procedure, such as eating, vomiting, bowel movements,
he is likely to compare the explanation to flatus, or abdominal pain.
normal sleep, so the nurse should explain 41. Answer 3: The nurse counts respirations first,
the concept of “special sleep.” Handling the because handling the infant can precipitate
mask is appropriate for younger children, but agitation or activity. Blood pressures are usu-
the school-age child needs a simple explana- ally not taken until age 3.
tion of how the mask works. Talking to a peer 42. Answer 1, 2, 5, 6: Three flexion creases are
would be appropriate for an adolescent. Reas- expected, so referral to a specialist is war-
surance about safety and necessity is an emp- ranted. Tufts of hair along the spine can be
ty response that is not very useful to patients associated with spina bifida. Lack of babbling
who can process information. at 9 months could indicate a problem with
35. Answer 3: The mother should try to instill hearing. Tongue protrusion is associated with
regular and typical family patterns of eating, cognitive impairment. Newborns and young
so that meals are associated with desired be- infants prefer en face position. Bumping into
haviors. Leaving food out creates an expecta- obstacles at age 1 is normal because of visual
tion that meals and food are at the whim of acuity.
the child. Restraining in a high chair will cre- 43. Answer 2: The nurse would describe the type
ate frustration for everyone. Five-hour time of stool that is expected for breastfed babies.
increments are excessive for most people; 44. Answer 3: The concentration of proteins and
toddlers will eat more if they are given small, minerals in whole milk taxes the infant’s im-
frequent meals. mature kidneys, so it is not recommend before
36. Answer 1, 4: The birth weight should double the age of 1 year.
by age 6 months and it is likely that the infant 45. Answer 3: Honey has caused infant botulism
is enjoying rattles and peek-a-boo. Active and this mother was well-informed. The other
exploration of environment will occur at an elements are acceptable.
older age and parallel play is characteristic 46. Answer 2: The infant demonstrates an active
of toddlers. Breastfeeding is recommended interest in getting nutrition from alternative
as the exclusive food source until at least 6 sources. Comparing children to standards or
months. to siblings is a way for parents to understand
37. Answer 2: The vastus lateralis is good site time frames for readiness. Returning to work
because the chance of damaging underlying is a valid reason for the mother’s readiness to
structures is less likely. The site is also the wean.
most developed in an infant, which is desir- 47. Answer 2: The American Academy of Pe-
able. Ease of exposure is not a factor. Pain is diatrics recommends cholesterol testing for
equal at this site compared to others. children whose parents or grandparents have
38. Answer 3: Children will exhibit concern when total cholesterol levels of 240 mg/dL or higher
others are crying, but apprehension could be a or whose parents or grandparents have had
sign that the child is experiencing some abuse. heart attacks or been diagnosed with blocked
The other children are exhibiting normal be- arteries at age 55 or earlier in men, or age 65 or
haviors for developmental age. earlier in women.

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 Answer Key  89  

48. Answer 1: The health care team first seeks 52. a. Refer to Box 30-4 on p. 938. Guidelines
out and treats immediate injuries. The other for the pediatric physical examination in-
options are likely to follow once the team has clude:
ensured physical safety. Performing the examination in an appro-
49. Answer 4: The child is allowed to assume priate area
a position of comfort and perceived safety, Providing time for play and becoming
then the nurse gets on the child’s eye level. acquainted
This position creates less threat. Making faces Observing behaviors that signal readiness
could be perceived as a threat. In addition, to cooperate
whenever the nurse stands in the doorway, it Using techniques to promote cooperation
gives the impression that the nurse is getting Beginning the examination in a nonthreat-
ready to leave. Sitting on mom’s lap is a good ening manner
strategy, but touching is never the first action Using the “paper doll” technique
for any patient. Putting chairs in a small circle Involving the child in the examination
would be a good strategy for an adolescent. process
50. Answer 1: The nurse compares the sensation b. The nurse can have the child assist with
of wearing the electrode to a known sensation the auscultation of the lungs by:
of a band-aid and allows the child to handle Asking the child to “blow out” the oto-
it. Being hooked to a machine sounds scary, as scope light or flashlight
does the idea of being electrocuted or having Placing a cotton ball in the child’s palm
someone watch your heart. and asking the child to blow the ball in
the air
Critical Thinking Activities Placing a small tissue on the top of a pen-
51. a. The nurse can reduce anxiety for the child cil and asking the child to blow the tissue
and parents during hospitalization by: off
Orienting them to the unit and explaining Having the child blow a pinwheel, party
routines. horn, or bubbles
Introducing them to the staff and room- 53. The pediatric nurse should enjoy working
mate. with children of all ages. He/she must be able
Providing tours and audiovisual aids. to provide care to the child while also identi-
Having the child handle equipment and fying family stressors and providing care for
supplies. other members of the family. The nurse must
Allowing the child to keep his own have specialized skills, including excellent
clothes or toys. assessment skills, the ability to establish trust,
Encouraging parents to visit and stay. teaching ability, and the ability to serve as a
Explaining procedures and the status of patient advocate. A pediatric nurse serves as
the child. a role model for children by demonstrating
b. Strategies for communicating with a child appropriate health promotion and prevention
include: behaviors such as maintaining good nutri-
Using a calm, unhurried voice tion, a healthy lifestyle, and personal hygiene,
Speaking clearly; being direct and specific or for parents by exhibiting age-appropriate
Stating directions in a positive way responses to children. What the nurse needs
Focusing communication on him most is the ability to recognize and appreciate
Talking to the child and the parents the uniqueness that each child or adolescent
Using play as a method to initiate conver- brings to the nurse-patient relationship.
sation
Listening to and observing the child at
play CHAPTER 31—CARE OF THE CHILD WITH
Looking for opportunities to offer the A PHYSICAL AND MENTAL OR COGNITIVE
child choices DISORDER
Being honest
Explaining in a concrete manner Matching
1. c
2. g

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 Answer Key  90  

3. a Table Activity
4. i 30. Clinical Manifestations of Dehydration (See
5. f Table 31-1, p. 1008.)
6. e
7. b Assessment Signs and Symptoms
8. j Skin Cold, dry, gray, loss of
9. d turgor
10. h
Mucous Dry
Fill-in-the-Blank Sentences membranes
11. 20 mm Hg Eyes Sunken
12. 12 Fontanelles Sunken
13. deficient
14. 90% Behavior Lethargic
15. Reed-Sternberg Pulse Rapid, weak
16. infections
Blood pressure Low
17. 600 to 1200
18. drug Respirations Rapid

True or False Figure Labeling

19. True 31. A hip dysplasia is usually assessed by the
20. True nurse upon finding uneven thigh and gluteal
21. False. Cryptorchidism, which is undescended folds. When placed in the prone position,
testes, requires surgical fixation of the testes. there is limited abduction of the hip on the
22. False. Essentially, the nutritional needs of chil- affected side. A weight-bearing infant may
dren with diabetes are no different from those have the affected leg shorter than the other,
of unaffected children. Children with diabetes with evident limping. Refer to Figure 31-21a,
require no special foods or supplements. p. 1025.
23. True
24. True Clinical Application of Math and Conversions
32. 3.6 kg
Short Answer 7 pounds = 3.2 kg
25. (a) Increased pulmonary blood flow, (b) de- 15 pounds = 6.8 kg
creased pulmonary blood flow, (c) obstruction 6.8 – 3.2 = 3.6 kg
to systemic blood flow, and (d) mixed blood 33. 2.6 mL
flow 40 mg × 7 mg = 2.625 rounded to 2.6 mL
26. (a) Pulmonary stenosis, (b) ventricular septal 15 mL x
defect (VSD), (c) right ventricular hypertro- 34. 35 mL. The volume of fluid in milliliters is
phy, and (d) overriding aorta equal to the weight of the fluid measured in
27. (a) The decrease in RBCs causes anemia, (b) grams.
neutropenia leads to infection, and (c) the de-
crease in platelets causes bleeding. Multiple Choice
28. (a) Bacterial, (b) viral, (c) mycoplasmal, (d) 35. Answer 1: The clinical signs and symptoms of
foreign body aspiration mild to moderate anemia (hemoglobin: 6-10
29. E: Enlarge the nipple, S: Stimulate the suck g/dL) are often vague and nonspecific and
reflex, S: Swallow fluid appropriately, R: Rest include irritability, weakness, decreased play
when infant signals with facial expression. activity, and fatigue. When hemoglobin falls
below 5 g/dL, the child will have anorexia,
skin pallor, pale mucous membranes, glos-
sitis, concave or “spoon” fingernails, inability
to concentrate, tachycardia, and systolic mur-
murs.

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 Answer Key  91  

36. Answer 1: Murmurs are heard as the blood finitively diagnose HIV infection early in this
moves through the defective structures. age group.
37. Answer 3: Surgery is generally required 46. Answer 3: The nurse reflects back the
because the defects are structural so diet, thoughts of this young person who is fac-
exercise, and medication will not correct the ing this life-altering chronic disease. This is
defects. the best response, because it indicates to the
38. Answer 3: Iron deficiency anemia is the most adolescent that the nurse is really listening
common. and understands his concerns. This response
39. Answer 2: The ascorbic acid in citrus fruits or also invites continued discussion. The other
juices enhances iron absorption. responses are more likely to dissuade the ado-
40. Answer 1, 3, 4: A breastfed infant should start lescent from further disclosure.
iron supplements at 4 month of age. Preterm 47. Answer 1: Nonsteroidal antiinflammatory
infants have less iron reserve to begin with, drugs (NSAIDs) are the first line of drug
so they also need supplements. A 16-year-old treatment. Stronger NSAIDs are tried if
girl who is dieting will have iron deficiency over-the-counter medications do not work.
related to menstruation, so she should also Corticosteroids could be used to decrease
have supplements. It is recommended that a inflammation. Slower-acting antirheumatic
toddler obtain the necessary iron by eating drugs (SAARDs), disease-modifying antirheu-
lean meats, legumes, and fortified cereal. The matic drugs (DMARDs), and tumor necrosis
10-month-old is eating commercial infant factor (TNF) blockers are added in that order
cereal, which is the best solid food source of if previous drugs are not working.
iron. 48. Answer 3: Suctioning is based on assessment
41. Answer 3: The trip to the beach is less likely of lung sounds and noting excessive moisture
to include the usual precipitating factors: in- in the tube. Infant could also show signs of ir-
fection, fever, hypoxemia, dehydration, high ritability and fussiness. Facility policy will not
altitudes, cold, or emotional stress. stipulate specific time frames and the health
42. Answer 3: The nurse recommends to the care provider relies on the nurse to make a
mother the best toy would be swim fins. The clinical judgment about need for suctioning.
other toys offer a bigger risk for falls and inju- The neonate is not able to cough up secre-
ries that could cause bleeding. tions.
43. Answer 4: In idiopathic thrombocytopenia 49. Answer 3: Parenteral nutrition is ordered to
purpura, the platelet count is lowered and reduce the risk of aspiration. Bottle-feeding
this increases the risk for bleeding, even if in- and breastfeeding interfere with respiration
juries are minor. and all enteral methods increase the risk for
44. Answer 2: Any person with an active infection aspiration.
should not enter the room. Also, the 3-year- 50. Answer 4: The nurse first tries to explain the
old who has symptoms of a cold is likely to rationale for not prescribing the antibiotics.
touch, crawl, climb, and desire to play with The nurse may have to give additional expla-
his/her sibling. Pregnancy is not a contraindi- nation about superinfections. If the mother is
cation. Parents should routinely shower and still dissatisfied after the nurse’s best effort,
change clothes before coming to the hospital the nurse can contact the health care provider.
to visit. The 5-month-old is not infectious; 51. Answer 2: Rheumatic fever and acute glo-
however he/she is likely to have a weaker im- merulonephritis are associated with a history
mune system and parents should reconsider of untreated streptococcal infections.
exposing him/her to the hospital environ- 52. Answer 2: This increase of pulse could signal
ment. hemorrhage, which is the chief concern in
45. Answer 2: Most exposed infants up to 18 the postoperative period. The other reports
months of age will test positive for HIV an- are also of concern and indicate that the UAP
tibodies, but it is unclear whose antibodies needs to be instructed on positioning (semi-
are being detected during this time. In infants Fowler’s), and fluids (no red or purple fluids
younger than 18 months, a polymerase chain that would confuse the observation of bleed-
reaction (PCR) test, which actually tests for ing). Active running and playing should be
HIV, not for the antibody, is available to de- discouraged in the immediate postoperative
period.

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 Answer Key  92  

53. Answer 3: The nurse would intervene if the 60. Answer 4: Immediate surgical repair of the
inexperienced health care provider started diaphragm with replacement of the herniation
to examine the throat by using a tongue is required because severe respiratory distress
blade because this could trigger a laryngeal develops within hours after birth.
spasm and cause respiratory arrest. The child 61. Answer 3: Pharmacologic therapies include
should sit on the mother’s lap for psychologi- cimetidine (Tagamet), ranitidine (Zantac), fa-
cal safety, because crying could also cause a motidine (Pepcid), metoclopramide (Reglan),
spasm. The diagnosis is based on symptoms, or proton pump inhibitors (PPIs) such as
preceding history, and diagnostic studies. omeprazole (Prilosec) and lansoprazole (Pre-
The operating room could be notified in case vacid) to reduce acid secretion.
emergency intubation is required. 62. Answer 2: The kidney function must be veri-
54. Answer 3: A cool-mist humidifier helps re- fied because nonfunctional kidneys contribute
lieve cough. Liquids are given so that secre- to hyperkalemia. For presence of crackles or
tions are thinned and easier to expectorate. wheezes, the nurse would notify the health
Antibiotics and cough suppressants are not care provider if a high flow rate of fluid had
usually prescribed. been ordered. Bowel sounds are likely hyper-
55. Answer 4: The nurses who are assigned to active because of the diarrhea. Bowel sounds
care for children with RSV should not also can be hypoactive if the patient is hypokale-
care for high-risk patients. This is an addition- mic. If the patient were hyperglycemic, the
al measure to prevent cross-contamination. nurse is likely to notify the health care pro-
The other option is to put all of the patients in vider before starting the potassium, because
the same room, but five patients in one room elevated blood sugar can be accompanied by
is likely to exceed the occupancy space in hyperkalemia; for example, in diabetic keto-
most modern hospitals. The children are not acidosis.
in reverse isolation, but personnel with minor 63. Answer 1, 2, 3: The nurse is trying to deter-
infections should alert the charge nurse so mine if the child has a learned repression
that the staff is used to best advantage. Caring habit, which may come from holding back the
for patients who are in isolation is more time- urge because it is painful to defecate. Some
consuming, which is one reason that all isola- children will ignore the urge if they are too
tion patients are usually not assigned to one busy playing and other children may hold the
nurse. urge because of an embarrassing incident at
56. Answer 4: Cystic fibrosis is a multiorgan dis- school. A 5-year-old has insufficient informa-
ease, but pulmonary complications and pul- tion to have insight into cause of constipation.
monary failure are the usual cause of death. Offering fruit versus medicine sounds like
57. Answer 3: Clear fluids, including water or a threat and is not the most therapeutic ap-
dextrose and water, are given first and then proach.
there is a gradual progression to formula. If 64. Answer 3: If the barium enema was success-
the mother intends to breastfeed, she should ful in reducing the intussusception, normal
be directed to pump the breasts until the in- bowel functions will return as indicated by
fant is able to feed directly from the breast. the presence of bowel sounds and the passage
58. Answer 2: It is acceptable to offer a com- of stool containing the barium.
mercially available oral rehydration solution 65. Answer 4: Adrenocortical steroids (predni-
in small amounts for the first 4-6 hours fol- sone) are ordered to reduce the proteinuria
lowing the onset of diarrhea. The American and subsequently the edema. Bedrest is or-
Academy of Pediatrics no longer recommends dered initially. A good protein intake is need-
withholding food or fluids for 24 hours fol- ed to offset the loss of protein through the
lowing the onset of diarrhea or administer- urine. Dietary restrictions include a low-salt
ing the traditional BRAT diet (bananas, rice, diet and restricted fluids.
applesauce, and toast or tea). 66. Answer 1: Congenital hypothyroidism can re-
59. Answer 3: Umbilical hernias usually show sult in permanent cognitive impairment. Poor
spontaneous closure by 2 years of age in small outcomes are usually attributed to noncompli-
defects (less than 2 cm); surgical closure is ance.
performed if the condition persists after age
2-5 years or for defects larger than 2 cm.

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 Answer Key  93  

67. Answer 4: Hyperthyroidism is rare in young more grid lines within a 2- to 4-week period is
children, primarily affecting young adoles- suggestive of hydrocephalus.
cents. 76. Answer 4: The child with ADHD is often eas-
68. Answer 4: Treatment of clubfoot consists of ily distracted by extraneous stimuli, so a calm
manipulation and the application of a series and quiet space with limited objects will offer
of short leg casts. fewer distractions. The other strategies may
69. Answer 1: Atopy refers to an allergy for which cause him to get more excited. If the child is
there is a genetic or inherited predisposition. physically tired, he may seem to have less
A familial history of asthma, allergic rhinitis, energy to bounce about, but he will also have
or dry skin is often present. Food allergies and less energy for learning.
abnormal skin function are implicated by as- 77. Answer 1: Tricyclic antidepressants or selec-
sociation. tive serotonin reuptake inhibitors (SSRIs) such
70. Answer 4: Vesicles on an erythematous base as fluoxetine (Prozac), trazodone (Desyrel),
are observed in varicella. Pinpoint red spots sertraline (Zoloft), bupropion (Wellbutrin),
with white specks in the buccal cavity are ob- venlafaxine (Effexor), and paroxetine (Paxil)
served with rubeola (measles). A pinkish-red are helpful in alleviating symptoms
maculopapular rash that begins on the face 78. Answer 2: The child with an IQ of 40 can be
is observed with rubella (German measles). trained to independently do activities of daily
A rose-pink macular rash on the trunk is ob- living. (1) Mild (educable cognitive-impaired),
served for roseola infantum (exanthema subi- IQ of 50 or 55 to approximately 70; (2) moder-
tum). ate (trainable cognitive-impaired), IQ of 35 or
71. Answer 1, 2, 4: The child with idiopathic sco- 40 to 50 or 55; (3) severe, IQ of 20 or 25 to 35
liosis will have unequal hip height and shoul- or 40; and (4) profound, IQ below 25.
der height, scapular and rib prominence, and 79. Answer 1: The behavior is considered a type
a posterior rib hump that is visible when the of stress response. The parents and the child
child bends forward at the waist. should be reassured that he is okay and that
72. Answer 4: Left untreated, the child is at risk he must return to school. Encourage parents
for amblyopia (lazy eye; reduction or dim- to be firm and not negotiate with the child.
ness of vision, especially in which there is no 80. Answer 1, 4: In working with children with
apparent pathologic condition of the eye), in autism, remember that change and stimula-
which there is a loss of visual acuity. tion are very stressful for them, so familiar
73. Answer 2: The skin becomes thick and leath- possessions and routines are best. Commu-
erlike with repeated scratching. nicate directly, limit direct eye contact, and
74. Answer 1, 3, 4, 6: Padded side rails are for don’t touch or hold unless the child signals
safety to prevent injury if extremities or head that it is okay to do so. There is no cure, but
are moving around uncontrollably. Loosening some children will be able to achieve a level of
restrictive clothing facilitates breathing. Turn- independence.
ing the head prevents aspiration. Staying with
the child is for safety and observation. Mov- Critical Thinking Activities
ing the child to the bed is not necessary and 81. a. The nurse would advise parents not to
picking him/her up may actually increase the smoke. Bed sharing, adult beds, sofas,
risk for falls for the nurse and the child. Push- and soft bedding such as pillows or quilts,
ing a tongue blade between the teeth during stuffed animals, or towels potentially cre-
the seizure is not recommended; however, ate a risk for accidental entrapment and
after the seizure is over, the nurse could insert suffocation. Do not overbundle the infant;
an oral airway to prevent the tongue from dress the infant in light clothing and keep
falling back into the throat and occluding the the room at a comfortable temperature.
airway. Infants should always be placed on their
75. Answer 2: In infants, measurement of the back for sleep until one year of age. Offer
head circumference is the most important the infant a pacifier when sleeping to re-
diagnostic technique. It is important to mea- duce the risk of SIDS.
sure the head circumference routinely in all b. SIDS occurs more often in males and in
infants. Any measurement that crosses one or siblings of SIDS victims. Incidence is in-
creased in winter months, with peak inci-

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 Answer Key  94  

dence occurring in January. Native Ameri- d. Nursing interventions—vital signs, hy-

cans and African Americans are most dration, positioning (high Fowler’s), ad-
often affected, and there is an increased equate rest, breathing exercises, teaching
occurrence in lower socioeconomic class- to avoid allergens and undue exertion
es. The cause of SIDS is unknown, but 83. a. Most common cause—bacterial infection
SIDS is often associated with poor prena- b. Classic signs and symptoms—positive
tal care, premature birth, low birth weight, Kernig’s and Brudzinski’s signs, nuchal
multiple births, and CNS and respiratory rigidity
dysfunctions. There is also an association c. Diagnostic test—lumbar puncture to test
between SIDS and smoking, drug addic- cerebrospinal fluid (CSF)
tion, and maternal age of younger than 20 d. Medical treatment—IV antibiotics, isola-
years. Breastfed infants have a lower inci- tion, fluids, antipyretics, seizure precau-
dence of SIDS. Sleep position has been as- tions
sociated with SIDS, along with congenital e. Preventive measures—Hib vaccine, pro-
abnormalities, including sleep apnea and phylactic rifampin
depressed ventilator response to increased 84. a. Sources of lead—lead-based paint or
carbon dioxide or decreased oxygen lev- caulking, contaminated soil and dust,
els. Sleeping in a prone position possibly drinking water that comes through lead
predisposes the infant to oropharyngeal pipes
obstruction or affects ventilatory arousal. b. Prevention—recognition of sources/haz-
Soft polystyrene-filled mattresses or pil- ards, community education
lows have the potential to cause suffoca- c. Screening—blood levels, history, and en-
tion in the infant sleeping in a prone posi- vironmental assessment for all children
tion. ages 6 months to 6 years
There are a large number of risk fac- d. Parent guidelines to reduce lead levels—
tors and some parents could be offended Restrict access to hazards, reduce dust,
if the nurse is careless about presenting wash hands and toys, run water from
the information. The nurse could opt to cold water tap, avoid certain pottery and
say, “Because we care about all babies, ceramic ware, provide regular meals.
we give all parents the same information 85. a. What are your fantasies about suicide?
about preventing SIDS” or “The cause When have these thoughts occurred?
of SIDS is unknown, but your baby has How long have you been having these
several risk factors that have been associ- thoughts?
ated with SIDS.” Or “Would you like ad- Do you have a plan?
ditional information about SIDS and risk Do you have access to the means to carry
factors?” out the plan?
The nurse is likely to decide that the Have you shared your thoughts with
approach will need to be modified for your parents or any other adults?
individual parents; assessment of respon- b. The threat of suicide should always be
siveness to information is essential. taken seriously. If the child tries to laugh
82. a. Signs/symptoms—tightness in chest, it off or minimize the threat, the nurse
wheezing, shortness of breath, tachypnea, would gently explain the need for follow-
dyspnea, coarse breath sounds, restless- up as an act of caring and concern. The
ness, anxiety, dark red color of the lips, nurse would also tell that child about who
cyanosis, paroxysmal cough, fatigue, and must be informed. In this case, the parents
diaphoresis will need to be informed first and a health
b. Diagnostic tests—physical examination, care provider should be identified by the
pulmonary function tests, laboratory parents. If there is a policy at the school
studies, and radiographic examinations for informing school administrators the
c. Medical treatment—medications nurse would follow those instructions. In
(metered-dose inhalers) including bron- extreme cases, for example, if the child
chodilators and steroids, chest physio- threatened to leave or to harm self or the
therapy, and allergy testing nurse, the police could be summoned and

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 Answer Key  95  

the child could be escorted to the hospital a. Vision—decreased number of eyelashes,

for her own safety. decreased tear production, increased dis-
coloration of lens, decreased tissue elastic-
ity, decreased muscle tone
CHAPTER 32—HEALTH PROMOTION AND b. Hearing—decreased tissue elasticity, de-
CARE OF THE OLDER ADULT creased joint mobility, decreased number
of hair cells in inner ear
Short Answer c. Taste and smell—decreased number of
1. Refer to Table 32-3 on p. 1075. Examples of papillae on tongue, decreased number of
changes in the integumentary system are de- nasal sensory receptors
creased vascularity, sebaceous gland function, 10. Refer to Table 32-12 on p. 1095. Neurologic
sweat gland function; subcutaneous fat thick- changes are decreases in number of brain
ness; hair pigment and growth; and hormone cells, number of nerve fibers, and number of
production. neuroreceptors
2. Refer to Table 32-4 on p. 1077. Changes in the
gastrointestinal system are an increase in den- Table Activity
tal caries and tooth loss, and decreases in gag 11. Refer to Table 32-13, p. 1097.
reflex, muscle tone of sphincters, gastric secre-
tions, and peristalsis. Multiple Choice
3. Refer to Table 32-5 on p. 1081. Changes in 12. Answer 1: Patient used to be very engaged
urinary function are a decrease in the number with life, but shows a gradual withdrawal
of functional nephrons, blood supply, muscle from interaction, and the people who know
tone, and tissue elasticity, and an increase in him support this behavior. In the Exchange
prostate size. theory, there is also reduced interaction, but
4. Refer to Table 32-6 on p. 1083. Examples of it is based on decreasing value of interac-
changes in cardiovascular function are a de- tion. In Activity theory, older adults develop
crease in cardiac output and elasticity of heart a positive concept of self and find new roles.
muscle and blood vessels, and an increase in In Continuity theory, personality remains the
atherosclerosis. same, and behavior becomes more predictable
5. Refer to Table 32-7 on p. 1085. Changes in the as people age.
respiratory system are decreased body fluids, 13. Answer: 1770 calories/day. (Note to student:
number of cilia, tissue elasticity, and number If you based your calculation on 14 calories/
of capillaries, and increased calcification of pound the answer would be 1820/day.) In a
cartilage. Kyphosis, muscle weakness, and real clinical situation, you might opt to tell
thoracic rigidity have an influence on respira- the patient to aim for 1800 calories, because it
tory function. would be an easier number for the patient to
6. Refer to Table 32-8 on p. 1087. Changes in remember.
musculoskeletal function are decreases in 14. Answer 3: Unilateral sudden onset of a cold
bone calcium, fluid in intervertebral discs, foot on either side suggests an arterial clot
blood supply to muscles, joint mobility, and that should be reported for further evalua-
muscle mass. tion. Tissue damage will occur within hours.
7. Refer to Table 32-9 on p. 1090. Changes that Progressive edema suggests fluid retention,
occur in the endocrine system are decreases the gradual progression makes this symptom
in pituitary excretions, production of thyroid- somewhat less urgent. Excessive warmth sug-
stimulating hormone, production of parathy- gests an inflammatory process. Cramping of
roid hormone, production and utilization of calf muscles after exertion is also characteris-
insulin, and release of testosterone, estrogen, tic of arterial insufficiency. All of these symp-
and progesterone. toms should be reported to the health care
8. Refer to Table 32-10 on p. 1091. Reproductive provider.
changes include decreased estrogen levels, 15. Answer 1: Dysphagia is difficulty swallowing,
increased vaginal alkalinity, decreased testos- so swallow precautions need to be performed
terone, and decreased circulation. to prevent aspiration, which could lead to
9. Refer to Table 32-11 on p. 1093. Sensory pneumonia. Aphasia is difficulty understand-
changes that occur with aging are: ing words, which may improve as the condi-

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 Answer Key  96  

tion improves. Presbyopia is farsightedness yet to demonstrate advantages or disadvan-

resulting from a loss of elasticity of the lens of tages, but at this point it is unwise for seniors
the eye. Akinesia is hypoactivity. to trust that all is well.
16. Answer 3: Getting up once a night to urinate 23. Answer 4: Conflict within the family is an
would be considered normal for this patient, additional source of stress and her comment
but a change of pattern to 4-5 times a night suggests that others are complaining but not
suggests possible infection or other causes helping. The other statements indicate that
that need medical treatment. The other op- the daughter is experiencing some strain;
tions are good suggestions for dealing with however, there is evidence of coping and ad-
the routine inconvenience of nocturia. aptation.
17. Answer 2: Antibacterial soaps are harsh and 24. Answer 3: Setting realistic short-term goals
will worsen the pruritus. The other options empowers people to move forward and ac-
are all correct interventions for pruritus. complishment increases self-esteem. Cheerful
18. Answer 1: Patients with dysphagia will fre- behavior will come across as insensitivity to
quently do better with semi-solid foods, rath- loss and grief; thus it is inappropriate at this
er than thin liquids. Feeding quickly, placing time. Being alone and thinking about losses
in a low Fowler’s position, or talking while will exacerbate the problem. This behavior
eating increase the risk of aspiration. should be limited. Assessment of patient’s
19. Answer 1: Alendronate (Fosamax) is pre- and family’s feelings and thoughts about liv-
scribed for the treatment of osteoporosis. Frac- ing together should be assessed before mak-
tures can occur from routine activities such ing this type of suggestion.
as bending or lifting; thus gentle handling is 25. Answer 2: Shifting the patient’s weight mim-
necessary. Purse-lipped breathing is useful ics movement that would normally occur. The
for patients who have COPD. Frequent pulse other options may also be appropriate, but are
checks would be appropriate for patients with not as important as repositioning.
cardiac disorders, fluid imbalance, or for any 26. Answer 1, 2, 3, 5: Having the patient slide
who are critically ill or injured. Kegel exercis- across wet linens creates a shearing force that
es help patients who have stress incontinence. damages underlying tissues. Tape should be
20. Answer 4: Kyphosis is a curvature of the used very sparingly, because the skin is eas-
spine that decreases overall air exchange and ily torn when tape is removed. Patient should
secretions are retained. Heartburn is related to be handled gently; firm grip on the forearm
decreased muscle tone of sphincters in the GI is likely to cause bruising. Asking for lifting
tract. Swelling of the ankles can be caused by help is appropriate.
decreased heart function or fluid retention; for 27. Answer 2: Diminished gag reflex increases
example, from renal system problems. Weak the risk for choking and aspiration. Function
stream of urination is related to incontinence of other reflexes is unrelated to gag reflex in
or enlarged prostate. this circumstance. Pain in the neck area is not
21. Answer 1, 2, 3, 5: Primary prevention focuses anticipated with a diminished gag reflexes.
on the strengths, resources, and abilities of Nutritional status would be a consideration if
the person; thus modifying lifestyle factors the patient is having ongoing difficulty swal-
and getting recommended vaccinations are lowing.
included. Treatment of disease to prevent 28. Answer 4: Encourage whole grains, fruit and
further deterioration is considered secondary vegetables, and high-quality protein. Fats,
prevention. refined sugars, and products made with white
22. Answer 3: When a certain amount is reached, flour offer more calories with less nutritional
Medicare recipients must pay 100% of the value. Fruits are preferred over juices because
cost of prescriptions up to a yearly maximum fresh fruits offer more fiber and less sugar per
out-of-pocket limit. After the maximum limit serving.
is met, the coverage gap ends and the pre- 29. Answer 2: Controlling incontinence is the is-
scription plan pays a percentage of the cost of sue; thus proposing a voiding schedule is the
covered drugs again. The statement about the most useful suggestion. Use of adaptive de-
dentist is not true. Generic medications are vices are for patients who have trouble hold-
less expensive and therefore preferable if okay ing or grasping a cup. Dividing fluid is used
with prescriber. The Affordable Care Act has when patients are on fluid restriction. Edu-

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 Answer Key  97  

cating about fluid intake is the second best coronary artery disease, which could be con-
option and many people recognize that they current with diabetes.
need to drink more fluid, but have a variety of 38. Answer 3: Total cholesterol level of 130 g/dL
excuses for not doing so. increases risk for cardiac disease and saturat-
30. Answer 1: Gastric motility can slow with age, ed fat should contribute no more than 7% of
so exercise is one way to stimulate peristalsis. calories/day. Fluid and fiber are more directly
The other options are interventions that ad- related to bowel function, but this is generally
dress loss of appetite and difficulty achieving good advice. Body mass index is important,
adequate nutritional intake. but people with normal or below-normal
31. Answer 2: Being overweight could contribute weight can have elevated cholesterol levels.
to gastric reflux and achieving ideal body 39. Answer 1: Levothyroxine is used to treat hy-
weight will help to solve the problem. Pa- pothyroidism. Without the medication, the
tients who do not drink milk need education symptoms of hypothyroidism will return.
about alternative calcium sources. Changes Heat intolerance, diarrhea, and weight loss
in bowel habits or sores that won’t heal need are symptoms of hyperthyroidism.
additional medical evaluation, possibly for 40. Answer 4: Generally, questions about sexuali-
cancer or other disorders. ty should occur after talking about other body
32. Answer 3: Assess the bowel pattern first; systems. This allows time for the nurse to
problems are often reported when there is a establish rapport with the patient and feelings
minor deviation from what is perceived as of discomfort should decrease. If the patient
normal elimination. Other options might be gives permission, this may also decrease the
considered based on assessment findings. nurse’s feelings of discomfort. Asking for help
33. Answer 1, 4, 5, 6: Blood pressure medication, is appropriate if unable to complete a task.
body mass index of 18.5-24.9 kg/m2, adequate Self-assessment should occur before the occa-
sleep, and avoiding secondhand smoke are sion to interview arises.
appropriate measures. Complex carbohydrates 41. Answer 1: As the patient reads the newspaper
and vegetable protein are desirable. Exercise is out loud, note accuracy of content and the dis-
recommended for most days of the week. tance that the patient holds the paper while
34. Answer 4: Patients with COPD frequently reading. Ask if the print seems clear. Suggest
have thick sputum, which is difficult to cough a follow-up appointment as appropriate. Yel-
up. Making sure that patients are well hydrat- lowing of the lens may affect color perception.
ed is the best way to thin secretions. The other Noting pupil reaction is not incorrect, but this
options are good teaching points for patients data is less relevant.
with COPD to help ensure adequate oxygen- 42. Answer 4: Primary open-angle glaucoma oc-
ation. curs very gradually and painlessly; visual loss
35. Answer 3: The nurse should assess for other begins with deteriorating peripheral vision.
signs and symptoms, especially those indicat- The other symptoms are associated with acute
ing a source of infection such as urinary tract angle-closure glaucoma which is a medical
infection or pneumonia. emergency that requires immediate attention
36. Answer 2: Assess for other injuries before at- to prevent blindness.
tempting any interventions or reporting to 43. Answer 2: Sitting directly in front of the pa-
health care provider. Resist the urge to im- tient allows the patient to watch the lips and
mediately put the patient back into bed. Addi- to look at facial expressions. Standing in front
tional helpers are needed and injuries can be of the window creates a glare that interferes
worsened by movement. with visualization of the nurse’s face and lips.
37. Answer 2: The symptoms that the patient Sitting beside the patient may be culturally
described are characteristic of adult-onset offensive; also visualization of nurse’s lips
diabetes and hyperglycemia is the laboratory will be difficult. Standing over the patient
result that is expected. Elevated thyroid- frequently occurs in the hospital, but this
stimulating hormone level would be associ- is never the best position from the patient’s
ated with hyperthyroidism. Elevated estrogen point of view if it can be avoided. In addition,
level is not expected for a 56-year-old woman; continuously leaning in to eye level would be
thus follow-up studies would be required. very poor body mechanics for the nurse.
Elevated serum cholesterol is a risk factor for

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 Answer Key  98  

44. Answer 1: Sudden change of behavior sug- good nursing care for any patient. Breast self-
gests a medical problem such as infection, or a examination should be done monthly.
metabolic, oxygenation, or perfusion disorder. 51. Answer 2: OBRA requirements include com-
The health care team needs to quickly identify prehensive resident assessments, increased
the cause and initiate treatment. The patient is training requirements for unlicensed assistive
temporarily restrained because of heightened personnel (UAP), greater number of nursing
risk for injury to self or others. Other patients staff, availability of social workers, standards
are also at risk for injury, but their issues for nursing home administrators, and quality-
should be managed without restraints. assurance activities. Availability of an om-
45. Answer 2: Parkinson’s disease is character- budsman is from the Long-term Ombudsman
ized by tremors, muscle rigidity, and hypo- Program which is a national effort to support
activity. Intellectual function is not impaired. the rights of residents and facilities. Disrepect-
Patients with Parkinson’s disease may have ing a resident is related to residents’ rights.
trouble articulating pain, but the disease itself Dealing with employees who disrespect oth-
is not characterized by pain. ers is usually the responsibility of the nurse
46. Answer 3: Hemianopia is blindness in half the manager. Immediate reassignment of a room
visual field; thus if patient does not turn head would be a common event.
to look at the whole tray, only half of the food
will be visualized. Sitting up and focusing on Critical Thinking Activities
chewing and swallowing are strategies for 52. Examples of nursing assessments are:
dysphagia. Difficulty manipulating utensils or a. Integumentary—Observe skin for signs of
small objects is related to hemiplegia. dryness, tears, lesions; observe condition
47. Answer 1, 2, 4, 6: An increased number of of hair and nails.
medications (including over-the-counter), b. Cardiovascular—Observe for edema and
prescribers, or pharmacies contribute to risk chest pain, monitor vital signs, check pe-
for the patient. A pill box is a reminder tool ripheral pulses.
that will not prevent polypharmacy, but may c. Respiratory—Observe respiratory effort,
prevent overdosing or underdosing due to monitor for activity tolerance.
forgetfulness. Seeing the primary health care d. Gastrointestinal—Observe integrity of
provider on a regular basis is a good way to oral cavity, assess characteristics of bowel
prevent the problems associated with poly- elimination, check intake and output
pharmacy. (I&O) and weight.
48. Answer 4: The nurse should follow up to find e. Urinary—Observe for frequency, quantity,
out the meaning of “whatever they want with color, or discomfort when urinating. Ask
you.” This is a cryptic statement that could about incontinence or problems with re-
underscore a minor issue or possible abuse. tention or difficulty passing urine.
Being left alone may need investigation if f. Musculoskeletal—Determine ability to
there appears to be a safety issue; however, perform activities of daily living, range of
the patient could be lonely. This is not an motion; check for muscle weakness, pa-
abuse issue, but the daughter may need sug- ralysis, and pain.
gestions about increasing social opportunities g. Neurologic—Observe behavior and re-
for her mother. Being invited to visit or asking sponses; check for presence of pain; iden-
for lunch are benign comments that could be tify level of awareness.
related to the patient’s age. h. Vision and hearing—Observe for eye
49. Answer 3: Explaining the benefit of ambulat- irritation or discomfort. Ask about blur-
ing is the best response. Negotiating for prom- ring, decreased night vision, or sensitivity
ises of future behavior invites manipulation. to glare. Assess visual acuity and use of
Being defensive or shifting the responsibility corrective lenses. For hearing, ask about
to the helath care provider invites further ar- subjective loss of hearing. Note behaviors,
guments. such as turning up volume on television,
50. Answer 3: One of the goals is to reduce emer- or failing to respond when spoken to.
gency visits due to falls. Checking blood Note balance when walking or perform-
pressure at least every 4 hours and reporting ing position change.
new symptoms are expected actions related to

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 Answer Key  99  

53. a. Do you have sensations of heartburn or to see if there are cultural, ethnic, or age
nausea? factors that are influencing perception of
How’s your appetite? others.
Describe your typical 24-hour dietary pat- Finally, the nursing student deserves
tern. Any changes? a chance that is not clouded by the behav-
Have you recently gained or lost weight? ior of others.
If so, how much and over what time pe- 55. The husband and wife are in the age group
riod? that has high risk for falls. The wife has al-
Have you had any pain or cramping? If ready fallen once, so the nurse would gather
so, please describe. information about what contributed to that
What is your typical bowel pattern? Any fall, because history of falls is a risk factor.
changes? If so, please describe. Both take blood pressure medication, so or-
Have you noticed a change in the color thostatic hypotension may be a problem. Ar-
or consistency of your stool? If so, please eas of the house are dark and there are many
describe. possessions in the house that may create ob-
b. For some patients, gastric reflux can be stacles (and need upkeep). Stairs are problem-
controlled by eating small meals, avoid- atic. For suggestions for fall prevention, see
ing eating before bedtime, elevating Safety Alert, p. 1101.
head of bed, and maintaining ideal body
weight. For the older adult with constipa-
tion, the nurse should promote adequate CHAPTER 33—CONCEPTS OF MENTAL
fluid intake, exercise, and a diet that con- HEALTH
tains fiber. Such foods include vegetables,
fruit, and whole-grain bread. Fill-in-the-Blank Sentences
54. a. There is no right or wrong answer to this 1. Mental illness
type of question. Your reaction to this 2. 50
question is likely to be based on personal 3. schizophrenia
experiences. Consider that the nurse ap- 4. psychotherapeutic
pears to have entered the job with an 5. housing; crisis
open mind. At that point, she had no
reason to judge people according to age Multiple Choice
or any other criteria. She was open to the 6. Answer 2: Displacement occurs when emo-
experience of interacting with and learn- tions are expressed toward someone or
ing from others. After she begins to feel something other than the actual source of the
more comfortable, she gravitates towards emotion. Projection is attributing to others
people whom she likes and enjoys. This is undesirable characteristics that the person
normal and expected behavior. The older has, but does not want to admit possessing.
staff members are then defined as being Identification incorporates a characteristic
rigid and slow. Based on their behavior, (thought or behavior) of another individual or
the nurse then superimposes that impres- group. Reaction formation is conscious behav-
sion on the older nursing student. Thus, it ior completely opposite to the unconscious
appears that the nurse is guilty of ageism, process.
at least toward the nursing student. 7. Answer 4: Regressive behavior is demonstrat-
b. In order to make the situation better, let’s ed by a return to behavior of an earlier age or
go back to where the nurse decides that stage of development. Laughing about abuse
the older staff members are rigid and would be a manifestation of dissociation. Act-
slow. This small sample of older nurses ing as though incontinence did not occur is an
may be excessively rigid and slow, but example of repression. Aggression can be sub-
they are coworkers so focusing on their limated by competitive participation in sports.
strengths, rather than their deficits, would 8. Answer 2: Anxiety can be defined as a vague
be one strategy. If there is truly a problem feeling of apprehension that results from a
(i.e., patient safety), then talking to the perceived threat to the self. Stress is the non-
nurse manager is another option. The specific response of the body to a demand.
nurse could also examine her own values

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 Answer Key  100  

Crisis can be defined as an unstable period in 14. Answer 3: Panic level of anxiety is demon-
a person’s life characterized by the inability to strated by extreme terror, possible immobility,
adapt to a change from a precipitating event. and a potential danger to self and others. The
Mental illness or disorder is a manifestation patient who is assisting another with a wheel-
of dysfunction (behavioral, psychological, and chair is using mild anxiety to problem-solve
biologic). and move towards productive action. The
9. Answer 1: The adolescent who is participating patient walking towards the safe area is prob-
in activities and has reasonably good grades ably arguing to relieve tension and increase
is demonstrating success at school, which is a feelings of control. The patient who is search-
possible positive factor. The other three ado- ing for the wedding ring recognizes that there
lescents have some evidence of dysfunctional is a problem, but severe anxiety is distorting
relationships: extreme sibling rivalry, lack of her ability to make a logical judgment.
mother-child bonding at birth, and excessive 15. Answer 4: If test results have a greater im-
parental expectations. pact on future life events, than the degree of
10. Answer 2: Setting small realistic goals is evi- anxiety is likely to be higher. The student who
dence of good mental health. Denial (“don’t has done well over the semester has a posi-
have any problems”) is way of coping, but tive history with studying and testing. This
for substance abusers it is the most common student probably would have done better
overly used defense mechanism. If one’s with sleep, but knows that he/she is likely
behavior is contingent on another’s success, to be okay. The student who sees the test as
then the relationship is not healthy. Rational- another hurdle is not threatened by the test-
ization is another defense mechanism and ing process, but is more likely to see the test
the speaker may also be projecting feelings of as a relatively mundane event. The smart,
being judged. Both can be used as excuses for busy student is also likely to have a lot of
continued substance abuse. stress because of the multiple stressful factors,
11. Answer 3: In every care setting on a daily but this student may have developed coping
basis, the nurse will care for patients who are strategies over time that have helped him/
vulnerable to stress, anxiety, and depression. her juggle multiple stressors. For example, the
In addition, recall that more than 50% of the student may recognize that excellent grades
population in the US is likely to have a mental are less important than passing grades when
health disorder in their lifetime. The other op- considering the context of his/her life circum-
tions are also true or partially true. stances.
12. Answer 2: The superego guides moral action 16. Answer 3: When a patient enters the hospital,
and allows the nurse to think and act at the he/she loses normal social, employment, and
highest level of abstraction. The ego is reality- family roles. Normal clothes, daily routines,
based and would cause the nurse to be fo- and control over own body are taken away.
cused on duties, although the id may mediate Acknowledging difficulties and offering self
to cause the nurse to ignore requests if those are two forms of therapeutic communica-
requests cause unpleasantness or threats to tion. Offering to call the health care provider
self-interest. The id would minimize an error, deflects the patient’s concerns away from the
because it would be easier and less painful nurse. Suggestion of wearing own clothes is
than taking responsibility for it. Obtaining okay, but the nurse should assess first, be-
CEUs is a reality-based activity driven by the cause the clothes may be the smallest issue.
ego. Leaving an angry patient does not help meet
13. Answer 3: The nurse could recall the memory, emotional needs.
but generally the memory, especially the pain- 17. Answer 2: First the nurse would assess for
ful parts, is repressed. This repression allows factors that may constrain the patient from
the nurse to have a relatively happy life. The fully participating in social interactions. Based
unconscious level holds memories that are not on the assessment findings, the nurse may use
readily recalled. The conscious level allows the other options.
vivid thoughts and memories. The id part of 18. Answer 2: “Did something happen?” Is a
the personality would drive attempts to expe- closed question and generally open questions
rience pleasure and block pain. are preferred; however, the child is young and
may have some difficulty fully articulating a

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 Answer Key  101  

problem at school. The nurse would assess the d. Panic anxiety is characterized by terror,
child’s nonverbal behavior as he/she answers possible immobility, and potential for
the question. The other questions might also harm to self or others. An example of
be used during the interview if there seems to panic would be a woman trapped in a
be a problem at school. burning building who is unable to move
19. Answer 1: Validating the son’s feelings helps or follow the directions of rescuers.
him to recognize that even though the situa- e. Possible coping responses are overeating,
tion is complex, he is not alone. Listening to oversleeping, overfunctioning (e.g., work-
him is supportive and therapeutic. The nurse ing excessive hours), drinking, smoking,
could consider using the other options to as- withdrawal, seeking out someone to talk
sist this family. with, yelling, exercising or performing
20. Answer 4: Standing close allows the nurse to other physical activity, fighting, pacing, or
assess the wife’s needs and nonverbal behav- listening to music. Defense mechanisms
ior. Closeness, touching, and hugging can be are listed in Table 33-1, p. 1117.
therapeutic if the wife is receptive to physical f. Examples of healthy coping could be
touch from nursing staff. The nurse would ask seeking someone to talk to. This behavior
if the wife needs assistance to notify family/ is reinforced by encouraging and iden-
friends before initiating the call. Making the tifying people who are willing to listen
patient comfortable and pain-free will help to and be supportive. Exercise is another ex-
comfort wife, but first the nurse should ad- ample of healthy coping; help the person
dress the wife’s immediate emotional distress. identify how he/she feels after exercise
Antianxiety medication is not needed at this and encourage regular “preemptive”
time. physical activity. The circumstances of
unhealthy behaviors such as drinking or
Critical Thinking Activities smoking should be identified. This will
21. a. In a mild anxiety state, the body is read- help the individual recognize when and
ied for action and reaction to danger. how the stress causes these unhealthy re-
Stressful demands are addressed with sponses.
problem-solving and constructive action. 22. a. Refer to Box 33-7 on p. 1120. Assessment
Mild anxiety is common and actually of emotional status includes the person’s
useful in situations where motivation re- general appearance, behavior, speech pat-
sults in purposeful action. For example, tern, thought content, mood and affect,
it is likely that most nursing students are sensory function, insight and judgment,
mildly anxious prior to an examination, and potential for harm to self or others.
so they focus on the material and devote Also ask the husband how Martha used to
more time to studying. respond to stress or change when she was
b. In moderate anxiety, tension is increased, younger. Current behavior may be an ex-
but perception is decreased. The person is aggeration of behavior at a younger age.
alert to specific information and may feel b. Older adults may experience social isola-
irritable with some physical signs such as tion, exaggeration of personality and be-
headache or increased vital signs. An ex- haviors, losses related to role, depression,
ample of moderate anxiety is the person and addictions. Care must be taken in as-
who has waited all day long in an airport sessment not to mistake changes that oc-
after repeated delays in flights and has cur with aging, such as sensory changes,
a relatively urgent need to reach his/her as manifestations of disorientation or mal-
destination. adjustment. For Martha, withdrawal and
c. Severe anxiety manifests as a narrowing helplessness may be a result of the recent
of perceptual field, with distortions in changes or losses experienced during hos-
communication and a feeling of impend- pitalization.
ing danger. An example of severe anxiety 23. The mentally healthy individual can suc-
is a bystander at the scene of a fatal ac- cessfully adapt to change, set realistic goals,
cident who is trying to call 911, but is problem-solve and enjoy life. Being able
having trouble clearly communicating the to juggle the schedule, assignments, and
situation to the dispatcher. demands of nursing school would be an ex-

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 Answer Key  102  

ample of successful adaptation to change. De- 18. False. Behavior that indicates a persistent de-
ciding to enter nursing school and graduate sire to be the opposite sex is termed transsexu-
within the designated amount of semesters is alism.
a realistic goal. Balancing your finances with 19. False. One in every 10 are affected.
tuition and cost of living is an example of 20. True
problem-solving. Enjoying life is more diffi-
cult in nursing school, but it is likely that as a Multiple Choice
nursing student, you are enjoying the interac- 21. Answer 2: During the manic phase, the pa-
tion with classmates. tient will display excessive energy; thoughts
24. In theory, deinstitutionalization was intended will rapidly shift from topic to topic. Physical
to be a humane and rational way to address motion can be excessive to the point of ex-
the needs of patients with mental illness. The haustion. In the acute phase, the nurse must
idea was to have patients return to live and assist the patient to stay focused enough to eat
function in the community with supportive and rest as much as possible. Inconsistency
services. Unfortunately, the lack of funding increases contention and agitation.
and abrupt closure of facilities resulted in 22. Answer 4: Drug therapy using clomipramine
large numbers of people being turned out into (Anafranil) has been of great value in treating
the streets with few skills and no resources. OCD.
People with chronic mental illness do better 23. Answer 2: Reduced salt intake is a possible
if family is available to remind them about contributor to lithium toxicity.
medication, appointments, etc., and to help 24. Answer 4: The best response is to state reality
them navigate the community mental health and then the nurse conducts further assess-
system. The prison system has had to absorb ment. The nurse may try to find the underly-
some of these individuals for behavioral is- ing feeling, but should try to phrase questions
sues that are more related to mental health that do not validate the reality of voices. For
disorders than to criminal intent. example, “What is the reason for not eating?”
If the patient persists in talking about the
voices, then redirecting is appropriate. For ex-
CHAPTER 34—CARE OF THE PATIENT WITH A ample, “Ignore the voices and come and help
PSYCHIATRIC DISORDER me wipe off the lunch table.”
25. Answer 3: The nurse recognizes that going to
Matching meet the wife (who is dead) could be a veiled
1. e suicide threat, a metaphor, a casual remark,
2. h or part of a hallucination or delusion. Because
3. a of the potential for suicide, this patient needs
4. j priority assessment. The nurse also needs to
5. b assess the content of the message from God
6. c as a possible command hallucination to harm
7. i self or others.
8. f 26. Answer 4: Hallucinations are considered a
9. d positive symptom; sensory distortion without
10. g a stimulus. Nurse should assess the patient
for possible sources of body odor or infection,
Fill-in-the-Blank Sentences as there is also a possibility of illusion, which
11. disorganized thinking is a misinterpretation of a real stimulus. Avoli-
12. anhedonia tion is a negative symptom. Akathisia is a side
13. alogia effect of some antipsychotic drugs.
14. flat affect 27. Answer 2, 4: Schizophrenia is frequently ac-
15. Apathy companied by psychotic features that can
16. multiaxial include paranoid delusions, hallucinations,
and severe disorganized thinking. Phobias
True or False are usually associated with anxiety disorders.
17. False. They usually do have insight. Mania is usually associated with bipolar dis-

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 Answer Key  103  

order. Redoing is a behavior associated with have laughed at the patient who hopped
compulsions. around.)
28. Answer 2: The patient is compelled to drive 35. Answer 2: The nurse would talk to the teen-
back and check the lock. The patient is ob- ager and assess for other symptoms such
sessed by the thought of disordered towels. as affect, emotional lability, and speech pat-
Voices in the head are a type of hallucination. terns. Content, consistency, and rationality of
Being afraid of spiders is a phobia. beliefs and ideas may also give information.
29. Answer 4: The woman is hypomanic and is The nurse can then point out to the neighbor
likely to feel very good about herself and the the normal findings and reinforce the need
world. At this point she has less incentive to to follow up with the provider. Advise the
seek medical attention, even though she could neighbor to tell the provider about family his-
progress to mania. tory. Comparing current behavior to previous
30. Answer 1, 2, 4: A person with neurosis re- behavior is not very useful, because normal
mains oriented to reality, with some degree adolescent behavior is generally quite differ-
of distortion of reality manifested by a strong ent from previous ages. The neighbor should
emotional response to the trigger event. Vari- be able to independently judge whether the
ous complaints of nervousness or emotional son’s religious beliefs are consistent with the
upset, compulsions, obsessiveness, and pho- rest of the family.
bias are common with a neurosis. A neurotic 36. Answer 1: Psychosomatic illness refers to a
person will often exhibit poor self-esteem and physical disorder arising as a result of a
have social relationships that suffer due to the psychological trigger. Posttraumatic stress
various complaints noted. Being out of touch disorder is related to experiencing an extreme
with reality and having impaired judgment life-or-death event that results in symptoms
are more associated with psychosis. that recur with triggering stimuli. Generalized
31. Answer 1: The information has to be shared anxiety disorder is characterized by excessive
with other team members to activate a multi- worrying about daily aspects of normal life.
disciplinary plan. Disclosures of harm to self Bulimia nervosa is an eating disorder.
or others cannot be kept in confidence. Sug- 37. Answer 4: The nurse can acknowledge that
gesting a spiritual advisor may be appropriate the feeling of being listened to would create
after assessing the patient’s spiritual beliefs. anxiety and fear. The other actions make it
Documentation and verbal discussions will appear that the nurse also believes that “they”
both occur. are listening. Moving to the garden could be
32. Answer 3: Talk to the patient first to assess the an option, but the nurse would say, “I don’t
gift-giving. Giving valued sentimental items think there is a problem with the intercom,
in conjunction with “remember me” could be but it’s nice day; we could go to the garden if
a signal of suicidal intent. The other options that would be more comfortable for you.”
might be used after the initial assessment. 38. Answer 4: The nurse’s goal is to reflect real-
33. Answer 2: All of these people are having ity in the most accurate way possible, thus
stress related to a life event, but psychologi- the nurse makes a general statement about
cally, the person who has just been released how television advertisements affect all view-
from prison faces the greatest changes in ers. The nurse needs to recognize that ideas
integrating back into society and is likely to of reference are theorized as demonstrating
have fewer resources or skills to help him/her the patient’s need to feel special. “He wasn’t
adapt. really talking to you” demeans the patient’s
34. Answer 2: Patients who have schizophrenia feelings. “You can’t buy it right now” is real-
display concreteness and will have trouble ity, but signals the nurse’s agreement that the
with metaphors or similes or idiomatic lan- advertisement was just for the patient. Asking
guage. Patients with dementia will also dem- about interest in motorcycles is possible if the
onstrate concreteness. (Note to student: The nurse feels that the patient would benefit from
nurse might consider talking to the staff mem- a “normal” conversation topic.
ber about use of language forms when talking 39. Answer 2: The nurse must first assess what
to patients. The goal of the unit is to move pa- the patient considers as disturbing. Although
tients toward normal everyday conversation, closing the door, turning off lights, and de-
but it is also likely that other patients would creasing sources of sound are good general

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 Answer Key  104  

practices, the patient with an anxiety disorder group activities, and no evidence of sui-
may actually become more anxious if left cidal thoughts.
alone in the dark to contemplate tomorrow’s b. Specific treatments for a patient who is
surgery. depressed are antidepressant medications,
40. Answer 2, 3, 4: A very small amount of cur- participation in group activities, promo-
rent induces a controlled and brief grand tion of self-care (hygiene, grooming), and
mal seizure. Confusion and memory loss are electroconvulsive therapy (ECT) if the
expected, but both are transient. The patient medication is not effective.
does not experience pain and the treatments c. Medications typically used for the de-
are frequently done on an outpatient basis. pressed patient are Prozac, Desyrel, Elav-
il, Tofranil, Zoloft, and Effexor.
Critical Thinking Activities d. Side effects: hypotension, anticholinergic
41. a. Refer to Box 34-1 on p. 1130. Warning effects, dry mouth, increased or decreased
signs of suicide are withdrawal from appetite, headache, blurred vision, chang-
family or friends, talking about death or es in heart rate/rhythm
suicide, giving away prized possessions, Nursing actions: vital signs, check BP,
drug or alcohol abuse, personality chang- candy or gum for dry mouth, advising pa-
es, signs of depression, and previously tients on MAOIs to avoid foods with tyra-
failed suicide attempts. mine (red wine, beer), monitoring overall
b. Refer to Box 34-1 on p. 1130. Assess both effects
patients for a plan and means to carry
out the plan. (Note to student: A detailed
plan with a realistic means to carry it CHAPTER 35—CARE OF THE PATIENT WITH
out increases the risk.) Precautions to AN ADDICTIVE PERSONALITY
be implemented for the elderly resident
include removing articles that could be Matching
used for suicide (shoelaces, sharps), re- 1. c
moving furniture, moving patient close to 2. e
nurses’ station, checking the patient every 3. f
15 minutes, obtaining order for 1-to-1 ob- 4. a
servation as necessary, instructing visitors 5. i
not to leave gifts, making sure all medica- 6. b
tion is swallowed, attending the patient 7. d
during meals (silverware), and making 8. g
frequent therapeutic verbal contact. The 9. j
patient with quadriplegia will need some 10. h
different interventions. For example, fam-
ily counseling may be needed, because True or False
the resident may try to enlist someone 11. False. It is possible to suffer from more than
from the family to assist in the suicide. one addiction at the same time. An example is
The resident could also stop eating or the alcoholic person who is also a smoker and
start refusing treatments such as antibiotic a compulsive gambler.
therapy for infections or even routine hy- 12. True
gienic care. Frequently checking the pa- 13. False. There has been a decrease in alcohol use
tient and therapeutic communication are over the years that experts attribute to educa-
necessary, even if the nurse determines tion of the public and laws set forth to limit
that the likelihood of suicide attempt is availability to minors.
low because of the quadriplegia. Both pa- 14. True
tients may benefit from additional consul- 15. True
tation by the clinical nurse specialist. 16. False. Marijuana is the most commonly used
42. a. Possible outcomes for a patient with illicit drug in the United States.
depression are verbalization of feelings, 17. False. Currently, there is no mandatory report-
completion of ADLs, participation in ing for suspected abuse. Healthcare Integrity
and Protection Data Bank (HIPDB) requires

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 Answer Key  105  

federal and state government agencies (in- and respiratory arrest in most people. See
cluding nursing boards and health agen- Table 16-1, p. 433 and Table 35-2, p. 1159 for
cies) to report all final adverse actions taken additional information.
against a health care provider, supplier, or 22. Answer 4: The nurse would first assess the
practitioner. current consumption of food and drink,
which are the usual sources of caffeine. Sup-
Short Answer plements and over-the-counter medications
18. (a) Excessive use or abuse, (b) display of psy- can also contain caffeine. The nurse may de-
chological disturbance, (c) decline of social cide to use all of the questions.
and economic function, and (d) uncontrollable 23. Answer 3: If heavy users stop suddenly, with-
consumption, indicating dependence. drawal symptoms occur including craving,
19. (a) Low stress tolerance, (b) dependency, (c) irritability, restlessness, impatience, hostility,
negative self-image, (d) feelings of insecurity, anxiety, confusion, difficulty concentrating,
and (e) depression disturbed sleep, increased appetite, and de-
creased heart rate.
Table Activity 24. Answer 4: Withdrawal signs and symptoms
20. Disorders Associated with Alcoholism (See are not anticipated for abuse of hallucinogens.
Table 35-1, p. 1149.) 25. Answer 1, 2, 5: Characteristics of amotiva-
tional cannabis syndrome are decreased
System Disorders goal-directed activities, abrupt mood swings,
Gastrointestinal Gastritis; pancreatitis; cancer abnormal irritability and hostility, apathy, and
(GI) of mouth, esophagus, and decline of personal grooming. Depression,
stomach; esophageal varices; paranoia, and suicidal thoughts or attempts
GI bleeding; malabsorption of are possible.
nutrition; ascites 26. Answer 1: The patient is developing a toler-
ance, which is expected when patients are
Hepatic Hepatitis, cirrhosis, fatty prescribed opioids for acute pain; abstinence
liver, liver failure, hepatic will resolve the problem. The nurse should
encephalopathy not recommend medications; this is outside
Cardiovascular Hypertension, enlarged heart, the scope of practice. For patients who have
and blood high cholesterol, heart failure, chronic pain, continued opioid prescriptions
disorders portal hypertension, low can result in addiction, but at this point, the
blood sugar, anemia, poor patient is still having acute pain. The health
clotting ability, increased care provider is unlikely to increase the dos-
susceptibility to infection age, because the fracture is healing; he/she
Respiratory Decreased cough reflex, will probably recommend NSAIDs.
aspiration pneumonia 27. Answer 3: When friends and family begin
to query use, this is a sign that a problem is
Uroreproductive Prostatitis, impotence, urinary developing and the nurse can help the friend
flow problems evaluate behaviors of an alcohol problem.
Musculoskeletal Myopathies, bone fractures Substance use becomes a problem when the
from falls, joint damage from user loses control and obtaining and using the
injury substance begin to exert control over the indi-
vidual. The form of alcohol is irrelevant. If the
Neurologic Neuritis, organic brain
friend has talked to her boyfriend, it is likely
diseases such as Wernicke’s
that he would deny or minimize the problem.
encephalopathy and
28. Answer 4: The nurse paraphrases the moth-
Korsakoff’s psychosis, nerve
er’s underlying source of guilt. Denial is a
palsies, gait changes, short-
normal and typical response for most family
term memory loss
members. The other responses are also par-
tially true and the nurse may decide to use
Multiple Choice
them at the appropriate time.
21. Answer 4: A blood alcohol level of >500 mg/
29. Answer 2: While all of these factors are pres-
dL (>0.50%) will cause respiratory depression
ent in the middle stage, abuse of many dif-

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 Answer Key  106  

ferent types of substances is most likely to Critical Thinking Activities

hasten progression to the late stage. 38. a. Possible contributing factors to alcohol
30. Answer 3: Many Asians, American Indians, abuse include genetics, deficiencies in
and Inuit have deficiencies in the enzymes hepatic enzymes, personality traits, or
that metabolize alcohol. Alcoholism is higher cultural/familial behaviors.
in these ethnic groups than in the general b. The CAGE questionnaire has four ques-
public. Jews, Mormons, and Muslims have tions that can be used to assess alcohol-
very low rates of alcoholism, whereas the ism. Two or more “yes” responses to any
French and the Irish have high rates. of the four questions suggests alcoholism.
31. Answer 4: All of these patients have serious (See Box 35-2, p. 1149.)
problems; however, alcoholism is a national c. The family can experience anger, frus-
health problem surpassed only by heart dis- tration, guilt, or denial. Family can in-
ease and cancer. In addition, the increasing advertently contribute to alcohol abuse
number of elderly patients who need com- of affected member with codependent
plex health care services is a national issue. behavior, such as making excuses or over-
32. Answer 1: All of these statements about compensating. Family members can be
alcohol are true, but vitamin B1, folic acid, advised to seek help for themselves.
and vitamin B12 deficiency are caused by the 39. a. At this point, the nurse may decide to
prolonged use of alcohol, which has a toxic continue observing for other behaviors
effect on the intestinal mucosa that results in that the night-shift nurses display or to
decreased absorption of these nutrients. collect more data about the patients who
33. Answer 3: If the nurse suspects alcohol with- were having the pain before drawing a
drawal, then the nurse gives the patient a conclusion. Or the nurse may decide to
matter-of-fact explanation about symptoms discuss the patients’ reports with a super-
and directly asks the patient about alcohol visor.
use. Assessing for pain is a correct action, but b. Specific role-related signs of the chemi-
recall that the symptoms could also be related cally impaired nurse are requesting night-
to other conditions such as pulmonary embo- time assignments, making frequent trips
li, anxiety, or hypoglycemia. The nurse would to the bathroom, being absent from the
call the provider to report findings. A blood unit, being involved in inaccurate opioid
alcohol level is not useful if withdrawal is oc- counts or noting excessive wasting of
curring. Making the medical diagnosis is out opioids, charting illogically or carelessly,
of the scope of nursing practice, but gathering having patients who do not get relief from
data to give to the health care provider is a pain medication, and making mistakes in
nursing responsibility. treatments. (See Box 35-10, p. 1160 for ad-
34. Answer 1: Delirium tremens (DTs) is a com- ditional information.)
plication of alcohol withdrawal. The risk of c. The chemically impaired nurse is referred
death from this complication is as high as for a peer-assistance program for treat-
15%, even with treatment. ment and supervision in order to main-
35. Answer 2: Denial is the most commonly used tain licensure.
defense mechanism used by substance abus- d. The Healthcare Integrity and Protection
ers. Data Bank (HIPDB) is a national data
36. Answer 1, 2, 3, 4, 6: Elevated liver enzymes, bank wherein federal and state govern-
hypoglycemia, abnormal clotting times, and ment agencies are required to report all fi-
abnormal blood protein levels occur with al- nal adverse actions that are taken against
coholism. Magnesium levels will be decreased a health care provider, supplier, or prac-
in some cases. It is not uncommon to find ane- titioner. This is an incentive for impaired
mia. professionals to seek treatment.
37. Answer 2: Respiratory depression is the most e. Nobody wants to be a tattletale, especially
serious problem and the airway should be if the coworker is a friend. Also, when an
assessed and managed to prevent aspiration. incident happens, the morale of the unit
The other actions are also important. is affected. Seeking advice and counseling
is helpful during these dilemmas and if
injury to a patient is prevented, then the

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 Answer Key  107  

outcome is positive, even for the impaired 13. Answer 3: Telehealth is best utilized for pa-
nurse who will have to participate in an tients who need monitoring for standard
assistance program and have extra super- measurements such as vital signs and blood
vision. glucose. The other patients will require a
home health professional to go to the home
and perform the skill or do the assessment.
CHAPTER 36—HOME HEALTH NURSING 14. Answer 4: For entry into the system, Medicare
and Medicaid require an interdisciplinary
Fill-in-the-Blank Sentences treatment plan that outlines frequency and
1. legislative; regulatory; health care duration. The health care provider must have
2. 60 a face-to-face visit with the patient and the
3. physical strengths; functional abilities provider must sign the plan.
4. Medicare 15. Answer 1: The patient who is able to eat with-
out choking has returned his/her pre-stroke
True or False functional ability (restorative). The patient
5. False. Licensure by the state is only one type who stops smoking has improved and moved
of home health agency. Other methods are towards a higher level of health (improve-
certification by state or by need and accredita- ment). The patient who is routinely exercising
tion by an outside agency. is maintaining current level of health (main-
6. False. Medicare and Medicaid have specific tenance). The patient who is compliant with
requirements that must be met in order to recommended diet is using health promotion
qualify. People who do not have private insur- information to minimize health disorder (pro-
ance or those who cannot pay out-of-pocket motion).
expenses must often rely on self, family, or 16. Answer 2, 3, 4, 5: The LPN/LVN can perform
friends. skills related to medication administration
7. True and the ongoing monitoring of parameters
8. False. Medicaid is coverage for all ages. Medi- such as vital signs, blood glucose readings,
care is for those over the age of 65. and assessment of physical status. Reinforcing
9. False. DRGs are used to set a pay rate accord- dietary information is also appropriate. The
ing to diagnosis for hospitals to receive Medi- RN is responsible for the admission assess-
care reimbursement. ment and should review and evaluate the pa-
10. True tient’s progress to determine if goals are met
or if the plan must be recertified by the health
Multiple Choice care provider.
11. Answer 4: Occupational therapy will suggest 17. Answer 3: Medicare will not cover visits that
assistive devices such as eating utensils that only involve household chores. The patient
are easier to manipulate and exercises that must require some skilled nursing or physical
that can build fine motor control and coordi- therapy service and then a home health aide
nation. The health care provider would sign is able to provide personal care and physical
the plan of care that would include occupa- assistance.
tional therapy. Physical therapy assists with 18. Answer 4: The aide should be given specific
issues of mobility, strength, and balance. The information about what to look for and what
home health aide assists with ADLs as need- to report. All team members should foster in-
ed. dependence rather than doing everything for
12. Answer 2: “No Smoking” signs should be the patient. The nurse should direct the aide
clearly visible to decrease risk of fire. Water- as to type of bath procedure, because the pa-
based gel is recommended for lips. Disposable tient may be used to taking a bath, but physi-
equipment should be examined frequently cal condition now makes getting in and out
and changed as needed. Once a month is like- of the bathtub very dangerous. Instructions
ly to be too long for some items; heat, humid- to “report problems” is too vague. This puts
ity, hygiene, and maintenance of equipment the aide in the position of having to determine
are factors affecting the equipment. Wool what is or is not a problem.
blankets are likely to increase static. 19. Answer 3: The supervisor would first ask the
nurse to describe a typical home visit to assess

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 Answer Key  108  

what the nurse is doing and how the time is motivation, creativity, clinical proficiency,
being spent. Based on the assessment of the flexibility, compassion, empathy, and patience
nurse’s performance, the supervisor may also are all essential attributes. Good communica-
consider using the other options. tion skills—both written and spoken—are
20. Answer 1, 3, 4, 5: Home health documenta- necessary. The ability to work alone, follow
tion is similar in purpose to any health care directions, recognize important changes in
documentation. When quality of care is condition, and assist in patient teaching are
recorded, assessment and improvement of needed. It is important to understand and
care can occur through review of documenta- practice the concept of teamwork. Nurses
tion. All patient records are legal documents. who prefer the structure of the institutional
Reimbursement is even more closely tied to setting and benefit from immediate direction
documentation in home health because of and frequent peer support find the indepen-
Medicare and Medicaid regulations. Docu- dence of home care practice difficult. (Note
mentation does not replace verbal communi- to student: Home health may not be the ideal
cation. The family does not have free access to first job for a new nurse because of the level of
patient records. Rights to privacy continue in independence that is required. If you choose
the home setting. to do home health as your first job, make sure
that your prospective employer offers a good
Critical Thinking Activities preceptor program and ongoing clinical sup-
21. a. The RN should do the initial assessment. port.)
The LPN/LVN works under the supervi- 23. Admission to the home health care agency in-
sion of the RN and observes wound heal- cludes a complete patient evaluation, environ-
ing and performs/teaches wound care, mental assessment, identification of primary
monitors blood pressure, and the patient’s problems, family/support person assessment,
self-care efficacy for management of dia- determination of level of knowledge about
betes. All care and observations are care- care, involvement of the patient in the plan,
fully documented to meet the standards notification of patient rights, costs, billing,
of Medicare and third-party insurance and information on advance directives.
companies. Differences between home care and acute
b. RN or LPN/LVN must ensure that appro- care admission would be the explanation of
priate instructions are given. Delegation costs and billing related to different funding
of interventions to assistive personnel in sources. The home environment is considered
the home can include provision of hygien- in the overall discharge planning in an acute
ic care and assistance with other activi- care facility, but the home environment as-
ties of daily living, measurement of vital sessment is more in-depth and detailed by
signs, glucose monitoring, and possibly the home health nurse. Also, the home health
medication supervision. nurse is more likely to obtain a better assess-
c. i. Physical therapy—Services provided ment of family and community support.
by a qualified and licensed physical
therapist, with the goal of treatment
being restorative.
ii. Home health aide—A primary skilled
or therapy service must be needed
before HHA services can be provided.
22. Personal and professional attributes described
for RNs also apply to the LPN/LVN. Indepen-
dent practice is not allowed, but self-direction,

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 Answer Key  109  

CHAPTER 37—LONG-TERM CARE ambulating. Shopping would be considered

an instrumental ADL. Occasionally, CNAs
Table Activity will assist with shopping; for example, when
See Box 37-1, p. 1182. the patient lives at home. In long-term care
settings, this duty would be less common. So-
Definition of Services to cialization is important and will occur as the
Terminology Support Older Adults CNA and nurse interact with the patient, but
1. Respite care Scheduled stays for the is not technically considered an ADL.
older adult to give the 12. Answer 2: The subacute unit offers the skilled
caregiver a break from the nursing services that the patient will require
responsibility of providing and he needs these services for a limited time.
care. 13. Answer 3: OBRA defines requirements for the
quality of care given to residents and covers
2. Daycare Facilities are frequently many aspects of institutional life, including
used by family members nutrition, staffing, qualifications required of
and caregivers who work personnel, and many others. Use of restraints
during the day. for confused patients would be a considered
3. Home health Includes homemakers, a violation of OBRA. The nurse could review,
care shoppers, respite care but does not update, the residents’ advance
workers, personal care directives. Medicare and Medicaid place
attendants, home health many stipulations on long-term care and the
aides, and nursing care goals of these programs are intertwined with
staff. OBRA, but the nurse is not responsible to en-
4. Nutrition Senior centers serve meals sure that the residents are qualified for Medi-
programs or home delivery of one care or Medicaid.
hot meal per day. 14. Answer 4: This couple mostly needs help with
ADLs; an assisted-living facility would sup-
5. Senior centers Centers that provide rec- ply their needs, but would also allow them to
reational activities, lunch, live in relative independence as a couple with
health screening, exercises their own belongings in their own private
classes, educational classes, space.
and transportation to and 15. Answer 1, 2, 3, 4, 6: Ideally, everyone except
from the site if needed. the other residents can be involved in the
6. Transportation Service for grocery shop- meeting, because all have a contribution to
services ping or medical appoint- make to the overall care plan. Including other
ments. residents would be a violation of privacy and
confidentiality.
True or False 16. Answer 3: A primary concern for any patient
7. False. The need for long-term care arises population is safety, but for the nursing home
when an individual is not capable of meeting residents safety is emphasized because the
daily needs independently. residents are likely to have physical and cog-
8. True nitive deficits or changes related to aging that
9. True increase the risk for injury. Communication,
10. False. PACE has 88 sites in 29 states and re- documentation, and assistance are also impor-
quires only that the patient be 55 years of age tant.
or older, live in a “service area,” be screened 17. Answer 1: The RAI is a comprehensive assess-
by a group of health professionals, and sign ment that is done at admission. The intent is
and agree to enrollment terms. to look at all aspects of the residents’ status.
The information is used to develop an indi-
Multiple Choice vidualized plan of care for each resident.
11. Answer 1, 2, 4, 6: Activities of daily living 18. Answer 3: It is typical for summaries to be
(ADLs) include the routines of hygiene, done monthly. If there were any acute changes
dressing and grooming, toileting, eating, and noted they would be documented as they oc-
curred.

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 Answer Key  110  

19. Answer 3: First, the nurse would ask the fam- have to be liquidated and used initially.
ily what they have been considering. It is If that money runs out, she might be eli-
likely that repeat episodes of wandering have gible for Medicaid. Medicare may cover
triggered some preliminary thoughts or inves- some of the costs if your grandmother has
tigation of some options. The other questions a specific medical condition that needs
could also be used after the family discloses treatment; for example, a broken hip. But
initial ideas and concerns. if she just needs help with ADLs or the
20. Answer 2: For the benefit of the resident, the functional activities of living, you should
CNA should be invited to attend. The resi- not count on Medicare. Many families are
dent is currently not adjusting to being in the paying out-of-pocket for long-term care
facility, and the positive relationship with the for their elderly relatives.
CNA should be incorporated into the plan of 23. All nurses need to have an awareness of how
care. Also the CNA may be doing something legal aspects affect their practice. In long-term
with or for the resident that others should also care, the nurse will care for the residents for
be doing. extended periods of time. The residents are
more likely to be elderly, possibly confused,
Critical Thinking Activities and to have given power of attorney to some-
21. a. The usual patient or resident in a long- one or to have a guardian. Elderly residents
term care facility demonstrates cognitive will frequently rely on health care staff to ex-
impairment, incontinence, inability to plain and interpret complex information. The
perform ADLs, and an inability to be sup- nurse must know who to call and when to
ported in a home environment. Residents call if problems occur. The nurse must make
usually experience cardiovascular disease the immediate interpretation of the advance
(hypertension and stroke), mental and directives when there is illness or injury and
cognitive disorders (Alzheimer’s), and will have to make the decision whether to call
endocrine disorders (diabetes). If you see 911 or to perform comfort measures or other
yourself as a good match for these pa- interventions.
tients, long-term care is an option for you. In an acute care facility, patients stay a
b. Medications in long-term care facilities very short time and the goal is to care for im-
may be administered by certified medica- mediate needs and then discharge them back
tion aides or technicians because of the into the community. There are usually more
large number of residents who require resources in acute care facilities for decision-
medications. There is also a 2-hour win- making. Decisions such as informed consent
dow of administration in this setting be- for major procedures are handled by the
cause of the volume of administration. health care provider. While all patients are
If you are about to graduate from encouraged to complete advance directives,
nursing school, the idea of allowing medi- the directives are usually not needed for the
cation aides to do this important duty majority of patients whom the nurse cares for
may make you feel uncomfortable. Del- on a daily basis. During acute care, the fam-
egation, assignment, and supervision of ily is frequently at the bedside for a portion
personnel is a learned skill that will come of the day and available to answer questions;
with opportunity and practice. Work be- whereas in long-term care, family is more
side the medication aide to see how he/ likely to visit on weekends or holidays.
she performs and discuss scope of prac-
tice. This will help you develop trust in
other coworkers and leadership skills. CHAPTER 38—REHABILITATION NURSING
22. a. See Box 37-4, p. 1187.
b. Funding long-term care is an important Matching
issue for most families and it is likely that 1. c
your family is or will be concerned about 2. a
this issue. If your grandmother has long- 3. d
term care insurance, than you are lucky, 4. e
because many people do not. If your 5. b
grandmother has any assets, those will

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 Answer Key  111  

Fill-in-the-Blank Sentences of DVT. Fluid restriction would contribute to

6. chronic illnesses the development of DVT. Application of heat
7. functional; complications; environment could mask the symptoms.
8. behavioral; image; dynamics 21. Answer 4: Observation is the best method to
9. goal-oriented (outcome-oriented) determine the level of assistance required.
10. adapt For example, if the patient can manipulate a
11. charge spoon, he can probably manipulate a comb.
12. educator; caregiver; counselor; care coordina- Asking the UAP to assist as needed is inap-
tor; case manager; patient advocate; consul- propriate delegation and this places the as-
tant; researcher; administrator; manager sessment of the patient’s abilities on the UAP.
13. variants Patient may overestimate or underestimate
14. developmental potential abilities by self-report; however, asking the
15. early patient for input is part of the overall plan.
Reading the documentation is also appropri-
Multiple Choice ate, but the patient’s status may have changed
16. Answer 1: Level of injury is at thoracic spine and a baseline assessment for rehabilitation
T1-T12 and involves paralysis of lower ex- therapy is needed.
tremities. Paralysis of bladder, bowel, and 22. Answer 4: Sitting in a stable chair will allow
sphincters; pain in chest or back; abdominal the patient to independently manipulate the
distention; and loss of sexual function are soap, water, and washcloth. She can wash and
other potential symptoms. Patient will have rinse herself. Getting in and out of a tub is dif-
use of the upper extremities. ficult for many older people. In addition, pa-
17. Answer 3: Level of injury is at cervical spine tients with hip fractures are usually instructed
C2-C7 and involves paralysis of all extremities to avoid hip flexion. The patient could lose
and trunk, respiratory failure, bladder and balance and fall, even if the UAP is very close
bowel disturbance, bradycardia, perspiration, by. Using a bath basin may be appropriate in
elevated temperature, and headache. Immo- some circumstances, but generally patients
bility increases risk for respiratory infections. are encouraged to get out of bed if they are
Cognitive problems are not anticipated unless able to, because ambulation prevents many
there is a concurrent head injury or if there are complications.
complications such as sepsis or hypoxia sec- 23. Answer 3: Most people benefit if distractions
ondary to perfusion problems. are minimized during learning; however, the
18. Answer 1: Patient has sustained a mild brain patient with traumatic brain injury is the most
injury and headache and vertigo are expected likely to have trouble concentrating and fo-
findings. Difficulty with judgment and rea- cusing on new information.
soning accompany moderate injury. Pro- 24. Answer 2: If the patient can independently
longed posttrauma amnesia and behavioral stay at home and the spouse acknowledges
problems accompany severe injury and coma- this ability, then one person is unemployed
tose or unresponsive states are characteristic rather than two. Continuously working to-
of catastrophic injuries. ward an unrealistic goal will only increase the
19. Answer 3: Autonomic dysreflexia is frequent- stress for patient and spouse. If the spouse
ly caused by a distended bladder and removal quits her job, than her fears for her husband
of the source of irritation should resolve the may subside, but it is likely that financial is-
problem. Sitting or high Fowler’s is the posi- sues will eventually cause stress. The patient
tion of choice to decrease intracranial pres- can acknowledge the spouse’s stress, but tell-
sure. Giving an antihypertensive medication ing her to stop worrying is unlikely to be suc-
may result in hypotension once the source of cessful.
irritation is located and removed. Calling the 25. Answer 1, 2, 3, 4, 6: Air-filled cavities in the
provider is appropriate if initial nursing mea- body (ears, lungs, and gastrointestinal tract)
sures do not resolve the problem. and organs enveloped by fluid-filled cavities
20. Answer 2, 4, 5, 6: Passive and active range-of- (brain and spinal cord) are most susceptible
motion exercises, anticoagulants, and elastic to compression damage from high-explosive
stockings are preventive measures. Vigilant blasts. Airborne debris embedded in any
assessment is needed to identify development body part comprises the secondary injury cat-

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 Answer Key  112  

egory. Injuries that occur from being thrown cation by health care providers, and patient
as the result of an explosive shockwave are and caregiver’s willingness to participate.
considered tertiary. Inhalation and exposure Cancer is the most common diagnosis in hos-
to toxic chemicals, traumatic amputations of pice, but any terminal conditions could also
limbs, and burns are examples of quaternary be included. Informing family members is
injuries. Myocardial infarction is not part of correct, but the patient and primary caregiver
the expected injury pattern; however, it could will generally be making the decisions and
occur if the patient has a preexisting condition comfort is the goal, rather than life support.
or secondary to injuries that cause blood loss 8. Answer 1: Respite care is a period of relief
or decreased oxygenation. from responsibilities of caring for a patient.
Palliative care consultant gives advice about
Critical Thinking Activities relief of patient’s pain or symptoms. Bereave-
26. a. In a rehabilitative assessment of a patient ment counseling assists family/caregiver after
with a traumatic brain injury, the nurse the patient has died. The hospital ethics com-
may expect to see inconsistent perfor- mittee advises about ethical issues such as
mance of activities, anger, depression, and discontinuation of feeding.
frustration. There may be multiple prob- 9. Answer 1, 2, 4, 6: Anticholinergics help to
lems with cognition along with a lack of manage excessive secretion. Anticonvulsants
initiative. Egocentric behavior is normal. are prescribed for neuropathic pain. Antiemet-
b. Most patients with traumatic brain inju- ics are for nausea and vomiting. Anxiolytics
ries require physical, cognitive, and psy- are for anxiety and reduced anxiety helps to
chosocial intervention for many years, if decrease the subjective experience of pain.
not the remainder of their lives. Emphasis Anticoagulants and antihypertensives could
is on attainment of a maximum level of be ordered, but are less emphasized in hos-
functioning, whether it is a return to an pice care.
occupation or achievement of basic ADLs. 10. Answer 4: The explanation of “managing the
c. Examples of possible outcomes for pa- pain and keeping him alert” reassures the
tients with traumatic brain injuries are: wife that specific and measurable goals are
Will demonstrate ability to perform ADLs being met. The other responses are partially
related to grooming by combing own hair. correct, but vague responses are less helpful
Will remain injury-free. to the wife.
Will demonstrate an awareness of safety 11. Answer 3: Primary caregiver and patient are
hazards. encouraged to live and enjoy life; thus go-
ing to an occasional movie or taking a break
would be advisable. The patient and family
CHAPTER 39—HOSPICE CARE may decide that a long-term care facility is a
good choice, but this is just one of many op-
Fill-in-the-Blank Sentences tions that should be presented to the whole
1. cancer family. Hoping for remission would not be a
2. Curative treatment hospice goal; however, hope for realistic goals
3. professional staff visits; medication; equip- would be encouraged (e.g., hope to live for
ment; respite; acute daughter’s wedding). The patient should be
4. Palliative care offered food and fluids, but the emphasis is
5. in the last 6 months not on healing and recovery. Emphasis is on
helping the patient’s symptoms (e.g., taking
Table Activity some fluid will help relieve dry mouth and
6. See Table 39-1, p. 1213. eating prevents hypoglycemia symptoms).
12. Answer 2: The nurse is first and foremost a
Multiple Choice patient advocate. Giving the patient the op-
7. Answer 3: The patient and the primary care- portunity to continue or stop is way of show-
giver must desire and be willing to participate ing respect and giving the patient control. The
in planning care. Hospice care should be other options could also be considered once
available without discrimination; however, the nurse knows that the patient desires to
there are criteria related to prognosis, certifi- have the rituals continue.

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 Answer Key  113  

13. Answer 4: The volunteer coordinator’s re- liquids. Favorite foods should be held until
sponsibility is to assess the patient and fam- patient feels well enough to enjoy them.
ily’s needs and to train the volunteers and 20. Answer 4: Assess discomfort and bowel func-
match them with the patient and family; thus tion before offering any other interventions.
the situation needs to be reassessed, the vol- 21. Answer 3: Stomatitis is an inflammation of
unteer needs to be retrained, and possibly a the tissues in the mouth. It is uncomfortable
different volunteer should be assigned to this to eat; therefore, hygiene and swabbing the
family. mouth help relieve the discomfort. Antiemet-
14. Answer 2: The nurse will recognize that the ics are given to decrease nausea and vomiting.
aide spends a lot of time with the patient, so it Weighing the patient is not recommended,
is natural for them to develop a rapport. Fre- because the patient will feel depressed about
quent reports from the aide will be valuable weight loss and weight gain is unlikely. Bring
to the entire team. The nurse may also decide meals in, if cooking smells seem to be affect-
to use the other options. Praising reinforces ing the patient.
desirable behavior. Reminding about scope of 22. Answer 1: The patient and family need emo-
practice may be appropriate if the aide starts tional support in understanding and experi-
giving the patient advice about personal or encing this untreatable condition. The other
health problems. Having rapport and trust options are possible, but rarely considered at
with a patient is always desirable. this stage.
15. Answer 4: The nurse coordinator coordinates 23. Answer 2: Applying oxygen will make the
the services of the hospice team, which in- caregiver feel better while the nurse is on the
cludes the physical therapist, who would be way. The “death rattle” is often heard 24-48
the specialist to actually teach the wife how to hours before death, so the nurse should go to
do the transfer skills. It is likely that the nurse the house, support the caregiver, explain the
coordinator will have to assess and document death rattle, and help the caregiver prepare
the patient’s abilities for purposes of obtain- for imminent death. Bronchodilators can be
ing health care provider’s orders. The assess- used for dyspnea and air hunger when appro-
ment data are also used for reimbursement. priate. Calling 911 is not appropriate. Pooling
16. Answer 2: ESAS addresses the areas of pain, of mucus and fluids is the cause of the noise,
tiredness (lack of energy), drowsiness, nau- and is somewhat expected; however, explain-
sea, appetite, shortness of breath, depression ing this over the phone is insufficient. The
(feeling sad), anxiety or nervousness, and the caregiver needs support.
patient’s overall feeling of well-being. 24. Answer 4: Transdermal scopolamine will help
17. Answer 2: The nurse would try a prescribed to control the excess secretions. Assess the
nonopioid medication and nonpharmaceuti- patient’s ability to successfully use coughing
cal options and observe for relief of pain. The and deep-breathing. This could be a useful
nurse should not encourage a patient to take a intervention, but it is likely that weakness will
medication after the patient reports ill effects. prevent successful production of secretions.
The nurse should contact the provider and Droperidol (Inapsine) is an antiemetic medi-
report the patient’s reluctance to take opioid cation. Suctioning is usually not done because
medication and the response to the nonopioid it is uncomfortable for the patient and the
medication. Changing to alternative routes or caregiver would have to wake frequently dur-
lowering the dose without a provider’s orders ing the night.
is practicing outside the scope of practice. 25. Answer 2: This is serious and complex is-
18. Answer 4: Metoclopramide (Reglan) is contra- sue, so the nurse should go up the chain of
indicated for patients with suspected obstruc- command. While it is normal for the staff to
tion because it increases gastric motility. The grieve, the aide’s behavior is excessive and
other medications could be ordered for nau- potentially burdensome to the caregiver. The
sea. nurse coordinator should investigate the
19. Answer 1: Replace fluids first; very mild salt aide’s behavior, the caregiver’s response, and
solutions may be better tolerated than sweet the need for counseling. The outcomes could
tastes; however, if the patient prefers sweet, impact the caregiver’s grieving and the aide’s
clear liquids those are acceptable. Rice and future participation as a team member.
pudding are okay if the patient is tolerating

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 Answer Key  114  

26. Answer 4: The caregiver is apparently very 28. In this case, the patient is not able to con-
stressed out, so the nurse would listen to the tribute to the decision-making process. This
caregiver and assess the situation. Contacting family, like all families, has strengths and
the team is premature. The nurse coordinator weaknesses and everyone seems to have an
would be contacted after the nurse assesses opinion. The nurse coordinator should assess
and determines that the plan needs revision. If each the family member’s abilities and feel-
the caregiver had demonstrated fear, anxiety, ings. The social worker can help the family
or had indicated that something was wrong work through communication issues so that
with the patient, the nurse would check the members understand each other. Nurse coor-
patient’s status first. Anger and frustration dinator or social worker can help the family
suggest that the patient’s health status is not understand different options. For example,
the problem; the caregiver’s feelings of help- in long-term care, the staff is considered the
lessness are the issue. primary caregiver. It is also possible that they
could hire someone to assist as caregiver in
Critical Thinking Activities the home setting. Family members could also
27. a. Refer to Box 39-2 on p. 1216. Pain assess- be assisted in developing a plan to divide re-
ment includes presence of pain, location, sponsibilities and take turns in doing the actu-
intensity (use of scale), variation in in- al caregiving. Discussing additional resources
tensity, subjective description, treatments such as respite care, volunteer services, and
being used, rating of relief with current spiritual and bereavement will help reassure
treatment, factors that precipitate or ag- the family that they are not alone in the pro-
gravate the pain, and its effect on ADLs. cess.
b. Nursing responsibilities in addition to
pain assessment are monitoring the use
and effectiveness of pain relief medica- CHAPTER 40—INTRODUCTION TO ANATOMY
tions and treatments, having dosages of AND PHYSIOLOGY
medications adjusted according to the
patient’s needs, and educating family Crossword Puzzle
members/caregivers about pain relief 1.
measures.
c. i. Mild to moderate pain is usually
1 2 3
P H A G O C Y T O S I S
controlled by NSAIDs (nonsteroidal O Y
4 5
C M M I T O S I S
antiinflammatory drugs). 6
D Y E E T
ii. Severe pain is usually treated with 7
F I L T R A T I O N M E
opioids. F O S B M
iii. Long-lasting results are achieved
8 9
F P T O R G A N T
with MS Contin, OxyContin, and U L A A I
10 11
S A S P I N O C Y T O S I S
Duragesic patches. I S I E E S
d. Additional measures for pain relief in- O
12
O S M O S I S L U
clude application of hot or cold packs, N
13
N U C L E U S E
repositioning, music therapy, relaxation
techniques, TENS devices, imagery, hyp-
nosis, and biofeedback. Fill-in-the-Blank Sentences
2. anterior
3. posterior
4. superior
5. superficial
6. inferior
7. medial
8. lateral
9. distal
10. proximal

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 Answer Key  115  

Table Activity
11. See Table 40-6, p. 1238 for additional information.

One Body Part of

Major System Major System Function
Lungs Respiratory Exchange of carbon dioxide for oxygen; regulation of acid-base
balance
Heart Cardiovascular Transportation of nutrition, water, oxygen, and wastes
Brain Nervous Coordination of body’s activities; communication
Stomach Digestive Mechanical and chemical breakdown of food; absorption of
nutrients
Kidneys Urinary Clearing blood of waste products; water and electrolyte balance;
acid-base balance
Bones Skeletal Support; movement; storage of minerals; blood cell formation
Voluntary muscles Muscular Movement; maintenance of posture; heat production
Skin Integumentary Protection; regulation of body temperature; synthesis of
chemicals; sense organ
Thyroid gland Endocrine Production of hormones that affect metabolism
Lymph nodes Lymphatic Protection
Gonads Reproductive Production of sex cells

Figure Labeling: Planes of the Body but a patient who develops a small bowel ob-
12. The sagittal plane runs lengthwise from the struction at home will often seek health care
front to the back. A sagittal cut gives a right because of vomiting and abdominal pain. A
and a left portion of the body. A midsagittal cut proximal obstruction is one that is closer to
gives two equal halves. The coronal (frontal) the beginning of the small intestine; therefore,
plane divides the body into a ventral (front) the blockage is higher up in the system. Vom-
section and a dorsal (back) section. The trans- iting can occur whenever there is an intestinal
verse plane cuts the body horizontal to the sag- obstruction; however, in a distal large intesti-
ittal and frontal planes, dividing the body into nal obstruction, vomiting is less likely. If it de-
caudal and cranial portions. See Figure 40-2, p. velops, it usually occurs later and the emesis
1228 for additional information. could have a fecal odor.
18. Answer 1: The epidermis or skin is composed
Multiple Choice of stratified squamous tissue. One of the main
13. Answer 3: The gallbladder is located just functions is to protect the body from infection.
below the right ribs. The spleen is on the left Bones are for strength and structure. Simple
side. The small intestine and cecum are lo- columnar tissue participates in the secretion
cated lower in the abdominopelvic cavity. of mucus. Adipose tissue provides insulation.
14. Answer 2: The urinary bladder is located in 19. Answer 3: The mucous membranes are de-
the hypogastric region. See Figure 40-4, p. signed to trap microorganisms and dryness
1229 for additional information. decreases that function. Poor oral hygiene
15. Answer 1: The stomach is located in the epi- contributes to respiratory infection, especially
gastric region. See Figure 40-4, p. 1229 for ad- for patients who are bedridden. Patients who
ditional information. are in a coma are not given solid food. Dignity
16. Answer 2: The appendix is located in the right and preservation of the teeth are desirable for
lower quadrant. See Figure 40-5, p. 1230 for all patients.
additional information. 20. Answer 3: The bursae are small cushionlike
17. Answer 4: Once diagnosed, patients are usu- sacs that are found between joints; therefore,
ally placed on “nothing by mouth” (NPO),

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 Answer Key  116  

the nurse would assess the movement and 3. f

discomfort of the major joints. 4. e
5. b
Critical Thinking Activities 6. g
7. c
Activity 1 8. i
21. Knowledge of how the body works helps the 9. h
nurse to distinguish normal findings from
abnormal findings. Knowledge of location True or False
and function of organs helps the nurse pre- 10. True
dict the involvement of underlying structures 11. True: Ablative surgery is an excision or re-
that are related to patients’ reports of pain moval of diseased body part.
and discomfort and design interventions that 12. False: Palliative surgery is surgery for relief or
will enhance function or repair dysfunction. reduction of intensity of disease symptoms;
Knowledge of physiology at the cellular level will not produce cure. Breast biopsy is a diag-
helps the nurse implement interventions that nostic procedure.
keep the body in homeostasis. 13. True: Diagnostic surgery is surgical explora-
tion that allows the health care provider to
Activity 2 confirm diagnosis.
22. A 2-cm ecchymosis noted on distal tip of first 14. True: Same-day admit conditions are when
digit of right foot. the patient enters the hospital and undergoes
surgery on the same day and remains for con-
Activity 3 valescence.
23. Accuracy is an important part of documenta- 15. True: Transplant surgery is replacement of
tion; thus using the patient’s words in direct malfunctioning organs.
quotes is acceptable. In addition, assessment 16. True: Constructive surgery is restoration of
data should reflect the nurse’s ability to make function lost or reduced as result of congenital
and record professional observations. When anomalies.
the nurse’s records are reviewed by other 17. True: Reconstructive surgery is restoration of
health care professionals or by legal or finan- function or appearance to traumatized or mal-
cial consultants, use of correct terminology functioning tissue.
and accuracy reflect the quality of care. 18. True: Major surgery involves extensive recon-
struction or alteration of body parts; poses
great risks to well-being.
CHAPTER 41—CARE OF THE SURGICAL 19. False: Cataract surgery is considered a minor
PATIENT ambulatory procedure.

Matching
1. d
2. a

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 Answer Key  117  

Table Activity
20.

Assessment Normal Findings Frequency

a. Vital signs Same as or close to preoperative q 15 minutes x 4, q 30 minutes x 4,
q 60 minutes x 4, q 4 hours x 4, until
assessments are within normal range
b. Incision Dressing dry and intact; no drainage Every time vital signs are assessed
c. Ventilation Respiration normal rate and volume q 1-2 hours
d. Pain Relieved by analgesics Pain is considered the fifth vital sign
and should be assessed concurrently
with vital signs
e. Urinary function Voids adequate amount Within 6-8 hours of surgery
f. Venous status Extremities are warm, pulse present, q 2 hours
and normal color
g. Activity According to order and patient: Per health care provider’s orders and
muscle-strengthening exercises, patient’s ability
sitting, dangling, and walking as
ordered and tolerated
h. Gastrointestinal Flat abdominal area; bowel sounds q 2 hours
function audible

Multiple Choice 26. Answer 3: Resuscitation equipment must be

21. Answer 4: In the induction phase, the patient readily available in case the patient has re-
is awake and the administration of anesthetic spiratory depression or cardiac dysrhythmia.
agents begins. The stage is completed when the Recovery is rapid and relatively less risky
patient loses consciousness, and endotracheal than other types of anesthesia. The patient is
intubation is established and placement veri- not routinely intubated. Nurses frequently
fied. give central nervous system depressants (e.g.,
22. Answer 2: Anesthesia may be maintained morphine). In the case of conscious sedation,
through a combination of inhalation and IV the provider will frequently administer the
medications. Emergence from anesthesia oc- medication; however, policies vary by facility.
curs when the procedure is completed and 27. Answer 3: For Arab Americans, verbal con-
reversal agents are given. sent often has more meaning than written
23. Answer 3: Spinal anesthesia is often used for consent because it is based on trust. Fully ex-
lower abdominal, pelvic, and lower extrem- plain the need for written consent.
ity procedures; urologic procedures; or sur- 28. Answer 1: Teaching 1 or 2 days before surgery
gical obstetrics. is ideal because the patient’s anxiety is not
24. Answer 2: Local anesthesia is commonly used too high. Teaching too far in advance would
for minor surgical procedures, such as a bi- affect retention of the information. The teach-
opsy of a superficial skin lesion. ing cannot be delayed because of the nurse’s
25. Answer 4: Combinations of sedatives, tran- schedule.
quilizers, anesthetics, or anesthetic gases are 29. Answer 3: Before bowel surgery, medication
commonly used for conscious sedation. The (neomycin, sulfonamides, erythromycin) may
health care provider is frequently focused be given over a period of days to detoxify and
on the procedure and relies on the nurse to sterilize the GI tract.
monitor the patient. Monitoring vital signs 30. Answer 2, 3, 4: Antihypertensives interact with
is necessary to detect adverse effects of the anesthetic agents to cause bradycardia, hypo-
medication or the procedure. tension, and impaired circulation.

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 Answer Key  118  

31. Answer 1: NSAIDs inhibit platelet aggrega- 39. Answer 2: The UAP can assist with oral care;
tion and may prolong bleeding, increasing however, the patient and the UAP should
susceptibility to postoperative bleeding. be instructed that fluids should not be swal-
32. Answer 2: In the immediate postoperative lowed. During NPO status, patients usually
period, all patients are at risk for aspiration are not given any fluid. The exception could
related to nausea and vomiting and will have be small sips of water to take certain medica-
impaired abilities to manage secretions. Elder- tions. Some providers will allow the patient
ly patients have additional problems related to have small hard candies, but sucking hard
to age. candies does stimulate peristalsis, so this is
33. Answer 2, 4, 6: The UAP can assist the pa- not standard practice for all patients who are
tient to remove any personal clothing and NPO.
don hospital attire and can also apply the UAPs are not responsible for checking IV
antiembolic stockings. The UAP can assist the fluids.
patient to move from the bed to the stretcher. 40. Answer 3: Coughing increases intracranial
Comparing data, checking IV sites and equip- pressure; therefore, coughing is contraindi-
ment, and ensuring that the postoperative cated for patients with intracranial surgery.
list is completed are nursing responsibilities. 41. Answer 2: The nurse would check for disten-
(Note to student: Knowledge of correct nursing tion first and then consider the other options.
action and principles of delegation are com- 42. Answer 3: Slowing of the respiratory rate sug-
bined to decide which action can be assigned gests that the level of anesthesia is causing
or delegated to a UAP. Remember that UAP respiratory paralysis; the patient may require
need specific instructions.) resuscitation. A decrease in blood pressure is
34. Answer 4: The patient may be feeling fear also serious because of possible vasodilation.
of the unknown or fear of cancer; long-term, Loss of sensation and decreased movement of
she may be thinking about death, mutilation, the lower extremities are expected.
or change of lifestyle. First address the feel- 43. Answer 3: The nurse would assess the extrem-
ings and then ask her to expand on her fears. ity for the new report of discomfort. Based on
Based on assessment findings, the other op- assessment findings, the nurse could consider
tions might be used. the other options. (Postoperatively, the patient
35. Answer 2: While all of these patients have the could have an emboli or a deep vein throm-
potential for adverse reactions and drug-drug bus. Positioning on the operating table could
interactions, the elderly patient with poly- put pressure on tissues or nerves. Patient
pharmacy and chronic health conditions is the could also have a problem that is not directly
most vulnerable. related to surgery; for example, cardiac.)
36. Answer 2: Smoking increases the risk for re- 44. Answer 1: The patient is instructed to get
spiratory complications, such as pneumonia up and void before getting the medication
and atelectasis. The patient’s reading on pulse because it causes most people to get drowsy.
oximeter is likely to be lower than normal or Urinary retention is also a common complica-
low-normal because of the smoking. Patient- tion after surgery. The surgeon should mark
controlled analgesia pump and call bell are the site and obtain consent. Most preoperative
also important, but less related to the issue of checklists require noting that the site has been
smoking. marked and that the consent form is signed.
37. Answer 4: “What...?” is an open-ended ques- Vital signs can be taken before or after medi-
tion. This allows the patient to seek informa- cation.
tion and the nurse can determine areas where 45. Answer 1, 2, 4, 6: The UAP can obtain most
the patient needs clarification. The other ques- of the equipment, but is not responsible for
tions are closed-ended and do less to encour- checking the function of pumps or suction
age the patient to speak. equipment. The nurse should ensure that
38. Answer 4: If consent is obtained while the pa- these items are functional, as they are likely to
tient is under the influence of consciousness- be needed when the patient arrives. (Note to
altering substances (even if prescribed), the student: Knowledge of correct nursing action
consent is not considered valid. The other and principles of delegation are combined to
information is also relevant and the provider decide which action can be assigned or del-
should be advised.

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 Answer Key  119  

egated to a UAP. Remember that UAP need allergy to poinsettia plant; history of allergies
specific instructions.) and asthma
46. Answer 4: The patient must have stable vital Methods of prevention: Screen prior to
signs before he/she is transferred to the nurs- admission, provide a latex-free environment,
ing unit. If the order for transfer has been communication to all members of the health
written, the PACU nurse would be respon- care team, clearly marking the chart
sible for informing the anesthesia provider
about the unstable vital signs. Nausea, vomit- Activity 2
ing, a sore throat, and wound pain are expect- 52. See Box 41-3, p. 1244.
ed.
47. Answer 1: First the nurse would check the Activity 3
patient. If there are no obvious signs or symp- 53. Older patients have higher morbidity and
toms of shock, then the nurse would instruct mortality rates than younger patients.
the UAP to take and report BP and pulse to Older individuals often have other coex-
determine a trend. A lower-than-baseline isting conditions that increase stress on the
blood pressure is not uncommon after sur- older patient. Recovery can be affected by the
gery. level of mental functioning, individual cop-
48. Answer 4: The scrub nurse performs actions ing abilities, and the availability of support
that require sterile handling. The circulating systems. These are often altered in the older
nurse is considered nonsterile and can per- adult.
form tasks that require asepsis. He/she helps Risks of aspiration, atelectasis, pneu-
the scrub nurse and surgeons maintain steril- monia, thrombus formation, infection, and
ity. altered tissue perfusion are increased in the
49. Answer 3: The ambulatory surgery patient older adult.
is released to home, so the patient must be Disorientation or toxic reactions can oc-
alert and pain, nausea, and vomiting must cur in the older adult after the administration
be controlled. The patient is not allowed to of anesthetics, sedatives, or analgesics. Older
drive himself home and family’s willingness adults often have a slower metabolism of
to assume responsibility does not absolve the these substances. These reactions may linger
nurse from making decisions about the pa- days after administration.
tient’s safety.
50. Answer 3: Any of these findings warrant fur-
ther investigation; however, for diabetic pa- CHAPTER 42—CARE OF THE PATIENT WITH
tients, there is an increased susceptibility for AN INTEGUMENTARY DISORDER
infection and poor wound healing. Impaired
communication can be a problem for patients Matching
who have had a cerebrovascular accident. 1. j
Bloody emesis could be related to esophageal 2. h
varices. Hypoventilation is a problem for pa- 3. b
tients with preexisting respiratory disorders. 4. e
5. a
Critical Thinking Activities 6. i
7. c
Activity 1 8. d
51. Types of latex reaction: Irritant reaction, types 9. n
I and IV allergic reaction 10. m
Factors influencing: The patient’s suscep- 11. f
tibility and the route, duration, and frequency 12. t
of latex exposure 13. o
Risk factors: History of anaphylactic 14. k
reaction of unknown cause during a medi- 15. r
cal or surgical procedure, multiple surgical 16. s
procedures, food allergies, a job with daily 17. l
exposure to latex, history of reactions to latex; 18. p

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 Answer Key  120  

19. q 32. Answer 1: Isotretinoin (Accutane) is terato-

20. g genic; thus pregnancy is an absolute contra-
21. u indication and strict contraception is advised
for 1 month before starting and 1 month after
Short Answer completing treatment. Avoiding sun exposure
22. Protection from infection is also advised.
Regulation of temperature 33. Answer 2: A raised, black nevus is considered
Synthesis of vitamin D one of the most threatening skin lesions, and
Prevention of dehydration removal is recommended to prevent it from
Excretion of waste becoming malignant. Any change in color,
23. P—Provocative and palliative factors (things size, or texture or any bleeding or pruritus
that bring the condition on) deserves investigation. The other comments
Q—Quality/quantity (characteristics and reflect typical changes associated with aging.
size) of the skin problem 34. Answer 1: Clubbing of the fingertips indicates
R—Region (specific region of the body) chronic hypoxemia, which is associated with
S—Severity (of the signs and symptoms) conditions such as emphysema.
T—Time (length of time the patient has had 35. Answer 2: The palm of the hand supplies
the disorder) more information about temperature and tex-
24. A—Is the mole Asymmetrical? ture than the fingertips, and both sides should
B—Are the Borders irregular? be compared. A cotton-tipped applicator can
C—Is the Color uneven or irregular? be used to test for sensation. Use of gloves is
D—Has the Diameter of the growth changed recommended if the skin is broken or if mu-
recently? cous membranes are being assessed.
E—Has the surface area become Elevated? 36. Answer 3: The nurse may suspect self-
mutilation, but must conduct further assess-
Figure Labeling—Rule of Nines ment. Based on the assessment, the nurse
25. See Figure 42-19, p. 1324. might consider using the other options.
26. a. 36% 37. Answer 4: The eschar provides protection, so
b. 54% at the this point it is left intact. The RN and
c. 18% LPN/LVN would collaborate to develop a
comprehensive, long-term care plan, which
Multiple Choice may include the wound care specialist. The
27. Answer 2: Alopecia is hair loss, which is a ulcer is currently unstageable because it can’t
common side effect of chemotherapy. Use of be fully assessed.
scarves or wigs could help. Also teach the pa- 38. Answer 3: Health care staff who have received
tient that the hair will grow back. Therapeutic two doses of the varicella vaccine should be
baths and applying lotions after bathing help assessed for symptoms 8-21 days after expo-
with pruritus. Shaving, tweezing, or pumice sure to the patient with shingles. Staff who
stones can be used for hirsutism. develop symptoms consistent with herpes
28. Answer 1: Paronychia is an infection of the zoster should be removed from active duty.
nail that spreads around the nail. Topical Health care staff who have not received the
antibiotics and wet dressings are the usual two doses of varicella vaccine may be infec-
treatment; sometimes a surgical incision and tive for 8-21 days and should be moved to
drainage of the infected area are performed. another duty location away from patient care.
29. Answer 4: Skin disease, endocrine problems, 39. Answer 3: Dermatitis medicamentosa can
and malnutrition are associated factors for cause patients to have respiratory distress.
hypotrichosis. Dermatitis venenata is caused by contact with
30. Answer 3: The most likely diagnosis is celluli- plants and the area should be immediately
tis. The extremity should be immobilized and washed. Pain, itching, and infection are pos-
elevated and warm, moist dressings are ap- sible complications for many skin disorders,
plied to relieve discomfort. Therapeutic baths but these problems have lower priority than
are usually used for dry or itchy skin. respiratory distress.
31. Answer 3: Eczema is associated with allergies 40. Answer 4: Wheals and hives after exposure to
to chocolate, wheat, eggs, and orange juice. foods, insect bites, drugs, and other allergens

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 Answer Key  121  

can lead to anaphylactic shock. Epinephrine CHAPTER 43—CARE OF THE PATIENT WITH A
would be given to this patient for respiratory MUSCULOSKELETAL DISORDER
symptoms or if rapid worsening occurs. Her-
pes simplex is accompanied by burning sen- Figure Labeling
sation and a dry, crusty lesions. Single pink, 1. See Figure 43-2 A, p. 1338.
scaly patch that resembles a large ringworm
occurs with pityriasis rosea. Skin maceration, Short Answer
fissures, and vesicles around the toes is typi- 2. a. Support
cal of tinea pedis. b. Movement
c. Mineral storage
Critical Thinking Activities d. Hemopoiesis
e. Protection
Activity 1 3. a. Motion
41. a. Emergent phase: Stop the burning by b. Maintenance of posture
removing clothes and shoes. Open the c. Production of heat
airway, control bleeding, and remove all 4. Perform the 7 Ps of orthopedic assessment to
nonadherent clothing and jewelry. Cover establish a baseline and monitor changes in
the victim with clean sheet or cloth, as- the patient’s muscular function, bone integ-
sess ABCs, and look for life-threatening rity, distal circulation, and sensation:
injuries. Assessment every 30 minutes to Pain: Does it seem out of proportion to the pa-
1 hour. Initiate fluid therapy, insert Foley tient’s injury? Does the pain increase on active
catheter, monitor intake and output every or passive motion?
hour, insert NG tube to prevent aspira- Pallor
tion, and administer analgesics in small, Paresthesia or numbness
frequent doses. Paralysis
b. Acute phase: ABCs—assessment of re- Polar temperature: Is the extremity cold com-
spiratory pattern, vital signs, circulation, pared with the opposite extremity?
intake and output, ambulation, bowel Puffiness from edema or a hematoma
sounds, inspection of wound, and mental Pulselessness: A Doppler ultrasound device
status. Control of pain decreases anxiety, may be useful to determine the presence or
promotes sense of support. Initiate pro- absence of blood flow if unable to palpate dis-
tective measures for skin by maintain- tal pulses
ing protective isolation. Dressing and 5. Treatment of sprains usually consists of rest,
treatment of burns as ordered. Monitor ice, compression, and elevation (RICE) of the
of eschar, débridement of wound, range affected area.
of motion. Postoperative care after each
surgery. Maintain and assess nutritional True or False
status. 6. False: The pillow is used to maintain leg ab-
c. Rehabilitation phase: Return to produc- duction.
tive life, address social and physical skills; 7. False: Scoliosis is a lateral (or “S”) curvature
may take years. of the spine. Kyphosis is a rounding of the
thoracic spine (hump-backed appearance).
Activity 2 8. True
42. a. Oxygenation, pulmonary function, car- 9. True
diac function, blood count, temperature 10. True
b. Assess for pallor by looking at the mu-
cous membranes, lips, nail beds, conjunc- Multiple Choice
tivae of lower eyelids 11. Answer 1: Diarrhea, nausea, and vomiting
c. Palpation for warmth and induration are potential side effects of colchicine. Fluid
retention and sodium retention are side effects
of adrenocorticosteroids. Seizures and dys-
rhythmias are side effects of meloxicam (Mo-

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 Answer Key  122  

bic), which is an NSAID. Hypercalcemia and 17. Answer 1: Osteomyelitis is an infection of the
orthostatic hypotension are side effects of bone. Drainage precautions are initiated, be-
teriparatide (Forteo) which is used for post- cause the wounds frequently require débride-
menopausal women who are at increased ment, irrigation, and sterile dressing changes.
risk for osteoporosis fractures or who cannot Ambulating may be restricted because the
use other treatments. affected part is usually rested. Patients with
12. Answer 1, 2, 4: Foods that are good sources arthritis or fibromyalgia are more likely to
of calcium include whole and skim milk, yo- have trouble moving in the early morning. Ice
gurt, turnip greens, cottage cheese, ice cream, packs are more appropriate for patients with
sardines with bones, spinach, many green sprains or strains; sometimes for patients with
vegetables, calcium-fortified orange juice, and arthritis.
soymilk. 18. Answer 1, 2, 4, 5: Coughing and deep-
13. Answer 2: The health care provider is most breathing, clear liquids with transition to a
likely to order an x-ray examination of the regular diet, assessing ability to use assis-
ankle to rule out fracture. The radiation ex- tive devices, and monitoring IV fluids and
posure is minimal; however, female patients antibiotics would be included in the care of
of childbearing age should always be asked the patient who had unicompartmental knee
about pregnancy. Assessment of allergies and surgery. The patient would not have a cast
medications and past treatments are good and intraarticular injections of corticosteroids
general questions for all patients, but in this would be given by the health care provider
case are less relevant to the diagnostic test for rheumatoid arthritis.
that will most likely be ordered. 19. Answer 2: The nurse’s first action would be
14. Answer 3: Loss of sensation and movement to assess for signs/symptoms of hypovolemic
are unexpected complications that should shock. An increase in pulse is an early sign.
be reported. Headache is the most common A decrease in blood pressure comes later. The
symptom, but if correct positioning and or- nurse could also look at the urinary output,
dered analgesics do not relieve the pain, this but the most useful piece of data is to know
should also be reported. Patients are encour- output per hour. Reassurance and visitors are
aged to take fluids flush the dye from the appropriate if the patient is physically stable,
body. Patients are usually in a flat or semi- and needs additional emotional support.
Fowler’s position for 8-12 hours; the nurse 20. Answer 2: Pain is a primary symptom of
would explain the purpose of the position and compartment syndrome or infection. In ad-
initiate diversion interventions (e.g., televi- dition, pain is a subjective symptom that the
sion, reading, listening to music). child will have to report to parents. Capillary
15. Answer 2: AKS can affect the cardiovascular refill and other assessments, cast care and
and respiratory systems. Inflammatory bowel maintenance are important, but the parents
disease occurs in about 3-10% of patients. can be given written information about these
Back pain and stiffness, weight loss, vision topics. Fiberglass casts do not degrade if they
change, and fatigue are common. The 7 Ps get wet, but drying them out can be time-
could be used, but apply more to assessment consuming.
of extremities. Mental status and urination 21. Answer 4: The head of the bed should not be
should not be directly affected. elevated past 45 degrees to a avoid acute flex-
16. Answer 3: The patient is describing the symp- ion on the device. The other actions are part of
toms of gout; thus, the nurse would do a the postoperative care.
dietary history to include specific questions 22. Answer 1: Bedrest is typically for the first 24
about alcohol, organ meats, anchovies, yeast, hours. The other comments are correct.
herring, mackerel, or scallops, because foods 23. Answer 2: When a person falls, the natural
high in purines worsen gout. Patients with instinct is to extend the arms out to break the
ankylosing spondylitis should be asked about fall. This results in a Colles’ fracture, which
bowel changes. All patients should be asked is a fracture of the distal portion of the radius
about exercise routines. Jaw tension, excessive within 1 inch of the wrist joint. A head-to-toe
fatigue, or anxiety would be more typical for assessment always gives good information,
patients with fibromyalgia. but the obvious injuries should be addressed

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 Answer Key  123  

first in this “field” situation. Mental status ex- with elevated alkaline phosphatase). Phan-
amination would be the priority if the patient tom limb pain occurs after amputation for
could not relate details of the fall (e.g., loss of some individuals. Fibromyalgia has a variety
consciousness because of a cardiac, neurolog- of symptoms, but the pain tends to be in the
ic, or metabolic event). Based on the patient’s muscles and in the low back. Compartment
current status, the environmental assessment syndrome is the result of excessive pressure
should be performed after other potential in- within the fascial compartments, usually
juries are assessed. caused by a cast or dressing, but can also be
24. Answer 1: The patient has signs and symp- caused by a crushing injury.
toms of a pelvic fracture and hemorrhage
is the most life-threatening complication. Critical Thinking Activities
Hemoglobin and hematocrit are laboratory
indicators of blood loss. Blood type and Rh Activity 1
are important if the patient needs emergency 31. Genetic and environmental factors, such as
surgery. Urinalysis and stool for occult blood small bone structure and lack of exercise, can
are performed because of the position of the contribute to the rate of bone loss. Individuals
bladder and the colon in the pelvic area. most at risk for developing osteoporosis are
25. Answer 4: The nurse performs the assessment small-framed, white (European descent) or
first. Based on the assessment findings, the Asian race, smoking, and alcoholism. Medi-
nurse may decide to use the other options. cal conditions associated with an increased
26. Answer 2: Volkmann’s contracture is a per- development of the disease include hyper-
manent contracture that can result from unde- thyroidism, chronic lung disease, cancer,
tected and untreated compartment syndrome. inflammatory bowel disease, alcoholism, and
The result is clawhand with flexion of the Vitamin D deficiency. Medications that are
wrist and hand and atrophy of the forearm. linked to the development of osteoporosis
The nurse would assess the patient’s abilities include steroids, anticonvulsants, immuno-
to perform ADLs. The other options are ac- suppressant therapies, and heparin. Diets low
tions that should have been performed during in calcium or high in caffeine and protein are
the patient’s initial injury and treatment. also implicated.
27. Answer 2: The arterial blood gases are within Nursing interventions are aimed at pre-
normal limits. The patient with a long bone venting further bone loss and fractures. Teach
fracture is at risk for fat embolism, but the the patient to include milk and dairy products
occurrence is relatively rare. However, respi- in the diet. Use vitamin D supplements as
ratory failure is the most common cause of prescribed. Food and beverages that contain
death associated with fat embolism, so the caffeine also contain phosphorus, which
nurse would continue to monitor the patient. contributes to bone loss. Encourage smoking
28. Answer 2: Frequent position changes and cessation. Safety measures, such as side rails,
stretching hands are preventive measures handrails, bedside commodes with seat eleva-
for carpal tunnel syndrome. Warm packs tors, and rubber mats in showers can help
will worsen the inflammation and edema. prevent falls in older adults. Efforts are made
Suggesting use of medication, even over-the- to keep patients with osteoporosis ambula-
counter medications, is not advised, especially tory to prevent further loss of bone substance
because the health care provider has not as a result of immobility. Encourage weight-
evaluated the medical condition. Wrapping bearing exercise to increase bone density.
the wrist may help a bit, but the health care
provider is likely to recommend the use of a Activity 2
commercial splint. 32. FMS is not life-threatening, but 50% of pa-
29. Answer 3: Patients who have had a laminec- tients report that they have trouble complet-
tomy are at risk for a paralytic ileus; therefore, ing ADLs. There is a wide range of symptoms,
the nurse would first assess for possible bowel such as aches, fatigue, cognitive difficulties,
obstruction. problems sleeping, anxiety, depression, and
30. Answer 4: An elevated serum alkaline phos- tingling sensations. Symptoms can overlap
phatase signals osteogenic sarcoma or other with chronic fatigue syndrome. There are no
bone disorders (liver disease is also associated specific diagnostic tests; thus, an exclusion

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 Answer Key  124  

approach is used and the diagnosis could 6. water; feces; expulsion

take years. FMS is hard to treat and many will 7. blood clotting
have trouble achieving remission. 8. fats
9. proteins; fats; carbohydrates
Activity 3 10. hypothalamus
33. Women are at greater risk for hip fracture
due to their increased occurrence of osteo- Multiple Choice
porosis and longer life expectancy compared 11. Answer 2, 3, 4, 5: Injury, trauma, or disruption
with men. This woman is thin and therefore of the anal sphincter can result in fecal incon-
has inadequate local tissue to absorb shock. tinence. Spinal cord lesions can result in loss
Climbing stairs to the second floor requires of conscious control of defecation. Normal
coordination and balance that change with changes that occur with aging are usually not
age. The loose rugs and clutter are hazard- significant enough to cause incontinence. Vol-
ous and low light impairs vision. Bending to untary inhibition of defecation is learned in
pet the dog or having him jump on her can childhood as a means to control emptying of
put her off balance; the physiologic changes the rectum.
of aging result in decreased joint flexibility 12. Answer 2: Musculature of the bowel contains
and muscular strength. The cane, walker, and its own nerve centers that respond to disten-
eyeglasses appear to have low value for this tion through peristalsis. Therefore, even when
woman, even though they could help prevent the patient has motor paralysis, reflex defeca-
falls. tion often persists or can be stimulated. Bowel
training is a better long-term option; the other
Activity 4 options could be considered as interim mea-
34. Rheumatoid arthritis (RA) is a progressive, sures until bowel control is achieved.
inflammatory, systemic disease believed to be 13. Answer 1: Biofeedback training has been
autoimmune in nature. Osteoarthritis (OA) proven effective with alert, motivated patients
is a disease resulting from the deterioration who have motility disorders or sphincter
of joints. It is nonsystemic and noninflam- damage that causes fecal incontinence. The
matory. RA may affect any area of the body patient learns to tighten the external sphincter
and is characterized by periods of remission in response to manometric measurement of
and exacerbation. OA involves joints. Both responses to rectal distention.
disorders include signs and symptoms of 14. Answer 3: High-fiber foods facilitate defeca-
muscle weakness, pain, and stiffness. RA pa- tion. Fluids should also be encouraged.
tients also report malaise and loss of appetite. 15. Answer 2: Sucralfate (Carafate) acts by coat-
Management of RA includes administration ing the gastric mucosa. Misoprostol (Cytotec)
of antiinflammatory medications to control is contraindicated during pregnancy. Cimeti-
the progression of the disease, pain relief, and dine (Tagamet) increases the serum levels of
measures to prolong joint function. Manage- oral anticoagulants, theophylline, phenytoin,
ment of OA includes physical therapy, heat some benzodiazepines, and propranolol.
applications, drug therapy, and joint replace- Diphenoxylate with atropine (Lomotil), di-
ment. The prognosis for each is variable. menhydrinate (Dramamine), atropine, sco-
polamine, hyoscyamine, dicyclomine, and
clidinium (Donnatal, Bentyl) are just a few of
CHAPTER 44—CARE OF THE PATIENT WITH A the drugs that can cause sedation.
GASTROINTESTINAL DISORDER 16. Answer 1: Intrinsic factor (a substance se-
creted by the gastric mucosa) is produced to
Figure Labeling allow absorption of vitamin B12. Pernicious
1. See Figure 44-1, p. 1403. anemia can develop because of vitamin B12
deficiency. Patients with a partial gastrectomy
Fill-in-the-Blank Sentences should have a blood serum vitamin B12 level
2. Peristalsis measured every 1 to 2 years so that replace-
3. infections; decay ment therapy of vitamin B12 via a monthly
4. reflux injection or via nasal route weekly can be in-
5. proteins; fats; simple sugars stituted before anemia appears. Hemoglobin

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 Answer Key  125  

and hematocrit would be monitored when could provide some relief and are used in the
blood loss is suspected. Iron dextran can be treatment of reflux and gastritis. Decompres-
given for anemia associated with blood loss in sion of the stomach can provide relief; for
Crohn’s disease. Increasing fruits and vegeta- example, in the case of obstruction or pancre-
bles and decreasing red meat and fat is good atitis.
general advice, but is inadequate to address 23. Answer 1: Barium is a contrast medium that
the patient’s risk for pernicious anemia. can interfere with visualization during a colo-
17. Answer 2, 3, 4, 5: Stomach carcinogenesis noscopy or in the interpretation of the flat
probably begins with a nonspecific mucosal plate and ova and parasite examinations.
injury as a result of aging; autoimmune dis- 24. Answer 2: Removing the plaques can cause
ease; or repeated exposure to irritants such pain and bleeding. The other actions are cor-
as bile, antiinflammatory agents, or smoking. rect in the care of oral candidiasis.
Other factors include history of polyps, perni- 25. Answer 3: For lesions that do not heal within
cious anemia, hypochlorhydria (deficiency of 2-3 weeks, the neighbor should seek medical
hydrochloride in the stomach’s gastric juice), attention. Diluted hydrogen peroxide can be
chronic atrophic gastritis, and gastric ulcer. used for candidiasis or halitosis. Lipstick or
Because the stomach has prolonged contact lip balm that includes sunscreen and consum-
with food, cancer in this part of the body is ing fruit and vegetables are good preventive
associated with diets that are high in salt, measures, but inadequate to address the exist-
smoked and preserved foods (which contain ing lip lesion.
nitrites and nitrates), and low in fresh fruits 26. Answer 2: The conservative approach mostly
and vegetables. includes modification of lifestyle, which in-
18. Answer 2, 4, 5: The onset of Crohn’s disease is cludes avoiding foods and beverages that
usually insidious, with nonspecific complaints contribute to discomfort, smoking and alcohol
such as diarrhea, fatigue, abdominal pain, and cessation, losing weight, sleeping with head
fever. As the disease progresses, the patient elevated, and not lying down immediately af-
experiences weight loss, malnutrition, dehy- ter eating. Medications are also used in a step-
dration, electrolyte imbalance, anemia, and up fashion. Nissen fundoplication is a surgical
increased peristalsis. procedure that would be used if medical ther-
19. Answer 2, 4, 5: The patient should be kept on apies are not successful. Barrett’s esophagus is
bedrest and kept NPO. Vital signs should be considered precancerous and requires endos-
monitored because there is a risk for perito- copy and biopsy every 1-3 years. Discussion
nitis. Antibiotics can be given if perforation is of this information is premature, unless the
suspected or may be given as a preoperative provider or nurse suspects that the patient is
medication. Enemas and heating pads should likely to be noncompliant and needs to hear
not be used because of increased risk for peri- the worst-case scenario in order to comply.
tonitis. Antacids are unlikely to offer relief to 27. Answer 3: Perforation is the most lethal com-
this patient. plication of peptic ulcer disease (PUD) be-
20. Answer 3: The nurse would assess the ab- cause of peritonitis. An elevated white blood
dominal pain, check the vital signs, and assess cell count will accompany this potentially
for other symptoms of hypovolemic shock. lethal infection. Fecal assay antigen and occult
Other symptoms of perforation would include blood are used to diagnosis PUD. Pain during
melena, oral bleeding, and guarding. the hydrochloric test is used to diagnose gas-
21. Answer 1: The patient returns in 8 hours to troesophageal reflux disease.
have the monitoring device removed. The pill 28. Answer 2: The patient is describing symptoms
camera passes through the gastrointestinal of dumping syndrome which occurs in ap-
system in 2-3 days. There is no need to re- proximately one-third to one-half of patients
trieve the camera and problems with passing who have surgery for peptic ulcer disease.
the device or change in stool are not expected. Symptoms are usually triggered by a bolus of
22. Answer 4: During the procedure, mild hydro- hypertonic food. The other questions could be
chloric acid is administered through the NG used to gather additional information.
tube. If pain increases, then the test is con- 29. Answer 3: The use of antidiarrheals is not
sidered positive. Relief of pain by nitrates is recommended because the body is trying to
more associated with anginal pain. Antacids rid itself of the E. coli pathogen. The health

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 Answer Key  126  

care provider could order antidiarrheals if 37. Answer 2: For acute diverticulitis, the patient
the fluid loss is relentless. Oral fluids are the is likely to be NPO. The other actions are cor-
first choice, but IV fluids can be ordered if the rect.
patient is having trouble with oral fluids or 38. Answer 1: The nurse recognizes the potential
to replace initial fluid loss. Contact isolation for peritonitis; however, additional assess-
would be appropriate to prevent the spread to ment with vital signs should be performed
others. before sitting the patient in semi-Fowler’s
30. Answer 4: C. difficile is not destroyed by an- position (BP could be low and pulse elevated
tiseptic hand rub, so soap and water are re- because of shock) or notifying the health care
quired for adequate hand hygiene. The other provider who will ask about the last set of
options are not part of contact isolation or vital signs. PRN pain medication is not appro-
needed for the care of this patient. priate if peritonitis is suspected. (Remember
31. Answer 4: Patients with celiac sprue must to apply the nursing process; the first step is
avoid wheat, rye, and barley. assessment.)
32. Answer 3: First the nurse acknowledges 39. Answer 1, 2, 4, 6: Monitoring vital signs, pain,
feelings and then assesses what the patient bowel sounds, fluid balance, and drainage
understands about the disease and the diag- and bleeding are appropriate care. The pa-
nostic process. Based on the assessment, the tient should turn, cough, deep-breathe, and
nurse may decide to use the other options. be encouraged to ambulate. The Foley should
(Note to student: Recall principles of thera- be removed as soon as possible to prevent
peutic communication by starting where the infection and to allow adequate time to assess
patient is emotionally; acknowledge feelings the patient’s ability to void. Suction should be
and encouraging expression of feelings.) temporarily discontinued during ambulation.
33. Answer 1: With severe diarrhea, the body 40. Answer 3: Increasing fluid intake and a high-
loses sodium, potassium, calcium, and bi- fiber diet decrease the likelihood of constipa-
carbonate. Hematocrit levels are likely to be tion; straining at stool can cause hemorrhoids.
elevated because of fluid loss. A fecal sample Suggesting use of hydrocortisone creams or
is likely to show blood because of irritation to rubber-band ligation is the responsibility of
the mucosa. Liver function tests should not be the health care provider.
relevant to this condition.
34. Answer 2: First the nurse tries to help the pa- Critical Thinking Activities
tient express feelings about the procedure and
other concerns. Based on the assessment of Activity 1
concerns, the nurse may decide to use the oth- 41. a. Assessment: Includes noting difficulty
er options. (Note to student: Recall principles of swallowing and painful swallowing. Ob-
therapeutic communication by starting where serve for regurgitation, vomiting, hoarse-
the patient is emotionally; acknowledge feel- ness, chronic cough, and iron-deficiency
ings and encouraging expression of feelings.) anemia.
35. Answer 1: Crohn’s disease causes ulceration b. Nursing diagnoses and planning: Ineffec-
with fistula formation that can connect the tive breathing pattern related to incisional
colon with the urinary tract. The urine of pain and proximity to the diaphragm;
patients with suspected appendicitis will be Imbalanced nutrition, less than body
tested to rule out urinary infection as a source requirements related to dysphagia; De-
of the pain. Patients with ulcerative colitis creased stomach capacity related to gas-
could develop urinary tract infections related trostomy tube
to improper hygiene of the perineal area; thus c. Implementation: Monitor respirations
staff and patients should be aware to clean carefully because of proximity of incision
and wipe from front to back. Peptic ulcer dis- to diaphragm and patient’s difficulty car-
ease should not contribute directly to urinary rying out breathing exercises. Monitor
tract infections. intake and output and daily weights to
36. Answer 4: The side-lying with knees flexed determine adequate nutritional intake.
(fetal position) is preferred because this de- Assess to determine which foods patient
creases the strain on the abdominal wall. can and cannot swallow, and to select and
prepare edible foods.

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 Answer Key  127  

d. Evaluation: Evaluation should reflect the d. The manifestations of mechanical and

patient’s response to interventions and intestinal obstructions are similar. Regard-
the resolution, partial resolution, or fail- less of the cause of the obstruction, the
ure to resolve the problems identified by result is an inability of gastric contents to
nursing diagnoses. pass through the GI tract. The primary
difference between the types is the un-
Activity 2 derlying cause. Nonmechanical intestinal
42. a. Preoperative obstructions result from a neuromuscular
i. Preparation: Encourage improved or vascular disorder. Mechanical obstruc-
nutritional status; offer a high- tions are caused by a physical occlusion in
protein, high-calorie diet if oral the intestinal tract.
diet is possible. Total parenteral
nutrition may be necessary for
severe dysphagia or obstruction. CHAPTER 45—CARE OF THE PATIENT WITH
Gastrostomy tube feedings may be A GALLBLADDER, LIVER, BILIARY TRACT, OR
indicated. Give prescribed antibiotics. EXOCRINE PANCREATIC DISORDER
ii. Knowledge: Discuss what to expect
during entire procedure, review Matching
activities that will be done during 1. i
recovery process. 2. a
b. Postoperative 3. f
i. Knowledge: Discuss availability of 4. b
pain medications. 5. j
ii. Pain: Review nonpharmacologic 6. h
methods to relieve pain. 7. m
iii. Noncompliance: Discuss the 8. g
implications for recovery and the 9. k
development of complications with 10. e
noncompliance. 11. d
iv. Nutrition: Start clear fluids at 12. l
frequent intervals when oral intake 13. n
is permitted; introduce soft foods 14. c
gradually, increasing to several small
meals of bland food; have patient Fill-in-the-Blank Sentences
maintain semi-Fowler’s position for 2 15. discoloration; 2.5 mg/dL
hours after eating and while sleeping 16. two to three; three to four
if heartburn (pyrosis) occurs. 17. liver
18. 16,000
Activity 3 19. gallstones
43. a. Presence of distention, visibility of 20. cigarette smoking
peristaltic waves, vomiting, tenderness,
guarding behaviors, presence and charac- Multiple Choice
teristics of bowel sounds 21. Answer 4: Patient should exhale and not
b. Abdominal x-rays, CT scans, sigmoid- breathe while needle is being inserted. This
oscopy or colonoscopy may be used to allows the health care provider to insert the
confirm the presence of an intestinal ob- needle between the sixth and seventh or
struction. Hematologic studies may be eighth and ninth intercostal spaces and into
used to assess the degree of impact of the the liver.
obstruction. These blood studies include 22. Answer 1: The purpose of the T-tube is to
electrolyte levels and hemoglobin and he- allow the bile to drain out. Initially, up to
matocrit readings. 500 mL of drainage would be considered an
c. Removal of gas and fluid, correction of expected outcome. The flow should decrease
electrolyte imbalances, relief or removal over time. Inflammation, pain, and bleeding
of the obstruction are not expected findings.

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 Answer Key  128  

23. Answer 4: The pain is expected because of required. The serum ammonia test is accom-
diaphragmatic irritation secondary to abdom- plished by drawing a blood sample. Oral
inal stretching and to residual carbon dioxide. cholecystography and radioisotope liver scan
The appropriate intervention is to give an an- do not require any care beyond routine assess-
algesic. ment after returning from the procedure.
24. Answer 2: The level of lipase is more specific 30. Answer 3: The purpose of a soft toothbrush
for diagnosing acute pancreatitis. Low albu- with gentle brushing action is a precaution
min, increased glucose, and elevated amylase initiated when patients are at risk for bleed-
are likely to accompany the diagnosis of ing. In this case, the cirrhotic liver cannot
pancreatitis; however, changes in albumin, absorb vitamin K or produce the clotting fac-
glucose, and amylase can be associated with tors VII, IX, and X. These factors result in the
many other disorders. patient with cirrhosis to develop bleeding ten-
25. Answer 1: Hepatitis E is most often seen in dencies.
southeastern and central Asia, the Middle 31. Answer 1, 2, 4: Preoperative patients need to
East, Africa, and Mexico. Drinking water from learn about coughing and deep-breathing and
questionable sources and eating raw shellfish would be ideal candidates for the student.
increase the risk for hepatitis E. High-risk sex- The patient with chronic hepatitis is also a
ual behaviors and sharing needles are sources good choice. The patient with esophageal var-
of hepatitis B and C. Hepatitis G has shown ices should not be encouraged to cough be-
up in Europe, Asia, and Australia. cause of the potential for rupture. The patient
26. Answer 2: The number of tablets or ingestion with acute pancreatitis needs to cough and
of fatty food just before the test could alter deep-breathe, but this patient is less than ideal
the outcome. Also, vomiting and diarrhea can for a first-semester student, because acute
alter the absorption of the dye. Laxatives and pancreatitis causes severe pain and the patient
enemas are usually not required. Amount of may have little tolerance for the novice.
fluid should not affect examination; however, 32. Answer 3: Hepatic encephalopathy is a type
fat in the fluids (i.e., whole milk) could be a of brain damage caused by liver disease and
factor. consequent ammonia intoxication. The other
27. Answer 1: For a pregnant woman, ultrasound tests are also included in the general diagno-
offers an option that is safe. Oral cholecystog- sis of liver disease.
raphy and intravenous cholangiography and 33. Answer: 1.4 mL
computed tomography require exposure to 155 lbs ÷ 2.2 = 70.45, rounded to 70 kg
x-rays. 70 kg × 0.02 mL/kg = 1.4 mL
28. Answer 3: There are no special instructions 34. Answer 4: If the patient knows that the pro-
that the UAP needs to care for a patient after cedure will provide relief for noxious symp-
a HIDA scan; verbally reassuring the UAP toms, he/she is more likely to cooperate.
is a good idea, because he/she may not be Nasogastric tube insertion is extremely un-
familiar with what happens during diagnos- comfortable, but giving pain medication does
tic procedure. The amount of radioisotope not alleviate the sensations of tearing or gag-
is very minimal, so use of the dosimeter is ging. An antianxiety medication may be more
not required. (Note to student: Certain units effective in this case. Having the most experi-
or jobs may require that all personnel wear enced nurse insert the tube is a good strategy
dosimeters all the time.) The isotope is given for an anxious patient, but he/she must still
intravenously, but bleeding is not an expected agree to cooperate. Calling the health care
side effect of the procedure. (Note to student: provider is also appropriate if the patient is
Knowledge of correct nursing action and prin- determined to leave the hospital.
ciples of delegation are combined to decide
which action can be assigned or delegated to Critical Thinking Activities
a UAP. Remember that UAP need specific in-
structions.) Activity 1
29. Answer 2: The needle liver biopsy is an in- 35. a. Infection and rejection of the organ
vasive test that creates a potential for hemor- b. Respiratory complications (pneumonia,
rhage, shock, peritonitis, and pneumothorax; atelectasis, pleural effusions), hemor-
thus, frequent assessment of vital signs is rhage, infection, electrolyte imbalances

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 Answer Key  129  

c. The patient will be closely observed for ages expression of fears and concerns.
signs of rejection. There will be medica- Give information as needed to decrease
tions to reduce the likelihood of rejection. anxiety. Expert care and anticipating
Cyclosporine is an effective immunosup- needs also helps to decrease the patient’s
pressant drug. Other immunosuppres- anxiety. Refer to social services and sup-
sants used include azathioprine (Imuran), port groups as appropriate.
corticosteroids, tacrolimus (Prograf), my-
cophenolate mofetil (Cellcept), and new
agents including the interleukin-2 recep- CHAPTER 46—CARE OF THE PATIENT WITH A
tor antagonists basiliximab (Simulect) and BLOOD OR LYMPHATIC DISORDER
daclizumab (Zenapax).
d. Coughing and deep-breathing exercises, Short Answer
monitoring neurologic status, signs of 1. The blood performs three critical functions.
hemorrhage, input and output, assess- First, it transports oxygen and nutrition to the
ment of drainage from Jackson-Pratt cells and waste products away from the cells,
drains, NG tubes, and T-tubes. Protective and it transports hormones from endocrine
isolation is likely to be needed and the glands to tissues and cells. Second, it regulates
nurse should monitor for signs and symp- the acid-base balance (pH) with buffers, helps
toms of infection and rejection. regulate body temperature because of its wa-
ter content, and controls the water content of
Activity 2 its cells as a result of dissolved sodium ions.
36. a. Cholelithiasis Third, it protects the body against infection by
b. Increased heart and respiratory rates, dia- transporting leukocytes and antibodies to the
phoresis, elevated temperature, elevated site of infection and prevents blood loss with
leukocyte count, mild jaundice, steator- special clotting mechanisms.
rhea 2. The lymphatic system has three basic func-
c. Fecal studies, serum bilirubin tests, ul- tions: (1) maintenance of fluid balance, (2)
trasound of the gallbladder and biliary production of lymphocytes, and (3) absorp-
system, HIDA scan, or operative cholangi- tion and transportation of lipids from the in-
ography (OCG) may be done. Ultrasound testine to the bloodstream.
of the gallbladder is highly accurate in 3. Lymph nodes (glands) have two functions: (1)
diagnosing cholelithiasis. to filter impurities from the lymph and (2) to
produce lymphocytes (WBCs).
Activity 3 4. The spleen: (1) has a major role in homeostasis
37. a. Smoking, obesity, red meat, pork, fat, and by destroying worn-out or defective RBCs;
coffee contribute to risk for pancreatic (2) is a reservoir for blood; (3) forms lympho-
cancer. Symptoms can be vague and in- cytes, monocytes, and plasma cells; (4) houses
sidious; therefore, cancer is usually well- white blood cells in the lining of the hollow
established before it is diagnosed and life cavities within the spleen; (5) produces RBCs
expectancy can be 4 to 6 months after di- before birth (the spleen is believed to produce
agnosis. The patient may have to undergo RBCs after birth only in cases of extreme he-
many diagnostic tests and will then be molytic anemia).
told that tumors are inoperable. The pain
is likely to be significant. True or False
The patient may express regret be- 5. False: Blood is slightly alkaline, with a pH
cause of failure to modify lifestyle, fear range of 7.35 to 7.45.
related to death, frustration related to in- 6. False: White blood cells defend the body
tensive diagnostic testing, and treatments against bacteria and viruses. The primary
that provide little hope for cure. The function of the red cells is the transportation
patient will be dealing with severe pain of oxygen.
while having to face loss of social, work, 7. False: There is a greater risk of penetrating
family, and community roles. underlying structures if the sternum is select-
b. The nurse is aware that the patient faces ed as the site. The posterior superior iliac crest
many challenges. Active listening encour- is considered the preferred site for children.

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 Answer Key  130  

8. True
9. True
10. True

Table Activity
11. See Table 46-1, p. 1491 for additional information.

Blood Test Normal Values

Red blood cells (RBCs) Males: 4.7-6.1 million/mm3
Females: 4.2-5.4 million/mm3
Hemoglobin Males: 14-18 g/dL
Females: 12-16 g/dL
Hematocrit Males: 42%-52%
Females: 37%-47%
Platelet count 150,000-400,000/mm3
White blood cells (WBC) actual cell count 5000-10,000/mm3
Prothrombin time (PT) 11-12.5 seconds
International Normalized Ratio (INR) 0.7-1.8
Partial thromboplastin time (PTT) 60-70 seconds

Multiple Choice Court. It is however within the rights of a

12. Answer 1: When patients are dehydrated, the responsible and coherent adult to refuse treat-
hemoglobin and hematocrit appear higher ment.
than normal. Restoring fluid balance will 16. Answer 4: The UAP can assist the patient with
yield normal results for hemoglobin and he- self-care activities and toileting, but the nurse
matocrit. Platelet counts and prothrombin must assess the patient’s limitations and give
time should not be affected. the UAP specific instructions. The UAP might
13. Answer 3: Bandemia is seen in patients who apply oxygen if there was a true emergency,
have serious bacterial infections, so the nurse but generally the patient’s shortness of breath
is aware of the need to monitor for develop- should be reported to and assessed by the
ment of sepsis, which could lead to septic nurse. Teaching the visitors and patients
shock. Conditions such as dehydration or about limitations and designing an appropri-
polycythemia vera increase the risk for deep ate visit schedule should be done by the nurse
vein thrombosis. Thrombocytopenia is a with consideration of the patient’s wishes and
reduction of platelets. The basophils are in- his/her limitations. (Note to student: Knowl-
volved in allergic response. edge of correct nursing action and principles
14. Answer 3: If the father is Rh-positive and the of delegation are combined to decide which
mother is Rh-negative, anti-D antibodies can action can be assigned or delegated to a UAP.
exist from a previous pregnancy, miscarriage, Remember that UAP need specific instruc-
ectopic pregnancy, or transfusion. In subse- tions.)
quent pregnancies, if the baby is Rh-positive, 17. Answer 3: Subtle changes in behavior such as
hemolytic disease (in the newborn) could be restlessness or anxiety are considered early
triggered by the presence of the mother’s anti- signs. Orthostatic blood pressure is manifest
D antibodies. after patient loses 1000-1500 mL of blood. De-
15. Answer 1: Some Jehovah’s Witnesses will creased red cell count may not be evident in
accept volume expanders (colloids) and au- the early stages. Decreased urine output is a
tologous blood. The health care team can compensatory mechanism that indicates that
administer blood to children without the con- blood is being shunted away from the kidneys
sent of parents according to the US Supreme in order to preserve the brain and heart.

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 Answer Key  131  

18. Answer 3: The patient has a risk for internal locytosis (severe reduction of white cell com-
bleeding (risk for hypovolemic shock) and ponents).
peritonitis (risk for septic shock). If the pain is 25. Answer 1: Drawing pictures and storytelling
worse, the nurse would reassess the pain and will help the child express fears and worries.
then call the health care provider to report The child is likely to need protection against
findings. Using SBAR (situation, background, infection and be in protective isolation.
assessment, recommendations), the nurse Treatments include chemotherapy and bone
could ask for orders for diagnostic testing or marrow transplant. In addition, the usual pro-
for a change in pain medication. cesses that combat infection are altered. Expo-
19. Answer 1: While waiting for the health care sure to animals, plants, or other people should
provider to call back, the nurse should enlist be avoided during neutropenic episodes.
the UAP to take and report vital signs. The 26. Answer 1, 2, 3, 4: Ecchymoses and petechiae
other actions are correct, but the nurse is suggest that the patient bruises very easily.
responsible for those tasks. (Note to student: This could be the result of a coagulation dis-
Knowledge of correct nursing action and prin- order or a medication such as prednisone. The
ciples of delegation are combined to decide nurse asks questions to determine if the pa-
which action can be assigned or delegated to tient has noticed bleeding from other sources.
a UAP. Remember that UAP need specific in- Asking the patient about the cause of bruises
structions.) is also appropriate to identify specific trauma
20. Answer 3: Blood thinners, aspirin, antiinflam- or injury to the bruised areas. Hydrocortisone
matory medications and vitamin E are likely cream is not useful in this case. Dietary assess-
to be discontinued before surgery. ment is always useful, but in this case is more
21. Answer 4: Pain is likely to be severe due to related to the patient’s general health than to
tissue ischemia. The other symptoms could the specific finding of ecchymoses and pete-
also occur. chiae.
22. Answer 1, 3, 5: Patients with sickle cell dis- 27. Answer 2: With a low platelet count, the
ease should avoid high altitudes, flying in nurse initiates bleeding precaution measures.
unpressurized planes, dehydration, extreme Placing pressure on the arms or legs during
temperatures, iced liquids, alcohol, and vig- movement can cause bruising. A mask is not
orous exercise. Patients should not smoke necessary, but good hand hygiene is always
and should protect extremities from injury appropriate. Patients with sickle cell disease
because of impaired circulation. Patients with would be encouraged to drink fluids to pre-
sickle cell disease have frequent problems vent dehydration. Patients with red blood cell
with infections. It is important for the patient disorders are more prone to fatigue; however,
to remain current with vaccinations and take the nurse would assess all patients for ability
prophylactic antibiotics to protect against to achieve ADLs and instruct the UAPs ac-
these infections. cordingly.
23. Answer 2: In polycythemia, the blood is very 28. Answer 4: Non-contact sports such as golf
viscous and there is an increased risk of deep would be recommended because of the poten-
vein thrombosis. There is a potential for life- tial for injury in other sports.
threatening pulmonary emboli if the clot 29. Answer 1: In the early stages, the patient may
breaks off and travels to the lungs. The nurse report a painless enlargement of a cervical, ax-
would perform all of the other assessments as illary, or inguinal lymph node. Night sweats,
part of total patient care. weight loss, and fever are “B” symptoms
24. Answer 2: For the patient’s safety and protec- associated with a poor prognosis. Alcohol-
tion from infection, the nurse would initiate induced pain is a feature associated with
protective isolation, wash hands, and don ap- Hodgkin’s, but does not consistently manifest
propriate apparel (e.g., mask, gown, gloves), in every patient.
then check the patient for signs of infection. 30. Answer 2, 3, 4: By the time non-Hodgkin’s is
Hand hygiene is important to stress to the detected and diagnosed, the disease is usu-
patient, but it’s more important to inform visi- ally widespread. Involvement of the digestive
tors and all caregivers. The medication list organs is likely, but the lymph system could
should be reviewed because adverse reactions spread the disease and cause pressure in any
to medication is the primary cause of agranu- area. Pleural effusion, bone fractures, and

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 Answer Key  132  

paralysis are possible complications. Che- food, iron should be taken about an hour
motherapy is the mainstay of treatment for before meals, when the duodenal mucosa
nonlocalized disease. The prognosis is worse is most acidic. Taking iron with vitamin
than Hodgkin’s and the diagnostic testing C (ascorbic acid) or orange juice, which
and treatment are rigorous, so it is likely that contains ascorbic acid, also enhances iron
the patient and family will need support. Lo- absorption.
calized pain in the spine that increases with Do not administer with an antacid
movement is more associated with multiple because it reduces the absorption of iron.
myeloma. Total assistance for ADLs is not an- If a dose is missed, continue with
ticipated until the end stage of the disease. schedule; do not double a dose.
Iron may interfere with absorption
Critical Thinking Activities of oral tetracycline antibiotics and quino-
lones (Cipro, Levaquin, Noroxin). Do not
Activity 1 take within 2 hours of each other.
31. a. Pernicious anemia Dilute liquid iron preparations in
b. The Schilling test for pernicious anemia juice or water, and administer with a
is being replaced by a serum test called straw to avoid staining teeth. Provide oral
megaloblastic anemia profile hygiene after taking.
c. Vitamin B12 injections, folic acid supple- Check for constipation or diarrhea.
ments, iron supplements, possible trans- Record color (iron turns stools green to
fusions black) and amount of stool.
d. The treatment must be lifelong. Failure to Iron is toxic, and caution must be
maintain treatment will result in death. taken to store iron preparations out of a
child’s reach.
Activity 2
32. a. Iron deficiency anemia Activity 3
b. Female, due to the occurrence of menses, 33. a. Ambulation helps counter hypercalcemia
recent pregnancy, history of stomach sur- because weight-bearing helps the bones
gery reabsorb some calcium. Calcium reab-
c. Tachycardia, spoon-shaped fingernails, sorption in the bones decreases the risk of
headache, burning tongue; desire to eat pathologic fractures. Fluids prevent de-
clay, starch, and ice hydration and dilute calcium and prevent
d. Iron supplements may be contraindicated protein precipitates that can cause renal
in peptic ulcer disease. tubular obstruction.
Side effects include gastrointestinal b. First, the nurse would assess the pattern
(GI) upset (nausea, vomiting), constipa- of pain and plan activities for when pain
tion or diarrhea, and green to black stools. is lower and energy is higher. Medicate
Iron is absorbed best from the duo- the patient 30-40 minutes before ambula-
denum and proximal jejunum. Therefore tion and explain the benefits of ambula-
enteric-coated or sustained-release cap- tion. Obtain assistive devices as needed;
sules, which release iron farther down in for example, a wheelchair can be nearby if
the GI tract, are counterproductive; they the patient wants to stop and rest. To in-
are also more expensive. crease sense of control, encourage the pa-
If side effects develop, the dose and tient to take an active role in the design of
type of iron supplement may be adjusted. the ambulation program. Enlist the family
Some people cannot tolerate ferrous sul- as appropriate. Setting small goals—for
fate because of the effects of the sulfate example, walking to the end of the hall—
base. Ferrous gluconate may be an accept- is also helpful.
able substitute.
Iron is best absorbed in an acidic en-
vironment. To avoid binding the iron with

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 Answer Key  133  

Activity 4
34.

Assessment Malaise, fatigue, and weakness. Patient may relate history of illness, easy bruising,
bleeding tendencies with petechiae and ecchymoses. Nonhealing cuts and
bruises, draining lesions, jaundice, and palpable subcutaneous nodules. Edema
and tenderness in lymph nodes. Gastrointestinal symptoms, cardiovascular and
respiratory changes. Neurologic symptoms such as headache, numbness, tingling,
paresthesia, and behavioral alteration. System-by-system approach to confirm
patient’s report of symptoms.
Nursing Risk for infection; Risk for injury (bleeding, falls); Fatigue; Deficient knowledge;
diagnoses Pain, acute; Pain, chronic; Ineffective tissue perfusion; Impaired gas exchange;
Activity intolerance; Ineffective coping; Impaired skin integrity.
Planning Determine the priority for nursing interventions from the list of nursing diagnoses
according to Maslow’s hierarchy of needs and set goals accordingly.
Implementation Place patient in private room. Avoid contact with visitors or staff members who
have an infection. Stress careful handwashing to the patient and other caregivers.
Assist in planning daily activities to include rest periods to decrease fatigue and
weakness. Oxygen is given for dyspnea or excessive fatigue with exertion. Patient
teaching stresses the disease process and continued medical follow-up.
Evaluation Patient shows no signs of infections; temperature and WBC count are within
normal limits. Patient has not fallen. Patient shows no signs of bleeding, or
bleeding is controlled quickly. Patient is able to bathe self in 30 minutes without
fatigue. Patient is able to explain measures to prevent infection and measures to
prevent hemorrhage. Patient states no shortness of breath.

CHAPTER 47—CARE OF THE PATIENT WITH f. Circumflex branch of left coronary artery
A CARDIOVASCULAR OR A PERIPHERAL g. Left coronary artery
VASCULAR DISORDER
Matching
Tracing a Drop of Blood 4. f
1. Superior or inferior vena cava → right atrium 5. e
→ tricuspid valve → right ventricle → pulmo- 6. d
nary semilunar valve → pulmonary artery → 7. q
capillaries in the lungs → pulmonary veins → 8. b
left atrium → bicuspid valve → left ventricle 9. a
→ aortic semilunar valve → aorta 10. k
Impulse Pattern 11. m
2. SA node → AV node → bundle of His → right 12. j
and left bundle branches of AV bundle → Pur- 13. i
kinje fibers 14. g
15. r
Figure Labeling 16. h
3. See Figure 47-6, p. 1537. 17. t
a. Anterior right atrial branch of right coro- 18. u
nary artery 19. v
b. Right coronary artery 20. c
c. Marginal branch of right coronary artery 21. l
d. Anterior interventricular branch of left 22. w
coronary artery 23. n
e. Marginal branch 24. o

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 Answer Key  134  

25. p 38. Answer 4: Recent studies indicate that type D

26. s personality has the highest risk for cardiovas-
cular problems because of increased anxiety
Fill-in-the-Blank Sentence and depression. The type A personality who
27. Troponins 1 and 2 is in a hurry and often angry or irritated was
28. B6; B12; folate formerly believed to have the highest risk.
29. 5 39. Answer 2: The monitor is showing a normal
30. Yoga; walking sinus rhythm. (Note to student: If there is ever
31. Intermittent claudication any doubt about the monitor function or dis-
32. smoking cessation play or if you doubt your interpretation of the
ECG tracing, just check on the patient.)
Multiple Choice 40. Answer 4: Recall that bearing down is one
33. Answer 1: Prothrombin time, International way to cause vagal stimulation. The other op-
Normalized Ratio, and partial thromboplastin tions can also cause sinus bradycardia, but are
time reflect blood clotting, so these laboratory less likely to have such a rapid recovery to a
values are the most important to follow up regular rate.
for patients who are on anticoagulant ther- 41. Answer 3: In third-degree heart block, the
apy. The electrolytes are important for heart impulses to stimulate heart muscle contrac-
muscle contraction. Enzyme creatine kinase, tion are not being transmitted through the AV
creatine phosphokinase, and myoglobin can junction. The rate is very slow and symptoms
be used to assist with the diagnosis of myo- of hypotension and angina are likely.
cardial infarction, but troponin levels are now 42. Answer 1: For this patient, there is an in-
more commonly used. B-type natriuretic pep- creased risk for ventricular fibrillation. The
tide is used in the diagnosis of heart failure. patient may or may not have symptoms dur-
34. Answer 4: Low hemoglobin indicates de- ing the episodes, but aggressive treatment is
creased ability to carry oxygen to the body likely in order to prevent ventricular fibril-
cells and anemia, so the first action is to make lation, which is a lethal dysrhythmia. Beta-
sure that the patient is getting supplemental adrenergic blockers are used in the ongoing
oxygen. (Oxygen is likely to have been previ- suppression of ventricular tachycardia.
ously ordered for a diagnosis of MI; if not, the 43. Answer 2: Ventricular fibrillation can be re-
nurse should start oxygen and then obtain an versed if an electrical countershock is applied
order.) The other options could also be includ- using the defibrillator. If defibrillation fails to
ed to correct low hemoglobin. convert the dysrhythmia, a bag-valve-mask
35. Answer 1: During cardiac catheterization, with supplemental oxygen and a crash cart
the catheter is inserted into a peripheral ves- will be needed. A temporary pacemaker is not
sel (usually the arm or the groin). There is a typically used for ventricular fibrillation.
potential for bleeding or injury to nerves, so 44. Answer 4: The arm on the pacemaker side
pulses and sensation distal to the site of inser- should be immobilized for the first several
tion must be checked. Electrocardiograms and hours; then for 6-8 weeks, the patient must
positron emission tomography are considered refrain from lifting the arm over the head.
noninvasive. Climbing stairs and participation in active
36. Answer 2: Smoking cessation or at least re- sports are more related to recovery during
ducing the number of cigarettes is a modi- cardiac rehabilitation. Electrical sources may
fiable factor. Heredity plays a role, but is interfere with the pacemaker’s fixed mode.
considered nonmodifiable. Prophylactic drugs 45. Answer 4: Stents are thrombogenic; thus, the
would not be the first line of therapy for this patient is likely to be prescribed an anticoagu-
healthy patient. Discussions of diet and exer- lant.
cise would be more appropriate. Body mass 46. Answer 2: Applying patches in the morning
index of 30 is too high because this indicates and removing them at bedtime prevents the
obesity. development of tolerance. Nitroglycerin tab-
37. Answer 2: Elevation of blood glucose is lets should always be carried in a pocket or
thought to contribute to damage to the arte- purse for immediate availability. A burning
rial intima and contribute to atherosclerosis. sensation under the tongue is expected dur-

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 Answer Key  135  

ing activation of the tablet. Up to three tablets nea. Worsening heart failure is accompanied
should be taken to determine if pain relief is by fluid retention and it is likely that sleeping
adequate. in a chair is causing the fluid to collect in the
47. Answer 3: Pain is the foremost symptom and lower extremities. As the edema worsens, the
is the target of immediate therapy, because abdominal girth will increase and the breath-
pain is a signal of ischemia. Diaphoresis is ing will become more labored as the fluid pro-
secondary to pain or possibly hypotension. gresses upwards. The nurse is also likely to
Palpitations could occur, but are not a typical assess compliance with diet and medications.
complaint. Shortness of breath is related to the The home health nurse has an additional ad-
body’s attempt to increase oxygen to the tis- vantage of being able to look at the environ-
sues. ment. Climbing stairs or navigating distances
48. Answer 4: Fortunately, rheumatic fever now between rooms may be an issue as the patient
occurs less frequently in the United States, becomes progressively more fatigued.
because treatment for group A β-hemolytic 55. Answer 3: Digoxin should be held for a pulse
streptococci infections has improved. For older under 60/min. The other actions are correct.
patients or for patients who have emigrated 56. Answer 2: Remember the priorities of airway
from undeveloped countries, the possibility for and breathing and give the patient oxygen.
rheumatic heart disease still exists. Next establish a peripheral IV for morphine
49. Answer 3: First, the nurse would determine if and diuretics. Arterial blood gases and aus-
the correct dose and form of the nitroglycerin cultating lung sounds will assist in the diag-
were taken. If the nitroglycerin was taken cor- nosis, but the patient is in severe distress and
rectly, than the nurse may opt to quickly assess the symptoms are attended to first.
for other symptoms that suggest cardiac or 57. Answer 3: The UAP can weigh the patient. The
digestive problems. Based on the assessment, other tasks are nursing responsibilities. (Note to
the nurse may decide to call 911 or the health student: Knowledge of correct nursing action
care provider. The neighbor should not drive and principles of delegation are combined to
himself to the hospital. decide which action can be assigned or del-
50. Answer 2: Thrombolytics are not used for pa- egated to a UAP. Remember that UAP need
tients with active internal bleeding, suspect- specific instructions.)
ed aortic dissecting aneurysm, recent head 58. Answer 1: In pericarditis, the membranous
trauma, history of hemorrhagic stroke within sac that surrounds the heart becomes in-
the past year, or surgery within the past 10 flamed. Fluid collects in the sac and the heart
days. becomes compressed by the pressure of the
51. Answer 4: For 24-48 hours, the patient is fluid. The effusion restricts the movement of
usually limited to getting up to the bedside the heart (cardiac tamponade).
commode; thereafter, the activity is gradually 59. Answer 3: Endocarditis puts the patient at
increased, but the nurse should carefully as- risk for emboli that can travel to any organ.
sess the patient before and after exertion and Sudden shortness of breath suggest that a
then give the UAP additional instructions large embolus or numerous small emboli have
about how to assist the patient. lodged in the lungs. The other signs/symp-
52. Answer 4: Teaching him how to read the toms are part of the presenting clinical mani-
labels gives him a practical skill that he can festations.
use at the grocery store. The other options are 60. Answer 2: The grandmother is historically cor-
incorrect. Healthy fats that do not exceed 30% rect in thinking that patients die within a year,
of the total calories are part of good nutrition. so she may be thinking about something that
Fiber intake should be 20-30 grams. happened in the past. Giving her accurate and
53. Answer: 2.27 rounded to 2.3 liters. up-to-date information can help her reevalu-
One liter of fluid equals 1 kg (2.2 pounds); a ate her granddaughter’s chances for recovery.
weight gain of 2.2 pounds signifies a gain of 1 Talking about surgical procedures is premature
liter of body fluid. at this point. Telling her about heart rest and
2.2 pounds : 5 pounds = 2.272 staff taking care of the child are okay, but these
1 liter x are generalized statements that do little to
54. Answer 1: The patient is describing a correc- explain the therapeutic advantages of current
tive action that he uses to deal with orthop- treatment.

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 Answer Key  136  

61. Answer 3: Cardiomyopathy caused by cocaine Critical Thinking Activities

abuse is seen more frequently now than ever
before. Cocaine causes intense vasoconstric- Activity 1
tion of the coronary arteries and peripheral 68. a. Myocardial infarction
vasoconstriction, resulting in hypertension. b. A myocardial infarction results from the
Cocaine also causes high circulating levels of occlusion of a major coronary artery or
catecholamines, which may further damage one of its branches. This leads to ischemia.
myocardial cells, leading to ischemic or dilated c. 12-lead ECG, chest radiograph, cardiac
cardiomyopathy. The prognosis is poor. Exces- fluoroscopy, myocardial imaging, echo-
sive alcohol intake over a prolonged period of cardiogram, PET scan, or multigated
time also increases the risk. acquisition scanning (MUGA). Blood
62. Answer 1: Transplant patients need immuno- workup may include electrolytes, CBC,
suppressive therapy and protective isolation. ESR, serum cardiac markers: CK-MB,
Pericardiocentesis is performed for cardiac myoglobin, troponin-I
tamponade. Percutaneous transluminal an- d. Prevention of further tissue damage, in-
gioplasty is diagnostic and reparative for terventions to promote tissue perfusion
coronary artery disease or embolism. e. Monitor vital signs, administer oxygen,
63. Answer 4: The prehypertensive category was monitor pain, administer medications as
created to help people recognize that small in- ordered
creases in blood pressure can have large conse-
quences on health. Patients would be advised Activity 2
about controlling modifiable risk factors and 69. a. Native American, history of hypertension
encouraged to participate in routine health ap- b. Nitroglycerin, aspirin, beta-adrenergic
pointments. blocking agents such as propranolol, meto-
64. Answer 3: For arterial insufficiency, the leg prolol (Lopressor), nadolol (Corgard), at-
should be dependent, because this will in- enolol (Tenormin), and timolol (Blocadren);
crease the blood flow to the tissues and help and calcium channel blockers such as nife-
decrease the pain. The other options are dipine (Procardia), verapamil, diltiazem,
likely to increase pain. Elevation and ice will and nicardipine (Cardene)
decrease the blood flow. Exercise must be bal- For patients unable to tolerate aspirin,
anced with rest. ticlopidine (Ticlid) or clopidogrel (Plavix)
65. Answer 1: Dark-green vegetables contain vita- may be given.
min K which counteracts the effect of the anti- c. Angina pain is caused by the temporary
coagulant drug. lack of oxygen and blood supply to the
66. Answer 2: The patient is showing signs and heart.
symptoms of a ruptured aneurysm and hypo-
volemic shock. The nurse would place the pa- Activity 3
tient in a shock position and immediately call 70. a. Changes in the cardiac musculature
for help. (Note to student: See Chapter 46 nurs- lead to reduced efficiency and strength,
ing interventions for hypovolemic shock for resulting in decreased cardiac output.
additional information. Rapid response team, Disorientation, syncope, and decreased
code team, or hospitalist may be available in tissue perfusion to organs and other body
different facilities.) The patient does need a tissues can occur as a result of decreased
patent IV. Giving pain medication is not a pri- cardiac output. Arterial disease resulting
ority, although oxygen should be started. from the aging process causes hyperten-
67. Answer 3: Early ambulation and encouraging sion because of the increased cardiac ef-
mobility, which includes change of position fort needed to pump blood through the
and range-of-motion exercises are the most circulatory system. Edema, secondary to
important preventive measures. Compression heart failure, may cause tissue impair-
stockings and calf measurements are part of ment in the immobile older adult. Im-
prevention and detection. Elevating the legs mobility leads to venous stasis, venous
may be ordered as a comfort measure if DVT ulcers, and poor wound healing. It also
occurs. increases the risk of venous thrombosis
and embolus formation. Older adults

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 Answer Key  137  

with cardiac disease often receive several d. Teach the patient to monitor for signs and
medications. Even with lower doses of symptoms of recurring problems such as
medications, the older adult may suffer shortness of breath; swelling of ankles,
toxicity, since the rate of drug metabolism feet, or abdomen; and frequent nighttime
and excretion decreases with age. Inde- urination. Plan activity to provide for rest
pendent older adults with cardiac condi- periods; take medications as prescribed;
tions should receive adequate teaching report signs of nausea, pain, lightheaded-
regarding medication, diet, and warning ness, and syncope to the doctor. Eat foods
signs of complications. Encourage them to high in potassium and low in sodium if
maintain regular contact with the health taking diuretics. Avoid alcohol when tak-
care provider and to seek care at the first ing vasodilators.
sign.
b. Signs and symptoms of heart failure in- Activity 4
clude: 71. a. Venous stasis ulcers result from vein in-
Decreased cardiac output sufficiency causing stasis of blood. People
• Fatigue who are homeless spend a lot of time with
• Anginal pain their legs in a dependent position. This
• Anxiety puts greater strain on vessels. The correc-
• Oliguria tive measure is to lie down and elevate
• Decreased gastrointestinal motility legs, but this is not always possible for
• Pale, cool skin homeless persons. Poor nutrition, expo-
• Weight gain sure to the elements, and lack of access
• Restlessness to hygienic facilities impairs healing of
Left ventricular failure ulcers.
• Dyspnea b. P for pulses: Assess the patient’s affected
• Paroxysmal nocturnal dyspnea extremity first. Compare the findings with
• Cough previous ones or correlate them with the
• Frothy, blood-tinged sputum patient’s signs and symptoms. Pulses
• Orthopnea should be present in venous disorders,
• Pulmonary crackles (moist popping but edema may interfere with palpation.
and crackling sounds heard most Use a Doppler as needed.
often at the end of inspiration) A for appearance: Note whether the
• Radiographic evidence of pulmonary extremity is pale; mottled; cyanotic; or
vascular congestion with pleural discolored red, black, or brown.
effusion T for temperature: If the problem is
Right ventricular failure venous, the extremity will feel normal or
• Distended jugular veins abnormally warm.
• Anorexia, nausea, and abdominal C for capillary refill: Capillary refill is
distention normally less than 2 seconds, but it may
• Liver enlargement with right upper be extended when the patient has PVD.
quadrant pain H for hardness: Palpate the extrem-
• Ascites ity to determine whether the tissues are
• Edema in feet, ankles, sacrum; may supple or hard and inelastic. Hardness
progress up the legs into thighs, may indicate long-standing PVD, chronic
external genitalia, and lower trunk venous insufficiency, lymphedema, or
c. Heart failure is managed with digoxin, chronic edema. Hardened subcutaneous
vasodilators, ACE inhibitors, beta block- skin also increases the risk of stasis ulcers.
ers, and angiotensin II receptor blockers. E for edema: Pitting edema frequently
Nesiritide is the first of the drug class indicates an acute process, and nonpitting
called human BNPs. It reduces pulmonary edema may be seen with chronic condi-
capillary pressure, improves breathing, tions, such as venous insufficiency. Assess
and causes vasodilation with increase in both extremities for edema and compare
stroke volume and cardiac output. and document the findings.

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 Answer Key  138  

S for sensation: In addition to asking and frozen premade meals are higher in fat.
the patient about pain, ask if he or she has For elderly housebound people, canned or
other abnormal sensations, such as numb- frozen food is likely to be more convenient,
ness or tingling, or heat or cold. but some product lines are better than oth-
c. Visibly ulcerated skin having dark pig- ers. One suggestion for single elders (or
mentation, dryness, scaling, and edema busy nursing students) is to make a batch of
may occur. Dull aching pain relived by healthy homemade soups, beans, casseroles,
elevation of the extremity. Peripheral etc., and freeze in single-serving portions.
pulses are usually present with venous
insufficiency. Pain, aching, and cramping
associated with venous disorders are usu- CHAPTER 48—CARE OF THE PATIENT WITH A
ally relieved by activity and/or elevating RESPIRATORY DISORDER
the extremity.
d. The focus is on promotion of wound heal- Matching
ing and preventing infection. Dietary 1. d
management including adequate protein 2. e
intake with supplements of vitamin A 3. f
and C, and mineral zinc. Débridement 4. b
of necrotic tissue, antibiotic therapy, and 5. g
protection of ulcerated areas. Homeless 6. h
patients may need assistance in obtaining 7 a
medication or nutritious foods. The nurse 8. c
should suggest ways to adapt wound care 9. j
and instruct about elevating legs when- 10. i
ever possible.
Fill-in-the-Blank Sentences
Activity 5 11. capillaries
72. Recall the patient teaching points when you 12. 2; 3
are doing the food product calculations. 13. carbon dioxide; oxygen
• Recommended daily intake is 2 g sodium, 14. increased; decreased
1500 calories, low cholesterol, and fluid 15. Nasal polyps
restrictions.
• Limit total fat intake to 25% to 35% of to- True or False
tal calories each day. Limit intake of satu- 16. False: The right mainstem bronchus is larger
rated fats to less than 7% of total fat in- and more vertical; therefore, foreign bodies
take. Teach the patient that saturated fats are more likely to go to the right.
(e.g., shortening, lard, or butter) are solid 17. False: Lung cancer is the leading cause of
at room temperature; better sources of fat death from cancer for men and women.
include vegetable, olive, and fish oils. 18. True
• Teach the patient to avoid foods high in 19. True
sodium, saturated fats, and triglycerides.
Review alternative ways of seasoning Table Activity
foods to avoid cooking with salt. Explain 20.
the need to limit intake of eggs, cream, pH 7.35-7.45
butter, and foods high in animal fat. Teach
the patient and family how to read labels Paco2 35-45 mm Hg
on foods. Pao2 80-100 mm Hg
• Teach the patient to eat 20-30 g of soluble
HCO –
21-28 mEq/L
fiber every day. Foods such as bran, 3

beans, and peas help lower bad choles- Sao2 95%

terol (low-density lipoprotein).
Recommendations will be based on what Multiple Choice
you found on the shelf. Typically, canned 21. Answer 3: Air cannot pass over the vocal
foods are higher in sodium than fresh foods cords, so normal speech is impossible. The

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 Answer Key  139  

patient can breathe through the tracheostomy thoracic cavity. Positioning the patient upright
opening. Secretions will be produced, but in- will facilitate the drainage.
terventions relate to keeping the skin around 28. Answer 3: Usually no more than 1300 mL of
the opening clean and dry. The esophagus fluid is removed at one time because there is
and trachea do not communicate, so choking a risk of intravascular fluid shifting that will
is not anticipated. result in pulmonary edema. Because of the
22. Answer 1, 2, 3, 5, 6: The nurse would ask the risk for pulmonary edema, the nurse is likely
patient to describe symptoms, onset, alleviat- to increase the frequency of assessment. Giv-
ing factors, and changes in ability to perform ing the patient extra fluid could worsen fluid
activities of daily living (ADLs). Patients with shifting. If the purpose was therapeutic, the
chronic lung disorders are likely to have had fluid may or may not have been sent to the
abnormal blood gas results (some may keep laboratory for analysis.
track of these results), but these findings are 29. Answer 4: Warfarin is an anticoagulant, so the
not relevant to the current status. nurse would hold pressure on the puncture
23. Answer 4: Flaring of the nostrils is usually wound for 20 minutes to prevent a hematoma.
considered a late sign. Increased respiratory 30. Answer 2: The student remembers that the
rate is associated with many conditions. Some automatic blood pressure cuff occludes blood
are serious (e.g., pulmonary edema), and oth- flow to the distal portions of the extremity, so
ers are benign (aerobic exercise). Adventitious the first pulse oximeter reading is likely to be
breath sounds can be present and the patient falsely low.
may not be aware that there is a problem (e.g., 31. Answer 3: With epistaxis, frequent swallow-
immobile patients can have crackles). The or- ing suggests that the blood is running down
thopneic position does signal respiratory dis- the back of the throat. This could either be
tress, but is also used by many patients who rebleeding or posterior bleeding. Posterior
have chronic respiratory disorders. bleeding is not always resolved with anterior
24. Answer 2: Trauma combined with uneven packing.
chest expansion are associated with pneumo- 32. Answer 1, 2, 3, 6: The goal is to keep the nasal
thorax (collapsed lung). mucous membranes moist, so a vaporizer,
25. Answer 1: The advantage of the helical saline nose drops and lubricants are recom-
computed tomography scan is that the en- mended. Nose picking and putting other
tire study can be performed in less than 30 objects into the nose should be avoided; this
seconds. The disoriented patient may have point is emphasized with pediatric patients.
difficulty cooperating for a V-Q scan or pul- Aspirin is considered an anticoagulant. Blow-
monary angiography, as both are much longer ing vigorously can restart bleeding. (Note to
procedures. A flat plate of the abdomen is student: The health care provider may have
the best exam for ingested foreign bodies. A had the patient blow vigorously just prior to
mediastinoscopy will be performed to obtain examination, so the patient may assume that
lymph tissue. A chest x-ray will be performed the action is okay.)
for the patient exposed to tuberculosis. 33. Answer 1: The nurse can administer the aller-
26. Answer 2: The UAP can assist the patient to gens and should mark the sites. The localized
move and make position changes. The other reaction should be measured and document-
tasks are nursing responsibilities. (Note to stu- ed. The health care provider is responsible for
dent: The UAP could ordinarily be expected evaluating the outcomes of the test, discuss-
to watch for and report seeing blood in speci- ing allergens to avoid, and instructing the pa-
mens; however, some blood is an expected tient about ambiguous results. The nurse can
finding after biopsy and the nurse should do reinforce what the health care provider tells
the assessment to determine if bleeding is the patient, but should not initiate discussion
excessive.) (Note to student: Knowledge of cor- of findings. Allergy testing and interpretation
rect nursing action and principles of delega- of results is not an exact science.
tion are combined to decide which action can 34. Answer 3: The universal sign for choking is
be assigned or delegated to a UAP. Remem- hand over the throat. People who are vigor-
ber that UAP need specific instructions.) ously coughing should be encouraged to
27. Answer 1: The goal of thoracentesis for thera- continue coughing. While running out of the
peutic reasons is to remove fluid from the room is not an obvious signal, people have

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 Answer Key  140  

been known to leave out of embarrassment. sound with a machinelike quality during
Waving hands frantically is a signal, but cause both inspiration and expiration. Crackles are
would have to be assessed. interrupted crackling or bubbling sounds
35. Answer 3: Resting the voice is the most im- more common on inspiration. Sonorous
portant measure to reduce the inflammation wheezes are deep, loud, low, coarse sounds
of the vocal cords. The other measures help (like a snore) during inspiration or expiration.
to promote comfort. Antibiotics are not pre- Sibilant wheezes are high-pitched, musical,
scribed for a diagnosis of viral laryngitis. whistlelike sounds during inspiration or expi-
36. Answer 2: A rapid strep test is performed to ration.
detect the presence of β-hemolytic streptococ- 43. Answer 4: Acetylcysteine (Mucomyst) is used
ci, which is a severe form of acute pharyngitis. to reduce the viscosity of secretions. This
If those results are negative, then the second makes expectoration easier and more effec-
swab is used to culture a medium and is al- tive.
lowed to grow so the infecting organism can 44. Answer 1: The UAP can help the patient
be identified. ambulate, but the nurse must give specific in-
37. Answer 3: The patient has symptoms of structions about holding the container below
sinusitis. Transillumination involves shin- the chest and ensure that the UAP and patient
ing a light in the mouth with the lips closed do not place undue pressure on the tubes.
around it; infected sinuses will look dark, (Note to student: Knowledge of correct nursing
whereas normal sinuses will transilluminate. action and principles of delegation are com-
38. Answer 4: Dairy products thicken secretions, bined to decide which action can be assigned
so they become more tenacious and harder to or delegated to a UAP. Remember that UAP
expectorate. need specific instructions.)
39. Answer 4: The symptoms will mimic other 45. Answer 3: IV fluids are usually withheld to
respiratory disorders; thus, diagnosis is de- prevent adding fluids to the overloaded pa-
layed because more common causes will tient. (An IV saline lock would be the expect-
be investigated first. During this delay, the ed order.) The other orders are appropriate for
infection will become more entrenched. Le- patients with pulmonary edema.
gionnaires’ and SARS can be transmitted via 46. Answer 2: The nurse would first check vital
droplets in air, so many people could be ex- signs and a pulse oximeter reading and assess
posed before the diagnosis is made. Anthrax for other signs of respiratory distress or de-
has been identified as a possible bioterrorism creased cardiac output. Notifying the RN and
agent. Morbidity is high for all three disor- health care provider would be the next step.
ders. For Legionnaires’ disease, 15-20% have A blood gas is likely to be ordered. Assessing
died in localized epidemics. For SARS, 10-20% the leg is not helpful once the thrombus be-
require intubation and risk for death is high. comes an embolus.
Anthrax responds to antibiotics once diagno- 47. Answer 1: Sepsis is the most common precur-
sis is made. sor of ARDS. The window is 5-10 days after
40. Answer 4: The drug regimen is prolonged onset of sepsis. ARDS due to injury usually
and for various reasons, many will fail to manifests in 12-24 hours. COPD or asthma
complete the therapy. This has contributed can be factors as underlying respiratory dis-
to multidrug-resistant TB strains. Family and eases, but many patients who have COPD or
friends are generally not at high risk for con- asthma never develop ARDS.
tracting TB. Hand hygiene and covering the 48. Answer 1: Care should be divided into short
mouth while coughing are encouraged as the sessions with intermittent periods of rest. Hy-
main infection control measures. Mortality gienic care should not be completely deferred;
rates of 72-89% are noted among HIV-infected the nurse should determine how the care can
people with multidrug-resistant TB strains. be abbreviated or adapted and inform the
41. Answer 2: Severe pain in peripheral lung can- UAP accordingly. The nurse must assess the
cer is likely to be caused by a pleural effusion. patient’s response to ambulation and patient’s
The treatment for this is a thoracentesis. ability to participate in range-of-motion exer-
42. Answer 3: A pleural friction rub is considered cises and then inform the UAP.
diagnostic for pleurisy. The nurse should 49. Answer 4: An increased number of red blood
hear a dry, creaking, grating, low-pitched cells (polycythemia) occurs as the body at-

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 Answer Key  141  

tempts to increase the oxygen to tissue. De- begin to forget to take medication once the
hydration could contribute to an elevated red symptoms are resolved. There is also a higher
cell count, but is not directly related to chronic incidence of TB among older people, urban
bronchitis. poor, minority groups, immigrants, and the
50. Answer 3: For newly diagnosed asthma pa- homeless. The barriers to care include finan-
tients, identification of allergens in the home cial concerns, access to facilities, problems
environment will help them to control/avoid understanding the provider’s instructions,
exposure and will decrease episodes of acute difficulty with follow-up care, and differences
attacks. These patients should be able to re- in health values and beliefs.
sume normal activities after treatment for an First the nurse should seek the patient’s
acute episode. opinion on what would help increase compli-
ance and the major stumbling blocks in meet-
Critical Thinking Activities ing that goal. Compliance can be increased
for some by including family members in
Activity 1 the teaching sessions. For others, directly
51. a. Obstructive sleep apnea observed therapy allows a health worker to
b. Risk factors include obesity and male observe while the person takes the medica-
gender. Personal history factors include tion. Education regarding the dangers of
recent motor vehicle accident caused by multidrug-resistant strains will encourage
falling asleep and reports of loud snoring some. Others may need help from social ser-
at night. vices to locate financial resources. Helping
c. Mild sleep apnea can be corrected by the patient link the medication to a routine
avoiding sedatives and alcohol for 3-4 activity (i.e., brushing teeth) could help. An
hours before sleep. Other corrective mea- electronic reminder could be used.
sures include weight loss, use of oral ap-
pliances to bring the mandible and tongue Activity 4
forward to enlarge the airway space, and 54. a. Assessment should include:
support groups. In severe cases, nasal • Breath sounds, vital sounds
continuous positive airway pressure • Note the amount and characteristics
(nCPAP) may be used. of the drainage
• Monitor laboratory results—
Activity 2 specifically ABGs, WBC count
52. a. Symptoms are generally mild. They may • Observe for bubbling or fluctuations
include cold symptoms, headache, an- in the drainage bottle
orexia, myalgia, and irritating cough that b. Keep tubing as straight as possible. Keep
produces mucopurulent or bloody spu- all connections tight and taped at con-
tum. nections. Never elevate the drainage col-
b. Blood and sputum cultures, chest ra- lection receptacles above the level of the
diographic studies, complete blood cell chest.
count, pulmonary function tests, ABGs, c. The absence of bubbling in the water seal
and pulse oximetry chamber indicates possible occlusion of
c. There is no definitive treatment for viral the system.
pneumonia. Medications that may be pre- d. Bubbling should be intermittent. Constant
scribed include analgesics, antipyretics, bubbling indicates a leak in the system.
expectorants, and bronchodilators.
d. Assessments should include vital signs,
breath sounds, assess characteristics of
sputum, and tolerance of activities.

Activity 3
53. Drug therapy for tuberculosis (TB) lasts be-
tween 6 and 9 months and many people will

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 Answer Key  142  

CHAPTER 49—CARE OF THE PATIENT WITH A primarily in the proximal convoluted tu-
URINARY DISORDER bules, Henle’s loop, and the distal convo-
luted tubules. This process reclaims im-
Word Scramble portant substances needed by the body.
1. anuria d. urinary output of less c. Secretion of certain ions, nitrogenous
than 100 mL/day waste products, and drugs occurs primar-
2. azotemia a. retention of excessive ily in the distal convoluted tubule. This
amounts of nitrogenous process is the reverse of reabsorption; the
compounds in the substances move from the blood to the
blood filtrate.
3. bacteriuria i. bacteria in urine 13. Urinary frequency, urgency, nocturia, reten-
4. hemodialysis f. requires access to the tion, and incontinence are common with aging.
circulatory system to These occur because of weakened musculature
route blood through the in the bladder and urethra, diminished neu-
artificial kidney rologic sensation combined with decreased
5. dysuria e. painful or difficult uri- bladder capacity, and the effects of medications
nation such as diuretics.
6. hematuria b. blood in the urine • Urinary incontinence can lead to a loss of
7. nocturia c. excessive urination at self-esteem and result in decreased par-
night ticipation in social activities.
8. oliguria h. decreased urinary out- • Older women are at risk for stress incon-
put , less than 500 mL in tinence because of hormonal changes and
24 hours. weakened pelvic musculature.
9. prostatodynia j. pain in the prostate • Older men are at risk for urinary retention
gland because of prostatic hypertrophy.
10. urolithiasis g. formation of urinary • Urinary tract infections in older adults are
calculi often associated with invasive procedures
such as catheterization, diabetes mellitus,
Short Answers and neurologic disorders.
11. a. Controlling body fluid levels by selective- • Inadequate fluid intake, immobility, and
ly removing or retaining water conditions that lead to urinary stasis in-
b. Assisting with the regulation of pH crease the risk of infection in the older
c. Removing toxic waste from the blood adult.
12. a. Filtration of water and blood products • Frequent toileting and meticulous skin
occurs in the glomerulus of Bowman’s care can reduce the risk of skin impair-
capsule. ment secondary to urinary incontinence.
b. Reabsorption of water, glucose, and nec-
essary ions back into the blood occurs

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 Answer Key  143  

Table Activity
14. Urinalysis

Constituent Normal Range Influencing Factors

Color Pale yellow to amber Diabetes insipidus, biliary obstruction, medications,
diet
Turbidity Clear to slightly cloudy Phosphates, white blood cells, bacteria
Odor Mildly aromatic Medication, bacteria, diet
pH 4.6-8 Stale specimen, food intake, infection, homeostatic
imbalance
Specific gravity 1.003-1.030 State of hydration, medications
Glucose Negative Diabetes mellitus, medications, diet
Protein Negative Renal disease, muscle exertion, dehydration
Bilirubin Negative Liver disease with obstruction or damage, medications
Hemoglobin Negative Trauma, renal disease
Ketones Negative Diabetes mellitus, diet, medications
Red blood cells Up to 2 LPF Renal or bladder disease, trauma, medications
White blood cells 0-4 LPF Renal disease, urinary tract infection
Casts Rare Renal disease
Bacteria Negative Urinary tract infection

Figure Labeling and normal. Prostatitis could cause an obstruc-

15. See Figure 49-13, p. 1720. tion to flow, but the kidneys continue to pro-
duce urine normally.
Multiple Choice 21. Answer 1, 2, 3, 4: The normal range is less
16. Answer 2: Phenazopyridine (Pyridium) causes than 4 ng/mL. Elevated levels may result
the urine to turn a bright-orange color. The from prostate cancer, inflammation or infec-
goal is to increase the acidity of the urine, so if tion, urinary tract infection, or recent cystos-
the patient is following the recommended diet, copy or prostatic biopsy.
the pH should actually decrease. The leuko- 22. Answer 3: For renal angiography, the nurse
cytes should decrease because of the Bactrim. must assess circulatory status of the involved
Ketones should not be present. extremity every 15 minutes for 1 hour, then
17. Answer 1: Ketones appear in the urine as every 2 hours for 24 hours. A kidney-ureter-
the body converts fats into energy, because bladder radiography and ultrasonography do
glucose is not available to use as an energy not require any special postprocedural care. For
source. the intravenous pyelogram, the patient needs
18. Answer 3: WBC casts in the urine indicate to be encouraged to drink water to flush the
involvement of the renal parenchyma in renal dye from the system, and the venipuncture site
disorders, such as acute pyelonephritis or should be routinely observed.
acute glomerulonephritis. 23. Answer 3: Cholinergic and anticholinergic
19. Answer 3: The normal range of specific grav- medications may be administered during uro-
ity is 1.003-1.030; thus, excessive body water dynamic studies to determine their effects on
decreases specific gravity. Water intoxication bladder function.
occurs when the patient drinks an excessive 24. Answer 4: Bedrest is instituted for 24 hours
amount of water. The other three conditions after the procedure. Mobility is restricted to
will cause dehydration and the specific grav- bathroom privileges for the next 24 hours, and
ity will increase. gradual resumption of activities is allowed
20. Answer 2, 3, 4, 5: The serum creatinine test is after 48-72 hours.
used to diagnose impaired kidney function. 25. Answer 4: Osmotic diuretics are used for
With normal renal excretory function, the se- acute renal failure to prevent irreversible fail-
rum creatinine level should remain constant ure, but they are contraindicated in advanced

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 Answer Key  144  

end-stage renal failure. (Note to student: construction of the urethra; thus, tension on
Knowledge of correct nursing action and prin- the catheter could result in disruption of the
ciples of delegation are combined to decide surgical site. The other patients have catheters
which action can be assigned or delegated to primarily for drainage purposes.
a UAP. Remember that UAP need specific in- 32. Answer 1: In nephrotic syndrome, excess fluid
structions.) in the body is the most common sign. Patients
26. Answer 2: The patient with urge and func- who develop acute glomerulonephritis may
tional incontinence will benefit the most from report a preceding episode of sore throat or
having an external condom, because he is skin infection with fever and malaise. Burning
unable to get to the bathroom in time. The with urination, low-back pain, hematuria, and
patient with Alzheimer’s is likely to pull the fever are more associated with cystitis. Dys-
external catheter off. If the patient with a uri- uria, weak stream, and increasing pain with
nary tract infection has problems with incon- bladder distention are seen in patients with
tinence, antibiotic therapy should resolve the urethral strictures.
problem. An enlarged prostate prevents flow, 33. Answer 4: Excess fluid causes edema and hy-
so the external catheter does not address the pertension, so the patient is placed on bedrest
underlying problem. until those symptoms resolve. The patient is
27. Answer 4: The nurse would first check to also likely to have orthopnea, so the head of
make sure that the tube and catheter are not the bed should be elevated.
kinked or obstructed and that the collection 34. Answer 2: Albumin and blood in the urine
bag is below the level of the bladder. Once are early indicators of renal failure. Residual
function of drainage system is checked and urine is a bladder outflow problem that is not
low urinary output is verified, the nurse related to actual kidney function. Retained
would assess for signs and symptoms of de- urine in the bladder is suspected to contribute
creased cardiac output, which will eventually to bladder cancer. Ketones in the urine are
contribute to renal failure. The RN and health usually associated with diabetes mellitus, al-
care provider would then be notified of find- though diet and medication could be factors.
ings. Prostate-specific antigen is a screening test for
28. Answer 2: Spironolactone (Aldactone) is a prostate cancer.
potassium-sparing diuretic, so it is contraindi- 35. Answer 2: The nurse would auscultate the
cated for patients who have hyperkalemia. arteriovenous fistula for bruit (adventitious
29. Answer 2: The nurse would advise the patient sound of venous or arterial origin heard on
that diphenhydramine (Benadryl) can cause auscultation) and palpate arteriovenous fistu-
urinary retention. This could add problems la for thrill (abnormal tremor). A nurse should
with passing urine, because BPH can cause never access the fistula to draw blood, to give
an obstruction of urine flow. In addition, the fluids or to check patency, unless he/she has
nurse would remind the patient that all OTC had special training in dialysis procedures.
medications should be reviewed with the Checking the distal pulses and sensation and
health care provider and on file with the local asking about pain are routinely done for all
pharmacist. patients, but circulation problems to distal tis-
30. Answer 1: Kegel exercises are recommended sues and pain are not anticipated.
in prevention and treatment of stress inconti-
nence, which is loss of urine during coughing, Critical Thinking Activities
laughing, sneezing, or straining.
Kegel exercises are recommended for all Activity 1
patients who are able to practice conscious 36. a. Signs and symptoms include pain in the
motor control over the pelvic musculature to costovertebral angle, elevated tempera-
reduce present or future episodes of inconti- ture, chills, and pus in the urine.
nence. Some patients who have Parkinson’s b. Urinalysis: pus, bacteria, and leukocytosis
or Alzheimer’s may be able to learn Kegel present
exercises, depending on cognition and motor IVP: presence of an obstruction or de-
control. generative changes
31. Answer 3: The Foley catheter is inserted to
splint and support the suture line after re-

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 Answer Key  145  

Activity 2 Activity 4
37. a. Urolithiasis 39. a. Women are more susceptible to UTIs than
b. Ideally, the stone will be passed without men because the urethra is short and
intervention. Fluid intake should be in- proximal to the vagina and rectum.
creased and monitored. The urine will be b. Complaints may also include frequency,
strained to check for the stone or “grav- urgency, and nocturia. Abdominal palpa-
eling.” Cystoscopy, surgical incision, or tion may also cause discomfort over the
chemolytic medications to dissolve the bladder.
stone may be ordered. Extracorporeal c. Antibiotics and urinary antiseptics
shock wave lithotripsy is an alternative to d. Teach the woman to cleanse the perineal
surgery. area from front to back to prevent con-
c. Dietary modifications to reduce the tamination of pathogens (especially E.
level of calcium phosphorus and purine- coli) from the rectum to the short urethra.
containing foods may be indicated. These • Encourage drinking 2000
foods include cheese, greens, whole mL of liquids per day unless
grains, carbonated drinks, nuts, chocolate, contraindicated.
shellfish, and organ meat. Fluid intake of • Instruct the patient to take all the
at least 2000 mL/day is also recommend- prescribed medications, even though
ed. symptoms may subside quickly.
Drugs may be ordered to prevent ab- • Empty bladder as soon after
sorption of minerals associated with stone intercourse as possible. If UTIs
formation. are associated with intercourse,
recommend cleansing of genitalia
Activity 3 with soap and water prior to having
38. a. The patient may experience anorexia, sexual relations.
nausea, vomiting, and edema. Special at- • Shower instead of tub baths.
tention should be paid to signs of hydra- • Limit use of bubble baths.
tion, including mucous membranes, skin • Instruct the patient about early
turgor, and urine output. There may also detection and testing with Chemstrip
be signs of drowsiness, muscle twitching, LN.
and seizures.
b. In the oliguric phase, BUN and serum
creatinine levels rise while urinary out- CHAPTER 50—CARE OF THE PATIENT WITH
put decreases to less than 20 mL/hr (less AN ENDOCRINE DISORDER
than 400 mL/24 hr). The oliguric phase
may last from several days to weeks to Matching
months. Some patients may experience 1. b
the nonoliguric form, usually caused by 2. a
nephrotoxic antibiotics, in which urinary 3. d
output may exceed 2 L/24 hr. In the di- 4. c
uretic phase, blood chemistry levels begin 5. g
to return to normal and urinary output 6. h
increases to 1-2 L/24 hr. The diuretic 7. e
phase usually lasts 1-3 weeks. Return to 8. f
normal or near-normal function occurs in 9. k
the recovery phase. Recovery begins as 10. l
the glomerular filtration rate rises. Recov- 11. i
ery can take up to 1 year. 12. j
c. The wife should be advised this would
not be the best option. The diet should be Figure Labeling
low in protein, potassium, and sodium. 13. See Figure 50-1, p. 1726.
Carbohydrates should be high. The items
she is proposing to bring in are high in Fill-in-the-Blank Sentences
protein and sodium. 14. antidiuretic hormone (ADH)

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 Answer Key  146  

15. 30; 2 to 3
16. insulin
17. 60-99 mg/dL; 5-6%
18. hypertension, obesity, dyslipidemia
19. Diabetes
20. 45%
21. Table activity (See Table 50-5, p. 1758 for additional information.)

Injection Time Risk Time for Hypoglycemic

Type of Insulin (Before Meal) Reaction Peak Action Duration
Lispro (Humalog) 5-15 min No meal within 30 min 15-30 min 1-2 hr
Regular 30 min Delayed meal or 3-4 hr after 30-60 min 2-4 hr
Humulin R injection
Novolin R
NPH/Regular Mix 30-60 min Delayed meal or 3-4 hr after 30-60 min 6-12 hr
70/30 injection
Humulin Mix 70/30
Lente 30 min 3-6 hr after injection 1-3 hr 6-12 hr
Glargine (Lantus) Usually take at Starting dose should be 20% less 1-2 hr No pronounced
9 pm, once daily than total daily dose of NPH peak
Ultralente 30 min 6 hr after injection 4-6 hr 18 hr

Multiple Choice 26. Answer 4: Brain edema will result in a change

22. Answer 3: First, the nurse acknowledges in mental status, progressive lethargy, or
the underlying feelings of change and loss. changes in personality. These symptoms are
Option 1 is false reassurance. Option 2 is a followed by seizures and loss of deep tendon
platitude. Option 4 may be a possibility after reflexes.
assessment, treatment, and discussion. 27. Answer 3: All of the findings are positive;
23. Answer 2: A school nurse would notify the however, a gradual increase of serum sodium
parents, so the child could be evaluated by a is the purpose of the therapy.
health care provider (for diagnostic testing to 28. Answer 3: In the postsurgical period, patients
rule out giantism). A nurse who works with/ who have had thyroidectomy surgery are
for the health care provider would perform encouraged to deep-breathe, but the nurse
the other options. The health care provider would check with the health care provider
might also contact the school nurse and ask about coughing, because of potential strain on
for regular height and weight reports. the suture line.
24. Answer 1, 2, 4: Nursing assessment and inter- 29. Answer 1: Graves’ disease is hyperthyroid-
vention for patients with diabetes insipidus is ism, so the symptoms that manifest reflect
focused on fluid loss and dehydration. Fluids an increased metabolism. Intolerance to cold,
should not be restricted. Patients should be constipation, and lethargy are symptoms
assisted to ambulate because they may be of hypothyroidism. Skeletal pain, pain on
tired. It is likely that they are frequently walk- weight-bearing, and paranoia are seen in hy-
ing to the bathroom during the day and at perparathyroidism. Polyphagia, polydipsia,
night; thus, encouraging additional ambula- and polyuria are characteristics of diabetes
tion is not necessary. mellitus.
25. Answer 1: For any of these patients, the nurse 30. Answer 4: Levothyroxine (Synthroid) is a
would be aware of the possibility of develop- replacement therapy for patients with hy-
ing SIADH; however, malignancies are the pothyroidism; thus, normalization of TSH
most common cause of SIADH; cancerous levels indicates that the therapy is working.
cells are capable of producing, storing, and Normalization of urine specific gravity would
releasing ADH. be a therapeutic goal for diabetes insipidus.

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 Answer Key  147  

Gradual improvement of serum sodium is the 37. Answer 2: Diabetes insipidus causes produc-
treatment goal for SIADH. A blood glucose of tion of urine with a very low (dilute) specific
250 mg/dL is used as a target to initiate intra- gravity.
venous dextrose solutions for patients who are 38. Answer 3: Simple goiter is usually caused by
being treated for diabetic ketoacidosis. a dietary insufficiency of iodine.
31. Answer 2: The patient is displaying symp- 39. Answer 3: Cortisol is a glucocorticoid that
toms of thyroid crisis. The risk is greatest in provides extra reserve energy in times of
the first 12 hours after surgery. stress. Aldosterone, the principal mineralocor-
32. Answer 3: Upon finding a palpable nodule, ticoid, regulates sodium and potassium levels
the health care provider would order diagnos- by affecting the renal tubules. Glucagon is a
tic testing to rule out thyroid cancer. Severe pancreatic hormone, which responds to de-
hypothyroidism in adults is called myxedema. creased levels of glucose in the blood.
It is characterized by edema of the hands, the 40. Answer 4: Regular insulin is given via the in-
face, the feet, and periorbital tissues. Con- travenous route for hyperglycemia.
genital hypothyroidism is called cretinism. 41. Answer 2: Corticosteroids should never be
Colloid goiter could manifest as an unsightly abruptly discontinued because of the risk
enlargement of the thyroid gland or with inducing adrenal insufficiency. The other op-
dysphagia, hoarseness, or dyspnea. tions could be done under the supervision of
33. Answer 1: Although the nurse may see that the health care provider.
the patient would benefit from a MyPlate 42. Answer 1: The skin is very thin and fragile
review, the dietary restriction related to the and easily torn; thus, gentle handling is nec-
hyperparathyroidism is dairy products. essary. The nurse must assess the skin; this
34. Answer 3: Hyperparathyroidism causes an cannot be delegated. Frequent washing or
increase in serum calcium and the goal is to shaving could contribute to skin damage.
rid the body of the excess. Thiazide diuret- 43. Answer 3: These are signs of impending
ics are not used because they decrease renal addisonian crisis, which is potentially life-
excretion of calcium and thus increase the threatening and the health care provider
hypercalcemic state. Diuretics can be used in should be notified immediately. The fre-
acute renal failure to preserve kidney function quency of assessment will increase because of
or in disorders that cause fluid retention, such acuity. Documentation is always appropriate,
as congestive heart failure. Diuretics are usu- but the patient’s condition must be addressed
ally included in the regimen for hypertension. first.
35. Answer 2: In this emergency situation, the 44. Answer 2: Recall that epinephrine and nor-
LPN/LVN recognizes that IV calcium can epinephrine are involved in the fight or flight
precipitate hypotension, serious cardiac response. Lethargy, constipation, and depres-
dysrhythmias, or cardiac arrest. Thus electro- sion could be evident in many disorders;
cardiographic monitoring is indicated when however, hypothyroidism could cause these
administering calcium. Assessing for allergies, symptoms. Kussmaul’s respiration, hypo-
verifying medication orders, and checking tension, and drowsiness are seen in patients
patency of the site are responsibilities of the with diabetic ketoacidosis. Excessive thirst,
nurse who is administering the drug. (Note increased urine output, and lethargy are seen
to student: When patients become unstable in diabetes insipidus.
or critical, the LPN/LVN should notify the 45. Answer 4: The glycosylated hemoglobin
health care provider and RN and the RN (HbA1c) blood test measures the amount of
should assume care and responsibility for the glucose that has become incorporated into
patient. The LVN/LPN uses knowledge and the hemoglobin within an erythrocyte; these
skills during a crisis to contribute to care of levels are reported as a percentage of the total
patients under the supervision of the RN.) hemoglobin. Because glycosylation occurs
36. Answer 2: Foods that are low in phosphorus constantly during the 120-day life span of the
are encouraged because calcium and phos- erythrocyte, this test reveals the effectiveness
phorus levels are reciprocal. In other words, if of diabetes therapy for the preceding 8-12
the serum phosphorus level is lower, the cal- weeks. The other tests give limited results re-
cium level will increase, which is desirable for lated to current status.
these patients.

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 Answer Key  148  

46. Answer 3: Type 1 diabetics have the great- • Increased risk for acute infections
est risk for diabetic ketoacidosis, which can Long-term complications may include
be brought on by minor illness. Presence of blindness, cardiovascular problems, re-
ketones should be reported to health care pro- nal failure, and increased risk of chronic
vider. infection (that could lead to amputation).
47. Answer: 15 mL/hour These complications may be avoided or
100 units : 3 units = 15 mL/hour lessened in severity with the appropriate
500mL x mL care and attention to the prescribed medi-
48. Answer 2: This patient is NPO for a proce- cation and dietary regimen.
dure, so the nurse decides not to feed this
conscious patient, but to use the emergency Activity 2
protocol to administer 50% dextrose. Once 50. a. Radiographic examinations to determine
the patient has received the bolus, the nurse bone age and a skull series to rule out tu-
should recheck the blood glucose and call the mors. Serum growth hormone levels will
health care provider. The nurse cannot make also be evaluated.
the decision to cancel the procedure. b. Underdevelopment of the jaw may cause
problems with teeth eruption. Sexual de-
Critical Thinking Activities velopment may be delayed.
c. The overall prognosis is favorable. Most
Activity 1 people with dwarfism are able to repro-
49. a. Type 1 diabetes mellitus duce normally.
b. In addition to polyuria, polydipsia, and d. Injection of growth hormone replacement
polyphagia, she may be thin with a sud-
den onset of symptoms including blurred Activity 3
vision, appearance of halos around lights, 51. Diabetes mellitus is more prevalent in older
and headaches. As the condition progress- adults. A major reason for this is that the pro-
es, there may be changes in electrolyte cess of aging involves insulin resistance and
balances. glucose intolerance, which are believed to
c. Insulin injection are given between the fat be precursors to type 2 diabetes. The classic
and muscle layers. signs and symptoms of diabetes may not be
Gently pinch up at least a 2-inch fold obvious in older adults. Older adult diabetic
of tissue (not just the skin). And quickly patients are at increased risk for infection and
insert the needle into the top of the fold, should be counseled to receive proper immu-
entering the subcutaneous tissue. The nizations and seek regular medical attention
needle should be inserted at a 90-degree for even minor symptoms. The older adult of-
angle. Inject the insulin slowly. Place the ten has difficulty managing diabetes. Dietary
alcohol swab against the needle hub at management may be complicated by a variety
the injection site, and pull the syringe unit of functional, social, economic, and financial
straight out in one swift motion. Do not factors.
massage the site. Teach the patient how to Some symptoms of hypothyroidism in the
rotate sites for injection. older adult are similar to those in a younger
Store insulin and other supplies prop- person but are more likely to be overlooked
erly. Patients can be reminded that aspira- because the symptoms—fatigue, mental im-
tion does not need to be done before injec- pairment, sluggishness, and constipation—are
tion and the injection site does not need to often attributed solely to aging. The older
be cleansed with alcohol. The open bottle person with hypothyroidism has more distur-
may be stored at room temperature once bances of the central nervous system, such as
opened. It is acceptable to store unused syncope, convulsions, dementia, and coma.
bottles in the refrigerator. There is often pitting edema and deafness.
d. Acute complications include: The older patient with hyperthyroidism
• Diabetic coma frequently has manifestations related only to
• Hyperglycemic hyperosmolar the cardiovascular system, such as palpita-
nonketotic coma tions, angina, atrial fibrillation, and breath-
• Hypoglycemic reaction lessness. Signs and symptoms often attributed

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 Answer Key  149  

to “aging” may actually indicate an endocrine True or False

problem. 21. False: Rigorous exercise or the insertion of a
tampon may tear the hymen. If the hymen
Activity 4 does remain intact, it is ruptured by coitus
52. Endocrine disorders can mimic other disor- (intercourse).
ders. For example, palpitations can occur in 22. False: The goal of patient education is to pro-
hyperthyroidism, but can also occur in cardiac vide information without influencing patient
disorders. Older patients especially can have choices, regardless of the nurse’s personal be-
endocrine disorders that cause disorienta- liefs.
tion, confusion, or lethargy. These symptoms 23. False: CA-125 has been touted as a way to de-
can be mistaken for other conditions, such as tect primary ovarian cancer, but unfortunately
dementia, delirium, drug side effects, or elec- it does not do so. CA-125 is useful mainly to
trolyte imbalances. Patients may not be able signal a recurrence of ovarian cancer and to
to answer questions about history or symp- follow the response to chemotherapy treat-
toms because of confusion or coma. Symptom ment.
development can be subtle or vague and 24. True
patients themselves may not be aware that
changes are occurring. In addition, many Short Answer
health care professionals are less familiar with 25. (a) Producing and storing sperm, (b) deposit-
endocrine disorders, so cardiac, respiratory, ing sperm for fertilization, and (c) developing
renal, or nervous system disorders may be the male secondary sex characteristics
suspected before endocrine disorders are con- 26. (a) Educating patient groups likely to have
sidered. sexual concerns, (b) providing anticipatory
guidance throughout the life cycle, (c) pro-
moting a milieu conducive to sexual health,
CHAPTER 51—CARE OF THE PATIENT WITH A and (d) validating normalcy about sexual con-
REPRODUCTIVE DISORDER cerns
27. (a) Amenorrhea: absence of menstrual flow
Figure Labeling (b) Dysmenorrhea: painful menstruation
1. See Figure 51-3, p. 1778. (c) Dysfunctional uterine bleeding (DUB), ab-
normal uterine bleeding
Matching (d) Menorrhagia: excessive bleeding in
2. g amount and duration
3. a (e) Metrorrhagia: bleeding between menstrual
4. e periods
5. h 28. (a) Cure the infection, (b) prevent reinfection,
6. b (c) prevent complications, and (d) prevent in-
7. i fection of the sexual partner(s)
8. c 29. (a) Unprotected sex, (b) antibiotic resistance,
9. j (c) treatment delay, and (d) sexual behavior
10. f patterns and permissiveness
11. d
12. m Figure Labeling
13. l 30. See Figure 51-12 A, p. 1817.
14. n
15. k Multiple Choice
31. Answer 1, 2, 4, 5: Many illnesses—such as
Fill-in-the-Blank Sentences diabetes mellitus, end-stage renal disease,
16. 40 hypertension, cancer, certain types of prostate
17. 3 surgery, spinal cord injuries, organ trans-
18. 9 plants, chronic obstructive pulmonary dis-
19. human chorionic gonadotropin (hCG) ease, and heart disease or heart surgery—may
20. 55; 70 cause patients concern or may result in actual
inabilities with sexual function. In primary

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 Answer Key  150  

syphilis, there may be a rash or painless chan- health. (See Chapter 43, Medical Management
cre, but sexual function is not impaired; thus, of Osteoporosis for additional information.)
the risk to infect others continues. 40. Answer 3: Dyspareunia is pain with sexual
32. Answer 1: The American Cancer Society intercourse. For postmenopausal women,
recommends that every woman begin an- this could be related to dryness in the vaginal
nual Pap tests within 3 years after becoming vault. Pruritus is itching. Procidentia is another
sexually active or no later than 21 years of term for uterine prolapse. Phimosis is a con-
age. Women age 30 years or older who have dition in which the prepuce (foreskin) is too
had three normal Pap tests in a row may be small to allow it to be retracted over the glans.
screened every 2 to 3 years instead of annu- 41. Answer 1: If the patient doesn’t experience
ally. Women who have had a hysterectomy any pain, it means that the tubes are occluded,
may stop having cervical cancer screenings so the gas is not passing through.
(unless their surgery was done as a treatment 42. Answer 3: First the nurse tries to help the
for cervical cancer or precancerous cells). patient identify what things, events, or fac-
33. Answer 3: In testicular biopsy, a sample is tors are making him experience this sense
obtained by aspiration or through an incision of losing power. After initial assessment, the
into the testes. For semen analysis, the semen nurse may decide to discuss with the patient
can be obtained by manual stimulation, or by feelings about aging, review past accomplish-
using a condom. The prostatic smear is ob- ments, or talk about coping strategies.
tained by massaging the prostate via the rec- 43. Answer 1: Sildenafil citrate (Viagra) can po-
tum. The prostate-specific antigen is a blood tentiate the hypotensive effects of nitrates
test. (nitroglycerin tablets). The nurse would alert
34. Answer 3: Pink-tinged urination, urinary the health care provider so the patient can
frequency, and burning with urination are be properly advised. Vitamin B6 supplement
considered normal because of the mechanical and ibuprofen (Motrin) could be prescribed
irritation caused the scope. The other findings for dysmenorrhea. Cefoxitin (Mefoxin) and
are not expected and could signal infection or corticosteroids are prescribed to treat PID. Da-
other complications. nazol (Danocrine) and vitamin E supplement
35. Answer 2: The pain of “menstrual cramps” could be prescribed to treat fibrocystic breast
that are characteristic of dysmenorrhea can be disease.
relieved with local heat applications or warm 44. Answer 3: For patients with PID, the Fowler’s
showers. In the other conditions, abdominal position facilitates the flow of vaginal drain-
pain is not anticipated; in addition for exces- age.
sive bleeding or irregular bleeding, heat ap- 45. Answer 2: Flulike symptoms often occur in
plications could worsen the bleeding. the first 24 hours. The other symptoms will
36. Answer 1, 2, 3, 4, 5: The nurse is assessing for occur later.
menorrhagia or abnormally excessive bleed- 46. Answer 4: Tampons and pads should be alter-
ing. Comparing flow and pad/tampon use nated. The use of super-absorbent tampons
to regular periods is one way to determine is not recommended. Tampons should be
amount of blood loss. Aspirin and anticoagu- changed every 4 hours. The hands should be
lants could potentiate blood loss. Rigorous washed after insertion, but washing them be-
exercise is more likely to be associated with fore is the key to preventing toxic shock.
amenorrhea. 47. Answer 3: Radiation therapy is usually start-
37. Answer 1: Premenstrual dysphoric disorder ed 2-3 weeks after surgery, when the wound
is a severe mood disorder that may be treated is completely healed and the patient can com-
with antidepressants. fortably raise her arm over her head.
38. Answer 3: This patient should be referred to 48. Answer 2: The technique uses a balloon cath-
the provider, because the bleeding could be a eter to insert radioactive seeds into the breast
signal of cancer. after the tumor is removed (at the time of the
39. Answer 2: The hormonal changes that ac- lumpectomy or shortly thereafter into the
company menopause lead to decreased bone tumor resection cavity). In brachytherapy, an
density. Calcium and vitamin D should be internal radiation therapy, the patient is hos-
encouraged throughout life to support bone pitalized for 48 hours. For external radiation,

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 Answer Key  151  

the treatments are usually done 5 days a week Critical Thinking Activities
for 5-6 weeks
49. Answer 1: Epoetin alfa (Procrit) is helpful in Activity 1
raising erythrocyte counts to help correct ane- 57. a. Genital herpes
mia. The other drugs could be ordered to con- b. There is no cure for herpes. The disease
trol the nausea and vomiting associated with can be treated and possibly controlled by
chemotherapy. lifestyle changes and medications. This
50. Answer 1, 2, 3, 4: Tamoxifen is not used for initial outbreak may last from 3-10 days.
women who desire continued fertility. The c. Keep the lesions clean and dry. Sitz baths
other statements apply to tamoxifen. may be helpful. Local anesthetics or sys-
51. Answer 2: Autologous indicates originating temic analgesics may be administered.
within self; thus, the patient donates the bone Antiviral therapy may be initiated with
marrow. Chemotherapy is performed prior to acyclovir, valacyclovir, or famciclovir.
the transplant. Radiation and plasmapheresis d. Patient education should include hygiene
are not used. methods to prevent secondary infections
52. Answer 2: A cone-shaped section will be cut and disease transmission, drug therapy,
from the cervix; thus, it is important to moni- safe sex practices, and future implications
tor for bleeding after the procedure. Schiller’s of the disease.
iodine test is used for the early detection of
cancer cells and to guide the health care pro- Activity 2
vider in doing a biopsy. Encouraging fluids 58. a. Menarche begins on average at age 12.
is done prior to ultrasound. Refraining from b. 1-2 ounces (30-60 mL)
powders, deodorants, or ointments is an in- c. Estrogen, follicle-stimulating hormone
struction given for mammography. (FSH), luteinizing hormone (LH), proges-
53. Answer 3: Oral contraceptives may be used terone
to suppress ovulation by inhibiting prosta- d. Personal hygiene
glandin levels. A recent theory proposes that • Wear pads during early period of
dysmenorrhea may be caused by hypercon- heavy flow.
tractility of the uterus resulting from higher- • Change tampons frequently to
than-normal levels of prostaglandins. decrease risk of toxic shock syndrome.
54. Answer 1: Parenteral benzylpenicillin (peni- • Consult health care provider if
cillin G) remains the treatment of choice for all tampon use frequently causes
stages of syphilis. In patients who have an al- discomfort.
lergy to penicillin, tetracycline, erythromycin • Take a daily shower for comfort;
and ceftriaxone are prescribed. warm baths may relieve slight pelvic
55. Answer 4: In the male signs and symptoms of discomfort.
gonorrhea are mild to severe transient urethri- • Keep perineal area clean and dry;
tis, dysuria, frequent urination, pruritus, and cleanse from anterior to posterior.
purulent exudate. Genital herpes is character- • Wear cotton underwear; remember
ized by recurrent episodes of acute, painful, that nylon pantyhose and tight-fitting
erythematous, vesicular eruptions (blisters) jeans retain moisture and should not
on or in the genitalia or rectum. The first be worn for extended periods.
sign of primary syphilis is a painless erosion • Feminine hygiene products such as
or papule that ulcerates superficially with a vaginal sprays and suppositories may
scooped-out appearance. In men, signs and contribute to a feeling of cleanliness.
symptoms of chlamydia may include a scanty • A daily douche is not recommended
white or clear exudate, burning or pruritus because it changes the protective
around the urethral meatus, urinary frequen- bacterial flora of the vagina and
cy, and mild dysuria. predisposes the woman to infection.
56. Answer 3: Pessaries are placed for uter-
ine support. They should be removed and Activity 3
cleaned every 3-4 months. Unattended pessa- 59. a. Young, single, urban, poor, male, or ho-
ries can cause erosion, fistula, and carcinoma. mosexual, frequent sexual contact with
multiple partners, and unprotected sexual

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 Answer Key  152  

activity are risk factors for STIs. Poor hy- able results. Infertility testing can be expensive
giene and poor nutrition are more likely and may not be covered by some insurance
to occur for the homeless and both con- carriers. Feelings of anger, frustration, sad-
tribute to infection. Poor nutrition also ness, and helplessness between partners and
contributes to problems with menstrua- between the couple and health care providers
tion. may increase as more tests are performed.
b. Until personal values are challenged, it is There are many factors that can possibly
difficult to know exactly how one will re- contribute to infertility. Some of these relate to
act or cope. Having as much information lifestyle, such as smoking, excessive alcohol
about the new job, the patient population, use, athletic training, obesity, being under-
and self is one way to prepare. Having weight, or deciding to delay childbearing.
support systems in place (family, friends, These factors can produce guilt and contrib-
colleagues) is another way to prepare for ute to anxiety.
new experiences.
With regard to gender identity dif-
ferences, the nurse is likely to encounter CHAPTER 52—CARE OF THE PATIENT WITH
gender issues in a large city that she never SENSORY DISORDERS
saw in her small hometown. In the begin- 1. See Figure 52-1, p. 1848.
ning, the nurse may wonder, “Should I 2. Crossword puzzle
use Mr. or Ms. when I am addressing this 1
H
androgynous person?” “Should I direct
Y
this person to the women’s restroom or P
the men’s restroom?” The nurse will learn 2
S E
to deal with these questions by relying on
3
C A T A R A C T
the principles of therapeutic communica- R O
4
M A P
tion. “How would you like me to address 5
K E R A T I T I S B I
you?” “The restrooms are over there to S I A
the right and the left.” 6
A S T I G M A T I S M
One of the more difficult aspects of
7
O M C
being a nurse is trying to be nonjudgmen- I U O
8 9 10
H O R D E O L U M S N
tal towards patients who contribute to 11
M T I Y J
their own health problems by repeatedly Y O T D U
participating in risky behaviors; thus, if O S I R N
the nurse sees the same young woman re-
12 13 14
P R E S B Y C U S I S M I O T I C S N
peatedly return to the clinic to be treated I L A T Y
15 16
A V E R T I G O T I N N I T U S
for STIs, the nurse may think, “What’s the
R I V T
use?” In order to continue in this job, the 17
P R E S B Y O P I A C I A
nurse will have to examine her own be- S T G
liefs and value system to determine if she
18
L A B Y R I N T H I T I S I M
can sustain commitment to the patient’s S S U
S
right of self-determination and continue
to offer accurate information and compas-
sionate care. The nurse could also decide True or False
that for her own sake and for the sake of 3. False: Most cataracts are age-related.
the patients, she should seek a different 4. True
type of job in a different environment. 5. False: Central vision damaged by macular de-
generation cannot be restored. Photocoagula-
Activity 4 tion is preventive, not curative.
60. The decision to have a child is possibly the 6. False: There is no apparent relationship be-
most important decision that people make tween vascular hypertension and ocular hy-
and inability to conceive creates self-doubt. pertension.
Diagnostic testing can produce a great deal of 7. True
anxiety and stress. This testing may continue
for fairly long periods with or without favor-

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 Answer Key  153  

Fill-in-the-Blank Sentences Figure Labeling

8. 180 16. See Figure 52-13, p. 1875.
9. 10 to 22
10. miotics Multiple Choice
11. sweet; salt; sour; bitter 17. Answer 2: The automated perimetry test is
a test for peripheral vision. Loss in the outer
Short Answer fields would make driving very dangerous.
12. a. Refraction: light rays are bent as they pass The other tasks require a more focused view
through the colorless structures of the of what is straight ahead.
eye, enabling light from the environment 18. Answer 3: During fluorescein angiography,
to focus on the retina. a dye is injected into a vein. The dye could
b. Accommodation: the eye is able to focus cause a similar allergic reaction for those who
on objects at various distances. It focuses react to seafood or iodine.
the image of an object on the retina by 19. Answer 2: Diplopia is double vision, so read-
changing the curvature of the lens. ing is going to be very difficult, if not impos-
c. Constriction: the size of the pupil, which sible. The patient should be instructed to
is controlled by the dilator and constrictor steady self by grasping the bed rail or the arm
muscles of the iris, regulates the amount of the chair when sitting upright. Foods that
of light entering the eye. can be eaten with the fingers will be easier for
d. Convergence: medial movement of both this patient. Listening to the radio would be a
eyes allows light rays from an object to hit better distraction than watching television.
the same point on both retinas. 20. Answer 2, 4, 5: The purpose of the cane is to
13. a. Total blindness is defined as no light per- determine the boundaries of the walking path
ception and no usable vision. and the tip of the cane is used to seek any-
b. Functional blindness is present when the thing obstructing the path. The helper should
patient has some light perception but no walk in front of the patient; patient can hold
usable vision. It may be congenital or ac- the elbow for security and to detect direction-
quired. ality of helper’s movements. Walking slowly
c. Legal blindness refers to individuals with is advised so that objects can be detected.
a maximum visual acuity of 20/200 with Descriptions of surroundings help to create a
corrective eyewear and/or visual field mental picture for the patient.
sight capacity reduced to 20 degrees. 21. Answer 4: In hyperopia, the patient can see
14. (a) Increased intraocular pressure (IOP) be- distant objects, but close objects such as fine
cause of obstruction of the outflow of aqueous print are blurry; using over-the-counter eye-
humor, (b) optic nerve atrophy, and (c) pro- wear that magnifies fine print may work ini-
gressive loss of peripheral vision tially.
15. a. In conductive hearing loss, sound is inad- 22. Answer 2: Contact lenses change the shape of
equately conducted through the external the cornea, so for a week or two prior to the
or middle ear to the sensorineural appara- initial evaluation, the health care provider will
tus of the inner ear. ask the patient not to wear them. Usually one
b. In sensorineural hearing loss, sound is day is sufficient for rest after surgery. Possibly,
conducted through the external and mid- anticoagulant medications would be held, but
dle ear in a normal way, but a defect in systemic complications related to refractory
the inner ear results in distortion, making surgery are unlikely.
discrimination difficult. 23. Answer 3: People who wear contact lenses
c. Mixed hearing loss is a combined conduc- know they are not supposed to use saliva to
tive and sensorineural hearing loss. clean the lenses; however, many users forget
d. Congenital hearing loss is present from to carry sterile solution or a spare contact
birth or early infancy. case. The nurse should help contact lens users
e. Functional hearing loss may be caused by plan ahead. Borrowing solution or lens cases
an emotional or a psychological factor. from others is not recommended because of
f. Central hearing loss occurs when the risk for infection. Adolescents generally prefer
brain’s auditory pathways are damaged, not to wear glasses, but possibly for active
as in a stroke or a tumor. sports they are preferable.

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 Answer Key  154  

24. Answer 3: Use of fresh makeup, individual 37. Answer 2: Progressive enlargement of the
applicators, and supervising the activity is the darkened area means the detachment is
best option. This may seem a little costly, but worsening and if the retina is not repaired,
the alternative would be to ban the activity irreversible blindness will result. Pain is not
with an explanation about eye infections. an expected symptom of detachment. Type 1
25. Answer 4: Eye pads are contraindicated be- diabetics are at risk for diabetic retinopathy
cause they facilitate bacterial growth. The and there is an increased risk for cataracts.
other actions are correct. Retinal detachment can be related to injury,
26. Answer 2: Severe eye pain is associated with but is mostly related to aging, not heredity.
this disorder. 38. Answer 3: Cotton is not used because of po-
27. Answer 1: Sjögren syndrome is an immuno- tential to scratch the cornea. The other meth-
logic disorder characterized by deficient fluid ods are acceptable.
production by the lacrimal, salivary, and other 39. Answer 2: The eye and stick are covered with
glands, resulting in abnormal dryness of the a cup to prevent dislodgment (cup should be
mouth, eyes, and other mucous membranes. sufficiently large to cover the stick without
28. Answer 4: The eyes feel gritty because of the touching it). Then the camper is taken to the
deficient fluid production in glands of the hospital if 911 is not available to respond to
mouth, eyes, and other mucous membranes. the camping site.
29. Answer 1, 2, 4, 5: Ectropion and entropion are 40. Answer 4: If the Romberg test is abnormal, the
characterized by abnormal direction of the patient lost his balance when standing erect,
eyelid with tearing and corneal dryness. Red- feet together, with eyes closed.
ness of the sclera may also be present. 41. Answer 2: A warm compress over the affected
30. Answer 3: The health care provider will use ear will help relieve the pain. Swallowing can
visual inspection and an ophthalmoscopic relieve the pressure, but sobbing and swal-
examination. Amsler’s grid assesses for dis- lowing increase the chance for vomiting. The
turbances in central vision. Snellen’s test as- acetaminophen will work, but recall that pain
sesses visual acuity. Pneumatic retinopexy is a medication is not as effective if given during
procedure used to correct retinal detachment. the peak of pain. A prescription for a sedative
31. Answer 2: In diabetic retinopathy, microhem- is possible if the pain and sleeplessness are
orrhages will cause floaters. excessive.
32. Answer 1: This older patient is reporting 42. Answer 2: Antivert is a medication used in the
symptoms of macular degeneration. treatment of vertigo, which causes dizziness
33. Answer 3: Tonometry is most commonly done and a sensation of spinning.
using puffs of air forced into the open eye. An 43. Answer 1: Keep the patient flat with the oper-
increased ocular pressure suggests glaucoma. ative side facing upward to maintain the posi-
34. Answer 1: Photophobia, dryness, burning, or tion of the prosthesis and graft; make certain
tearing should be reported to the health care that the patient is not turned.
provider. The other statements are correct.
35. Answer 2: Lifting, bending, coughing, or Critical Thinking Activities
stooping would increase intraocular pressure,
which is not desirable in the postoperative Activity 1
period. The surgery should improve the glare 44. a. Monitor pressure dressing over eye. The
that would occur while watching a movie. dressing should be inspected at least ev-
Sunglasses are recommended. Sexual activ- ery hour.
ity may be unadvisable for a period of time. Assess for pain on the affected side or
Sleeping with a spouse would be okay unless any headache. Monitor vital signs.
he/she tended to thrash around during sleep. b. Excess bleeding from site, headache, signs
36. Answer 1: High-dose nutritional supplements of excess blood loss
of zinc, beta-carotene, and vitamins C and E c. Encourage verbalization of specific con-
have been shown to reduce the risk of pro- cerns. Provide support. When appropri-
gression to advanced ARMD by 25% (NEI, ate, advise patient that with healing, he
NIH, 2008). A diet rich in fruits and dark- can be fitted with a prosthetic device in
green leafy vegetables is also recommended 4-6 weeks.
(NEI, NIH, 2008).

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 Answer Key  155  

Activity 2 adapt and cope so that the impact of your loss

45. a. Mastoiditis did not adversely affect them?
b. It is the result of a spreading middle ear
infection. The patient’s risk was enhanced
after not completing the prescribed antibi- CHAPTER 53—CARE OF THE PATIENT WITH A
otic therapy. NEUROLOGIC DISORDER
c. If caught early, treatment will include IV
antibiotic therapy and a myringotomy. If Figure Labeling
the infection has progressed, treatment 1. See Figure 53-2, p. 1899.
will include IV antibiotic treatment and a
simple mastoidectomy. Matching
2. e
Activity 3 3. f
46. Nursing interventions for the patient having a 4. a
vitrectomy include: 5. c
• The patient is required to maintain a posi- 6. i
tion on the abdomen or sitting forward 7. g
resting the nonoperative side of the head 8. b
on a table to allow air that is in the eye to 9. h
float against the retina. This position is 10. j
maintained for 4 to 5 days. 11. d
• Dark glasses are prescribed postopera- 12. k
tively to decrease the discomfort of photo-
phobia. Fill-in-the-Blank Sentences
• Assessing the eye patch 13. central; peripheral
• Applying ice packs 14. motor; sensory; visual; speech; auditory
• Monitoring vital signs 15. Global cognitive dysfunction
• Assessing the dressing for bleeding 16. Huntington’s
17. 100
Activity 4
47. It is likely that you have a grandparent, par- True or False
ent, or older aunt or uncle who has demon- 18. True
strated some of the behaviors associated with 19. True
hearing loss. The symptoms may have been 20. False: Seventy to eighty percent of people
gradual or only a few may have occurred so who become infected with the West Nile virus
far. There may be circumstances where the do not have any type of illness.
behaviors are more pronounced. Most people 21. False: Approximately 80% of patients with ad-
adapt to gradual losses and loss of hearing vanced HIV disease (AIDS) have neurologic
may be more noticeable to those around who symptoms that result from infection from HIV
are trying to communicate with that person. itself or from associated complications of the
disease.
Activity 5 22. False: Dementia is not a normal consequence
48. A sudden loss of any of the senses would be of aging, but may be a result of many revers-
devastating to anyone. Since you are currently ible conditions, including anemia, fluid and
in nursing school, the loss would impact your electrolyte imbalance, malnutrition, hypothy-
ability to complete your studies. Moreover, roidism, metabolic disturbances, drug toxicity,
imagine how difficult it would be to conduct a drug reaction or idiosyncrasy, and hypoten-
an assessment of a patient if you couldn’t see sion.
or hear. Would you be able to perform patient
care if you couldn’t see? How would you ad- Figure Labeling
minister medication if you couldn’t read the 23. See Figure 53-7, p. 1915.
label?
Perhaps you have small children and they Word Scramble
rely on you for everything. How would you 24. Alert e

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 Answer Key  156  

25. Disorientation d there are no signs immediately after the pro-

26. Stupor a cedure. Delayed reaction to contrast medium
27. Semicomatose b is possible, but usually the chief concern for
28. Comatose c contrast media is immediately after adminis-
tration. Nausea and vomiting might occur, but
Multiple Choice usually nausea will occur in response to the
29. Answer 1, 2, 3, 4, 6: Changes related to aging contrast medium and that sensation is gener-
include slowed reaction time, slowed learn- ally mild and transient.
ing, slight tremors when fatigued, increased 38. Answer 1: The health care provider is likely
difficulty with fine motor movement, and to suggest acetaminophen, phenacetin, ibu-
short-term memory loss. Nonpurposeful ac- profen, and aspirin. Narcotics are avoided be-
tion like shuffling items is associated with cause these drugs are often subject to abuse; it
dementia. Ability to locate misplaced items is much better to counsel patients to develop
demonstrates a retention of problem-solving other ways to relieve headaches. The nurse
ability, despite some forgetfulness. should suggest nonpharmaceutical measures
30. Answer 4: Fund of knowledge is an assess- such as relaxation techniques, regular exer-
ment of the patient’s retention of general cise, adequate sleep, and avoidance of alcohol.
knowledge that the average adult should 39. Answer 4: Many foods may contribute to
know. The other components are orientation migraines: such as aged cheeses (cheddar
to time, person, and place; assessment of and Swiss), cured meats, fermented cabbage
short-term memory; and ability to calculate. (sauerkraut), and soy and fish sauces. Nitrites
31. Answer 4: The patient is demonstrating the are present in curing substances used in the
maximum possible score which is 15 total preparation of meats such as bologna, ham,
points. hotdogs, and bacon. Other substances that
32. Answer 3: The FOUR Score coma scale in- may provoke headaches include vinegar,
cludes eye response, brainstem reflexes, motor chocolate, yogurt, alcohol, fermented or mari-
response, and respiration. nated foods, and caffeine.
33. Answer 3: In motor aphasia, the patient can 40. Answer 2: The patient is likely to be more
understand the nurse, but is unable to use the comfortable in a quiet, dark room. The pa-
symbols of speech; thus, pointing at pictures tient can turn self. Warm compresses are not
or objects and developing a language of ges- needed. Patient may refuse foods and liquids
tures will help the patient. during the peak of nausea, but does not need
34. Answer 4: The glossopharyngeal nerve is to be kept on NPO status.
involved in the gag reflex and swallowing 41. Answer 3: Gabapentin (Neurontin) is a medi-
movements. The trochlear and abducens cation that is prescribed for neuropathic pain.
nerves are involved in eye movement and the Diabetics frequently have this type of pain in
trigeminal is involved in jaw strength, facial the lower part of the legs.
sensation, and corneal reflex. 42. Answer 1: Change in level of consciousness is
35. Answer 1: In unilateral neglect, the patient an early sign. The others are late signs.
is unaware or inattentive to one side of the 43. Answer 2: The fixed and dilated pupil is the
body; thus, she is unlikely to be able to ac- most ominous sign, which warrants immedi-
complish any task that requires two hands. It ate notification of the health care provider.
is possible that she would struggle to put on None of these reactions are considered normal
one sleeve. and all should be pointed out to the health
36. Answer 4: UAP is not expected to assess for care provider.
numbness or tingling, but should be instruct- 44. Answer 1, 3, 5: Fluid is restricted to avoid
ed to report any patient complaints of numb- adding fluid volume to the system. Flexion of
ness, tingling, or pain. The patient should be the hips increases intraabdominal and intra-
flat in bed and fluids are usually encouraged. thoracic pressure. Oxygen is given to support
Both measures are to prevent headaches. impaired brain tissue. Head should be in a
37. Answer 3: If the access is at the carotid, he- neutral position. Enemas are not recommend-
matoma or swelling could cause an airway ed.
obstruction. Respiratory effort is the priority 45. Answer 4: In hemiplegia, the upper arm will
assessment. Infection is always a concern, but tend to fall forward, so the counter-position

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 Answer Key  157  

is abduction. It is unlikely that the patient the eyelid. The purpose of the eye shield at
can walk safely to the bathroom, even with night is to prevent corneal damage because
assistance. The affected arm should be put the eyelid will not close.
through ROM exercises. The prone position 54. Answer 2: The weakness and paralysis will
would be good for the patient, but the nurse start in the legs and move upwards. The pri-
should make the determination if the patient mary concern is that rapid progression up-
can tolerate it, rather than expecting the UAP wards will cause paralysis of the respiratory
to make that decision. muscles.
46. Answer 1, 2, 3, 4: Multiple sclerosis is a dis- 55. Answer 3: For this patient, the reduction of
ease that more frequently develops in young stimuli decreases the risk for seizures, which
women. The onset is insidious, the symptoms are a complication of meningitis. The other
are vague, and there are bouts of exacerbation options are correct rationales for different pa-
and remission, but with progressive deteriora- tient conditions.
tion. The patient will be discouraged, because 56. Answer 2: Headaches are the most prominent
many treatments will have been tried, some early sign. Patients often report that the head-
will give partial symptom relief, but there is ache is more severe in the morning.
no cure and the patient sees herself getting 57. Answer 1: Redirection is the best first action,
progressively worse to the point of being to- because it is possible that the nurse can get
tally helpless. him to focus on something else. Medicating
47. Answer 1: The classic triad of Parkinson’s him is possible, but is not the first action to
includes tremors, rigidity, and bradykinesia. try, because it would be considered a chemical
Bradykinesia affects the gait and he may be restraint. Allowing him to wander is a possi-
propelled forward until an obstacle stops him. bility, but his agitation could increase. Assign-
Stiffness in bending or moving the arms is a ing a UAP is also possible if the nurse believes
sign of rigidity. Tremors affect fine motor con- that the resident is a danger to himself.
trol. 58. Answer 4: Putting the patient in a sitting posi-
48. Answer 2: Eyelid drooping and double vision tion decreases the blood pressure, especially
are considered early signs. The other signs the pressure in the head. Bladder distention
will come later as the disease progresses. and fecal impaction are the most common
49. Answer 3: Stroke risk can be reduced by up to causes, so the nurse would check these and
42% with appropriate treatment of hyperten- try to resolve the issue. The nurse can direct
sion. Controlling the other factors will also the UAP to recheck the blood pressure. This
reduce risk. is a medical emergency and if the pressure
50. Answer 4: The nurse would check for unin- does not come down, the health care provider
tentional pouching of food on the affected must be notified so that drug therapy can be
side of the mouth. The other options are in- started.
correct, except use of covered cups is okay.
51. Answer 1: For thrombolytic therapy, the tim- Critical Thinking Activities
ing is critical to the outcome. The clinic staff
should work towards immediate transfer to a Activity 1
stroke center. If the patient were to suddenly 59. a. The nurse protects from aspiration and
become unresponsive, the clinic staff would injury and observes the seizure activity.
stop to intervene; otherwise no action should The nurse stays with the child and the
delay transfer to a stroke center. area is cleared of dangerous objects if pos-
52. Answer 3: The patient may prefer to do his sible. The child’s head is supported and
own care, because the face is very painful and protected and if possible, turned to the
he may fear that the UAP will cause pain just side to maintain the airway. Restrictive
by touching. Shaving, combing hair, and hy- clothing around the neck is loosened. The
giene in general can be deferred until the pain child is not restrained and no objects are
is better controlled. Warm puréed foods are placed in the mouth.
best. Cold liquids are likely to increase pain. b. The nurse would note, record, and report
53. Answer 2: Bell’s palsy is an inflammation of events that preceded the seizure, presence
the facial nerve and the muscles of the face of of aura, when the seizure occurred, length
the affected side become flaccid. This includes

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 Answer Key  158  

of ictal phase and postictal phase, and 7. e

what occurred during each phase. 8. h
9. i
Activity 2 10. j
60. a. Transient ischemic attack (TIA) 11. g
b. Yes, TIAs are significant because at least
one in three people who experience them Short Answer
will experience a cerebrovascular accident 12. (a) To protect the body’s internal environ-
within 2-5 years. ment by destroying foreign antigens and
c. Aspirin pathogens, (b) to maintain homeostasis by
removing damaged cells from the circulation,
Activity 3 and (c) to serve as a surveillance network for
61. a. See Box 53-2, p. 1934 for the Warning recognizing and guarding against the devel-
Signs of Alzheimer’s Disease. opment and growth of abnormal cells.
b. Currently no effective treatment is avail- 13. a. Recognize self from nonself
able to stop the progression of AD, which b. Respond to nonself invaders
occurs at a variable rate. The course of the c. Remember the invader
disease can span 5-20 years. The economic d. Regulate its action
costs of AD in the United States is on av- See Box 54-2, p. 1966 for additional infor-
erage $56,800 annually. While portions of mation.
this cost are absorbed by insurance cov- 14. a. Host response to allergen: The more sensi-
erage, large costs are borne by the fam- tive the individual, the greater the allergic
ily (Ramnarace, 2010). Ultimately, most response is.
patients die from complications such as b. Exposure amount: Generally, the more
pneumonia, malnutrition, and dehydra- allergen the individual is exposed to, the
tion. The burden on the individual, the greater the chance of severe reaction.
family, caregivers, and society as a whole c. Nature of the allergen: Most allergic reac-
is staggering. tions are precipitated by complex, high-
c. Engage in activities that require informa- molecular–weight protein substances.
tion processing (e.g., reading, learning a d. Route of allergen entry: Most allergens
new language, doing crossword puzzles). enter the body via gastrointestinal and re-
Participate in regular physical activity, spiratory routes. Injections of venoms and
leisure activities, and educational achieve- medications hold a more severe threat of
ments throughout the lifespan. Antioxi- allergic response.
dant-containing foods such citrus fruits, e. Repeated exposure: Generally, the more
dark-green vegetables, tomatoes, brown often the individual is exposed, the great-
rice, and foods high in beta-carotene er the response is.
(sweet potatoes and carrots) are consid- 15. In addition to gloves, latex-containing prod-
ered to lower the risk of the development ucts used in health care may include blood
of Alzheimer’s disease. pressure cuffs, stethoscopes, tourniquets,
IV tubing, syringes, electrode pads, oxygen
masks, tracheal tubes, colostomy and ileos-
CHAPTER 54—CARE OF THE PATIENT WITH tomy pouches, urinary catheters, anesthetic
AN IMMUNE DISORDER masks, and adhesive tape.

Figure Labeling Multiple Choice

1. See Figure 54-2, p. 1965. 16. Answer 1, 2, 3, 5, 6: Older adults are prone
to urinary tract infections and urinary stasis
Matching will contribute. Fluids are offered to thin
2. c secretions because older adults have trouble
3. d coughing up secretions. Skin becomes fragile
4. b and dry. Hand hygiene is always appropriate;
5. a older adults have increased risk for infec-
6. f tion. Oral hygiene is important because saliva

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 Answer Key  159  

(which fights bacteria) is decreased. High 0.2-0.5 mL of epinephrine 1:1000 is given sub-
temperatures are not always seen in older cutaneously for mild symptoms. The other
adults, even if a serious infection occurs. actions may also be needed if the symptoms
17. Answer 2: Progressively increasing the dose progress.
of allergens over time allows the individual to 25. Answer 1, 2, 3: Breastfeeding provides natural
build up a tolerance, but not have the symp- passive immunity for the baby. Antivenom
toms, because the initial dose is very dilute. after a snakebite and postexposure immuno-
Leukotriene inhibitors such as montelukast globulin provide artificial passive immunity.
(Singulair) are agents that significantly reduce Having a disease like measles provides natu-
symptoms of an allergic reaction caused by ral active immunity and getting vaccinated
the release of leukotrienes from mast cells and provides artificial active immunity.
basophils. Antihistamines compete with hista- 26. Answer 2: The patient can have visitors, but
mine by attaching to the cell surface receptors ideally the nurse should screen all visitors
and blocking histamine release. Epinephrine for potential minor infections, remind them
produces bronchodilation and vasoconstric- about handwashing, and check to make sure
tion and inhibits further release of chemical that no potentially infectious items or gifts
mediators of hypersensitivity reactions from are brought to the patient. Seven to 10 days
mast cells. is the time for tissue rejection; the UAP is
18. Answer 3: Intravenous administration of not responsible for knowing how to respond
medication is most likely to produce a rapid or check for this. An instruction, such as to
reaction if the patient has allergies to the med- report pain, could be given. The patient’s
ication, because the circulatory system will medications should not harm a pregnant
rapidly distribute the drug throughout the UAP. Health care staff with a cough or skin in-
body. In the other routes, the absorption will fection should not enter the room, even with
be delayed compared to the IV route. mask and gown, if there are alternative team
19. Answer 2: With friends, the nurse may be members who could be assigned. (Note to
tempted to joke, but apparently this indi- student: Knowledge of correct nursing action
vidual does not understand the physiology of and principles of delegation are combined to
allergic response. Every exposure to oysters decide which action can be assigned or del-
has the potential to create a more rapid and egated to a UAP. Remember that UAP need
rigorous response. Taking Benadryl may seem specific instructions.)
like a preventive measure to the friend, but 27. Answer 2: Hypotension and citrate toxicity,
abstinence is a better solution. which may cause hypocalcemia (headache,
20. Answer 4: The nurse could try any of these paresthesias and dizziness), are the most com-
strategies, but the patient is not able to clearly mon complications.
communicate or report on the complex factors
in the home setting. The home health nurse Critical Thinking Activities
will have better success assessing the situation
and helping make immediate recommenda- Activity 1
tions for the patient’s needs. (Note to student: 28. a. The patient should be monitored after
Use critical thinking to determine the best in- the allergy shot. This monitoring should
terventions for patients; in this case, making a include observation for adverse reactions
referral.) and take place for at least 20 minutes.
21. Answer 1: A urine specimen is obtained to as- b. The patient should be taught signs and
sess for hemolysis. symptoms to look for regarding hyper-
22. Answer 4: Immunoglobulin levels decrease sensitivity reactions. The patient should
with age and therefore lead to a suppressed have an EpiPen on hand at home.
humoral immune response in older adults. c. The health care provider should be noti-
23. Answer 1, 2, 3, 5: The plasma is generally re- fied. Interrupted doses put the patient at
placed with normal saline, lactated Ringer’s risk for hypersensitive reactions.
solution, fresh frozen plasma, plasma protein
fractions, or albumin. Activity 2
24. Answer 2: Immediate aggressive treatment 29. a. As a normal part of aging, a person’s im-
is the goal in anaphylaxis. At the first sign, mune system will often weaken. The risk

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 Answer Key  160  

of inflammation and infection increases CHAPTER 55—CARE OF THE PATIENT WITH

with age. Skin becomes more fragile and HIV/AIDS
may allow pathogens to enter. Infection in
most body systems also increases due to a Matching
reduction of activity and secretion mobil- 1. c (See Table 55-7, p. 2005 for additional infor-
ity and production. Aging often brings mation about dietary therapies.)
on diseases and disorders of several body 2. e
systems. These may further complicate 3. d
the patient’s health status. 4. a
b. Since the patient has demonstrated an 5. b
increase in illness, preventive measures 6. h
should be discussed. The importance of 7. g
handwashing, avoiding potentially harm- 8. f
ful situations, and the need for yearly flu
shots should be addressed. The signs of True or False
early illness may be subtle. To best coun- 9. True
teract illness, early intervention is key. Pa- 10. False: HIV can be transmitted via contami-
tients are advised to contact their health nated equipment used to inject steroids,
care providers when illness occurs. vitamins, and insulin, in addition to illicit in-
jectable drugs.
Activity 3 11. False: Currently, a person’s risk for acquiring
30. When did you first notice the rash? HIV through a blood transfusion is estimated
Can you describe what the rash first looked to be about one in 1.5 million. There is an 11-
like? day window where HIV could still go unde-
Where did it start? tected by the most current tests.
Did it progress? If so, how? 12. True
Have you had this type of rash before? If so, 13. False: Intravenous therapy, blood transfu-
how does it compare to this episode? sions, and antibiotic usage may be considered
What makes the rash worse? palliative in the end stage of HIV disease
Is there anything that seems to make it better? because these interventions keep the patient
Are you having any other symptoms; for ex- comfortable and help maintain quality of life.
ample, fever, coughing, congestion? 14. True
Have you used home remedies or over-the-
counter medications to treat the rash? If so, Table Activity
what were they and did they help? 15. See Figure 55-3, p. 1988.
Have you recently used any new lotions,
soaps, or other personal care products? Multiple Choice
Have you worn new clothes or brought any 16. Answer 2: Receptive anal intercourse is con-
new textiles or furniture into the house? sidered the most risky. The primary or late
Have you eaten any new foods? stages of the disease are periods of the high-
Is anyone in the same household having the est viral load and this also increases the risk.
same kind of rash? However, patients should be educated that
Do you have any pets? Do they go indoors transmission can occur at any time and any
and outdoors? transfer of semen or genital secretions offers
What do you do for work? potential risk.
Are you exposed to chemicals or pollutants at 17. Answer 1, 2, 3, 4, 6: Injection drug users could
work? If so, what are they? reduce risk by not sharing needles, but the
Have you recently taken any trips, especially lifestyle factors and addiction to substances
outside the United States? often result in sharing needles and other risky
behaviors. Ease of access to safe sterile equip-
ment would reduce risk of HIV.

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 Answer Key  161  

18. Answer 1: While all of these incidents should in feet with walking are associated with pe-
be reported, the deep puncture wound with ripheral neuropathy.
a hollow-bore needle full of blood creates the 28. Answer 1: Adolescents frequently believe in
greatest exposure. their invulnerability. Denial of risk would be
19. Answer 3: Unfortunately, the antiviral pro- typical.
phylaxis can cause hepatitis, which may lead 29. Answer 2: Mutual masturbation would be the
to a liver transplant. safest because there is no exchange of body
20. Answer 2: In developed countries, antiretro- fluids on mucous membrane surfaces. Vaginal
viral therapy, formula feeding, and cesarean sex with consistent condom use is considered
section have decreased the numbers from 25% reasonably safe. Mutual monogamy is only
(without interventions) to approximately 1%. safe if both partners are mutually exclusive.
21. Answer 3: For a CD4+ lymphocyte level of Serial monogamy is considered risky, espe-
200 cells/mm3 or less, opportunistic infections cially depending on types of sexual activities/
begin to emerge because the body can no lon- behaviors.
ger mount an adequate defense.
22. Answer 3: Typical progressors develop signs Critical Thinking Activities
and symptoms several years after seroconver-
ting. Long-term nonprogressors may not de- Activity 1
velop signs and symptoms even 30 years after 30. a. The nursing student should be counseled
seroconverting. Rapid progressors move from about treatment options. The discussion
being infected with HIV to an AIDS diagnosis should include recommended medica-
within 3 years. tions, testing, testing intervals, home care,
23. Answer 4: Although currently somewhat and follow-up.
theoretical, a low viral set point appears to be b. The risk of exposure is highest if the expo-
associated with longer survival times. sure is to known HIV-positive blood by a
24. Answer 3: Alternative and complementary blood-filled hollow-bore needle through a
therapies can provide hope and relief from deep injury. If the infected patient is criti-
symptoms. The health care team should be cally ill at the time of exposure, this also
open to hearing about the patient’s interests increases the risk.
and advise according to how they could fit in c. Higher success will occur with rapid
the treatment plan. onset of preventive drug therapy. An
25. Answer 1: As long as the phlebotomist is fol- exposed individual may have up to 36
lowing Standard Precautions, there is no need hours, but recommendations are to begin
to intervene. The nurse makes this decision antiretroviral therapy within 1-4 hours of
based on knowledge of Standard Precautions. exposure.
(Note to the student: In the early days of HIV, d. The pros include minimized chance of
the other options were being used because development of resistant virus, reduce
there was fear and uncertainty surrounding HIV transmission risk, and improve qual-
HIV/AIDS.) ity of life. Cons include drugs often have
26. Answer 1, 2, 3, 4: For the patient with HIV, unpleasant side effects and cause liver
medications, infection, damage, and malab- damage, therapy is expensive, and drug
sorption contribute to diarrhea. Hygiene and therapy is complex.
diet could be factors if the patient is noncom- e. Living with family members will not put
pliant with basic health promotion instruc- them at risk for HIV infection. Hugging,
tions. handholding, and sleeping with family
27. Answer 3: The HIV-associated cognitive mo- members will be safe. She should avoid
tor complex will first produce mild memory unprotected sexual contact with her part-
deficits, similar to early dementia. Physi- ner.
cal impairments such as poor balance and
coordination usually follow the cognitive Activity 2
impairments and safety becomes the priority. 31. The staff recognized that the worker had risks
Level of consciousness is usually not affected. and attempted to offer her HIV testing. Only
Numbness or tingling in hands or feet or pain in rare circumstances, such as the inability

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 Answer Key  162  

to give consent, can HIV antibody testing be 4. d

completed without the patient’s informed 5. b
consent. Many ethical and legal issues sur- 6. h
round HIV antibody testing; knowledge of 7. a
applicable state laws is essential. In many 8. i
states, charges of assault and battery can be 9. f
brought against health care workers who 10. k
perform HIV testing against a patient’s will. 11. m
If the patient had agreed to HIV testing and 12. j
been found positive, the clinic staff would 13. o
have faced another dilemma because of the 14. l
worker’s occupation and the potential ex- 15. q
posure to others. From the patient’s point of 16. p
view, she “tried to get her customers to use 17. n
condoms” and she may have considered this
the limit of her liability towards infecting oth- Short Answer
ers. From the staff’s point of view, prostitution 18. social, psychological, physical, and spiritual
is illegal and her behavior did increase risk for 19. Any five of the following: (1) fear of recur-
self and others; however, traditionally health rence, (2) chronic or acute pain, (3) sexual
care professionals do not refuse to treat prosti- problems, (4) fatigue, (5) guilt for delaying
tutes or notify the police. Unfortunately, there screening or treatment, (6) behavior that may
is no method to inform her customers, unless have increased the risk for cancer, (7) changes
she agrees to disclose their names. in physical appearance, (8) depression, (9)
sleep problems, (10) change in role perfor-
Activity 3 mance, and (11) being a financial burden on
32. HIV is now considered a chronic disease loved ones
and Standard Precautions are the norm. As 20. prostate; lung; colon; rectum
a contemporary nurse, you may not feel any 21. breast; lung; colon; rectum
different about caring for an HIV/AIDS pa- 22. a. Changes in bowel or bladder habits
tient than you would about caring for any b. A sore that does not heal
other patient. However, health care workers c. Unusual bleeding or discharge
have contracted HIV by work exposure, so all d. Thickening or lump in breast or elsewhere
workers should be mindful of the risk. e. Indigestion or difficulty swallowing
Compared to the early days of HIV, there f. Obvious change in warts or moles
is more information, more treatment op- g. Nagging cough or hoarseness
tions, and less stigma (although it still exists).
Health care workers and patients are likely True or False
to feel more empowered by safety measures 23. True
such as needleless systems and heightened 24. True
awareness of handling sharps. There are pro- 25. False: If a female has genes BRCA1 or BRCA2,
tocols for exposure that guide workers in the she has a 60% risk of having breast cancer
event of an accidental needlestick. In addition, during her lifetime.
there have been no new confirmed reports of 26. True
work-related exposure to health care workers
since 1999. Figure Labeling
27. See Figure 56-3, p. 2024.

CHAPTER 56—CARE OF THE PATIENT WITH Clinical Application of Math

CANCER 28. a. Answer 30 minutes
150 minutes ÷ 5 = 30 minutes
Matching b. Answer 25 minutes
1. c 150 minutes ÷ 6 = 25 minutes
2. e c. Answer 25 minutes
3. g 75 minutes ÷ 3 = 25 minutes

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 Answer Key  163  

d. Answer 11 minutes 39. Answer 3: The history of hip fracture should

75 minutes ÷ 7 = 10.71 rounded to 11 be investigated prior to the MRI. If the patient
29. Answer 7 pounds has some type of metal prosthesis in the hip,
140 pounds × 0.05 = 7 pounds that would be a contraindication for MRI.
40. Answer 2: Alkaline phosphatase is elevated
Table Activity if there is liver disease or metastasis to the
30. bone or liver. Serum calcitonin is elevated in
cancer of the thyroid. Normally, production of
carcinoembryonic antigen (CEA) stops before
Male Female
birth, but it may begin again if a neoplasm
Erythrocytes 4.7-6.1 million/ 4.2-5.4 million/ develops. CA-125 is a tumor marker for ovar-
(RBCs) mm3 mm3 ian cancer.
Hemoglobin 14-18 g/dL 12-16 g/dL 41. Answer 1: Eating red meat, turnips, melons,
aspirin, or vitamin C for 4 days before the test
Hematocrit 42-52% 37-47%
may cause a false-positive result.
42. Answer 1: The nurse conveys respect, but
Multiple Choice
tries to remain available to help the patient.
31. Answer 2: According to the American Can-
The nurse avoids offering platitudes. The
cer Society, smoking is the most preventable
nurse could call the health care provider, but
cause of death from lung cancer. Many other
the patient is currently using the provider as
cancers are associated with smoking. The oth-
a focus for his anger. If the nurse is skilled at
er lifestyle modifications are also important as
therapeutic communication, it is likely that
contributing factors to select cancers.
the patient will be more comfortable venting
32. Answer 4: Fruit and vegetable consumption is
his anger with the nurse.
currently low in the United States. Fruits and
43. Answer 2: No lotion, cream, ointments, or
vegetables are particularly important in pre-
powder should be applied over the markings.
venting GI cancers, but also contain nutrients
The markings must not be washed off. If the
that decrease overall risk.
skin should get wet, it should be patted dry.
33. Answer 3: The nurse could suggest trying
44. Answer 2: The nurse must carefully plan the
strawberries, peppers, tomatoes, or canta-
nursing care to limit the time spent in close
loupe. Fresh food sources are better than
contact with the patient. The nurse can protect
supplements. The patient might accept juice,
self by standing back, limiting time, and being
but compliance is unlikely since she dislikes
very organized.
citrus fruits. Carrots and cauliflower are good
45. Answer 1: The patient is on bedrest and the
anticancer vegetables, but offer less vitamin C.
UAP should only help with hygiene from the
34. Answer 4: The best time is to perform BSE 2-3
waist up. Time spent should be limited. The
days after the end of the menses. The first day
patient should not be turned from side to side.
of every month would be recommended to
46. Answer 3: Catheterization should be avoided
postmenopausal women. Women should not
because it is a way to introduce infection.
wait to see obvious symptoms. The purpose
The nurse would check to see if a midstream
of BSE is to detect subtle changes before obvi-
specimen would be adequate. The other inter-
ous symptoms occur.
ventions are correct.
35. Answer 2: African Americans have a higher
47. Answer 3: The patient’s mouth will be sore
risk for prostate cancer and should be advised
and irritated with open lesions. Frequent,
that age 40 is the time to start.
gentle mouth care with a soft brush or sponge
36. Answer 4: Stage IV indicates metastasis.
and rinsing with normal saline will help. Cool
37. Answer 1: T0; N0; M0 indicates no evidence
fluids and bland foods are likely to feel more
of primary tumor, no regional lymph node
soothing.
metastasis, no (known) distant metastasis. See
48. Answer 2: Epoetin alfa (Epogen) is used to
Box 56-2, p. 2023 for additional information.
treat anemia, which is reflected by the red cell
38. Answer 1: The radioisotope will concentrate
count.
in the tumor areas. Isotope that is not picked
49. Answer 4: Platelets help the blood to clot;
up by the bone can be flushed out by the kid-
therefore, spontaneous bleeding will occur at
neys.
a count of less than 20,000/mm3.

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 Answer Key  164  

50. Answer 1: The hair will grow back, but it may Activity 2
be a different color or texture. 57. a. Chemotherapy involves the use of medi-
51. Answer 1, 3, 4: The symptom should resolve cations to slow or reduce the growth of
when treatment ends. In the meantime, en- metastatic cancer. Radiation is used to
courage the patient to experiment with differ- cure or control cancer that has spread to
ent spices: lemon juice, onion, mint, basil, and lymph nodes or cannot be removed.
fruit juice marinades may improve the taste of b. The patient should not have a bath below
certain meats and fish. Ham and bits of bacon the level of the implant. She should be
may improve the taste of vegetables. Calories offered supplies for a sponge bath.
are important, but good nutrition is necessary c. A “Radiation in Use” sign should be post-
for healing. ed. Never touch the implant if it becomes
52. Answer 1, 2, 3, 6: People at different ages have dislodged.
different coping skills. If significant others d. Pregnant women and children younger
are supportive and symptoms are minimal, than 18 years of age should not be al-
it is easier for the patient to cope. Ability to lowed to visit the patient.
express feelings also helps the patient to cope. e. Frequent assessment of vital signs and
Socioeconomic status and gender have less the integumentary system should be con-
impact. ducted. The diet should be low in residue
53. Answer 1: Ondansetron (Zofran) is an anti- to minimize peristalsis. The applicator
emetic, so the nurse will try to eliminate nox- should be checked every 4 hours.
ious odors.
54. Answer 2: Early clinical manifestations in-
clude nausea, vomiting, anorexia, diarrhea, CHAPTER 57—PROFESSIONAL ROLES AND
muscle weakness, and cramping. Later signs LEADERSHIP
and symptoms may include tetany, paresthe-
sias, seizures, anuria, and cardiac arrest. Short Answer
55. Answer 3: For cancer patients, fixed-dose 1. Key components of the cover letter include
round-the-clock analgesia provides a constant identification of interest in employment, a
blood level of the pain medication. Bolus brief statement of qualifications, and avail-
doses can be given for breakthrough pain, but ability for the position being sought. It is
fixed doses should continue and the nurse important to personalize the cover letter and
should report a pattern of continuous break- emphasize strengths and desired qualities ap-
through to the health care provider for reeval- plicable to the position.
uation of dose. Patient-controlled analgesia 2. By joining, the nurse has a voice in his/her
and PRN medication are commonly used for own profession. The organization is stronger
patients with acute pain, such as postopera- and more effective if there are many actively
tively. interested members. There are opportunities
for continuing education, networking, and
Critical Thinking Activities information-sharing. There are newsletters,
publications, and other benefits such as insur-
Activity 1 ance programs.
56. a. Although the American Cancer Society 3. Certification for the LPN/LVN is available
recommends testing begin at age 50, the in a number of ways such as seminars and
presence of a family history of colon can- self-study for managed care, pharmacology,
cer may indicate the need to begin testing long-term care, and IV therapy. Continuing
sooner. The history should be reported to education units (CEUs) may be offered by
the health care provider. the employer through seminars, conferences,
b. The patient should be encouraged to add workshops, or online. Also nursing journals,
activity of at least 30 minutes per day private education companies, and Internet ed-
into his routine. Dietary intake should be ucation companies offer CEUs. In many states
evaluated. Fruits, vegetables, and whole CEUs are a requirement; therefore, the LPN/
grains should be encouraged, and fatty LVN should become familiar with require-
foods should be avoided. ments in the state of practice. There are many
colleges, private schools, and universities

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 Answer Key  165  

where the LPN/LVN could become a regis- Multiple Choice

tered nurse. There are degree programs such 11. Answer 2: Autocratic is the most efficient
as the associate of science in nursing (ASN), in an emergency situation. The style is very
baccalaureate of science in nursing (BSN), or direct and there is no opportunity for discus-
master’s of science in nursing (MSN). There sion.
are some programs that offer the LPN/LVN 12. Answer 3: The student should take NCLEX-
an accelerated pace for completion of their PN® in the current state of residency and
degree and may offer online or a combination investigate reciprocity because 24 states have
of classroom and online curriculum. adopted mutual recognition licensure. If the
4. a. Minimum number of questions: 85 (in- student moves after successfully passing the
cluding 25 trial questions) for PN; 75 for examination and fulfilled the educational
RN requirements, it is necessary to apply for a
b. Maximum number of questions: 205 for license or temporary practice permit before
PN; 265 for RN practicing nursing. The student should not
c. Maximum time allowed: 5 hours for PN; 6 delay taking NCLEX-PN® because long peri-
hours for RN ods of delay increase likelihood of failing the
d. Goal of CAT testing: Determine compe- examination.
tence based on the difficulty of questions, 13. Answer 4: Frequently a charge nurse or senior
not on how many questions are answered nurse will know what the health care provider
correctly has written, because the writing style will be
e. Average time to receive results: 1 week familiar or the orders from that provider will
f. Approval to take the test is given by the be familiar. If no one can interpret the order, it
state board of nursing is necessary to call the provider. Transcribing
g. Alternate-item format: multiple response; an order without knowing what it says is in-
ordering of items; fill-ins (including calcu- correct. Calling the nursing supervisor may be
lations); drag and drop; and “hot spot” to necessary if the problem cannot be resolved.
identify an area, picture, or graphic Waiting until the provider returns to the unit
5. A nurse practice act defines the title and the may cause serious delays in patient care.
regulations governing the practice of nursing. 14. Answer 3: Calling the provider, reporting the
The act delineates the legal scope of the prac- error, and getting a one-time order for addi-
tice of nursing within the geographic bound- tional pain medication is the first step. Then
aries. Its provisions assist the nurse in staying check the postoperative orders and inform the
within the legal scope of nursing practice in patient about the next time that a dose will
each state. It also states the requirements for be available. An incident report is likely to be
licensure and conditions for which a license required by facility policy that documents the
may be revoked or suspended. actions taken (calling provider and adminis-
6. Job settings are hospitals, long-term care fa- tering additional dose should be documented
cilities, home health, office or clinic, insurance in the patient’s record, but avoid using lan-
companies, temporary agencies, travel nurs- guage that points out the error).
ing, pharmaceutical or medical equipment 15. Answer 1, 2, 4: Vital signs, linen changes, and
sales, military, adult daycare, school, public ambulating patients are within the scope of
health, outpatient surgery, private duty, civil practice for the UAP. The nurse must ensure
service, occupational health, rehabilitation, that the UAP understands isolation precau-
mental health, hospice, and correctional facil- tions. Restocking medications and IV fluids is
ity nursing. usually done by the pharmacy. Assessing skin
and transcribing orders are nursing responsi-
Fill-in-the-Blank Sentences bilities.
7. mentor 16. Answer 2: Negligence is the commission of
8. Nursing informatics an act that a prudent person would not have
9. Malpractice insurance done or the omission of a duty that a pru-
10. to seek immediate assistance dent person would have fulfilled, resulting
in injury or harm to another person. Proof is
necessary that other prudent members of the

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 Answer Key  166  

same profession would ordinarily have acted the customers. Visit the facility before the day
differently under the same circumstances. of the interview, so that you will know where
17. Answer 1: Since the nurse is a friend, taking to park and how to find the location of the in-
her aside and warning her that others are terview.
listening is a good way to stop the behavior 22. Examples of how the nurse can “survive” on
and it also puts the responsibility on that the night shift are:
nurse to take corrective action. Ideally, the a. Staying alert at work—Sleep and eat well
nurse who broke confidentiality should take before the shift, wear a 24-hour watch, eat
responsibility to contact risk management, or drink something warm when feeling
the nursing supervisor, and write an incident chilled.
report. b. Getting to sleep—Make the sleeping area
18. Answer 4: The group is mixed in terms of ex- cool, quiet, and dark. Unplug the phone;
perience, task responsibilities, and work set- allow an hour to unwind after work.
ting; thus the leader will have to be flexible to c. Balancing life with work—Eat right, ex-
use the strengths of the members. There may ercise regularly, get outside for fresh air,
be elements of committee work where the maintain strong family and social rela-
leader will be more directive and other times tionships.
when the leader will want input from the d. Frequently, night-shift pay will include a
members. shift differential. (Note to student: Con-
19. Answer 3: “If anyone is having any problems” sider this point when you are looking for
is too vague. These instructions put the UAP a job.) Night shift can be a time when the
in the position of having to assess and make nurse gets to focus on the patient, because
decisions about behavior and symptoms (or there will be fewer visitors and students,
lack of symptoms). Assisting several patients less time off the unit for diagnostic test-
with am hygiene is within the scope of prac- ing, fewer requests from other depart-
tice of the UAP. Giving feedback is usually ments, and fewer interactions with health
best immediately after the task is completed. care providers. Night-shift staff frequently
20. Answer 3: First, the nurse should try to figure report bonding and cohesiveness among
out how he/she is using time. When the nurse themselves.
recognizes the pattern, he/she can make an 23. a. Most nurses know what should be in-
action plan. Asking for help is always a pos- cluded in shift report, but fewer nurses
sibility, but others cannot help out on a daily are able to give a concise, well-organized
basis; therefore, the nurse has to learn how report that includes relevant details and
to manage the patient load. Socializing with excludes gossip, complaints, or tangential
colleagues is important and should not be experiences.
eliminated, but can be done during break Information that should be included:
times. Setting goals is important, but patients’ vital signs (if abnormal), type of intrave-
needs or conditions can change, so the nurse nous (IV) fluids (including rate of infu-
will have to learn to continuously reevaluate sion, amount left to infuse, and IV site),
priorities and adjust accordingly. and intake and output for feces, urine,
and gastric secretions; output from all
Critical Thinking Activities drainage tubes and appearance of drain-
21. Once you have identified a position, do some age; PRN medications including the time
research about the facility and mission state- of administration and amount of patient-
ment. Try to interview one or two nurses who controlled analgesia. Dressing changes,
work there, if possible. This research will help amount and color of exudate, and the
you compose a focused cover letter. Create condition of any incisions or wounds
a professional résumé and have an objective should be reported. Report any abnormal
colleague review it. Role play a face-to-face signs and symptoms such as dyspnea,
interview (see Box 57-4, p. 2047). Prepare ex- tachycardia, or abnormal mental status
amples of how your experiences can transfer or level of consciousness, as well as neu-
into the new job. For example, if you have rologic deficits. It is also very helpful to
worked as a waitress, describe how you men- know if events are pending such as sur-
tally organized multiple tasks and needs of gery, x-ray, outstanding laboratory results,

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 Answer Key  167  

social service consults, etc. It is also very 24. a. Burnout among nurses is attributed to
helpful for new nurses to ask experienced higher patient acuity, less available sup-
nurses who are giving report to identify port staff, and the nursing shortage. Con-
patients who are at risk for worsening. current personal or family problems can
b. Report can be given to all nurses sitting add to the stress.
around a conference table behind a closed b. Burnout is characterized by constant ex-
door. Report may be given one-to-one in haustion, depression, irritability, insom-
the conference room, standing outside nia, negative feelings toward one’s job,
the patient’s room, or standing inside the difficulty focusing, becoming emotionally
patient’s room (in which case, patient detached, and feeling that one’s actions
input is included in the report). Report don’t make a difference to others. Diffi-
may be taped by off-going shift. Report culty delegating tasks and taking time for
can be given to charge nurse, who then self may occur. Dysfunctional coping such
gives it to oncoming shift verbally or in as overspending, overeating, or addic-
written form. There are advantages and tions may occur.
disadvantages to any method. For ex- c. Awareness of the problem is the first step.
ample, if all of the nurses listen to report Seek a balance among work, family, and
on all of the patients, report is very long leisure activities. Choose to change to a
and time-consuming. The advantage is different work environment. Compart-
that all of the nurses are aware of poten- mentalize work responsibilities. Pay at-
tial problems for all of the patients. There tention to own needs. Focus on finishing
is a danger of violation of confidentiality one project at a time. Set achievable goals.
when standing outside the patient’s room. Seek advice and support from people who
The advantage is that the patient’s chart are solution-focused. Restore personal in-
or flow sheet is usually at hand and if tegrity.
the nurses need to quickly check on the
patient they are there at the door. Another
disadvantage of this method is that the
off-going nurse may have to give report
to other nurses on other patients; thus un-
less the assignments are identical shift af-
ter shift, there are delays in getting report
on all patients. Taped or written reports
can save time. However, taped reports are
often difficult to understand and the off-
going shift must stay to answer any ques-
tions for taped or written reports.

Copyright © 2015, 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, an imprint of Elsevier Inc. All rights reserved.