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Test Bank Medical-Surgical Nursing, 7th Edition by Adrianne Dill Linton
Chapter 01: Aspects of Medical-Surgical Nursing
Linton: Medical-Surgical Nursing, 7th Edition
MULTIPLE CHOICE
1. What provides direction for individualized care and assures the delivery of accurate, safe
care through a definitive pathway that promotes the client’s and the support persons’
progress toward positive outcomes?
a. Physician’s orders
b. Progress notes
c. Nursing care plan
d. Client health history
ANS: C
The nursing care plan provides direction for individualized care and assures the delivery of
accurate, safe care through a definitive pathway that promotes the client’s and the support
persons’ progress toward positive outcomes.
DIF: Cognitive Level: Comprehension REF: p. 2 OBJ: 1
TOP: Nursing Care Plan KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
2. The nurse is performing behaviors and actions that assist clients and significant others in
meeting their needs and the identified outcomes of the plan of care. What is the correct
term for these nursing behaviors?
a. Assessments
b. Interventions
c. Planning
d. Evaluation
ANS: B
Caring interventions are those nursing behaviors and actions that assist clients and
significant others in meeting their needs and the identified outcomes of the plan of care.
DIF: Cognitive Level: Comprehension REF: p. 3 OBJ: 1
TOP: Interventions KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
3. The nurse understands the importance of being answerable for all actions and the
possibility of being called on to explain or justify them. What term best describes this
concept?
a. Reliability
b. Maturity
c. Accountability
d. Liability
ANS: C
Accountability means that a person is answerable for his or her actions and may be called
on to explain or justify them.
DIF: Cognitive Level: Comprehension REF: pp. 6-7 OBJ: 3 | 5 | 7
TOP: Accountability KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Reduction of Risk
MULTIPLE RESPONSE
1. The nurse manager is providing an inservice about conflict resolution. What modes of
conflict resolution should be addressed? (Select all that apply.)
a. Suppression
b. Accommodation
c. Compromise
d. Avoidance
e. Collaboration
f. Competition
ANS: B, C, D, E, F
The modes of conflict resolution include accommodation, collaboration, compromise,
avoidance, and competition.
DIF: Cognitive Level: Knowledge REF: p. 7|p. 8|Table 1.1
OBJ: 7 TOP: Conflict Resolution KEY: Nursing Process Step:
N/A
MSC: NCLEX: N/A
2. What are the characteristics of an effective leader? (Select all that apply.)
a. Effective communication
b. Rigid rules and regulations
c. Delegates appropriately
d. Acts as a role model
e. Consistently handles conflict
f. Focuses on individual development
ANS: A, C, D, E
Characteristics of an effective leader include effective communication, consistency in
managing conflict, knowledge and competency in all aspects of delivery of care, effective
role model for staff, uses participatory approach in decision making, shows appreciation
for a job well done, delegates work appropriately, sets objectives and guides staff, displays
caring, understanding, and empathy for others, motivates and empowers others, is
proactive and flexible, and focuses on team development.
DIF: Cognitive Level: Comprehension REF: p. 6 OBJ: 5
TOP: Leadership KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
COMPLETION
1. _________ is defined as the process by which information is exchanged between
individuals verbally, nonverbally, and/or in writing or through information technology.
ANS:
Communication
Communication is defined as the process by which information is exchanged between
individuals verbally, nonverbally, and/or in writing or through information technology.
DIF: Cognitive Level: Knowledge REF: p. 2 OBJ: 2
TOP: Communication KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
2. _________ is the collection and processing of relevant data for the purpose of appraising
the client’s health status.
ANS:
Assessment
Assessment is the collection and processing of relevant data for the purpose of appraising
the client’s health status.
DIF: Cognitive Level: Knowledge REF: p. 2 OBJ: 1 | 2
TOP: Assessment KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
3. _________ is concerned with the ethical questions that arise in the context of health care.
ANS:
Bioethics
Bioethics is concerned with the ethical questions that arise in the context of health care.
DIF: Cognitive Level: Knowledge REF: p. 4 OBJ: 3
TOP: Bioethics KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
4. Place the corresponding letter to each stage of conflict in the correct order. _________
(Place the events in the appropriate sequence with capital letters. Do not separate
answers with a space or punctuation. Example: ABCD.)
a. Outcomes
b. Conceptualization
c. Frustration
d. Action
ANS:
CBDA
The stages of conflict in order are frustration, conceptualization, action, and outcomes.
DIF: Cognitive Level: Comprehension REF: p. 7 OBJ: 7
TOP: Conflict KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
5. Place the corresponding letter to each key step in solving an ethical dilemma in the correct
order. _________ (Place the events in the appropriate sequence. Do not separate answers
with a space or punctuation. Example: ABCD.)
a. Negotiate a plan.
b. Clarify values.
c. Ask if it is an ethical dilemma.
d. Verbalize the problem.
e. Gather information.
f. Identify possible courses of action.
g. Evaluate the plan over time.
ANS:
CEBDFAG
The key step of solving an ethical dilemma in order are ask the question, is it an ethical
dilemma, gather information, clarify values, verbalize the problem, identify possible
course of action, negotiate a plan, and evaluate the plan over time.
DIF: Cognitive Level: Analysis REF: p. 4 OBJ: 3
TOP: Ethical Dilemma KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
Chapter 02: Medical-Surgical Practice Settings
Linton: Medical-Surgical Nursing, 7th Edition
MULTIPLE CHOICE
1. While a home health nurse is making the entry to a service assessment on a homebound
patient, the spouse of the patient asks whether Medicare will cover the patient’s ventilator
therapy and insulin injections. What is the best response by the nurse?
a. “Yes, Medicare will cover both the ventilator therapy and the insulin injections.”
b. “No, Medicare will not cover either of these ongoing therapies.”
c. “Medicare will cover the ventilator therapy, but it does not cover the insulin
injections.”
d. “Medicare will cover the ongoing insulin therapy, but it does not cover a highly
technical skill such as ventilator therapy.”
ANS: C
Medicare will cover skilled nursing tasks such as ventilator therapy, but common tasks
that can be taught to the family or the patient are not covered.
DIF: Cognitive Level: Application REF: pp. 12-13 OBJ: 3 | 4
TOP: Medicare Coverage for Home Health
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
2. The wife of a patient asks the nurse whether her husband would be considered for
placement in a skilled nursing care facility when he is discharged from the general
hospital. The patient is incontinent, has mild dementia but is able to ambulate with a
walker, and must have help to eat and dress himself. What is the nurse’s most appropriate
response?
a. “Yes, your husband would qualify for a skilled care facility because of his inability
to feed and dress himself.”
b. “No, your husband’s disabilities would not qualify him for a skilled facility.”
c. “Yes, your husband qualifies for placement in a skilled care facility because of his
dementia.”
d. “Yes, anyone who is willing to pay can be placed in a skilled nursing facility.”
ANS: B
Placement in a skilled nursing facility must be authorized by a physician. A clear need for
rehabilitation must be evident, or severe deficits in self-care that have a potential for
improvement and require the services of a registered nurse, a physical therapist, or a
speech therapist must exist.
DIF: Cognitive Level: Analysis REF: p. 13 OBJ: 6
TOP: Placement Qualifications for Skilled Nursing Facility
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment
3. A nurse has noted that a newly admitted resident to an extended care facility stays in her
room, does not take active part in activities, and leaves the meal table after having eaten
very little. The nurse should analyze this relocation response as
a. regression.
b. social withdrawal.
c. depersonalization.
d. passive aggressive.
ANS: B
Social withdrawal is a frequent response to relocation.
DIF: Cognitive Level: Application REF: p. 21 OBJ: 10
TOP: Relocation Response KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
4. A nurse clarifies to a new patient in a rehabilitation center what rehabilitation means.
What statement made by the patient indicates a correct understanding?
a. “I will return to my previous level of functioning.”
b. “I will be counseled into a new career.”
c. “I will develop better coping skills to accept his disability.”
d. “I will attain the greatest degree of independence possible.”
ANS: D
The rehabilitation process works to promote independence at whatever level the patient is
capable of achieving.
DIF: Cognitive Level: Comprehension REF: p. 15 OBJ: 7
TOP: Rehabilitation Goals KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Coordinated Care
5. A nurse assesses a patient who needs to be reminded to take premeasured oral
medications, wash, go to meals, and undress and come to bed at night, but coming and
going as he pleases is considered safe for him. What facility placement would be most
appropriate for this patient?
a. Skilled care
b. Intermediate care
c. Sheltered housing
d. Domiciliary care
ANS: D
Domiciliary care provides room, board, and supervision, and residents may come and go
as they please. Sheltered housing does not provide 24-hour care.
DIF: Cognitive Level: Comprehension REF: p. 19 OBJ: 3 | 9
TOP: “Levels of Care, Criteria for Domiciliary Residence”
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
6. A nurse is making a list of the members of the rehabilitation team, so the different types of
services available to patients may be taught to a group of families. Which lists should be
used?
a. Physical therapist, nurse, family members, and personal physician
b. Occupational therapist, dietitian, nurse, and patient
c. Rehabilitation physician, laboratory technician, patient, and family
d. Vocational rehabilitation specialist, patient, and psychiatrist
ANS: A
The rehabilitation team usually consists of all of the choices except the laboratory
technician, dietitian, and psychiatrist. (The mental health role is represented by the
psychologist.)
DIF: Cognitive Level: Comprehension REF: p. 17 OBJ: 7
TOP: Rehabilitation Team Members KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
7. A nurse explains the level of disability to a patient who was injured in a construction
accident that resulted in the loss of both his right arm and right leg. This loss has affected
his quality of life and ability to return to previous employment. At what level should the
client be classified as being disabled?
a. I
b. II
c. III
d. IV
ANS: B
The patient is limited in the use of his right arm for feeding himself, dressing himself, and
driving his car, which are three main activities of daily living. He may be able to work if
workplace modifications are made.
DIF: Cognitive Level: Application REF: p. 15 OBJ: 8
TOP: Levels of Disability KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
8. A nurse explains that in 1990, the Americans with Disabilities Act (ADA) was passed. For
which extended services for the disabled persons did this act provide?
a. Covering the costs for the rehabilitation of disabled World War I servicemen by
providing job training
b. Extending protection to the disabled in the military sector, such as wheelchair
ramps on military bases
c. Extending protection to the disabled in private areas, such as accessibility to public
restaurant bathrooms and telephones
d. Affording disabled persons full access to all health care services
ANS: C
The ADA of 1990 extended the previous legislative Acts of 1920, 1935, and 1973. The
ADA now covers private sector individuals and public businesses in particular.
DIF: Cognitive Level: Comprehension REF: p. 16 OBJ: 8
TOP: Americans with Disabilities Act (ADA) of 1990
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
9. A frail patient in a long-term care facility asks the nurse if a bath is to be given this
morning. What is the best reply by the nurse to encourage independence and give the
patient the most flexibility?
a. “Based on your room number, you get bathed on Monday, Wednesday, and Friday.
Today is Tuesday.”
b. “If you want to eat breakfast in the dining room with the others, you may sponge
yourself off in your bathroom.”
c. “When your daughter comes this evening, ask her if she can give you a bath.”
d. “I will bring a basin of water for a sponge off for right now. After breakfast, we
will talk about a bath schedule.”
ANS: D
The resident should be provided as much flexibility as possible and support for
independence.
DIF: Cognitive Level: Application REF: p. 22 OBJ: 11
TOP: Maintenance of Autonomy in Extended Care Facility
KEY: Nursing Process Step: Implementation
MSC: NCLEX Physiological Integrity: Basic Care and Comfort
10. A computer programmer who lost both legs is being retained by his employer, who has
made arrangements for a ramp and a special desk to accommodate the patient’s
wheelchair. What is the disability level of the computer programmer?
a. I
b. II
c. III
d. IV
ANS: B
Level II allows for workplace accommodation, which is the desk modification in this case.
DIF: Cognitive Level: Analysis REF: p. 15 OBJ: N/A
TOP: Reasonable Accommodation KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
11. A partially paralyzed forklift operator is to be retrained by vocational rehabilitation
services for less demanding office work. What law provides for this rehabilitation?
a. Vocational Rehabilitation Act of 1920
b. Social Security Act of 1935
c. Rehabilitation Act of 1973
d. Americans with Disabilities Act of 1990
ANS: C
The Rehabilitation Act of 1973 provided a comprehensive approach and expanded
resources for public vocational training.
DIF: Cognitive Level: Comprehension REF: p. 16 OBJ: 7
TOP: Rehabilitation Legislation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
12. The home health care nurse performs all the following actions. Which is the only action
that is reimbursable under Medicare payment rules?
a. Observing a spouse cleaning and changing a dressing
b. Taking a frail couple for a walk to provide exercise
c. Watching a patient measure out all medications
d. Teaching a patient to self-administer insulin
ANS: D
Medicare reimburses skilled techniques that are clearly spelled out; these include teaching
but not return demonstration–type actions by patient or family.
DIF: Cognitive Level: Comprehension REF: pp. 12-13 OBJ: 4
TOP: Medicare Reimbursable Actions KEY: Nursing Process Step: Assessment
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
13. A patient with multiple sclerosis must be fed, bathed, and dressed. How should the nurse
assess this patient?
a. Disabled
b. Disadvantaged
c. Handicapped
d. Impaired
ANS: D
Feeding oneself, dressing, and bathing are activities of daily living. The patient is impaired
in this scenario.
DIF: Cognitive Level: Analysis REF: p. 15 OBJ: 7
TOP: Principles of Rehabilitation | Defining Levels of Loss of Functioning Independently
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
14. Which law initially provided for rehabilitation of disabled Americans?
a. Vocational Rehabilitation Act of 1920
b. Social Security Act of 1935
c. Rehabilitation Act of 1973
d. Americans with Disabilities Act of 1990
ANS: A
The U.S. government has passed four pieces of legislation to identify and meet the needs
of disabled individuals with each one being more inclusive. The first one was passed in
1920.
DIF: Cognitive Level: Knowledge REF: p. 16 OBJ: 8
TOP: Rehabilitation Legislation KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
15. A client was admitted to a long-term residential care facility. On what should the
admitting nurse tell the family the concepts of long-term care are based?
a. Amount of activities the resident can do for herself
b. Maintenance care with an emphasis on incontinence
c. Successful adaptation to the regulations of the home
d. Maintenance of as much function as possible
ANS: D
Maintenance of function and encouraging autonomy and independence are some of the
basic concepts of long-term care.
DIF: Cognitive Level: Comprehension REF: p. 18 OBJ: 11
TOP: Principles of Nursing Home Care KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
16. A 58-year-old patient with diabetes is recuperating from a broken hip and is concerned
about how to pay for rehabilitation. The nurse should inform this patient that funds for
rehabilitation are available from which resource?
a. Vocational Rehabilitation Act of 1920
b. Rehabilitation Act of 1973
c. Disabled American Veterans Act of 1990
d. Title V, Health of Crippled Americans 1935
ANS: B
The Rehabilitation Act of 1973 assists in paying for rehabilitation for those who are
younger than 65 years of age and who will benefit from vocational rehabilitation through
teaching.
DIF: Cognitive Level: Comprehension REF: p. 16 OBJ: 8
TOP: Legislation for Funding Health Care
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
17. What is an example of a description of community health nursing?
a. Visiting patients in their homes after hospital discharge to assess their personal
health status
b. Asking a nursing assistant (NA) to identify the health services most needed in the
patient’s personal life
c. Meeting with residents of low-income housing to identify their health care needs
d. Developing a hospital-based home health care service
ANS: C
Whereas community-based nursing looks at identified community needs and provides care
at all levels of wellness and illness, community health nursing seeks to provide services to
groups to modify or create systems of care.
DIF: Cognitive Level: Comprehension REF: pp. 10-11 OBJ: 2
TOP: Defining Community-Based Nursing versus Community Health Nursing
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Coordinated Care
18. Home health nurses have some different nursing activities than those of community health
nurses. Which statement best describes the home health nurse’s activities?
a. Conducting health education classes in a senior citizens’ common residence
building
b. Conducting blood pressure screening on a regular basis at a local mall
c. Visiting and assessing the home care and further teaching needs of a patient who
has been recently discharged from the hospital
d. Acting as a nurse consultant to a chronic psychiatric section in a state institution
ANS: C
The home health nurse works with individuals in the home; the other descriptors are
community nurse activities.
DIF: Cognitive Level: Comprehension REF: p. 13 OBJ: 1 | 5
TOP: Activities of the Home Health Nurse
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
19. Based on guidelines from the Americans with Disability Act (ADA), which question is an
appropriate choice for the director of nurses to ask a nurse with an artificial leg who is
applying for a staff position in an extended care facility?
a. “How long have you had your prosthesis?”
b. “How many flights of stairs are you able to climb without assistance?”
c. “Are you able to lift a load of 45 lb?”
d. “Has your disability caused you to miss work?”
ANS: C
Queries to disabled job applicants can be made relative to specific job functions, but they
cannot be asked relative to the severity of the disability or the degree of disability in
general.
DIF: Cognitive Level: Application REF: p. 16 OBJ: 7 | 8
TOP: ADA KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
20. A nurse reminds a resident in a long-term care facility that he has autonomy in many
aspects of his institutionalization. What is an example of autonomy?
a. Selection of medication times
b. Availability of his own small electrical appliances
c. Smoking in the privacy of his own room
d. Application of advance directives
ANS: D
The application of advance directives is an autonomous decision. Agency protocols
relative to medication times, access to private electrical devices, and smoking are rarely
waived; these policies are not in the control of the resident.
DIF: Cognitive Level: Comprehension REF: p. 22 OBJ: 10
TOP: Autonomy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
MULTIPLE RESPONSE
1. What care skills are safe and appropriate for the licensed practical nurse (LPN) to teach
family members in the home health care setting? (Select all that apply.)
a. Insulin injection
b. Sterile dressing changes
c. Venipunctures
d. Periodic Foley catheter insertions
e. Instillation of eye drops
f. Changing dressings on small wounds
ANS: A, E, F
Insulin injections, instillation of eye drops, and small wound dressing changes are safe to
teach a nonprofessional caregiver. Sterile dressings, venipunctures, and inserting Foley
catheters are considered skilled, and the costs for these are reimbursed by Medicare.
DIF: Cognitive Level: Comprehension REF: p. 13 OBJ: 3
TOP: Skills Taught by Home Health Nurse
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
2. The nursing care plan in a long-term care facility calls for the documentation of regressive
behavior of a newly admitted 82-year-old resident who has had congestive heart failure
and osteoarthritis. Of these behaviors observed by the nurse, which should be documented
as regression? (Select all that apply.)
a. Talks nonstop to staff and other residents.
b. Wets and soils self several times a day.
c. Wakes in the middle of the night and is unable to return to sleep.
d. Wears the same clothes day after day.
e. Cries frequently for no apparent reason.
ANS: B, D, E
Behaviors that are infantile or immature in the absence of dementia are considered
regressive. Frequent episodes of crying and inattention to personal hygiene are regressive
in nature. Excessive talking and wakefulness may be related to relocation anxiety, but they
are not considered regressive.
DIF: Cognitive Level: Analysis REF: pp. 20-21 OBJ: 10
TOP: Impact of Relocation KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
3. From what do most quality-of-care problems in home health care result? (Select all that
apply.)
a. Patient’s noncompliance
b. Family’s reluctance to participate in the care
c. Inadequate documentation
d. Limited funding
e. Defective communication among care team members
ANS: C, E
Inadequate communication and incomplete documentation create most of the
quality-of-care problems.
DIF: Cognitive Level: Comprehension REF: pp. 11-12 OBJ: 2
TOP: Communication in Home Health Setting
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
4. An 80-year-old man is newly admitted to a long-term care facility and suddenly becomes
incontinent of urine at night. What nursing interventions should be used to help restore
self-toileting? (Select all that apply.)
a. Waking the resident every 2 hours and escorting him to the bathroom
b. Leaving a night-light on
c. Discouraging the use of long-legged pajama bottoms
d. Placing a urinal at the bedside
e. Keeping the room uncluttered
ANS: B, C, D, E
Providing light in an uncluttered room, encouraging clothing that does not impede
self-toileting, and making the urinal available increase independence and alleviate
situations that make self-toileting difficult. Waking a resident not only disturbs his or her
rest, but doing so also increases dependency on the staff.
DIF: Cognitive Level: Application REF: pp. 11-12 OBJ: 10 | 11
TOP: Independence in Long-Term Care Center
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
COMPLETION
1. The nurse clarifies that an impairment that creates a measurable diminished capacity to
work is a(n) _______.
ANS:
disability
When there is a measurable impairment that changes the individual’s lifestyle, it is
referred to as a disability.
DIF: Cognitive Level: Knowledge REF: p. 15 OBJ: N/A
TOP: Rehabilitation Concepts KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Coordinated Care
2. What should the home health nurse do when teaching a family member the skill of
injecting insulin effectively? Prioritize these nursing interventions for this situation.
______ (Place the events in the appropriate sequence. Do not separate answers with a
space or punctuation. Example: ABCD.)
a. Offer instruction at an appropriate pace.
b. Write down the steps of the procedure.
c. Assess the level of knowledge of the family member.
d. Inquire about the preferred learning style.
e. Evaluate the family member’s performance.
ANS:
CBDAE
Effective teaching depends on assessing the level of knowledge, breaking down the skill in
steps, offering instruction in the preferred style, pacing the instruction appropriately, and
evaluating the performance.
DIF: Cognitive Level: Application REF: p. 14 OBJ: 1
TOP: Home Health Teaching KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
3. Prioritize the steps in solving an ethical dilemma. ______ (Place the events in the
appropriate sequence. Do not separate answers with a space or punctuation. Example:
ABCD.)
a. Evaluate the outcome.
b. Plan an approach.
c. Visualize the consequences.
d. Take action.
e. Identify the problem.
ANS:
EBCDA
To solve an ethical dilemma, one must clearly identify the problem, plan an approach,
visualize the consequences, take action, and evaluate the outcome.
DIF: Cognitive Level: Comprehension REF: p. 11 OBJ: 7
TOP: Solving an Ethical Dilemma KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
Chapter 03: Medical-Surgical Patients: Individuals, Families, and Communities
Linton: Medical-Surgical Nursing, 7th Edition
MULTIPLE CHOICE
1. What should be included in a patient’s care plan in consideration of cultural similarities?
a. Family, educational background, and economic level should all be considered.
b. Subtle communication involving languages should be considered.
c. Families have strong patriarchal leaders.
d. Culture is learned, shared, and expressed similarly among members.
ANS: D
Different cultures have some similarities and some differences. How the culture is
expressed in health care settings will be diverse.
DIF: Cognitive Level: Comprehension REF: p. 26 OBJ: 4
TOP: Similarities among Cultures KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Coordinated Care
2. What is the basis for the health–illness continuum?
a. Prevention of acute illness
b. Individual response to health or illness
c. Promotion of health and wellness
d. Variation in degree of health or illness
ANS: D
Currently, health and illness are viewed as relative states along a continuum. Individuals
are at neither absolute health nor absolute illness but are in an ever-changing state of
being.
DIF: Cognitive Level: Comprehension REF: pp. 25-26 OBJ: 5
TOP: Current View of Health-Illness Continuum
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Safety and Infection Control
3. What is the current concern of the health care system?
a. Treating illness
b. Preventing illness
c. Promoting optimal function in the chronically ill
d. Caring for patients with acute and chronic illness
ANS: B
Health promotion activities are directed toward maintaining or enhancing well-being as a
protection against illness.
DIF: Cognitive Level: Knowledge REF: pp. 25-26 OBJ: 2 | 5
TOP: Health Promotion KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Safety and Infection Control
4. What is the primary reason that family is an important unit in society?
a. Offers unconditional love and acceptance.
b. Provides emotional support and security.
c. Is essential to life and society.
d. Promotes cultural values and attitudes.
ANS: B
A family is defined as being joined together by bonds of sharing and emotional closeness.
DIF: Cognitive Level: Comprehension REF: p. 33 OBJ: 8
TOP: The Family Unit KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
5. What should a nurse assess when a patient comes from an extended family?
a. Multiple wage earners
b. Three generations living together
c. Children from previous marriages
d. Parents of different ethnic origins
ANS: B
The extended family consists of relatives of either spouse who live with the nuclear
family. Children, regardless of their parentage, are considered part of the nuclear family.
DIF: Cognitive Level: Comprehension REF: p. 33 OBJ: 8
TOP: Types of Families KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
6. A nurse is designing a home care plan for a child with a congenital disease and is
assessing the family values regarding home care. What is the best resource for the nurse to
use?
a. Current literature on congenital deformities
b. General knowledge of the culture
c. Patient’s family
d. Written survey
ANS: C
Determining the family’s values, beliefs, customs, and behaviors that influence health
needs and health care practice is important. The best source is the family itself.
DIF: Cognitive Level: Comprehension REF: p. 34 OBJ: 11
TOP: Cultural Aspects KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
7. A nurse counsels a family regarding the stage of families with adolescents. Which
developmental task is appropriate for the nurse to include?
a. Maintaining relationships with the extended family
b. Developing parental roles to meet the needs of children
c. Maintaining a satisfying marital relationship
d. Maintaining open communication between parent and children
ANS: D
The family developmental tasks at this stage include balancing freedom with responsibility
and maintaining communication between parents and children.
DIF: Cognitive Level: Comprehension REF: p. 34|Table 3.3
OBJ: 8 TOP: Family Life Cycles
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
8. Which developmental task should families master in later life?
a. Becoming role models for their grandchildren
b. Making a significant contribution to society
c. Abandoning the parental role to grown children
d. Maintaining a satisfactory living arrangement
ANS: D
The last stage of the family life cycle includes families in later life who are adjusting to
retirement, the aging process, decreased self-esteem, and changes in status and health
issues. Maintaining a satisfactory living arrangement is the primary developmental task.
DIF: Cognitive Level: Comprehension REF: p. 34|Table 3.3
OBJ: 8 TOP: Family Life Cycles
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
9. Culture and social class usually set a precedent for different roles and responsibilities of
each family member. Which example best demonstrates the healthiest family?
a. The father assumes the role as breadwinner.
b. The mother assumes the role as homemaker.
c. The father or mother shares the roles of breadwinner and homemaker.
d. The roles of breadwinner or homemaker can be shifted as needed.
ANS: D
A healthy family is one in which the opportunity to shift roles occurs easily from time to
time.
DIF: Cognitive Level: Comprehension REF: p. 34 OBJ: 8
TOP: Family Role Structure KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
10. During a family counseling session, a patient, a mother of a 5-year-old son, states, “I don’t
understand why my husband continually tries to get our son involved in T-ball. My son
said the coach and his dad yelled at him and told him the game was lost because he
couldn’t catch the ball.” What is the most important family interaction to maintain a
healthy family unit?
a. Maintain open communication among all family members.
b. Encourage self-acceptance and self-esteem for all family members.
c. Encourage all family members to participate in community events.
d. Realize that not all family members may be able to fulfill assigned roles.
ANS: B
The most important influence on family interaction is the self-esteem of each member.
DIF: Cognitive Level: Comprehension REF: p. 35 OBJ: 9
TOP: Family Interaction KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
11. For the past three evenings, shortly after their arrival in the hospital unit, the parents of a
14-year-old daughter begin to argue about the cost of the hospitalization and the time
required to come to the hospital. The patient begins to cry and complains about her
abdominal pain. What role is the patient assuming?
a. Caretaker
b. Martyr
c. Blocker
d. Scapegoat
ANS: D
A scapegoat usually assumes the role to maintain homeostasis, serving to divert attention
from marital conflict between spouses.
DIF: Cognitive Level: Analysis REF: p. 34 OBJ: 9 | 10
TOP: Family Role Structure KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
12. A patient, a 36-year-old mother of four children, is crying. She relates to you that her best
friend just told her, “You are a good mother and you do everything perfectly, but I don’t
think you enjoy it.” What role is the patient assuming?
a. Caretaker
b. Martyr
c. Contributor
d. Harmonizer
ANS: B
A martyr sacrifices everything for the sake of the family.
DIF: Cognitive Level: Analysis REF: p. 34 OBJ: 9 | 10
TOP: Family Role Structure KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
13. What is the basis for the roles children assume in families?
a. Obligation
b. Instinct
c. Observation
d. Rewards
ANS: D
Parents reward children for fulfilling certain roles, which children adopt and maintain as
they mature.
DIF: Cognitive Level: Comprehension REF: p. 34|p. 35 OBJ: 9
TOP: Family Role Structure KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
14. A patient confides that her husband shares only the incidental happenings of his day at
work as he reads the paper, and he never tells her that he loves her anymore. She is
beginning to wonder if their marriage is getting stale. What communication pattern should
the nurse recognize?
a. Affective
b. Affectional
c. Functional
d. Dysfunctional
ANS: D
One type of dysfunctional communication involves using chitchat about unimportant daily
occurrences to avoid discussing meaningful issues or expressing feelings.
DIF: Cognitive Level: Analysis REF: p. 35 OBJ: 9
TOP: Functional Communication KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
15. What should a nurse consider when discussing the communication patterns of families
with the patient?
a. Cultural aspects of the family
b. Age of the family members
c. Role adopted by each family member
d. Number of members in the family
ANS: A
Although each option has significance, cultural aspects must be considered in determining
the functioning level of the family as it affects the roles taken.
DIF: Cognitive Level: Comprehension REF: p. 35 OBJ: 9
TOP: Functional Communication KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
16. A patient states that her 5-year-old daughter is always running up to relatives and friends
and wants to give them a big hug and kiss. The patient asks if her daughter is appropriate
in her actions. What is the most appropriate reply based on the concepts of functional
communication?
a. “Your daughter’s actions are definitely dysfunctional.”
b. “Your daughter is just being a ‘little girl’ and will outgrow being so affectionate.”
c. “Your daughter is going through a normal developmental phase.”
d. “Does your mother-in-law show signs of affection toward your daughter?”
ANS: C
Physical expression of emotion usually dominates in early childhood and is normal in the
developmental pattern.
DIF: Cognitive Level: Application REF: p. 35 OBJ: 9
TOP: Functional Communication KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
17. For what should functional patterns of communication in the family setting provide a
means?
a. Nurturing
b. Information
c. Closeness
d. Openness
ANS: A
Functional patterns of communication include emotional and affective communication that
deals with the expression of feelings and nurturing. A healthy family is able to
demonstrate a wide range of emotions and feelings.
DIF: Cognitive Level: Comprehension REF: p. 35 OBJ: 9
TOP: Functional Communication KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
18. What does the manner in which a family unit adapts to stress affect?
a. Ability to communicate and function
b. Health and function
c. Level of affective communication
d. Ability to adapt and function
ANS: B
The manner in which a family handles stress can affect the health of the family.
DIF: Cognitive Level: Comprehension REF: pp. 36-37 OBJ: 11
TOP: Stress and Adaptation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
19. A patient who was recently diagnosed with cancer tells the nurse that she is so grateful for
her children and family because she does not know what she would do without them.
Which coping response is being exhibited?
a. Internal family
b. External family
c. Family communication
d. Social support
ANS: A
The internal family coping responses are those that the family relationships use as support.
DIF: Cognitive Level: Comprehension REF: p. 36 OBJ: 10
TOP: Coping Strategies KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
20. What is the main role of the nurse when assessing families and their coping strategies?
a. Emotional support and reassurance
b. Information and reassurance
c. Emotional support and referral
d. Elimination of the stressor
ANS: B
Families need information and reassurance.
DIF: Cognitive Level: Comprehension REF: pp. 36-37 OBJ: 10
TOP: Role of the Nurse KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
21. What is the best description of the current view of the family as a unit?
a. Functioning together to provide security and support to its members
b. Functioning to meet the needs of society and support its members
c. A unit of two or more that shares common goals and mutual support
d. A unit of two or more joined together by mutual bonds and identity
ANS: D
Friedman (1997) defined the family as “…two or more persons joined together by bonds
of sharing and emotional closeness and who identify themselves as being part of the
family.”
DIF: Cognitive Level: Comprehension REF: p. 34 OBJ: 8
TOP: Family Role Structure KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
22. A nurse reminds a patient that communication in the family unit involves continual
exchange of information. Which is the best example of this concept?
a. Determining the intent of the communication being sent
b. Determining whether the communication is functional or dysfunctional
c. Accepting individual differences
d. Excluding emotional responses
ANS: C
Clear communication is a way of fostering a nurturing environment. Communication
patterns in a functional family demonstrate an acceptance of individual differences,
openness, honesty, and recognition of needs.
DIF: Cognitive Level: Comprehension REF: p. 35 OBJ: 9
TOP: Family Communication KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
23. What is the basis for the health–illness continuum?
a. Prevention of acute illness
b. Individual response to health or illness
c. Promotion of health and wellness
d. Variation in degree of health or illness
ANS: D
Currently, health and illness are viewed as relative states along a continuum. Individuals
are at neither absolute health nor absolute illness but are in an ever-changing state of
being.
DIF: Cognitive Level: Comprehension REF: p. 25 OBJ: 2 | 5
TOP: Current View of Health-Illness Continuum
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Safety and Infection Control
24. What should a nurse take into consideration regarding developmental tasks when planning
patient care?
a. All of the activities performed throughout life.
b. Activities learned primarily in the middle years of life.
c. Things to be learned and accomplished in each stage of life.
d. All actions taken when confronted with specific problems.
ANS: C
Developmental processes are changes that present challenges that must be undertaken and
mastered for a person to go on to the next stage successfully.
DIF: Cognitive Level: Comprehension REF: p. 30 OBJ: 8
TOP: Developmental Tasks KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
25. Which behavior is not characteristic of a young adult’s developmental task?
a. Living in his or her own apartment
b. Accepting a place on the board of a community agency
c. Interacting with a large group of friends
d. Dating many different young women
ANS: D
As young adults enter their 30s and 40s, their focus is directed mainly toward raising a
family and furthering their career. A heterosexual intimate relationship is not in keeping
with developmental tasks.
DIF: Cognitive Level: Comprehension REF: pp. 30-31 OBJ: 8
TOP: Developmental Tasks: Young Adulthood
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
MULTIPLE RESPONSE
1. What is included in the functional communication styles in a family? (Select all that
apply.)
a. Openness
b. Subtlety
c. Chitchat
d. Spontaneity
e. Self-disclosure
ANS: A, D, E
Functional communication is open and honest and has no subtlety or superficial chitchat.
DIF: Cognitive Level: Comprehension REF: p. 35 OBJ: 9
TOP: Functional Communication KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
2. A nurse makes a patient referral to a community resource. What benefit(s) will this referral
provide? (Select all that apply.)
a. Provision of helpful literature
b. Ongoing and consistent assistance
c. Reassurance to the family members that they are not alone
d. A variety of free services
e. Organization of a support group
ANS: A, B, C, E
Community resources can provide assistance, literature, and support in an ongoing and
consistent manner, but the services are not always free.
DIF: Cognitive Level: Comprehension REF: p. 37 OBJ: 12
TOP: Community Resources KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
COMPLETION
1. The process in which children mature and take on the values of their families and their
society is called ______.
ANS:
enculturation
Enculturation is the process of learning to be part of a culture.
DIF: Cognitive Level: Comprehension REF: p. 26|p. 27|p. 33
OBJ: 3 TOP: Enculturation KEY: Nursing Process Step:
N/A
MSC: NCLEX: N/A
2. A nurse congratulates a patient for successfully coping with a family crisis. The state of
having used coping strategies effectively is classified as ______.
ANS:
mastery
Mastery is attained when coping skills are successful in coping with a crisis.
DIF: Cognitive Level: Comprehension REF: p. 36 OBJ: 10
TOP: Mastery KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
3. The nurse includes the family in patient care to maintain the family’s ______.
ANS:
self-esteem
Self-esteem is supported and maintained when family is given opportunity to contribute to
the planning of patient care.
DIF: Cognitive Level: Comprehension REF: p. 37 OBJ: 8
TOP: Maintenance of Self-Esteem KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
Chapter 04: Health, Illness, Stress, and Coping
Linton: Medical-Surgical Nursing, 7th Edition
MULTIPLE CHOICE
1. What is the traditional view of health?
a. Promotes optimal function.
b. Views health and illness as separate concepts.
c. Defines health as an absence of illness.
d. Emphasizes the prevention of disease.
ANS: B
Traditionally, health and illness have been viewed as separate entities with a focus on the
illness and not in attaining the highest quality of life possible when a cure is not possible.
DIF: Cognitive Level: Comprehension REF: pp. 41-42 OBJ: 1
TOP: Traditional View of Health and Illness
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Safety and Infection Control
2. What is the current view of health?
a. Promotes the highest quality of life possible, both mentally and socially.
b. Includes mental, physical, social, and emotional adaptation to the environment.
c. Includes the basic physiologic needs and self-actualization.
d. Relies on alternative therapies for the treatment and cure of diseases.
ANS: B
A healthy person maintains stability and comfort by adapting physically, mentally,
emotionally, and socially to internal and external events.
DIF: Cognitive Level: Comprehension REF: pp. 41-42 OBJ: 1
TOP: Current View of Health and Illness
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Safety and Infection Control
3. During the initial gathering of data, a patient reveals a weight loss of 17 lb since the death
of his spouse 5 weeks earlier. He says that he is not sleeping and has no appetite. What
category of unmet needs should be considered by the nurse according to Maslow’s
hierarchy of needs?
a. Physiologic
b. Safety and security
c. Love and belonging
d. Self-actualization
ANS: A
Physiologic needs include oxygen, fluids, and nutrition and must be met before the higher
levels of needs are provided.
DIF: Cognitive Level: Application REF: p. 41 OBJ: 2
TOP: Maslow’s Basic Human Needs KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Safety and Infection Control
4. What is the major advantage of using Maslow’s hierarchy of needs when planning nursing
care for patients?
a. Establishes a nursing diagnosis.
b. Improves problem-solving techniques.
c. Prioritizes patient care.
d. Establishes priorities of care.
ANS: C
Priorities for nursing care can be based on the level of human needs; physical needs take
priority over security needs.
DIF: Cognitive Level: Comprehension REF: p. 41 OBJ: 2
TOP: Maslow’s Basic Human Needs KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
5. A nurse points out that a physiologic response to stress involves the total body. Which
syndrome is this considered?
a. General adaptation
b. Local adaptation
c. Negative feedback
d. Total adaptation
ANS: A
General adaptation syndrome is the physiologic response of the whole body to stress.
DIF: Cognitive Level: Knowledge REF: p. 43 OBJ: 4
TOP: Stress Response KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
6. What are the ability to solve problems and to maintain self-confidence and the willingness
to accept criticism incorporated in according to Maslow?
a. Safety and security
b. Self-esteem
c. Self-actualization
d. Love and belonging
ANS: C
Self-actualization is characterized by the ability to solve problems, the willingness to
accept suggestions and criticism from others, and the maintenance of broad interests and
communication skills.
DIF: Cognitive Level: Comprehension REF: p. 41 OBJ: 2
TOP: Maslow’s Basic Human Needs KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
7. A patient returning from surgery complains of incisional pain that is now rated 7 in
intensity on the 1-to-10 pain scale. What should the nurse be aware that pain exemplifies?
a. General adaptation syndrome
b. Local adaptation syndrome
c. Counter-current response
d. Neuroendocrine response
ANS: B
Local adaptation syndrome is a short-term, local response to a specific stressor. Examples
include pain, blood clotting, and wound healing.
DIF: Cognitive Level: Comprehension REF: p. 43 OBJ: 5 | 6
TOP: Stress Response KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
8. A nurse clarifies that a neuroendocrine response involves both the autonomic nervous
system and the endocrine system. Which syndrome is this considered?
a. Local adaptation
b. Total adaptation
c. Acute adaptation
d. General adaptation
ANS: D
The neuroendocrine response primarily involves the autonomic nervous and endocrine
systems and is considered part of the general adaptation syndrome, which is physiologic
and affects the entire body.
DIF: Cognitive Level: Comprehension REF: p. 43 OBJ: 5 | 6
TOP: Stress Response KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
9. Which syndrome includes the alarm reaction stage, resistance stage, and exhaustion stage?
a. Local adaptation syndrome
b. General adaptation syndrome
c. Total adaptation syndrome
d. Absolute adaptation syndrome
ANS: B
After the initial alarm stage (of the general adaptation syndrome), the body stabilizes and
physiologic processes return to normal levels. This is followed by the resistance stage. If
the stressor lasts too long, the individual may enter the third stage of adaptation, which is
exhaustion.
DIF: Cognitive Level: Knowledge REF: p. 43 OBJ: 4
TOP: Stress Response KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
10. A nurse gives the example of when an individual becomes frightened and experiences an
increased heart rate and mental activity along with increased blood flow to the skeletal
muscles and dilated pupils. The person is experiencing an alarm reaction that helps the
body defend against stressors. What type of response is the alarm reaction considered?
a. Positive feedback response
b. Negative feedback response
c. Fight-or-flight response
d. Homeostasis response
ANS: C
The alarm reaction causes the body to respond to stress physiologically. Hormone levels,
heart rate, cardiac output, respiratory rate, oxygen intake, and mental energy are increased,
and the pupils dilate. These reactions together are called the fight-or-flight response.
DIF: Cognitive Level: Comprehension REF: p. 46 OBJ: 7 | 8
TOP: Stress Response KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
11. A patient is being discharged from same-day surgery after a tonsillectomy. The nurse is
aware that the patient will be in the phase of general adaptation syndrome, in which the
body begins to heal after injury. Which stage is this considered?
a. Alarm stage
b. Resistance stage
c. Exhaustion stage
d. Initial stage
ANS: B
The resistance stage is characterized by adapting to the stressor. If the stressor can be
overcome or repaired, as in a short-term illness or injury, the body begins to heal.
DIF: Cognitive Level: Comprehension REF: p. 43 OBJ: 4
TOP: Stress Response KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
12. An anxious co-worker who is to present a comprehensive report to the hospital board on
innovative staffing patterns sits down at a table in the lunchroom and begins to tell you
what will be presented in the report. Which coping strategy is this co-worker using?
a. Event rehearsal
b. Problem solving
c. Event review
d. Social support
ANS: A
Coping strategies include event rehearsal, confrontation, distancing or denial, self-control,
social support, accepting responsibility, faith, problem solving, positive reappraisal, and
event review. Event review is discussing situations.
DIF: Cognitive Level: Comprehension REF: pp. 45-46 OBJ: 9
TOP: Coping KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Physiological Adaptation
13. What is the best example for a nurse to use when explaining chronic illness?
a. Acne
b. Appendicitis
c. Heart attack
d. Asthma
ANS: D
Chronic illness, such as asthma, usually involves lifetime impairment or disability and
requires long-term rehabilitation and medical or nursing treatment. Examples of chronic
illness include coronary artery disease, diabetes, and endocrine disorders. Acne,
appendicitis, and a heart attack are conditions that are acute in nature, although they may
indicate a serious illness.
DIF: Cognitive Level: Comprehension REF: p. 42 OBJ: 1
TOP: Concept of Illness KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
14. A nurse assesses that smoking, drinking alcohol, and exercising compulsively may occur
as responses to a stressful situation. What type of response should this be considered?
a. External
b. Withdrawal
c. Denial
d. Internal
ANS: D
Examples of internal resources are physiologic and psychologic responses such as
smoking, drinking alcohol, eating, and crying.
DIF: Cognitive Level: Comprehension REF: pp. 45-46 OBJ: 7 | 8
TOP: Adaptation to Stress KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
15. Which type of response is demonstrated when an individual seeks help from family,
friends, or a community resource during a time of stress?
a. Internal
b. External
c. Physiologic
d. Psychologic
ANS: B
Patients who deal with stress may use external responses, including help from family,
friends, and service agencies in the community.
DIF: Cognitive Level: Comprehension REF: pp. 45-46 OBJ: 7 | 8
TOP: Coping and Adaptation KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
16. What is the term for activities directed toward maintaining or enhancing well-being
against illness?
a. Health promotion
b. Health treatment
c. Health evaluation
d. Health assessment
ANS: A
Health promotion activities are directed toward maintaining or enhancing well-being as a
protection against illness.
DIF: Cognitive Level: Knowledge REF: pp. 48-49 OBJ: 5
TOP: Health Promotion KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
17. A home health nurse is assisting a patient who is chronically ill with congestive heart
failure to reorder time. What is the best intervention to assist this patient?
a. Encouraging the patient to get up earlier or to go to sleep later
b. Developing a daily schedule that allows time for activities, as well as for medical
regimens
c. Giving up time-consuming activities such as watching television or answering
e-mail messages
d. Encouraging the patient to complete only one task a day
ANS: B
Reordering time is developing a schedule that includes not only a medical regimen, but it
also includes social and interpersonal activities, as well as hobbies.
DIF: Cognitive Level: Application REF: p. 49 OBJ: 14
TOP: Reordering Time KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
18. What type of illness are the common cold, appendicitis, and urinary tract infections
considered?
a. Chronic
b. Disabling
c. Emergency
d. Acute
ANS: D
An acute illness or disease is one that has a relatively rapid onset and a short duration.
DIF: Cognitive Level: Comprehension REF: p. 42 OBJ: 1
TOP: Concept of Illness KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
19. What is the first step in helping patients to increase adaptability?
a. Assess past methods of coping with stress.
b. Suggest using past coping strategies.
c. Determine external coping strategies.
d. Determine what the patient perceives as stressful.
ANS: A
Nurses can help patients deal with stress by identifying the patient’s usual methods of
coping or adapting.
DIF: Cognitive Level: Knowledge REF: p. 43 OBJ: 10
TOP: Adaptation KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
20. How should a nurse describe a patient who has a functional interaction of the cognitive,
affective, behavioral, and social dimensions of his personality?
a. Effectively organized
b. Personally satisfied
c. Well rounded
d. Mentally healthy
ANS: D
Mental health depends on the functional integration of the four dimensions of the
personality.
DIF: Cognitive Level: Comprehension REF: p. 41 OBJ: 1
TOP: Definition of Mental Health KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
21. A nurse assesses that a 42-year-old patient lives with her parents and is dependent on them
for decisions about her life. Which mental health characteristic is this patient lacking?
a. Reality orientation
b. Autonomous behavior
c. Spontaneity
d. Ethical decision making
ANS: B
Autonomy is a mark of mental health.
DIF: Cognitive Level: Comprehension REF: p. 41 OBJ: 1
TOP: Definition of Mental Health KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
22. What is an example of a positive stressor?
a. Test anxiety
b. Loss of a job
c. Paying income tax
d. Single motherhood
ANS: A
Test anxiety can be beneficial to promote study and sharpen focus.
DIF: Cognitive Level: Knowledge REF: p. 43 OBJ: 7
TOP: Stress KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
23. Which action is an example of a person attempting to maintain homeostasis as a newcomer
in a community?
a. Joins a local church.
b. Buys a new car.
c. Stays in his or her apartment watching television.
d. Spends hours writing e-mail messages to old friends.
ANS: A
The newcomer who attempts to balance the newcomer status with belonging is an example
of homeostasis.
DIF: Cognitive Level: Comprehension REF: p. 43 OBJ: 5
TOP: Homeostasis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
24. Which behavior best exemplifies developmental activities in a 13-year-old teenager?
a. Going out with a group of friends
b. Reading an exciting book
c. Volunteering for the local hospital
d. Choosing a career
ANS: A
Interacting in peer relationships is a major developmental task of this age group.
DIF: Cognitive Level: Comprehension REF: p. 44 OBJ: 3
TOP: Growth and Development KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
25. In which stage is introspection a major characteristic?
a. Middle-aged adult
b. Middle childhood
c. Early adulthood
d. Older-age adult
ANS: D
Introspection is properly identified as an activity of older age.
DIF: Cognitive Level: Knowledge REF: p. 44 OBJ: 3
TOP: Growth and Development KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
26. A nurse hears a 5-year-old patient who just started kindergarten uses rude vocabulary.
What is the best response to this behavior?
a. Ignore it.
b. Speak to his teacher about it.
c. Praise him when he speaks properly.
d. Talk about it at the parent–teachers association.
ANS: C
Learned behaviors can be unlearned with rewards for the desired behavior.
DIF: Cognitive Level: Application REF: p. 44 OBJ: 14
TOP: Behavioral Theory KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
27. Which patient is most likely to experience the greatest cultural impact on his coping with a
chronic debilitating illness?
a. A 26-year-old Latino man with a family
b. A 30-year-old divorced white man with no dependents
c. A 35-year-old Asian wife with a family
d. A 65-year-old widowed black church pastor with married children
ANS: A
The Latino man will have to deal with the loss of his culturally expected role as the head
of the household.
DIF: Cognitive Level: Analysis REF: p. 44 OBJ: 9
TOP: Coping with Illness KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
28. A patient with low back pain confesses that he drinks heavily each night to help him sleep
and control pain. What does this behavior exemplify?
a. Alternate pain control methods
b. Coping with a chronic condition
c. Using a social coping mechanism
d. Using a maladaptive coping method
ANS: D
This behavior is an example of maladaptive coping. Drinking is not an appropriate means
of coping with chronic pain.
DIF: Cognitive Level: Application REF: p. 46|p. 49 OBJ: 9 | 13
TOP: Coping with Illness KEY: Nursing Process Step: N/A
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
29. What information should a nurse provide to a Native American patient taking herbal
remedies and nutritional supplements?
a. Herbs and vitamins are not helpful.
b. If herbs and vitamins are not harmful, then they will be integrated into the plan of
care.
c. Medical research has shown that such alternative remedies are a waste of money.
d. In the hospital, no physician will prescribe anything other than accepted medical
protocols.
ANS: B
Care planning for individuals with different cultural beliefs requires respect and
individualization.
DIF: Cognitive Level: Application REF: p. 44 OBJ: 10
TOP: Cultural Beliefs KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
30. When a patient is given a diagnosis of cancer, his first statement is, “What did I ever do to
deserve God punishing me?” What does this exemplify?
a. Maladaptive coping
b. Behavioral emotionalism
c. Spiritual distress
d. Spiritual maladaptation
ANS: C
This is a response to spiritual distress. The patient is questioning the meaning of illness
and suffering.
DIF: Cognitive Level: Comprehension REF: p. 45 OBJ: 10
TOP: Spirituality KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
31. A star quarterback on the high school football team is injured in a motorcycle accident. He
will be unable to play football again. Which patient problem is most appropriate when
planning care specific to coping?
a. Immobility
b. Impaired self-concept
c. Decreased socialization
d. Inadequate comfort
ANS: B
Athletes who sustain injuries can have impaired self-concept related to their altered body
image.
DIF: Cognitive Level: Application REF: p. 45 OBJ: 11
TOP: Self-Concept KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
32. A wife of a critically injured husband has been at his bedside constantly for 2 days. As the
nurse speaks to the wife, the wife sobs, “This is awful. I can’t take it anymore.” What is
the wife experiencing?
a. Fear
b. Denial
c. Compensation
d. Stress
ANS: D
Long-term stress causes fatigue and an inability to solve problems.
DIF: Cognitive Level: Application REF: p. 45 OBJ: 8 | 9
TOP: Emotions: Stress KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
33. How does fear differ from anxiety?
a. Fear is a useless emotion.
b. Fear is an ineffective coping strategy.
c. Fear is an irrational feeling.
d. Fear is a response to a specific threat.
ANS: D
Fear is a response to a specific threat (e.g., a rattlesnake in the garden); anxiety is a
response to a nonspecific threat (e.g., first day on a new job).
DIF: Cognitive Level: Comprehension REF: p. 45 OBJ: 10
TOP: Emotions: Anxiety and Fear KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
34. An older Italian woman has an egg yolk in a bowl under her bed that she believes is
absorbing the evil of her illness and making her feel better. Which action should a nurse
implement?
a. Move the egg yolk out of the way to the bathroom.
b. Replace the egg yolk with a hard-boiled egg.
c. Remove the egg for sanitary purposes.
d. Include maintenance of the egg in the nursing care plan.
ANS: D
A nursing approach should help with coping, not increase the stress.
DIF: Cognitive Level: Application REF: p. 44 OBJ: 11
TOP: Cultural Concepts KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
35. When a 25-year-old woman who had a hysterectomy 1 day earlier tearfully tells the nurse
that she is grieving for the children she will never have, the nurse assesses the grief as
positive. What does grief allow this patient to achieve?
a. Focus on her loss.
b. Forget about her concern.
c. Reappraise her values for the future.
d. Depend on others for grief support.
ANS: C
Grief and mourning signify an end to something. After the mourning, the patient is free to
reappraise values for the future.
DIF: Cognitive Level: Comprehension REF: p. 46 OBJ: 10
TOP: Perceived Loss and Grief KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
36. A 5-year-old patient was in an accident in which his cousin was killed. The patient starts
to wet the bed at night. What question should the nurse ask the mother when she confirms
that it has been several years since the patient had any difficulty with bedwetting?
a. “Do you think this is related to the accident?”
b. “Do others in the family have this problem?”
c. “Does your child drink lots of fluids late at night?”
d. “Are there any stressful situations in your family?”
ANS: A
Anxiety is the root of such defense mechanisms as regression. This behavior is an example
of regression, in which the 5-year-old child has gone back to behavior more suited to a
younger developmental age.
DIF: Cognitive Level: Application REF: p. 47 OBJ: 10
TOP: Defense Mechanisms KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
37. A 24-year-old man scheduled for brain surgery in the morning constantly listens to music
with his headphones on. What should a nurse recognize this behavior as?
a. Conversion reaction
b. Conscious coping strategy
c. Defense mechanism of undoing
d. Reaction formation
ANS: B
The use of a conscious coping strategy can help decrease stress.
DIF: Cognitive Level: Comprehension REF: pp. 47-48 OBJ: 11
TOP: Conscious Coping Strategies KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
38. When a patient is asked whether he wants his pain medication, he says to you, “I don’t
know; whatever you think is best.” What should the nurse recognize this maladaptive
coping mechanism as?
a. Powerlessness
b. Helplessness
c. Denial
d. Depression
ANS: A
The patient feels that he has lost control of his situation and has started to defer decisions
about his care to others.
DIF: Cognitive Level: Application REF: p. 49 OBJ: 13
TOP: Maladaptive Coping Mechanisms KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
39. Which patient diagnosis and behavior should lead a nurse to conclude the patient is using
the defense mechanism of denial?
a. A patient with emphysema continues to smoke.
b. A patient with diabetes mellitus uses a sugar substitute.
c. A patient with a drug problem blames his mother for his habit.
d. A patient with osteoarthritis angrily kicks the steps that he cannot climb.
ANS: A
The patient with emphysema is an example of denial, the patient with diabetes is an
example of an adaptive response, the patient with a drug problem is an example of
projection, and the patient with osteoarthritis is an example of regression.
DIF: Cognitive Level: Comprehension REF: p. 49 OBJ: 13
TOP: Maladaptive Coping KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
40. What is the goal of nursing care for the patient with a chronic illness?
a. Find the cause of the illness.
b. Tell the patient that he or she will learn to live with the illness.
c. Help the patient manage the illness.
d. Give the patient websites that have information about the illness.
ANS: C
The goal of caring for patients with a chronic illness is to help them manage the illness and
to develop coping skills.
DIF: Cognitive Level: Comprehension REF: p. 42|p. 49|p. 50
OBJ: 14 TOP: Nursing Goals
KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
41. What nursing action should be implemented when dealing with a patient who is an
alcoholic in denial and claims to only drink in social situations?
a. Insist that he stop drinking entirely.
b. Point out that the patient is using denial.
c. Help the patient investigate ways to reduce drinking.
d. Provide information on Alcoholics Anonymous.
ANS: C
In dealing with patients in denial, the nurse may have to accept the denial while still
getting cooperation.
DIF: Cognitive Level: Application REF: p. 49 OBJ: 13
TOP: Denial KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
MULTIPLE RESPONSE
1. How can a nurse assist when a caregiver is frustrated and is complaining of being
overwhelmed? (Select all that apply.)
a. Taking over the care
b. Referring the caregiver to a support group
c. Seeking assistance from a home health agency
d. Listening to the caregiver’s concerns
e. Assisting in making a daily schedule for the caregiver to follow
ANS: B, C, D, E
Taking over the care is not a permanent solution. Seeking a helpful support group,
listening, seeking assistance from a home health agency, and making a daily schedule to
help the caregiver identify duties that can be put aside are all helpful in coping with stress.
DIF: Cognitive Level: Application REF: pp. 42-45 OBJ: 14
TOP: Coping with Stress KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
2. What should the nurse explain as reasons why a person who is ill should be allowed to
adopt the “sick role.” (Select all that apply.)
a. Exempt from usual roles
b. Seeking attention
c. Expected to get well
d. Actively seeking remedy
e. Using illness as excuse for failure
ANS: A, C, D
The sick role allows the patient the time to recover by exempting him or her from the
usual obligations with the expectation that the patient will seek remedy and recover.
DIF: Cognitive Level: Comprehension REF: p. 42 OBJ: 9
TOP: Sick Role KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
3. What factors are known to influence coping strategies? (Select all that apply.)
a. Age
b. Financial status
c. Role expectations
d. Personal values
e. Cultural expectations
ANS: A, C, D, E
Financial status is not a basic part of building coping strategies. All the other options,
however, play integral parts in the patient’s ability to cope or design new coping strategies
or both.
DIF: Cognitive Level: Knowledge REF: pp. 47-50 OBJ: 11
TOP: Coping Strategies KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
4. What should a nurse evaluate to assess the social dimension of a patient’s persona? (Select
all that apply.)
a. Interaction with family
b. Formulation of thoughts
c. Presentation of self to community
d. Problem solving
e. Processing of information
ANS: A, C
Interacting with family and presenting oneself to the community are elements of the social
component. The other options belong to the element of the cognitive component.
DIF: Cognitive Level: Application REF: p. 40 OBJ: 1
TOP: Aspects of Personality KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
5. What are characteristics of a healthy person according to Maslow? (Select all that apply.)
a. Acceptance of self
b. Reality orientation
c. Spontaneity
d. Effective problem-solving skills
e. No need for privacy
ANS: A, B, C, D
Mentally healthy people require some element of privacy. All other options are
characteristics of self-actualization.
DIF: Cognitive Level: Knowledge REF: p. 41 OBJ: 1
TOP: Characteristics of Mental Health KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
COMPLETION
1. A tendency of biologic systems to maintain stability of the internal environment while
continually adjusting to changes is _______.
ANS:
homeostasis
The term is derived from Greek and describes the tendency of the body to maintain
stability.
DIF: Cognitive Level: Knowledge REF: p. 43 OBJ: 5
TOP: Homeostasis KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
2. The term that a nurse uses to refer to persons who fail to maintain treatment protocols is
_______.
ANS:
nonadherence
Nonadherence is a term that describes the patient who fails to maintain treatment
protocols. The term is less negative than the earlier term, noncompliant.
DIF: Cognitive Level: Knowledge REF: p. 42 OBJ: 6
TOP: No Adherence KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
3. A student nurse who was terrified of giving an injection now gives many injections every
shift. The change in the nurse is the result of _______.
ANS:
adaptation
Adaptation refers to a person’s efforts to respond to stressors in such a way as to overcome
the stress.
DIF: Cognitive Level: Comprehension REF: p. 43 OBJ: 5
TOP: Adaptation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
4. A nurse recognizes that mild stress can be a positive force that stimulates the patient to
_______ a problem.
ANS:
solve
Mild stress can cause a person to focus and be able to solve a problem.
DIF: Cognitive Level: Comprehension REF: p. 43 OBJ: 2
TOP: Mild Stress KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
Chapter 05: Immunity, Inflammation, and Infection
Linton: Medical-Surgical Nursing, 7th Edition
MULTIPLE CHOICE
1. A patient in early labor says to the nurse, “I will pass on protection from diseases, and the
baby will not ever need any shots.” What is the best response by the nurse?
a. “Babies are born with innate (natural) immunity at birth.”
b. “Babies are born with immunoglobulin E (IgE), an antibody that crosses the
placenta, but it only briefly protects the baby.”
c. “Yes, immediate antibody immunity from the mother is the first line of defense
against disease for babies.”
d. “Yes, the mother passes on cell-mediated immunity.”
ANS: B
Infants acquire antibodies from the mother, but they only last a few months.
DIF: Cognitive Level: Application REF: p. 58 OBJ: 4
TOP: Newborn Immunity KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
2. A school nurse starts a clean-up campaign at a local elementary school in an effort to
combat allergens. What is the most common allergic response disorder?
a. Anaphylaxis
b. Asthma
c. Contact dermatitis
d. Urticaria
ANS: B
Fungi are principle allergens that can trigger respiratory allergic responses such as asthma.
DIF: Cognitive Level: Knowledge REF: p. 77 OBJ: 18
TOP: Reduction of Allergens KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
3. A nurse is discussing the body’s first and second lines of defense against infection with a
community group. What does the body’s first line of defense include?
a. Teeth
b. Sweat
c. White blood cells
d. T lymphocytes
ANS: B
The sweat glands excrete an antimicrobial enzyme.
DIF: Cognitive Level: Knowledge REF: p. 56 OBJ: 1
TOP: Lines of Defense KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4. A nurse explains that a medication given to a patient with a severe inflammatory response
mimics a hormone secreted by the adrenal cortex. To what hormone is the nurse referring?
a. Aldosterone
b. Testosterone
c. Histamine
d. Cortisol
ANS: D
Cortisol slows the release of antihistamine and stabilizes lysosomal membranes.
DIF: Cognitive Level: Knowledge REF: p. 59 OBJ: 5
TOP: Anti-inflammatory Agents KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5. With the exposure to an antigen, a nurse explains that the initiator of the inflammatory
response is the presence of histamine. What is responsible for releasing histamine?
a. Neutrophils
b. Eosinophils
c. Basophils
d. Monocytes
ANS: C
Basophils release histamine.
DIF: Cognitive Level: Knowledge REF: p. 57 OBJ: 5
TOP: Inflammatory Response KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
6. A nurse is bathing a patient who is immunodeficient and has a Cryptococcus infestation.
What is the classification of this organism?
a. Bacterium
b. Virus
c. Fungus
d. Protozoa
ANS: C
Cryptococcus fungal infections can be life threatening.
DIF: Cognitive Level: Knowledge REF: p. 62 OBJ: 9
TOP: Fungi KEY: Nursing Process Step: Knowledge
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
7. A mosquito or a fly carries an organism that infects another living organism. What is this
mode of transmission of infection?
a. Common vehicle
b. Direct excretion
c. Ingestion
d. Vector
ANS: D
Vector-borne diseases are carried from one host to another. Part of the life cycle of the
pathogen occurs in the body of the fly, mosquito, or tick.
DIF: Cognitive Level: Comprehension REF: p. 63 OBJ: 10
TOP: Vector Transmission KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
8. What is the most effective method to control the spread of communicable disease?
a. Isolate the infected person from all contact with noninfected persons.
b. Vigorously petition the community health department to increase spraying.
c. Administer prophylactic antibiotics to the rest of the family.
d. Demonstrate and monitor a return demonstration of a good hand washing
technique by the family.
ANS: D
Good hand washing is the cornerstone of infection control.
DIF: Cognitive Level: Comprehension REF: p. 69 OBJ: 13
TOP: Prevention of the Spread of Infection
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
9. An air conditioner duct cleaning is recommended by a home health nurse. What should
this precaution prevent the spread of in the patient’s home?
a. Bacteria
b. Viruses
c. Fungi
d. Protozoa
ANS: C
Air blowing into a room may be the mode of transfer of fungi spores that have remained
dormant in the duct during nonuse.
DIF: Cognitive Level: Knowledge REF: p. 73 OBJ: 10
TOP: Infectious Disease Transmission in the Home
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
10. A school nurse cautions a group of parents about children playing barefoot on dirt. To
what infectious agents can this action expose the children?
a. Helminthes
b. Protozoa
c. Rickettsiae
d. Mycoplasmas
ANS: A
Worms in the dirt seek entry through the foot skin and into the blood circulation, where
they are carried to the lungs; coughed up into the mouth; and swallowed into the
gastrointestinal tract, where they cause serious infections. Barefooted children who do not
have proper hygiene are at risk for these worm infections.
DIF: Cognitive Level: Comprehension REF: p. 62 OBJ: 10
TOP: Helminth Transmission KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
11. A large, heavy, and older adult patient has a stroke and develops an infected decubitus
ulcer on the sacrum during the hospital stay. Approximately 2 weeks after the patient has
gone home, the patient returns to the hospital with pneumonia. What is the distinction
between these two infections?
a. The decubitus ulcer infection was transmitted from other patients on the unit, but
the pneumonia was transmitted from a neighbor visiting when the patient was at
home.
b. The decubitus ulcer and pneumonia are caused by the same host.
c. The decubitus ulcer is termed a health care–associated infection, and pneumonia is
termed a community-acquired infection.
d. The decubitus ulcer is considered to be caused by protozoa, but the pneumonia is
considered unpreventable because of the size of the patient.
ANS: C
Because the decubitus ulcer developed during the stay in a health care facility, it is
classified as a health care–associated infection. Because the patient did not have
pneumonia when he left the facility, it is classified as a community-acquired infection.
DIF: Cognitive Level: Comprehension REF: p. 64|p. 66 OBJ: 12
TOP: Community-Acquired versus Health Care–Associated Infections
KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
12. On a visit to administer the fifth in a series of 10 antibiotic doses, a home health nurse is
told that the patient is now complaining about a bothersome vaginal discharge. The nurse
communicates the problem and arranges for medication. What is the most likely cause of
the vaginal discharge?
a. Poor genital hygiene—not changing underwear often enough
b. Allergy to the soap or soap products used in the genital area
c. Superinfection response to the antibiotic medication
d. Sexual contact with another infected person
ANS: C
Antibiotics frequently wipe out good bacteria and cause other bacteria to overgrow,
causing vaginitis.
DIF: Cognitive Level: Comprehension REF: p. 67 OBJ: 12
TOP: Superimposed Infections KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
13. Which patient diagnosis is most likely related to acquiring a health care–associated
infection?
a. Abdominal abscess after a ruptured appendix
b. Lice and nits that have come from the emergency department
c. Urinary infection after the insertion of a Foley catheter
d. Two-day, postoperative foot fungus after a hip replacement
ANS: C
Iatrogenic or health care–associated infections are those acquired during the hospital stay.
Urinary catheters are frequently the source of such infections. Abscesses frequently follow
a ruptured appendix; lice and athlete’s foot are long-term conditions not caused by hospital
interventions.
DIF: Cognitive Level: Application REF: p. 67 OBJ: 12
TOP: Iatrogenic Infections KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
14. A community picnic is held. A number of the attendees become ill after the picnic. How
was the pathogen acquired?
a. Indirect contact
b. Common vehicle
c. Airborne transmission
d. Vector transmission
ANS: B
Food at the picnic that was shared in common became the vehicle for transmission.
DIF: Cognitive Level: Comprehension REF: p. 63 OBJ: 10
TOP: Common Vehicle Transmission KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
15. A nurse caring for a patient who is immunosuppressed is diligent about protecting the
patient from infection. When visitors come in, in addition to having them put on isolation
attire, what should the nurse also prohibit?
a. Battery-operated DVD player
b. Book
c. Potted plant
d. Box of candy
ANS: C
The soil in the flowerpot is a reservoir for bacteria and fungi.
DIF: Cognitive Level: Application REF: p. 73|p. 77 OBJ: 16 | 18
TOP: Reverse Isolation for Immunosuppressed Patient
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
16. A nurse explains that although some drugs reduce inflammation, they also hinder the
body’s immune response. What are examples of such drugs?
a. Antihistamines and salicylates
b. Bronchodilators and corticosteroids
c. Cardiotonic and anticholinergics
d. Diuretics and sedatives
ANS: B
The immune response is dampened by corticosteroids.
DIF: Cognitive Level: Comprehension REF: p. 76 OBJ: 18
TOP: Pharmacologic Care for Allergies KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
17. A patient has had several increasingly severe allergic reactions during last year’s pollen
season. This year, the patient comes regularly to the office to receive some antigen
injections. What education will the nurse provide regarding these injections?
a. They will combat infection brought on by the allergic response.
b. They will act as a steroid to lessen the allergic response.
c. They will increase tolerance to the antigen.
d. They will decrease the production of the antibodies.
ANS: C
Injections of increasing amounts of minute doses of the antigen will desensitize the body
against the antigen.
DIF: Cognitive Level: Application REF: p. 76 OBJ: 18
TOP: Long-Term Pharmacologic Treatment of Allergies
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
18. A patient who is receiving daily steroids for the control of a condition calls the nurse to
ask advice about whether a small child who has been exposed to influenza should come
and visit because she has not had any symptoms. What is the most appropriate response by
the office nurse?
a. “Yes, let the child visit. There is no reason not to visit because this child is not
sick.”
b. “No, the child should not visit. Infectious diseases are often most communicable in
the short period before the child actually becomes ill.”
c. “It would be up to the patient. Plan not to get overtired with a small child running
and bouncing around.”
d. “Take the child who is not sick to her own physician and ask this question first.”
ANS: B
Children, especially those who have been exposed to a contagious disease but are not yet
symptomatic, are still very contagious, especially to an immunocompromised patient.
DIF: Cognitive Level: Application REF: pp. 63-64 OBJ: 10
TOP: Contagious Infections KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
19. A patient with the diagnosis of Clostridium difficile infection asks what has caused the
diarrhea. What is the best response by the nurse?
a. It is caused by a protozoal infection.
b. It is caused by a fecal–oral contamination.
c. It is caused by an inflammatory response.
d. It is caused by a long-term antibiotic therapy.
ANS: D
Superinfections such as Clostridium difficile infections are caused by long-term antibiotic
therapy, which kills all the natural flora of the bowel and causes diarrhea.
DIF: Cognitive Level: Comprehension REF: p. 67 OBJ: 10
TOP: Superinfection KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
20. A patient receiving a large intramuscular dose of antibiotic was asked to please wait 20 to
30 minutes before checking out. What is the reason for this request?
a. The office staff needs to make sure that the right medicine was administered before
the patient leaves.
b. The nurse always forgets to ask the patient about allergies before administering the
antibiotic.
c. Antibiotics are a common source of severe allergic reactions within the first few
minutes after an injection.
d. The staff wants to make sure that the patient has time to pay for the services
delivered that day.
ANS: C
Antibiotic administration is a common cause of anaphylaxis. The patient is asked to wait
to allow medical personnel to reverse the condition should it occur within minutes after an
injection.
DIF: Cognitive Level: Comprehension REF: pp. 77-78 OBJ: 18
TOP: Antibiotic Anaphylaxis KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
21. After receiving an injection of penicillin, a patient undergoes an anaphylactic reaction.
What should the nurse do first?
a. Administer oxygen.
b. Prepare fluids to combat shock.
c. Notify the charge nurse.
d. Cover with several blankets.
ANS: A
The first intervention should be to supply oxygen. Notification of the charge nurse and the
administration of fluids to combat hypovolemia will come afterward. Covering with
blankets would increase the vasodilation and increase the shock.
DIF: Cognitive Level: Application REF: p. 78 OBJ: 18
TOP: Anaphylaxis Assessment and Intervention
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
22. The Centers for Disease Control and Prevention (CDC) has issued new guidelines for
infection control. Nursing care plans for patients with infection should mainly address
which protocol?
a. Disease-specific precautions
b. Manner in which clean gloves are worn
c. Standard Precautions guidelines
d. Placement of needles and sharps
ANS: C
The CDC has issued new guidelines for Standard Precautions for infection control. These
cover disease-specific precautions, the manner in which clean gloves are worn, and the
placement of needles and sharps. Only the Standard Precautions guidelines are all
inclusive.
DIF: Cognitive Level: Comprehension REF: p. 69 OBJ: 14
TOP: Centers for Disease Control and Prevention: Multiple Guidelines for Standard Precautions
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
23. Which vitamin can enhance wound healing?
a. A
b. B
c. C
d. D
ANS: C
The addition of vitamin C and zinc to the medication regimen can hasten wound healing.
DIF: Cognitive Level: Knowledge REF: p. 75 OBJ: 7
TOP: Wound Healing KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
24. A patient is hospitalized with cryptococcal pneumonia and AIDS. What is the most
important Standard Precaution for the health care team to implement?
a. Hands are washed before and after gloving.
b. After gloves are put on, they do not need to be changed until care is finished.
c. Needles and sharps should be placed in puncture-resistant containers on the
medicine cart out of the room.
d. Mouth-to-mouth resuscitation must be performed immediately unless the patient is
a designated as “do not resuscitate.”
ANS: A
Hand washing is necessary before and between care in areas of contamination.
DIF: Cognitive Level: Application REF: p. 69 OBJ: 14
TOP: Standard Precautions KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
25. The organs involved in immunity include the tonsils, spleen, and lymph nodes. What other
organ is involved in immunity?
a. Liver
b. Lungs
c. Periosteum
d. Pancreas
ANS: A
The liver filters the blood and plays a part in the immune response by the production of
globulins and other chemicals involved in the immune response.
DIF: Cognitive Level: Knowledge REF: p. 58 OBJ: 3
TOP: Organs Involved in Immune Response KEY: Nursing Process Step: