Test Bank For Medical Surgical Nursing

Clinical Reasoning in Patient Care 6th Edition,

LeMone
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CHAPTER 1
Question 1
Type: MCSA
The nurse is instructing a patient on the role of diet, exercise, and medication to control type 2 diabetes
mellitus. Which core competency for healthcare professionals is the nurse implementing?
1. Quality improvement
2. Evidence-based practice
3. Patient-centered care
4. Teamwork and collaboration
Question 2
Type: MCSA
The nurse is planning to utilize the core competency use informatics when providing patient care. Which
action should the nurse perform when using this core competency?
1. Change the sharps container in a patient’s room.
2. Document the effectiveness of pain medication for a patient.
3. Discuss the effectiveness of bedside physical therapy with the therapist.
4. Search through a database of articles to find current research on wound care.
Question 3
Type: MCMA
The nurse plans to implement evidence-based practice when providing patient care. Which activities
should the nurse perform?
Standard Text: Select all that apply.
1. Participate in education and research activities when possible.
2. Integrate research findings with clinical care to maximize patient outcomes.
3. Serve on the committee to create critical pathways for patient care.
4. Reinforce hand hygiene techniques with unlicensed assistive personnel.
5. Contact Environmental Services to report a malfunctioning infusion pump.
Question 4
Type: MCSA
The community health nurse is planning to meet with several community members during a health fair.
Which nursing activity exemplifies the core competency patient-centered care?
1. Provide smoking cessation classes and literature.
2. Increase the hours for the physician to see patients.
3. Attend a continuing education program on clean water initiatives.
4. Evaluate the effectiveness of weight reduction strategies.
Question 5
Type: MCSA
The nurse is instructing a patient on weight reduction and smoking cessation. Which code of nursing
practice is the nurse implementing?
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1. International Council of Nurses Code of Ethics for Nurses
2. American Nurses Association Standards of Professional Practice
3. American Nurses Association Code of Ethics for Nurses
4. State Board of Nursing Code
Question 6
Type: MCSA
The nurse is providing patient care within the American Nurses Association Standards of Professional
Performance. Which activity is the nurse implementing?
1. Integrating research findings into practice
2. Implementing a patient’s plan of care
3. Evaluating patient progress toward identified outcomes
4. Analyzing assessment data to determine issues
Question 7
Type: MCSA
The nurse prescribes strategies and alternatives to assist a patient achieve expected outcomes. Within
which American Nurses Association standard is the nurse practicing?
1. Planning
2. Assessment
3. Diagnosis
4. Implementation
Question 8
Type: MCSA
A patient with a terminal illness is concerned about pain control. If the International Council of Nurses
Code of Ethics for Nurses is followed, what should the nurse plan for the patient?
1. Measures to alleviate suffering
2. Modified activities of daily living
3. Enforcement of strict bed rest
4. Dietary interventions to maximize strength
Question 9
Type: MCSA
A patient is angry after waiting over an hour for pain medication. What should the nurse respond to the
patient that demonstrates critical thinking?
1. “I understand your anger and am sorry for the delay. I have your pain medication now.”
2. “I had other patients who needed my attention first, so I did a few things before getting the pain
medication.”
3. “I needed to find out what your medication is and if you can have more when you asked.”
4. “It seems that you always ask for pain medication when I am trying to do other things.”
Question 10
Type: MCSA
The nurse is reviewing data collected from a patient during an assessment. Which activity demonstrates
that the nurse is using divergent thinking when analyzing this data?
1. The nurse identifies abnormal data for further analyzing.
2. The nurse focuses on normal data to rule out health problems.
3. The nurse discriminates between facts and guesses.
4. The nurse thinks about the information to determine solutions.

CHAPTER 2
Question 1
Type: MCSA

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After purchasing a personal computer for use at home, the nurse enrolls in classes at the local
community college to learn more about using the device. Which building block of informatics
competencies is this nurse demonstrating?
1. Computer literacy
2. Information literacy
3. Relationship analysis
4. Computer integration
Question 2
Type: MCSA
While participating in the electronic communication committee, the nurse makes a recommendation to
alter one aspect of the system to support nursing documentation. Which informatics competency is this
nurse practicing?
1. Implement policies relevant to best practice.
2. Analyze and interpret information as part of planning care.
3. Use informatics applications designed for nursing practice.
4. Demonstrate expertise as a content expert in system design.
Question 3
Type: MCMA
The manager is evaluating a beginning nurse’s ability to use the computerized documentation system.
Which observations indicate that the beginning nurse needs additional training on the computer?
Standard Text: Select all that apply.
1. Documented care for one patient in 20 minutes
2. Input patient safety data on the appropriate screen
3. Stated laboratory results not available when they were entered 4 hours earlier
4. Retrieved a recent peer-reviewed article supporting an aspect of one patient’s care
5. Commented that a paper chart is the only legal and reliable form of documentation
Question 4
Type: MCMA
The staff development trainer is preparing a seminar for experienced nurses on the computerized clinical
documentation system. What should the trainer include in this presentation?
Standard Text: Select all that apply.
1. Strategies to locate information quickly
2. Tips on using the computers and software efficiently
3. Reasons the documentation system supports patient care
4. Approaches to identify relationships among data elements
5. Case studies to analyze data patterns to make clinical judgments
Question 5
Type: MCSA
A patient asks why the nurse is playing with an iPad in the midst of providing care. What should the
nurse respond to this patient?

1. “I’m just typing in notes to remember what care I provided to you.”

2. “This is just a way for nurses to communicate instead of calling out to each other.”
3. “I just needed to check and make sure I did everything that you needed at this time.”
4. “This is a part of the computer system that is used to confidentially document your care.”
Question 6
Type: MCSA
The computerized clinical documentation system installed in a healthcare organization has a feature that
alerts staff to potential safety hazards. Which computer message should the nurse interpret as a safety
warning when providing patient care?
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1. Warning: Scan the bar code on the item before using for patient care
2. Warning: Click on automatic calculation before leaving the graphic sheet section
3. Warning: Leaving the computer unattended for 1 minute will result in data not being saved
4. Warning: Administering this medication exceeds the maximum safe amount of acetaminophen
Question 7
Type: MCSA
While documenting care provided to a patient in the home, the nurse encounters a problem with the
electronic medical record. Which action indicates that the nurse was able to troubleshoot and address the
problem?

1. Followed the steps in the technical difficulties guide and completed documentation
2. Closed the electronic medical record and documented care in a traditional hard-copy note
3. Telephoned the information technology department and reported a problem with the system
4. Used the patient’s personal computer to access the electronic record to record documentation
Question 8
Type: MCMA
The nurse is a member of a committee charged with selecting a computerized clinical information
system for an organization. Which features should the nurse recommend be included in this system to
support patient care needs?
Standard Text: Select all that apply.
1. Standards of care
2. Quality improvement tracking database
3. Conditions of participation for health plans
4. Patient care policies and procedure manual
5. Clinical competency information and schedule
Question 9
Type: MCMA
The manager is on a committee that is investigating the implementation of evidenced-based practice for
the nursing staff. Which outcomes should the manager highlight as expected when this approach is
implemented?
Standard Text: Select all that apply.
1. Reduces costs
2. Promotes the best patient outcomes
3. Encourages healthcare worker retention
4. Reduces the cost of healthcare worker salaries
5. Reduces care variations between geographic locations
Question 10
Type: MCMA
The nurse is implementing evidence-based practice when caring for a patient with a chronic illness.
Which actions indicate that the nurse is implementing this approach appropriately?
Standard Text: Select all that apply.
1. Studies healthcare provider’s written orders
2. Analyzes patient’s requests for care approaches
3. Asks colleagues to identify best approaches to care
4. Plans intervention based upon researched information
5. Reviews findings from patient assessment and laboratory data

CHAPTER 3
Question 1
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Type: MCSA
When planning holistic care for a patient admitted with heart failure, what should the nurse include?
1. spiritual needs
2. measuring intake and output
3. daily weights
4. ambulating with assistance
Question 2
Type: MCSA
A patient tells the nurse that he has been fortunate since he has never experienced any major illnesses
and has enjoyed good health without much effort. How should the nurse realize this patient is defining
“good health?”
1. the absence of disease
2. effortless
3. fortunate
4. an integrated method of functioning
Question 3
Type: MCSA
A patient tells the nurse that he often is concerned with his declining mobility status even though he
continues to experience no major health issues. When planning care according to the wellness
framework, what should the nurse include for this patient?
1. interventions to restore the patient’s mobility status
2. activities to promote the current level of functioning
3. suggestions to maintain the patient’s current mobility status
4. activities to help the patient cope with the decline in mobility status
Question 4
Type: MCSA
The nurse has provided care to a patient according to the concept of wellness. Which outcome indicates
that care has been successful for this patient?
1. The patient is returning home with adjustments in the home environment to support a temporary
alteration in mobility status.
2. The patient needs additional teaching to understand the reason for taking Coumadin at the same time
every day.
3. The patient is not independent with personal care and will need assistance when at home.
4. The patient is easily fatigued and will need assistance with meal preparation and medication
administration.
Question 5
Type: MCSA
During an assessment, the nurse learns that a patient has a genetic predisposition to the development of
several disease processes. Which illness should the nurse realize is associated with genetic makeup?
1. cancer
2. hypertension
3. osteoporosis
4. myocardial infarction
Question 7
Type: MCSA
During an assessment, a patient tells the nurse that she is lactose intolerant. The nurse realizes that this
food intolerance is common within which cultural groups?
1. Mexican Americans
2. Scandinavian Americans
3. Indian Americans
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4. Mediterranean Americans
Question 9
Type: MCSA
The nurse is collecting data at the immunization clinic. Which disclosure by the patient would cause the
nurse to withhold the administration of the varicella vaccine?
1. a blood transfusion after undergoing surgery 3 months ago
2. history of an allergic reaction to yeast bread
3. itching and swelling on the face and hands after ingesting eggs
4. a low-grade temperature within the past 2 days
Question 10
Type: MCMA
The nurse is reviewing the goals for Healthy People 2020 with a group of patients in an outpatient
clinic. What should the nurse include in this presentation?
Standard Text: Select all that apply.
1. Eliminating preventable disease, disability, injury, and premature death
2. Achieving health equity, eliminating disparities, and improving the health of all groups
3. Creating social and physical environments that promote good health for all
4. Promoting healthy development and healthy behaviors across every stage of life
5. Achieving a body weight 20% less than recommended in current standardized height/weight charts

CHAPTER 4
Question 1
Type: MCSA
A patient tells the nurse that he must be having minor surgery since it will be done as an outpatient. How
should the nurse respond to this patient?
1. “Every surgical procedure is serious, and I will make sure you have information to have a successful
recovery.”
2. “You are right.”
3. “If it were more serious, you would be admitted to the hospital.”
4. “Your insurance plan does not cover inpatient surgical procedures. That’s why your surgery is being
done as an outpatient.”
Question 2
Type: MCSA
A patient scheduled for outpatient surgery asks the nurse why he will not be admitted to the hospital for
the surgery. What should the nurse explain as an advantage of having outpatient surgery?
1. reduced risk of healthcare-associated infections
2. ability to use home care for postoperative care in the home
3. reduced use of postoperative medications
4. inadequate staffing on the surgical care areas
Question 3
Type: MCMA
The nurse is preparing to discharge a patient after having outpatient surgery. Which criteria should the
nurse use to determine whether the patient is eligible to be discharged?
Standard Text: Select all that apply.
1. stable vital signs
2. no nausea or dizziness
3. pain controlled
4. adequate urine output
5. patient’s expressed readiness to go home
Question 4
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Type: MCSA
The nurse in the same-day surgical care area is preparing a patient for surgery. What should the nurse do
to ensure that this patient has a successful recovery from the surgery?
1. Provide teaching and additional resources to help the patient when at home.
2. Measure intake and output.
3. Assess vital signs.
4. Limit pain control measures since the patient will need to ambulate when leaving after the surgery.
Question 5
Type: MCSA
The nurse is providing care to a patient during the preoperative phase of surgery. Which of the following
interventions would be appropriate for the nurse to provide during this time?
1. assisting with bathing
2. patient safety
3. assessing level of consciousness
4. monitoring intake and output
Question 6
Type: MCSA
A patient was instructed on exercises to perform as part of preoperative teaching. While recovering from
surgery, the patient experiences a deep vein thrombosis (DVT). Which preoperative exercise should the
nurse identify as not having been effective for this patient?
1. leg exercises
2. deep breathing and coughing
3. use of incentive spirometry
4. splinting when coughing
Question 7
Type: MCSA
The nurse is assessing a patient who has returned to the care area after surgery. What should the nurse
do to ensure the patient receives appropriate care?
1. Check the physician’s orders to see if preoperative orders have been reordered.
2. Schedule the patient for vital signs assessments every four hours.
3. Orient the patient to person, place, and time.
4. Assess the patient’s mental status.
Question 8
Type: MCSA
After providing a patient with a preoperative sedative, the nurse notes that the surgical consent form has
not been signed by the patient. What should the nurse do?
1. Contact the surgeon.
2. Ask the patient to sign the consent form.
3. Send the patient for surgery with an unsigned consent form.
4. Phone the operating room suite to notify the nurse that the patient has not signed the consent form.
Question 9
Type: MCSA
A patient being prepared for surgery has been diagnosed with dehydration. Which laboratory values
support the diagnosis for this patient?
1. hemoglobin and hematocrit
2. glucose
3. white blood cell count
4. platelet count
Question 10
Type: MCSA
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A patient diagnosed with emphysema is being prepared for surgery. What laboratory value should the
nurse review to obtain information about the patient’s respiratory status?
1. carbon dioxide
2. white blood cell count
3. serum creatinine
4. blood urea nitrogen

CHAPTER 5
Question 1
Type: MCSA
The brother of a terminally ill patient states, “I’ll donate a million dollars to the hospital if they cure my
brother.” The nurse realizes this statement indicates which phase of Kübler-Ross’s stages of loss?
1. bargaining
2. denial
3. anger
4. acceptance
Question 2
Type: MCSA
A patient tells the nurse that her husband passed away a year ago and she is now beginning to realize
that he is truly gone. The patient is planning to begin a new job and possibly move to a new community.
The nurse realizes that this patient is in which stage of Bowlby’s theory of attachment?
1. detachment
2. protest
3. despair
4. anger
Question 3
Type: MCSA
A patient tells the nurse that since his wife died he has not been able to sleep and sees no reason to
continue living. According to Freud’s theory on grief and loss, what should the nurse realize this patient
is experiencing?
1. depression
2. grieving
3. emancipation
4. denial
Question 4
Type: MCSA
A patient has decided to join a support group for surviving spouses of victims of violent crime.
According to Engel’s theory of grief and loss, the nurse identifies that this patient is in which stage?
1. restitution
2. acute grief
3. shock and disbelief
4. denial
Question 5
Type: MCSA
A 30-year-old terminally ill patient is concerned about how her 7-year-old child will perceive her death.
What advice from the nurse would be most beneficial?
1. Children this age recognize that death is permanent.
2. Children this age emotionally distance themselves from the death.
3. Because the child fears separation the patient can prepare the child by explaining that death is
permanent.
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4. Children this age think death is sleeping.
Question 6
Type: MCSA
A patient of Native American descent is expected to die. The family arrives at the hospital and wants to
observe their religious and cultural traditions. Which intervention by the nursing staff would be most
appropriate?
1. Offer the family a private room to sit together.
2. Discourage the family from sitting with their loved one prior to death.
3. Discuss the possibility of transferring the patient home for the death.
4. Encourage the family to consider a DNR order.
Question 7
Type: MCSA
A patient tells the nurse that her estranged husband died a little over a year ago and states, “I am not sure
why this is so difficult. I really couldn’t stand him near the end.” Which response by the nurse is most
appropriate?
1. “Sometimes a rocky relationship with someone at the time of their death can affect your ability to
grieve.”
2. “You seem angry.”
3. “You should contact a therapist.”
4. “You are just entering the grief process. Things will get better.”
Question 8
Type: MCSA
A terminally ill patient is demonstrating signs of spiritual distress. Which should the nurse do first to
assist this patient?
1. Use the FICA assessment.
2. Help the patient with guided imagery.
3. Offer to pray with the patient.
4. Leave the patient alone with her thoughts.
Question 9
Type: MCSA
After an unsuccessful resuscitation attempt, a patient dies. What should the nurse do first?
1. Document the time of death.
2. Notify the funeral home.
3. Contact the physician.
4. Contact the orderly for transport to the morgue.
Question 10
Type: MCSA
A terminally ill patient is experiencing secretions pooling in the back of the throat. What can the nurse
do to help this patient feel more comfortable?
1. Raise the head of the bed.
2. Gently massage the patient.
3. Provide frequent small sips of fluids.
4. Provide oral care.

CHAPTER 6
Question 1
Type: MCSA
A patient tells the nurse that both of his parents are alcoholics and wonders about the likelihood of
becoming an alcoholic as well. How should the nurse respond to the patient?
1. “There are studies that support a genetic link for developing alcoholism.”
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2. “Why are you concerned about becoming an alcoholic?”
3. “You will likely become an alcoholic.”
4. “Don’t worry about that.”
Question 2
Type: MCSA
The mother of a patient admitted with alcohol abuse tells the nurse that alcohol is not consumed at home
and the patient is adopted. What should the nurse suspect about the patient?
1. The patient’s biological parents might have abused alcohol.
2. The patient spent time drinking with friends.
3. Consuming alcohol is a symptom of stress.
4. Alcoholism is a learned behavior.
Question 3
Type: MCSA
A patient tells the nurse that she started to have a glass of wine every evening at home after work to
“unwind” and then realized that she cannot continue with her day unless she has the wine. The nurse
realizes that this patient uses wine to
1. cope with day-to-day problems.
2. deal with difficulty expressing emotions.
3. suppress a genetic need for alcohol.
4. socialize with others.
Question 4
Type: MCSA
While analyzing data collected during an assessment, the nurse realizes that a patient’s risk for alcohol
abuse is low. What information did the nurse use to come to this conclusion?
1. The patient is Asian American.
2. The patient is diagnosed with type 2 diabetes.
3. The patient has two children.
4. The patient is employed as an accountant.
Question 5
Type: MCSA
A nurse is concerned about potential substance abuse by a coworker. What behavior warrants further
investigation?
1. The coworker frequently wastes medications.
2. The coworker frequently requests the largest patient care assignment for the shift.
3. The coworker prefers not to be the “medication nurse” on the shift.
4. The coworker declines to take scheduled breaks.
Question 6
Type: MCSA
A nurse consistently arrives to work wearing a long-sleeved blouse despite the temperature being in the
90s and the air humid. When colleagues mention her attire, the nurse becomes defensive and isolates
herself from others. What does the nurse’s behavior suggest?
1. substance abuse
2. a long-standing illness
3. introverted behavior
4. low self-esteem
Question 7
Type: MCMA
The nurse manager is concerned that one staff nurse is demonstrating signs of substance abuse. Which
behaviors did the manager observe in the staff nurse?
Standard Text: Select all that apply.
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1. calling for days off or illness before scheduled days off
2. using the bathroom frequently
3. excessive use of mouthwash
4. volunteering to transfer a patient to the intensive care unit
5. following up with nursing assistants on patient care needs
Question 8
Type: MCSA
The nurse is concerned that a colleague is experiencing depression from substance abuse. What does the
nurse observe to make this assumption?
1. The colleague leaves the unit and cannot be located for long periods of time.
2. The colleague uses the visitor bathroom instead of employee bathroom.
3. The colleague often eats lunch away from the hospital.
4. The colleague complains of frequent headaches at work.
Question 9
Type: MCSA
A patient recovering from outpatient carpal tunnel surgery returns to the surgical center the next day and
tells the nurse that she is having trouble attending to daily activities and the pain is “excruciating,” so

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she wants stronger pain medication immediately. What should this patient’s behavior suggest to the
nurse?
1. The patient could have a substance abuse problem.
2. A nerve was cut during the procedure.
3. The patient was not given strong enough postoperative pain medication.
4. The patient is under stress to return to work.
Question 10
Type: MCSA
A patient complaining of back pain tells the nurse that he needs several refills on any prescription since
he takes the medication more frequently than prescribed. What should this information suggest to the
nurse?
1. The patient has lost control over the consumption of the pain medication.
2. The patient is impulsive.
3. The patient uses the pain medication to fit in with a peer group.
4. The patient uses the pain medication to overcome low self-esteem.

CHAPTER 7
Question 1
Type: MCSA
A school bus transporting a local university’s basketball team has just crashed in the rain on the side of
the road. The bus was transporting approximately 60 people. Which classification should the nurse use
to describe the situation?
1. multiple-casualty incident
2. natural disaster
3. human-generated disaster
4. mass-casualty incident
Question 2
Type: MCSA
The nurse is caring for a patient with injuries received in an earthquake. Which type of incident should
the nurse identify as causing this patient’s injuries?
1. natural disaster
2. human-generated disaster
3. emergency
4. multiple-casualty incident
Question 3
Type: MCSA
A small commuter plane lost an engine and crashed into a shopping mall. The estimated number of
injured people from this accident is 500. Which classification of incident should the nurse use when
determining the care needed for these victims?
1. mass-casualty incident
2. multiple-casualty incident
3. accidental natural disaster
4. intentional human-generated disaster
Question 4
Type: MCSA
A train derailed in a local community. The contents of the train caused a hazardous spill, and noxious
gasses are being released into the environment. All local and surrounding fire control and Hazmat teams

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have been mobilized and the event is considered under control. Which type of situation should the nurse
prepare for?
1. emergency
2. disaster
3. human-generated accidental disaster
4. intentional emergency
Question 5
Type: MCSA
The nurse is caring for patients when a dirty bomb detonates at a nearby shopping mall. Which types of
injuries should the nurse expect to see in the victims?
1. radiation sickness
2. fractured limbs and spinal injury
3. thermal burns
4. overexertion and exhaustion
Question 6
Type: MCSA
Several patients are admitted after being exposed to a substance that was released in their manufacturing
plant. The patients are demonstrating flu-like symptoms, unproductive cough, and fever. These patients
should be assessed for which type of exposure?
1. anthrax
2. smallpox
3. dirty bomb
4. nuclear detonation
Question 7
Type: MCSA
The nurse is caring for a patient who was brought into the emergency department after an explosion at a
nuclear power plant. The patient is confused and keeps repeating that his skin is “on fire.” What does
this information indicate to the nurse?
1. The patient may not recover.
2. The patient’s clothing is burning his skin.
3. There is gastrointestinal system involvement and the patient will survive if he receives fluids.
4. There is bone marrow damage and the patient needs oxygen for the confusion.
Question 8
Type: MCSA
A patient is brought into the emergency department complaining of blindness after an explosion at an
atomic power plant. What should the nurse explain to this patient?
1. “The effects of the blast will disappear with time.”
2. “I’m afraid the blast has caused permanent blindness.”
3. “I will contact Social Services so that resources can be identified to help you with your disability.”
4. “There is a variety of resources available for those who are unable to see.”
Question 9
Type: MCSA
The nurse is caring for a patient who experienced a blast injury to the eye. Which intervention would be
appropriate?
1. Flush the eye with eyewash.
2. Encourage the patient to rub the eye to get out specks of dust.
3. Apply a warm compress to the eye.
4. Remove debris lodged in the eye.
Question 10
Type: MCSA
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The nurse is admitting the second patient in 2 days who is experiencing malaise, high fever, and
headache. Both patients attended a local air show the previous weekend. What should the nurse do?
1. Discuss the need to contact public health authorities regarding the similarity of the cases.
2. Plan to place the patients in the same room.
3. Ask the patients for permission to talk with family members regarding other symptoms.
4. Assess the patients for what foods they ate while at the air show.

CHAPTER 8
Question 1
Type: MCSA
A female patient tells the nurse that she is genetically predisposed to type 2 diabetes. What is the most
important information that the nurse should provide?
1. the importance of maintaining a healthy weight and activity level
2. the need to avoid carbohydrate intake
3. the need to begin monitoring daily blood glucose levels
4. the need to address active health problems and not those that have yet to manifest
Question 2
Type: MCSA
A patient tells the nurse that she does not want to pass on a disease that is genetic in origin to any future
children. How should the nurse respond to this patient?
1. “A complete genetic study could help guide you in your decision making.”
2. “I suppose, then, that you are not going to have any children.”
3. “Adoption is always a possibility.”
4. “Are you sure that the disease is genetic in origin?”
Question 3
Type: MCSA
A patient expresses concern about transmitting genetic illnesses to any future children. What can the
nurse do to help the patient determine which diseases might be transmitted?
1. Complete a pedigree.
2. Conduct a health promotion assessment.
3. Schedule for a complete genetic analysis.
4. Refer to a geneticist for diagnosis.
Question 4
Type: MCSA
At the completion of a genetic assessment, the nurse learns that a patient has three family members
diagnosed with rectal cancer before the age of 40 years. What should the nurse discuss with the patient?
1. importance of having screening for colorectal cancer at an earlier age
2. importance of ingesting a diet high in protein and carbohydrates
3. ways to maximize time spent in exercise
4. reasons why having children would not be recommended for this patient
Question 5
Type: MCSA
While assessing a patient, the nurse notes an irregularity that has been observed in other patients, but on
an inconsistent basis. What did the nurse most likely discover in this patient?
1. a polymorphism
2. a mutation
3. a single-gene inheritance pattern
4. an X-linked inheritance pattern
Question 6
Type: MCSA
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A patient has been told that her unborn child will most likely have Down syndrome. The nurse realizes
this diagnosis is consistent with which genetic finding?
1. trisomy
2. monosomy
3. translocation
4. deletions
Question 7
Type: MCSA
A nurse is planning to teach the parents of a child with cystic fibrosis about the disorder. Which
statement should the nurse include in this explanation?
1. “While all people carry the gene CFTR, which is responsible for cystic fibrosis, those who develop
the disease have a mutation in that gene.”
2. “A small percentage of the general population carries the gene for cystic fibrosis. If two carriers have
children, then 25% of those children will develop the disease.”
3. “One in four people carry the gene for cystic fibrosis. If two carriers have children, then 25% of those
children will develop the disease.”
4. “Some people carry the gene for cystic fibrosis. Of those carriers, one in four will develop the
disease.”
Question 8
Type: MCSA
A patient tells the nurse that many of her family members have a type of anemia that is genetic. What
should the nurse realize will occur in this patient?
1. The patient will develop the disease only if there is a mutation in the gene.
2. The patient will develop the same type of anemia.
3. The patient will die from the anemia.
4. The patient will develop the disease only if the gene translocates.
Question 9
Type: MCSA
At the completion of genetic testing it has been determined that a patient’s baby will have Down
syndrome. What should the nurse say to the patient after learning this information?
1. “I realize that this news is difficult for you. Is there anything that I can do to help you at this time?”
2. “It’s not too late to consider ending the pregnancy.”
3. “You are young enough to be able to handle the baby’s challenges.”
4. “It does not matter if the baby has problems; all life is precious.”
Question 10
Type: MCSA
The nurse is developing a teaching plan for parents who need genetic counseling. Which statement by a
parent indicates the need for further education?
1. “All the chromosomes are the same size in males and females alike.”
2. “Half of the sets of chromosomes come from the mother and the other half comes from the father.”
3. “The 23rd pair of chromosomes will determine if our child will be male or female.”
4. “One Y chromosome and one X sex chromosome will produce a male child.”

CHAPTER 9
Question 1
Type: MCSA
The nurse is assessing a patient’s response to pain. Why should the nurse do this for every patient
situation?
1. Everyone has a unique tolerance to pain.
2. Everyone has the same pain threshold.
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3. Everyone perceives painful stimuli at the same intensity.
4. Most people have the same the pain response to surgery.
Question 2
Type: MCSA
After assessing a patient for pain, the nurse concludes that the pain is caused by a mechanical stimulus.
What should the nurse consider as a possible cause of this patient’s pain?
1. muscle tear
2. burn
3. frostbite
4. myocardial infarction
Question 3
Type: MCSA
The nurse is using the neuromatrix theory when determining a patient’s pain. What should the nurse
consider when assessing a patient’s pain?
1. cultural and genetic factors
2. specificity
3. pattern
4. previous sensitization
Question 4
Type: MCSA
A patient tells the nurse that he has had deep, burning muscle pain for most of his adult life. What does
this information tell the nurse about how the patient’s pain is being transmitted in the body?
1. C fibers
2. A-delta fibers
3. endorphins
4. dynorphins
Question 5
Type: MCSA
A patient asks the nurse why he felt pain prior to a myocardial infarction primarily in his left arm. How
should the nurse respond?
1. “Pain in the arm related to cardiac tissue damage is a type of referred pain.”
2. “Cardiac pain is generally unexplainable.”
3. “Were you doing some physical activity with your arm just prior to the event?”
4. “What you are describing relates to psychogenic pain.”
Question 6
Type: MCSA
A patient is being treated for chronic pain. What should the nurse keep in mind when assessing this
patient’s level of pain?
1. The pain rating may be inconsistent with the underlying pathology.
2. There is usually a clear, physiologic cause.
3. Pain typically lasts 2 months or less.
4. The pain reported is usually less severe than acute pain.
Question 7
Type: MCSA
The nurse is managing care for a group of patients with pain. For which health problem should the nurse
expect the patient to experience acute pain?
1. cholecystectomy
2. phantom limb pain
3. complex regional pain syndrome
4. degenerative joint disease
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Question 8
Type: MCSA
The nurse is planning care for a patient with chronic pain. Which pain control goal would be most
appropriate for this patient?
1. Reduce the focus on pain.
2. Reduce the sympathetic stress response.
3. Be completely pain free.
4. Improve patient outcomes.
Question 9
Type: MCSA
A patient scheduled for knee surgery tells the nurse, “I know I won’t feel as much pain with this knee
surgery as I did with the other one when I was 20 years younger.” What should the nurse respond to this
patient?
1. “There might be more pain, because the pain response can get worse with aging.”
2. “You are most likely correct.”
3. “It should not be quite as bad with the newer technology.”
4. “Pain responses diminish with age.”
Question 10
Type: MCSA
A female patient tells the nurse that at times the pain she has is so severe that she cannot move or get out
of bed at home. What should the nurse realize is contributing to this patient’s pain?
1. gender
2. overuse of alcohol
3. overuse of pain medication
4. too much sleep and rest

CHAPTER 10
Question 1
Type: MCSA
The nurse is caring for an older patient who is occasionally confused. What should be the nurse’s
primary concern regarding fluid and electrolytes when caring for this patient?
1. risk of dehydration
2. risk of kidney damage
3. risk of stroke
4. risk of bleeding
Question 2
Type: MCSA
The nurse is planning care for a patient with severe burns. What condition should the nurse realize that
this patient could develop?
1. intracellular fluid deficit
2. intracellular fluid overload
3. extracellular fluid deficit
4. interstitial fluid deficit
Question 3
Type: MCSA
A patient experiencing multisystem fluid volume deficit has tachycardia; pale, cool skin; and decreased
urine output. The nurse realizes these findings are most likely a direct result of which process?
1. the body’s natural compensatory mechanisms
2. pharmacological effects of a diuretic
3. effects of rapidly infused intravenous fluids
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4. cardiac failure
Question 4
Type: MCSA
A pregnant patient is admitted with excessive thirst and increased urination. For which problem should
the nurse focus the care of this patient?
1. imbalanced fluid
2. fluid overload
3. nutritional deficiency
4. insufficient blood flow
Question 5
Type: MCSA
A patient recovering from surgery has an indwelling urinary catheter. For which 24-hour urine output
volumes should the nurse notify the patient’s healthcare provider?
1. 600 milliliters
2. 750 milliliters
3. 1000 milliliters
4. 1200 milliliters
Question 6
Type: MCSA
A patient is receiving intravenous fluids postoperatively following cardiac surgery. On which potential
postoperative complication should the nurse focus the assessment of this patient?
1. fluid volume excess
2. fluid volume deficit
3. seizure activity
4. liver failure
Question 7
Type: MCSA
A patient is diagnosed with severe hyponatremia. The nurse realizes this patient will mostly likely need
precautions implemented for what event?
1. seizure
2. infection
3. neutropenia
4. high-risk fall
Question 8
Type: MCSA
A patient is diagnosed with hypokalemia. After reviewing the patient’s current medications, which drug
should the nurse consider that might have contributed to the patient’s health problem?
1. corticosteroid
2. thiazide diuretic
3. narcotic
4. muscle relaxer
Question 9
Type: MCSA
A patient prescribed spironolactone is demonstrating ECG changes and complaining of muscle
weakness. The nurse realizes this patient is exhibiting signs of which electrolyte imbalance?
1. hyperkalemia
2. hypokalemia
3. hypercalcemia
4. hypocalcemia
Question 10
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Type: MCSA
The nurse is planning care for a patient with fluid volume overload and hyponatremia. What should be
included in this patient’s plan of care?
1. Restrict fluids.
2. Administer intravenous fluids.
3. Provide Kayexalate.
4. Administer intravenous normal saline with furosemide.

CHAPTER 11
Question 1
Type: MCSA
A patient is brought to the emergency department with injuries sustained in a motor vehicle crash. What
should the nurse consider as the cause of this patient’s injuries?
1. trauma
2. not wearing a seat restraint
3. a drunk driver
4. not paying attention while driving
Question 2
Type: MCSA
The spouse of a patient admitted with a gunshot wound asks the nurse when her husband will be
discharged so that they can resume their life together. How should the nurse respond?
1. “Right now there is no way of knowing how soon your husband can return to his previous life.”
2. “I would say in a few weeks.”
3. “Probably never.”
4. “As soon as the wound heals, your husband can return to work.”
Question 3
Type: MCMA
An older patient is admitted after falling on the steps at home. Which components of trauma should the
nurse consider when planning care for the patient?
Standard Text: Select all that apply.
1. host
2. environment
3. intention
4. source
5. transmission
Question 4
Type: MCSA
A patient comes into the emergency department with leg pain after falling on ice. For which
classification of injuries should the nurse expect to plan care for this patient?
1. Class 3 minor
2. Class 1 minor
3. Class 1 penetrating
4. Class 3 penetrating
Question 5
Type: MCSA
A patient is brought to the emergency department with injuries sustained when a wall collapsed in the
home. The nurse recognizes that this patient’s injuries were most likely caused by which mechanism of
injury?
1. crushing
2. shearing
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3. deceleration
4. blast
Question 6
Type: MCSA
A patient was admitted with a head injury caused by rapid acceleration and deceleration. How should
the nurse expect this patient’s injuries to be classified?
1. blunt
2. shearing
3. blast
4. minor
Question 7
Type: MCSA
A patient is admitted with a thermal injury. Which mechanism of injury should the nurse consider as the
most likely cause of this patient’s injuries?
1. fire
2. lightning
3. ultraviolet radiation
4. gunshot
Question 8
Type: MCSA
A pediatric patient is admitted after ingesting a household cleaning solution. The nurse should plan care
for this patient’s injuries based on which energy source?
1. chemical
2. physical
3. thermal
4. mechanical
Question 9
Type: MCSA
A patient recovering from a motor vehicle accident tells the nurse that the other car “barely” hit him and
asks why he has so many injuries. How should the nurse respond?
1. “The car that hit you transferred a large amount of energy to your body, causing these injuries.”
2. “You have other health problems that make the injuries worse.”
3. “The driver of the other car intended to hit you.”
4. “Because you are older, your injuries will be worse.”
Question 10
Type: MCSA
A construction worker was admitted after falling from the roof of a building. The nurse should plan care
for this patient’s injuries based on which energy source?
1. gravitational
2. mechanical
3. physical
4. electrical

CHAPTER 12
Question 1
Type: MCSA
The nurse is reviewing the white blood cell count differential for a patient and notes that the basophil
count is elevated. What should this laboratory value indicate to the nurse?
1. The patient is experiencing an acute hypersensitivity reaction.
2. The patient has a gastrointestinal infection.
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3. The patient is fighting a tuberculosis infection.
4. The patient is fighting cancer.
Question 2
Type: MCSA
The nurse is caring for a patient recovering from a splenectomy. What should the nurse realize will
occur regarding this patient’s immunity?
1. The liver and bone marrow will take over the spleen’s functions.
2. The patient will need to avoid infections every day of his life.
3. The patient will have edematous lymph glands throughout his body.
4. The thymus gland will take over the spleen’s functions.
Question 3
Type: MCSA
A patient’s white blood cell count is 11,000/mm3. What does the nurse understand this value to
represent?
1. the total number of circulating leukocytes
2. the total number of circulating neutrophils
3. the total number of circulating eosinophils
4. the total number of circulating basophils
Question 4
Type: MCSA
A patient sustains fractures to the ribs, both femurs, and one humerus. When planning care for this
patient’s immunologic status, what should the nurse include?
1. Monitor complete blood count daily.
2. Limit food rich in iron.
3. Perform passive range of motion to unaffected extremities.
4. Keep on bed rest.
Question 5
Type: MCSA
A patient is diagnosed with a positive tuberculosis skin test. The nurse understands that this response is
due to what?
1. performing a cell-mediated inflammatory response
2. promoting phagocytosis of the antigen by neutrophils
3. clumping antigens to form a noninvasive aggregate
4. coating the antigen with antibodies
Question 6
Type: MCSA
A patient tells the nurse that he’s happy that his wife did not “catch” the same cold from which he has
recently recovered. The nurse realizes that what most likely occurred in his wife?
1. Helper T cells had a memory of a previous exposure to the same virus that caused the patient’s illness.
2. Suppressor T cells killed the virus.
3. The virus was eliminated via phagocytosis by neutrophils.
4. Cytokines were released.
Question 7
Type: MCSA
The nurse is caring for a patient diagnosed with a lung infection. Which immunoglobulin level should
the nurse expect to be elevated in this patient?
1. immunoglobulin A
2. immunoglobulin M
3. immunoglobulin E
4. immunoglobulin D
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Question 8
Type: MCSA
A patient who just delivered a newborn baby is concerned that the baby will “catch” a cold from a
healthcare provider who was coughing and sneezing in the delivery room. How should the nurse
respond?
1. “The baby has some protection from infections from the time of birth.”
2. “The baby should be isolated.”
3. “I will be sure to have everyone check the baby’s temperature for signs of an infection.”
4. “The healthcare provider should not have been participating in your care.”
Question 9
Type: MCMA
The nurse is concerned that a patient is exhibiting signs and symptoms of inflammation. What did the
nurse assess to come to this conclusion?
Standard Text: Select all that apply.
1. leg edema
2. severe pain from swelling
3. severe erythema of leg
4. leg cool to the touch
5. decreased peripheral pulses
Question 10
Type: MCSA
An older patient has a small pressure ulcer on the coccyx. What should the nurse do to promote healing
of the wound?
1. encourage high-protein food choices in the diet
2. limit carbohydrate intake
3. encourage a high intake of vitamin E
4. restrict caloric intake

CHAPTER 13
Question 1
Type: MCSA
A patient is admitted to receive a kidney transplant from a live sibling. The nurse realizes that what must
have occurred for this surgery to be planned?
1. The human leukocyte antigens between the patient and sibling must be very similar.
2. The human leukocyte antigens between the patient and sibling must be very different.
3. The patient has an overactive immune system.
4. The donor has an overactive immune system.
Question 2
Type: MCSA
A patient in isolation for an incompetent immune system asks the nurse what “disease” he has that
requires placement in isolation. How should the nurse respond?
1. “Because your immune system is weak, you can develop a disease. The isolation is to protect you.”
2. “I will have to find out from your doctor.”
3. “It’s not a bad disease. The isolation is just to make sure it doesn’t spread.”
4. “I am sure that once your medications start to work, you won’t have to remain in isolation.”
Question 3
Type: MCSA
A patient tells the nurse that she used to get the “common cold” at least three times a year but now can’t
remember the last time she had one. What should the nurse realize this patient is describing?
1. healthy B cell functioning
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2. healthy helper T cell functioning
3. T cell secretion of antibodies
4. healthy regulator T cell functioning
Question 4
Type: MCSA
An older patient tells the nurse that he develops pneumonia easily; however, his wife of the same age
rarely “gets sick.” How should the nurse respond?
1. “Not everyone’s immune system is the same, regardless of their age.”
2. “Your wife must be doing something that you’re not doing.”
3. “Maybe your wife just doesn’t tell you when she’s sick.”
4. “It’s just a matter of time. Your wife will have the same illnesses you do.”
Question 5
Type: MCSA
A patient comes into the emergency department with itching, swelling, and slight shortness of breath
after being stung by a bee. The nurse realizes this patient is experiencing which type of hypersensitivity
reaction?
1. type I IgE-mediated hypersensitivity
2. type II cytotoxic hypersensitivity
3. type III immune complex-mediated hypersensitivity
4. type IV delayed hypersensitivity
Question 6
Type: MCSA
A patient is diagnosed with a type IV delayed hypersensitivity reaction. What is an example of this type
of reaction?
1. latex allergy
2. reaction to a wasp sting
3. serum sickness
4. autoimmune hemolytic anemia
Question 7
Type: MCSA
A patient develops hemolytic anemia after receiving a dose of penicillin. What action should the nurse
realize is indicated for this patient?
1. Administer no further doses of penicillin.
2. Administer a blood transfusion.
3. Provide oxygen.
4. Increase fluids.
Question 8
Type: MCSA
A patient develops a fever, rash, joint and muscle pain, and swollen lymph nodes after receiving a
sulfonamide. What should these symptoms suggest to the nurse?
1. serum sickness
2. exacerbation of a disease process
3. acute influenza
4. subacute rheumatoid arthritis
Question 9
Type: MCSA
A patient who has received a bone marrow transplant develops a maculopapular rash on the palms of
both hands and the soles of the feet. The patient complains of severe abdominal pain with bloody
diarrhea. What should the nurse suspect this patient is experiencing?
1. graft-versus-host disease
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2. chronic tissue rejection
3. acute tissue rejection
4. hyperacute tissue rejection
Question 10
Type: MCSA
A patient is diagnosed with valvular heart disease after experiencing rheumatic heart fever. The nurse
understands this disorder is caused by what action?
1. molecular mimicry
2. release of hidden antigens into the circulation
3. biologic changes that cause self-antigens to produce autoantibodies
4. autoimmune response by slow-growing mycobacteria

CHAPTER 14
Question 1
Type: MCSA
A patient shows the nurse a new sore on the forearm that has been increasing in size and will not heal.
The nurse knows that which sign could also point to a diagnosis of a malignant neoplasm?
1. noncohesive, invasive, and invades and destroys surrounding tissues
2. rapid growth, well-defined borders, and cohesiveness
3. invasive, local, and does not stop at tissue border
4. slow growth, well-defined borders, and encapsulated
Question 2
Type: MCSA
After learning that he has a benign tumor in his abdomen, the patient is overheard telling his wife that he
has cancer. What should the nurse say to the patient and spouse?
1. “There is a growth in the abdomen but it is encapsulated and after being removed, will not recur.”
2. “This type of cancer is easily treated.”
3. “This type of cancer will not spread to other tissues.”
4. “Even though this growth has invaded other tissues, it can be contained.”
Question 3
Type: MCSA
A patient tells the nurse that he has a benign tumor that has spread into his lymph glands. How should
the nurse respond to this patient?
1. “What did your doctor tell you about the tumor?”
2. “Benign tumors do not spread.”
3. “That’s a good thing that the tumor is benign.”
4. “Since it is benign, are you going to have surgery to remove it?”
Question 4
Type: MCSA
A patient with a history of cancer is surprised to learn that new cancer has been diagnosed in another
body part. What should the nurse realize this patient is experiencing?
1. metastasis
2. contact inhibition
3. destructive force from a benign neoplasm
4. a solid mass
Question 5
Type: MCSA
A patient asks the nurse how his cancer developed. Which statement should the nurse avoid in
responding to this patient?
1. “The theory of cellular mutation suggests that carcinogens cause mutations in cellular RNA.”
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2. “Oncogenes are genes that promote cell proliferation and are capable of triggering cancerous
characteristics.”
3. “The majority of people do not have an inherited form of cancer.”
4. “Known carcinogens include viruses, drugs, hormones, and chemical and physical agents.”
Question 6
Type: MCSA
A patient with a history of smoking is diagnosed with cancer. If applying the cellular mutation theory of
cancer to this patient’s diagnosis, the nurse realizes that smoking impacted which stage?
1. promotion
2. initiation
3. progression
4. replication
Question 7
Type: MCSA
A female patient asks the nurse why she needs a procedure to remove part of her cervix that was
infected with a virus. What should the nurse explain to this patient?
1. Human papillomavirus can cause cervical cancer.
2. The medication to treat this virus is toxic to the body.
3. If left untreated, it could spread to the liver.
4. If left untreated, it could spread to the breast.
Question 8
Type: MCSA
A patient with a history of using recreational cocaine tells the nurse that he would rather be addicted to
cocaine than be diagnosed with cancer. What should the nurse respond with to this patient?
1. “Cocaine has been linked to the development of cancer.”
2. “I guess if that’s what you would prefer.”
3. “People who use cocaine do have a lower risk of developing cancer.”
4. “As long as the cocaine is pure and not mixed with toxic chemicals.”
Question 9
Type: MCMA
A college student is diagnosed with Epstein-Barr virus. The student has a history of smoking and
recreational cocaine use and works for a floor refinishing company part-time. Which factors increase
this student’s risk for developing cancer?
Standard Text: Select all that apply.
1. drug use
2. occupation
3. smoking
4. viral infection
5. age
Question 10
Type: MCSA
The nurse is preparing to provide care to a group of assigned patients. Which patient should the nurse
realize is at the highest risk for developing cancer?
1. an African American man
2. a Native American woman
3. an Hispanic man
4. an Hispanic woman

CHAPTER 15
Question 1
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Type: MCSA
A patient is experiencing a problem with the eccrine sweat glands. Because of this structural problem,
the nurse realizes that which function will be affected in this patient?
1. regulation of body temperature
2. regulation of body heat by excretion of perspiration
3. sebum secretion
4. sexual scent gland
Question 2
Type: MCSA
During a conversation with the nurse, a patient comments that he rarely goes outside when the sun is
shining because he is afraid of developing skin cancer. Which health problem is this patient at risk for
developing?
1. vitamin D deficiency
2. hypercholesterolemia
3. hypokalemia
4. hypernatremia
Question 3
Type: MCMA
A patient who has experienced a burn involving both the epidermis and the dermis asks if the area will
heal and be as it was prior to the burn. What knowledge of skin structures should the nurse use to
respond to this patient?
Standard Text: Select all that apply.
1. Most hair follicles are in the dermis.
2. Most sweat glands are in the dermis.
3. Hair follicles are located in the subcutaneous tissue.
4. Sebaceous glands are located in the dermis.
5. Receptors for pain and touch are located in the dermis.
Question 4
Type: MCSA
The nurse is caring for an African American patient who has a serum bilirubin of 6 mg/100 mL. What is
the best way of assessing skin color changes in this patient?
1. Assess the sclera.
2. Assess the palms of the hands.
3. Assess the fingernails.
4. Assess the skin of the inner arms.
Question 5
Type: MCSA
The nurse is caring for an African American patient who has an ashen cast to his normally black skin.
Which laboratory test results should the nurse review to determine a possible cause of the skin color
change?
1. BUN
2. hemoglobin and hematocrit
3. bilirubin
4. oxygen saturation
Question 6
Type: MCSA
A Caucasian patient is admitted with possible carbon monoxide poisoning. What skin color can the
nurse expect to find that would support this diagnosis?
1. bluish
2. dusky red
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3. cherry red
4. orange green
Question 7
Type: MCSA
While conducting a patient’s health history, the nurse learns that the patient has worked at a landfill for
the last 35 years. Why should the nurse find this information significant?
1. Explains possible exposure to environmental toxins
2. Helps understand the patient’s lack of communication skills
3. Validates that the patient is an older adult
4. Confirms the patient’s level of education
Question 8
Type: MCMA
A patient is seen for an erythematous generalized rash. Which questions should the nurse ask regarding
the rash?
Standard Text: Select all that apply.
1. “Have you recently eaten any new foods?”
2. “What medications do you take?”
3. “Have you changed your soap?”
4. “Have you changed skin care lotions?”
5. “How often do you walk outside?”
Question 9
Type: MCSA
A patient being seen for an elevated, darkened area of excess scar tissue asks the nurse what caused it.
How should the nurse respond?
1. “This scar was caused by the wearing away of the superficial epidermis, which left a moist, shallow
depression.”
2. “This scar was caused by excessive collagen formation during healing.”
3. “This scar was caused by skin loss extending into the dermis or subcutaneous tissue.”
4. “This scar was caused by wasting of the skin due to loss of collagen.”
Question 10
Type: MCMA
The nurse is performing an assessment of a patient’s nails. What should be included in this examination?
Standard Text: Select all that apply.
1. nail thickness
2. nail color
3. nail curvature
4. nail length
5. for grooves

CHAPTER 16
Question 1
Type: MCSA
The mother of a teenage girl voices concerns about her daughter’s acne. Which response by the nurse is
best?
1. “The skin needs to be washed at least twice a day with mild soap and water to remove surface oil.”
2. “The greatest culprit for acne is dietary habits, not inadequate hygiene.”
3. “Are you embarrassed by her appearance?”
4. “What are your concerns about her hygiene practices?”
Question 2
Type: MCSA
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A patient has a lesion in the left axilla that is deep, painful, and contains pus. It is 3 centimeters in
diameter. After the assessment, what type of lesion should the nurse determine that the patient has?
1. furuncle
2. folliculitis
3. carbuncle
4. herpes varicella
Question 3
Type: MCSA
An African American patient has reoccurring folliculitis on the face. What should the nurse instruct the
patient to do about this health problem?
1. Practice good hygiene.
2. Shave daily.
3. Shave very closely.
4. Shave in the opposite direction of hair growth.
Question 4
Type: MCSA
The nurse is counseling a patient who has atopic dermatitis (eczema) and has developed a secondary
infection. What should the nurse emphasize so that the patient can prevent this type of infections in the
future?
1. methods to prevent itching
2. continuous antibiotic treatment
3. frequent bathing
4. allergy testing
Question 5
Type: MCSA
A patient has a small, red, scaling lesion that is sitting on an elevated base on the forehead. The patient
states that lesion began several weeks before and will not heal. What type of lesion does the nurse
consider the patient is experiencing?
1. squamous cell carcinoma
2. melanoma
3. psoriasis
4. seborrheic keratosis
Question 6
Type: MCSA
A patient diagnosed with scabies asks the nurse how he “caught” the disorder. What information should
be provided to the patient?
1. The disorder is transmitted by contact with infected persons or their possessions.
2. The disorder is transmitted by the feces of infected animals.
3. Scabies is a bacterial infection transmitted by direct contact with infected persons.
4. Scabies is a fungal infection transmitted by contact with infected respiratory secretions.
Question 7
Type: MCSA
The nurse is planning care for a patient with herpes zoster. Which problem should the nurse identify as
being the priority for this patient?
1. managing pain
2. avoiding breakouts
3. relieving itchiness
4. improving hygiene
Question 8
Type: MCSA
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The patient with herpes zoster has pruritus and reports difficulty resting at night. Which intervention will
best aid the patient?
1. Encourage the patient to take prescribed antipruritic agents approximately one hour before bedtime.
2. Massage the irritated skin areas with lotion.
3. Apply powder to the lesions.
4. Use heavy bed linens to avoid chilling at night.
Question 9
Type: MCMA
A patient at risk for the development of skin cancer is discussing sun exposure prevention with the
nurse. What information should be included in the discussion?
Standard Text: Select all that apply.
1. A higher-rated sunscreen is needed between 10 a.m. and 3 p.m.
2. Sunscreen is needed even on cloudy days.
3. Apply a sunscreen with an SPF of 15 or more.
4. The higher the sunscreen rating, the less the protection provided.
5. When swimming, sunscreen should be reapplied every 4 hours.
Question 10
Type: MCMA
The nurse is planning care for a patient at risk for pressure ulcer development. What should the nurse
include in this patient’s plan of care?
Standard Text: Select all that apply.
1. Initiate a frequent toileting schedule.
2. Turn the patient every 2 hours.
3. Massage pressure areas with lotion every 4 hours.
4. Use inflatable donut rings to reduce pressure on the sacrum.
5. Use hot water to cleanse the skin immediately after incontinence.

CHAPTER 17
Question 1
Type: MCMA
A patient comes into the emergency department with a chemical burn from contact with lye. Which facts
about this type of burn should guide the nurse when assessing and planning care for this patient?
Standard Text: Select all that apply.
1. This is an alkali burn.
2. This type of burn tends to be deeper.
3. This is an acid burn.
4. This type of burn is easier to neutralize.
5. This type of burn tends to be more superficial.
Question 2
Type: MCMA
A patient arrives at the emergency department with an electrical burn. What assessment questions
should the nurse ask when determining the possible severity of the burn injury?
Standard Text: Select all that apply.
1. What type of current was involved?
2. How long was the patient in contact with the current?
3. How much voltage was involved?
4. Where was the patient when the burn occurred?
5. What was the point of contact with the current?
Question 3
Type: MCSA
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A nurse sees a patient get struck by lightning during a thunderstorm on a golf course. What is the first
action the nurse should perform?
1. Check breathing and circulation.
2. Look for entrance and exit wounds.
3. Cover the victim to prevent heat loss.
4. Move the victim indoors to a dry place.
Question 4
Type: MCMA
The nurse is teaching a class of older adults at a senior center about household cleaning agents that may
cause burns. Which agents should be included in this discussion?
Standard Text: Select all that apply.
1. drain cleaners
2. household ammonia
3. oven cleaner
4. toiler bowl cleaner
5. lemon oil furniture polish
Question 5
Type: MCSA
A patient with a burn that is pale, waxy, and with large flat blisters asks the nurse about the severity of
the burn and how long it will take to heal. How should the nurse respond?
1. The wound is a deep partial-thickness burn and will take more than 3 weeks to heal.
2. The wound is a superficial partial-thickness burn and could take up to 2 weeks to heal.
3. The wound is a superficial burn and will take up to 3 weeks to heal.
4. The wound is a full-thickness burn and will take 1 to 2 weeks to heal.
Question 6
Type: MCMA
The nurse is classifying a patient’s burn injuries. What information should the nurse assess to ensure this
classification is correct?
Standard Text: Select all that apply.
1. depth of the burn
2. extent of burns on the body
3. causative agent and duration of exposure
4. location of burns on the body
5. time that the burns occurred
Question 7
Type: MCMA
A patient has a scald burn on the arm that is bright red, moist, and has several blisters. The nurse would
classify this burn as which type?
Standard Text: Select all that apply.
1. a superficial partial-thickness burn
2. a thermal burn
3. a superficial burn
4. a deep partial-thickness burn
5. a full-thickness burn
Question 8
Type: FIB
A patient is brought to the emergency department with the following burn injuries: a blistered and
reddened anterior trunk, reddened lower back, and pale, waxy anterior right arm. Calculate the extent of
the burn injury (TBSA) using the rule of nines.
_____ %
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Standard Text: Record your answer rounding to the nearest whole number.
Question 9
Type: MCSA
A 25-year-old patient is admitted with partial-thickness burns on both lower legs, over 20% of the total
body surface area. How should the nurse classify this burn?
1. moderate burn injury
2. minor burn injury
3. major burn injury
4. severe burn injury
Question 10
Type: MCSA
A patient has sustained a partial-thickness burn of 28% of total body surface area (TBSA) and full-
thickness burn of 30% or greater of TBSA. How should the nurse classify this burn injury?
1. major
2. moderate
3. minor
4. superficial

CHAPTER 18
Question 1
Type: MCSA
The nurse is assessing a patient diagnosed with hypothyroidism. Which health assessment interview
question should the nurse ask this patient?
1. “Is your skin feeling rough and dry?”
2. “Is your skin smooth or flushed?”
3. “Does your skin feel clammy?”
4. “Do you have brown, shiny patches on the lower extremities?”
Question 2
Type: MCSA
When measuring the blood pressure of a patient with hypoparathyroidism, the nurse notes spasms of the
patient’s hand. How should the nurse document this finding?
1. Trousseau sign
2. Chvostek sign
3. Turner sign
4. Cullen sign
Question 3
Type: MCSA
A patient has a positive Trousseau sign. For which problem should the nurse plan care for this patient?
1. pain
2. excessive fluid
3. difficulty breathing
4. reduced blood flow
Question 4
Type: MCMA
During an endocrine assessment, the nurse asks a patient about changes in weight. For which organs is
the nurse assessing function in the patient?
Standard Text: Select all that apply.
1. adrenal
2. thyroid
3. pituitary
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4. parathyroid
5. gonads
Question 5
Type: MCSA
The nurse is assessing a patient with a pituitary disorder. Which finding does the nurse assess for in this
patient?
1. enlargement of the hands and feet
2. thin, soft hair
3. excessive growth of facial hair
4. purple striae over the trunk
Question 6
Type: MCSA
A patient is demonstrating signs of exophthalmos. What additional finding should the nurse expect to
assess in this patient?
1. enlarged thyroid gland
2. dry, thick nails
3. dry skin
4. decreased reflexes
Question 7
Type: MCSA
The nurse is reviewing data collected during a patient’s health history. What information would indicate
a disorder of the pituitary gland?
1. dwarfism
2. carpal spasms
3. enlarged thyroid nodule
4. hyperpigmentation of the skin
Question 8
Type: MCSA
The nurse is caring for a patient with Graves disease. On which laboratory value should the nurse focus
for this patient?
1. thyroxine
2. urine-specific gravity
3. cortisol
4. calcium
Question 9
Type: MCSA
The nurse is conducting a physical assessment with a patient. Which assessment technique should the
nurse use to assess the patient’s thyroid gland?
1. Stand behind the patient and palpate the thyroid.
2. Stand in front of the patient and palpate the thyroid.
3. Place the patient supine and palpate one side of the neck at a time.
4. Have the patient flex the neck forward and palpate the thyroid.
Question 10
Type: MCMA
The nurse is beginning the assessment of a patient with an endocrine disorder. What should the nurse
include in this assessment?
Standard Text: Select all that apply.
1. height and weight
2. skin, hair, and nails
3. deep tendon reflexes
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4. musculoskeletal system
5. respiratory system

CHAPTER 19
Question 1
Type: MCSA
While assessing a patient with an alteration in thyroid function, the nurse notes smooth, fine hair and
warm, dry skin. Which question should the nurse ask this patient?
1. “Have you experienced any recent weight loss?”
2. “Have you been feeling constipated?”
3. “Have you noticed increased bruising?”
4. “Have you noticed a change in your skin color?”
Question 2
Type: MCSA
The nurse is providing preoperative teaching to a patient scheduled for a subtotal thyroidectomy. What
should the nurse include in these instructions?
1. Report sensations of tingling in toes, fingers, or lips.
2. Report signs of constipation.
3. Report the improvement of hoarseness.
4. Take aspirin before the surgery.
Question 3
Type: MCSA
The nurse is caring for a patient with elevated serum T3 and T4 levels who receives a new prescription
for methimazole (Tapazole). Which patient statement indicates that additional teaching is needed about
this medication?
1. “This medication will increase my metabolism.”
2. “I must contact my physician if I plan to become pregnant.”
3. “It may take several weeks for this medication to take effect.”
4. “I may take a beta-blocker along with this medication.”
Question 4
Type: MCSA
The nurse is reviewing postoperative care for a patient scheduled for a thyroidectomy. What information
should the nurse include in this teaching?
1. “Avoid the use of iodized salt after your procedure.”
2. “Plastic surgery may be required to conceal the surgical scar.”
3. “Use iodized salt when preparing foods.”
4. “Perform neck flexion and extension exercises twice daily for several weeks postoperatively.”
Question 5
Type: MCSA
The nurse is caring for a patient with elevated serum thyroid hormones and new-onset proptosis. Which
problem would be a priority for this patient?
1. change in appearance
2. altered immunity
3. weight gain
4. fluid retention
Question 6
Type: MCSA
A patient whose thyroid gland produces an insufficient amount of thyroid hormone is concerned about
an elevated cholesterol level. What should the nurse explain to this patient?
1. “The thyroid gland malfunction can affect your cholesterol level.”
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2. “Maybe you don’t realize how much fat is in the foods you eat.”
3. “Elevated cholesterol is a normal part of aging.”
4. “Describe your typical bedtime snack.”
Question 7
Type: MCSA
The family of an older patient with hypothyroidism is concerned about the open wounds on the patient’s
legs and arms. How should the nurse respond to the family’s questions about bathing?
1. “Use warm water to bathe the patient.”
2. “Make sure she has a daily bath.”
3. “Use firm, consistent strokes when bathing.”
4. “Follow the bath with a rubbing-alcohol massage.”
Question 8
Type: MCMA
The nurse is assessing a female patient who has an abnormally high level of parathyroid hormone.
Which assessment findings would be consistent with this diagnosis?
Standard Text: Select all that apply.
1. muscle atrophy
2. muscle weakness
3. diarrhea
4. weight gain
5. hypotension
Question 9
Type: MCMA
The nurse is providing care to a patient with a low level of serum parathyroid hormone. What should the
nurse expect to assess in this patient?
Standard Text: Select all that apply.
1. facial grimacing
2. abdominal cramps
3. hair loss
4. dysrhythmias
5. smooth, soft skin
Question 10
Type: MCSA
A patient taking steroids for an autoimmune disorder asks when the weight loss in the legs is going to
stop. What should the nurse realize the patient is experiencing?
1. muscle wasting
2. poor wound healing
3. risk for compression fractures
4. increased susceptibility to infections

CHAPTER 20
Question 1
Type: MCSA
A patient with diabetes mellitus and poor circulation has thick and ingrown toenails. What should the
nurse instruct the patient to do?
1. Soak feet in Epsom salts daily.
2. Use a clean sharp razor blade to trim nails.
3. Make an appointment with a podiatrist.
4. Cut toenails immediately prior to bathing.
Question 2
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Type: MCSA
A patient with diabetes asks what can be done to prevent the development of corns on the feet. How
should the nurse respond to this patient?
1. “Make sure that you select shoes that are appropriately fitted.”
2. “Use corn pads to gradually remove the growths.”
3. “Corns are best treated by shaving them off.”
4. “A mild abrasive soap can be used to scrub the area to remove them.”
Question 3
Type: MCSA
A patient at risk for the development of type 2 diabetes mellitus asks why weight loss will reduce risk of
the condition. Which response by the nurse is most accurate?
1. “The amount of foods taken in require more insulin to adequately metabolize them, resulting in
diabetes.”
2. “Excess body weight impairs the body’s release of insulin.”
3. “Thin people are less likely to become diabetic.”
4. “The physical inactivity associated with obesity causes a reduced ability by the body to produce
insulin.”
Question 4
Type: MCSA
A patient recently diagnosed with type 1 diabetes mellitus does not understand why the disease
developed because the patient is thin and eats all of the time. What is the most appropriate response by
the nurse?
1. “Thin people can be diabetic, too.”
2. “Your condition makes it impossible for you to gain weight.”
3. “Diabetes makes it difficult for your body to obtain energy from the foods you eat.”
4. “Your lab tests indicate the presence of diabetes.”
Question 5
Type: MCSA
A 78-year-old patient without polyuria, polydipsia, or polyphagia has a serum glucose level of 130
mg/dL. What should the nurse conclude about this patient?
1. The patient might have eaten a meal with high sugar content prior to the testing.
2. The laboratory results might be erroneous.
3. The patient has type 1 diabetes mellitus.
4. The patient will need to be assessed for other manifestations of diabetes.
Question 6
Type: MCSA
The nurse notes that a 41-year-old patient’s fasting blood glucose level is 125 mg/dL. What should the
nurse suspect is occurring with the patient?
1. severe hyperglycemia
2. consistent with diabetes
3. normal results
4. consistent with prediabetes
Question 7
Type: MCSA
A patient recently diagnosed with diabetes wants to check the urine for glucose instead of using
capillary blood because of the cost. Which response should the nurse make to the patient?
1. “Urine testing is best when combined with serum testing.”
2. “Urine testing is as reliable as finger stick testing.”
3. “Yes, urine testing is cheaper than glucose test strips.”
4. “Would you like to switch to this method of monitoring?”
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Question 8
Type: MCSA
A patient with type 1 diabetes mellitus who had one episode of vomiting in the past 2 hours asks if the
routine insulin injection should be taken. What action by the nurse is best at this time?
1. Contact the physician.
2. Explain the need to take the insulin.
3. Document the refusal and continue on with the planned care.
4. Check the patient’s fasting serum glucose level.
Question 9
Type: MCSA
A patient beginning insulin for type 2 diabetes is experiencing blurred vision and is concerned about
becoming blind. What response by the nurse is most appropriate?
1. “I will make an appointment for you to see an ophthalmologist.”
2. “I will call the physician to report your symptoms.”
3. “Blurry vision is very common. Do not worry.”
4. “This is a normal response when insulin therapy is initiated.”
Question 10
Type: MCSA
A patient with diabetes is diaphoretic, has a heart rate of 112 beats per minute, and is feeling nervous
and shaky. What action should the nurse take first?
1. Provide the patient with a snack of milk and crackers.
2. Administer insulin utilizing the prescribed sliding scale dosages.
3. Contact the laboratory and order a serum glucose level.
4. Obtain a capillary serum glucose level reading with a glucose meter.

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