Study Guide for Understanding Medical Surgical Nursing 6th Edition best in 2021

Answers 1 CHAPTER 1 CRITICAL THINKING AND THE NURSING PROCESS AUDIO CASE STUDY Jane and the Nursing Process 1. Assessment/data collection, diagnosis, planning, implementation, and evaluation. 2. Jane was exhausted, failed a test, and was pulled in too many directions. 3. Jane’s resources included a good friend, sick time from work, and wasted time between classes that she could better utilize. Your resources will be different, but they’re there! VOCABULARY Nursing Process Definition: An organizing framework that links thinking with nursing actions. Steps include assessment/data collection, nursing diagnosis, planning, implementation, and evaluation. Critical Thinking Definition: The use of those cognitive (knowledge) skills or strategies that increase the probability of a desirable outcome. Also involves reflection, problem-solving, and related thinking skills. Assessment Definition: Gathering subjective and objective data to plan care. Objective Data Definition: Factual information obtained through physical assessment and diagnostic tests. Objective data are observable or knowable through the health care worker’s five senses. Referred to as signs. Subjective Data Definition: Information that is provided verbally by the patient and referred to as symptoms. Nursing Diagnosis Definition: Per NANDA International, a nursing diagnosis is a ―clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group or community. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability‖ (from Evaluation Definition: Examination of outcomes and interventions to determine progresstoward desired outcomes and effectiveness of interventions. Vigilance Definition: The act of being attentive, alert, and watchful. SUBJECTIVE AND OBJECTIVE DATA 1. Subjective (symptom) 2. Subjective (symptom) 3. Objective (sign) 4. Objective (sign) 5. Subjective (symptom) 6. Objective (sign) 7. Subjective (symptom) 8. Objective (sign) 9. Subjective (symptom) 10. Subjective (symptom) 11. Objective (sign) 12. Objective (sign) 13. Subjective (symptom) 14. Objective (sign) 15. Objective (sign) 2 Chapter 1 Answers Could it be low Am I diabetic? blood sugar? Frontal area "Sick" feeling Hard Tylenol helps Hunger makes it worse Patient's perception Where is it? Quality Aggravating and alleviating factors Food helps Headache Useful other data Severity Timing Sometimes feel sick to stomach Mother is diabetic 7–8 on 0–10 scale Lasts 1–2 hours once starts Before meals Early in the morning CRITICAL THINKING This is just one possible way to complete a cognitive map. REVIEW QUESTIONS—CONTENT REVIEW The correct answers are in boldface. 1. (3) is a nursing diagnosis. (1, 2, 4) are medical diagnoses. 2. (1) is a medical diagnosis. (2, 3, 4) are nursing diagnoses. 3. (1) is correct. The nurse who keeps trying until the problem is solved is exhibiting perseverance. (2, 3, 4) are incorrect. 4. (3, 4, 5, 1, 2) is the correct order. 5. (1) is the best definition. (2, 3, 4) do not define critical thinking but are examples of good thinking. REVIEW QUESTIONS—TEST PREPARATION The correct answers are in boldface. 6. (4) is correct. Evaluation determines whether goals are achieved and interventions effective. (2) is the role of the physician. (1, 3) encompass data collection and implementation, which are earlier steps in the nursing process. 7. (1) is correct. The licensed practical nurse/licensed vocational nurse can collect data, which includes taking vital signs; assessment is the first step in the nursing process. (2, 3, 4) are all steps in the nursing process, for which the registered nurse is responsible; the licensed practical nurse/licensed vocational nurse may assist the registered nurse with these. 8. (1, 4, 5) can be observed through use of the five senses. (2, 3) are subjective data that the patient must report. 9. (2) indicates that the patient is concerned about freedom from injury and harm. (1) relates to basic needs such as air, oxygen, and water. (3) relates to feeling loved. (4) is related to having positive self-esteem. 10. (4) is objective, realistic, and measurable with a time frame. (1, 2, 3) are all good outcomes, but they relate to airway clearance, nutrition, and strength, not directly to swallowing. 11. (2) is correct. The three parts of a diagnosis include the problem (from the NANDA International [NANDA-I] list), etiology (―related to‖), and symptoms (―as evidenced by‖). (1) does not include symptoms. (3) is a medical diagnosis. (4) is not a NANDA-I diagnosis, and the evidence is not related to dyspnea. Answers 1 CHAPTER 2 EVIDENCE-BASED PRACTICE AUDIO CASE STUDY Marie and Evidence-Based Practice 1. Thirdhand smoke is the dangerous toxins of smoke that linger on hair, clothing, furniture, and other surfaces in an area after a cigarette is put out. Marie learned that exposure to these toxins can be neurotoxic to children and can trigger asthma attacks in sensitive people. 2. Evidence-based practice is considered the gold standard of health care. 3. Step 1: Ask the burning question. Step 2: Search and collect the most relevant and best evidence available. Step 3: Think critically. Appraise the evidence for validity, relevance to the situation, and applicability. Step 4: Measure the outcomes before and after instituting the change. Step 5: Make it happen. Step 6: Evaluate the practice decision or change. 4. Combination therapy with a nicotine patch and nicotine lozenges worked best, although bupropion (Zyban) and nicotine lozenges worked well, too. A Cochrane Review found that advice and support from nursing staff can increase patients’ success in quitting smoking, especially in a hospital setting. VOCABULARY 1. Evidence-based practice: A systematic process that uses current evidence in making decisions about patient care. 2. Evidence-informed practice: Consideration of patient factors along with the use of evidence for shared decisionmaking between the health care provider and the patient. 3. Randomized controlled trials: True experimental studies in which as many factors as possible that could falsely change the results are controlled. 4. Research: Scientific study, investigation, or experimentation to establish facts and analyze their significance. 5. Systematic review: A review of relevant research using guidelines. 6. Health literacy: Degree to which a person has the capacity to obtain, process, and understand basic health information and services to make the best-informed health decisions. EVIDENCE-BASED PRACTICE 1. proof 2. context 3. quality 4. care 5. randomized 6. outcomes 7. gold 8. nursing 9. patient’s 10. information CRITICAL THINKING 1. By questioning the existing way of doing things to ensure that the patient receives the best care possible. 2. A thorough search of the literature in the area of music therapy. 3. Cumulative Index to Nursing and Allied Health Literature (CINAHL) Database, Joanna Briggs Institute evidence-based resources, Cochrane Reviews, Medline/PubMed. 4. Measure patient outcomes before instituting the evidence-based change in practice so comparisons can be made after implementation to determine if the intervention worked. 5. Evaluate the results to determine whether the change made a significant difference and if it was worthwhile in terms of cost and time. REVIEW QUESTIONS—CONTENT REVIEW The correct answers are in boldface. 1. (2) is Level I evidence. (1, 3, 4) are not examples of the best evidence. 2. (1) is a nursing database. (2, 3, 4) are primarily medical databases. 2 Chapter 2 Answers 3. (3) is the website for the Joint Commission, where you can find the National Patient Safety Goals. (1, 2, 4) are incorrect. 4. (2) is the definition of a randomized clinical trial. (1, 3, 4) are incorrect. 5. (1) is correct. Evidence-based practice begins with a burning question designed to solve a clinical problem. (2, 3, 4) are incorrect. REVIEW QUESTIONS—TEST PREPARATION The correct answers are in boldface. 6. (2, 3, 4, 5, 6) are all independent nursing interventions because no health care provider’s order is required. (1) is a dependent function because it requires a health care provider’s order. 7. (1, 5) are Level I research. (2, 3, 4) are not systematic reviews of randomized controlled trials. 8. (1, 3, 5, 6) because the evidence-based practice process involves ―ASKMME!‖: ask, search, think, measure, make it happen, and evaluate. (2, 4) are not steps in the process. 9. (2, 3, 5) are correct, as they have been found to be best practice for oral care. (1, 4) do not remove plaque and only freshen the mouth. 10. (4) is correct. The search should be narrowed to include the focus on the question. (1, 2, 3) do not focus on the question being asked. Answers 1 CHAPTER 3 ISSUES IN NURSING PRACTICE AUDIO CASE STUDY Jim and the Health Care System 1. The use of information technology in nursing practice. 2. Ambulation, teaching leg exercises to prevent blood clots, and using sterile technique to prevent surgical site infections. 3. To avoid violating the Health Insurance and Portability and Accountability Act (HIPAA). VOCABULARY 1. (3) 2. (1) 3. (4) 4. (2) 5. (8) 6. (5) 7. (6) 8. (7) 9. (10) 10. (9) NURSING PRACTICE AND ETHICAL AND LEGAL PRINCIPLES 1. high, poor 2. state, protect, quality 3. Veracity 4. beneficence, fidelity, justice 5. knowledgeable, role, humor, respect VALUES CLARIFICATION There are no correct answers to this section because this is an exercise requiring personal responses. CRITICAL THINKING There are no correct answers to this section because this is an ethical exercise that has many choices to be considered for the best outcome for the patient. REVIEW QUESTIONS—CONTENT REVIEW The correct answers are in boldface. 1. (3) is correct. (1, 2, 4) are incorrect. 2. (1) is correct. (2, 3, 4) are incorrect. 3. (4) is correct. (1, 2, 3) are incorrect. 4. (2) is the first step. (1, 3, 4) are incorrect. 5. (1) is correct. (2, 3, 4) are incorrect. 6. (3) is correct. (1, 2, 4) are incorrect. 7. (4) is correct. (1, 2, 3) are incorrect. 8. (1) is correct. (2, 3, 4) are incorrect. REVIEW QUESTIONS—TEST PREPARATION The correct answers are in boldface. 9. (4) is correct. The patient is chronically ill but able to meet most goals and so has moderate wellness. (1) is incorrect. The patient is not near death. (2) is incorrect. The patient cannot meet all goals, so high-level wellness is not being achieved. (3) is incorrect. The patient is not in poor health because most goals are met through adaptation. 10. (2) is correct. The nurse–patient relationship is based on trust that the nurse will maintain all patients’rights. (1) is a constitutional right, not an ethical issue. (3) is a legal issue. (4) is not an ethical principle. 11. (3) is correct. Paternalism occurs when a health care provider tries to prevent patients from making autonomous decisions or decides what is best for patients without regard for their preferences. (1) is incorrect. The nurse might be nonresponsive about the purpose of the medication due to lack of knowledge, but there are no indications that this is true. (2) is incorrect. Advocacy supports providing the medication information so that the patient is informed to make autonomous decisions. (4) is incorrect. Telling the patient not to worry is not therapeutic communication, as it does not address the patient’s concerns. 12. (1) is correct. Knowing the patient’s wishes helps the nurse advocate for and act in the best interest of the patient. (2, 3, 4) are incorrect. They are not the wishes of the patient. 13. (1, 2, 4, 5) are correct. These are all part of the five steps of delegation. See 2 Chapter 3 Answers (3) is incorrect. In delegation, it is the right person not the right patient that is considered. (6) is incorrect. The right route relates to medication administration. 14. (2, 3, 4, 6) is correct. The patient is a likely victim of human trafficking; after completing data collection (ideally but unlikely in private), suspicions should be reported to the health care team and then local law enforcement should be called. (1) is incorrect. Confrontation should not occur for the safety of all. (5) is incorrect. The patient should not be alerted to impending assistance, as this might alert the trafficker. Answers 1 CHAPTER 4 CULTURAL INFLUENCES ON NURSING CARE AUDIO CASE STUDY Dan and Cultural Assessment 1. Mrs. Basiouny did not want a male caregiver to bathe her or provide her personal care. She wanted her husband to be present during the health history. She did not like touch but did respond to eye contact. She preferred her own traditional foods. 2. Patients can appear noncompliant when in reality they are not receiving culturally appropriate care. 3. Assess and learn from each patient and avoid stereotyping. VOCABULARY 1. (2) 2. (10) 3. (3) 4. (11) 5. (4) 6. (1) 7. (8) 8. (5) 9. (7) 10. (6) 11. (12) 12. (9) CULTURAL CHARACTERISTICS 1. Primary characteristics of culture include nationality, race, skin color, gender, age, spirituality, and religious affiliation. 2. Secondary characteristics of culture include socioeconomic status, education, occupation, military status, political beliefs, length of time away from one’s country of origin, urban versus rural residence, marital status, parental status, physical characteristics, sexual orientation, and gender issues. 3. Traditional practitioners are health care providers from a patient’s native culture. They are typically native to another country, although they may practice in the United States. 4. Present-oriented people accept the day as it comes with little regard for the past and see the future as unpredictable. Past-oriented people may worship ancestors. Future-oriented people anticipate a better future and place a high value on change. Some individuals balance all three views; they respect the past, enjoy living in the present, and plan for the future. CRITICAL THINKING: IMMIGRANTS AND PERSONAL INSIGHTS There are no correct or incorrect answers for these sections because these are exercises requiring personal responses. CRITICAL THINKING: BATHING 1. In some cultures, it is improper for someone of the opposite sex to help with bathing. It is important to assess whether this is the case with this gentleman. 2. Find a male nurse’s aide, ask a family member to help, or skip the bath again. 3. Having a male aide do the bath is the best solution. If no male aide is available, the family may be approached for help, although this is not the best solution. Because this is the fourth day without a bath, skipping the bath is not the best option. REVIEW QUESTIONS—CONTENT REVIEW The correct answers are in boldface. 1. (4) is correct. Tay-Sachs disease is an inherited disease most common among people of Eastern European Jewish (Ashkenazi) heritage. (1, 2, 3) are incorrect. 2. (3) is correct. Ethnocentrism is the tendency for human beings to think that their culture’s ways of thinking, acting, and believing are the only right, proper, and natural ways. (1, 2, 4) are incorrect. 3. (1) is correct. Hispanic Americans and American Indians generally have a higher glucose level than whites. They also have a higher than average risk of diabetes. (2) is incorrect. REVIEW QUESTION—TEST PREPARATION The correct answers are in boldface. 4. (3) is correct. Initially you must assess what the family’s food practices are before an eating plan can be set up. (1) is incorrect. Giving a patient who has just moved to 2 Chapter 4 Answers the United States an exchange list of foods does not ensure that the patient will change dietary practices. (2) is incorrect. Being able to calculate carbohydrates does not respect the family’s cultural preferences. (4) is incorrect. Although this is certainly an option for the future, the initial step is to obtain a dietary assessment. 5. (4) is correct. Patients can have religious counselors visit as long as the counselor does not do anything to interfere with treatment or cause a safety problem. (1) is incorrect. It is not necessary to get the supervisor’s permission. However, it is a good idea to let the supervisor know that a religious counselor is going to visit. (2) is incorrect. Religious counselors are allowed to visit. (3) is incorrect. The patient has the right to see a religious counselor. 6. (4) is correct. Extended family may be very important to members of some cultures, and it may help these patients to have them nearby. (1) is incorrect. Large numbers of family members in the cafeteria may cause further disruption in the cafeteria. (2) is incorrect. Large groups in the lobby may cause overcrowding for other families. (3) is incorrect. All family members should be allowed to visit. It may help to have them choose a spokesperson to control visiting for this patient. 7. (2) is correct. Reducing portion size decreases the overall calorie and fat consumption but will still allow the patient to cook and enjoy traditional foods in her culture. (1) is incorrect. Telling a patient to not purchase lard does not mean she will comply. (3) is incorrect. Rarely does a person bake two separate pies. The goal is to reduce overall fat and calorie consumption. (4) is incorrect. It is inconsistent with the goal of reducing fat and calories. 8. (2) is correct. The patient must make her own decision, but she should be fully aware of the consequences. (1) is incorrect. Scare tactics are not appropriate; she may live whether or not she receives radiation therapy. (3) is incorrect. It borders on harassment by the staff. (4) is incorrect. Radiation therapy may be the best choice for this type of cancer. 9. (2) is correct. Changing the schedule slightly is preferable to omitting the medication. (1) is incorrect. Blood levels can be maintained on a different schedule, as long as the doses are reasonably spread out. (3) is incorrect. Omitting the medication will alter blood levels. (4) is incorrect. It does not respect the patient’s religious beliefs. 10. (3) is correct. This response seeks to discover the patient’s pastspiritual practices. (1) isincorrect. Questionnaires are not appropriate when assessing patient’s spirituality. (2) is incorrect. Although it is important to be self-aware of one’s own spirituality and beliefs, it is not appropriate to share those beliefs with patients when they can cause distress, as in this case. (4) is incorrect. ―Why‖ questions tend to feel critical and attribute blame. Answers 1 CHAPTER 5 COMPLEMENTARY AND ALTERNATIVE MODALITIES AUDIO CASE STUDY Susan and Complementary Therapy 1. Complementary modalities are added on to traditional therapies. Alternative modalities are used instead of traditional therapies. 2. Susan used biofeedback, progressive muscle relaxation, and imagery. 3. Patients should learn everything they can about a therapy before trying it. They should find information from reliable sources—not dot-com websites that are selling products. Before trying something new, they should check with their health care providers to make sure there are no interactions or contraindications. VOCABULARY 1. (5) 2. (4) 3. (6) 4. (2) 5. (1) 6. (3) COMPLEMENTARY MODALITY: GUIDED IMAGERY Purpose: To help the patient use mental imagesto reduce stress and promote changes in attitude or behavior. May be useful in treating stress-related conditions, such as high blood pressure or insomnia, and may even boost the immune system. Teaching Plan: See Box 5-1 in textbook. CRITICAL THINKING 1. Feverfew is used for migraine headaches, inflammation, and menstrual problems, among other things. 2. Capsaicin is used for pain associated with a variety of disorders. 3. St. John’s wort is used for depression. 4. Several sources should be consulted before taking herbs. The Internet has a lot of good information, but the source should be carefully evaluated. The Mayo Clinic website () is an excellent resource. A pharmacist knowledgeable in herbs and herb–drug interactions as well as the health care provider should be consulted. 5. ―Mrs. Lawless, I am concerned that these herbs could interact with your heart failure medications. I will check with your doctor and the hospital pharmacist to be sure they are safe before you take them.‖ REVIEW QUESTIONS—CONTENT REVIEW The correct answers are in boldface. 1. (4) is correct. Progressive muscle relaxation is being added to a traditional therapy, making it complementary. (1) is incorrect. Inhalers and oral medications are both traditional therapies for asthma. (2) is incorrect. Cardiac rehabilitation is a traditional therapy. (3) would be considered an alternative modality because echinacea is being used in place of a traditional therapy. 2. (1) is correct. Hydrotherapy would be considered an alternative modality because it is being used in place of nonsteroidal anti-inflammatory drugs. (2) is incorrect. Because chemotherapy is still being used, the addition of the spiritual healer would be considered complementary. (3) is incorrect. Antibiotics and bronchodilators are both traditional medical therapy. (4) is incorrect. Aspirin is traditional therapy for a headache. 3. (3) is correct. Allopathy is the proper term for traditional Western medicine. (1, 2, 4) are all nontraditional medical practices. 4. (1) is correct. Echinacea has been shown in some studiesto be potentially effective against colds and viruses. (2) is incorrect. Feverfew is used for headaches and inflammation, among other things. (3) isincorrect. Chamomile is used for anxiety. (4) isincorrect. Ginger is used for nausea. 5. (1, 2, 6) are correct. Energetic modalities include biofeedback, magnet therapy, Reiki, spiritual healing, and therapeutic touch. (3, 5) are incorrect. Music therapy and yoga are mind–body therapies. (4) is incorrect. Hydrotherapy is considered a miscellaneous therapy and is not designed to alter energy fields. REVIEW QUESTIONS—TEST PREPARATION The correct answers are in boldface. 6. (4) is correct. The patient should keep his or her eyes closed during imagery, so this statement indicates that more teaching is needed. (1, 2, 3) are all parts of guided imagery. 2 Chapter 5 Answers 7. (2) is correct. Chiropractors do not perform surgery. (1, 3, 4) are potentially true, but the nurse needs to safeguard the patient by informing the patient that a chiropractor is not trained or qualified to do surgery. 8. (2) is correct. The health care provider can help determine which alternative modalities are safe. (1) is incorrect. Any therapy can be potentially safe or unsafe. (3) is incorrect. Many alternative modalities are safe when used correctly. (4) is incorrect. Alternative and complementary modalities can be effective for chronic pain. 9. (3) is correct. It is least appropriate to tell the patient he will be able to reduce his pain medications; this is a possibility but not a guarantee. (1, 2, 4) are all appropriate measures to take before beginning to practice any new alternative modality. 10. (4) is correct. Ginseng can lower blood glucose and can interfere with warfarin and aspirin. The patient needs to be aware of the risks and then be encouraged to speak with the health care provider. (1) is incorrect. Ginseng can lower glucose, but it should not be encouraged without health care provider approval. (2) is incorrect. While the patient may check out a website before taking the ginseng, he must be educated while he is still in the hospital. (3) is incorrect. It might be safe to take some herbal agents with the prescribed medications; the patient needs to understand how to exercise caution. Answers 1 CHAPTER 6 NURSING CARE OF PATIENTS WITH FLUID, ELECTROLYTE, AND ACID–BASE IMBALANCES AUDIO CASE STUDY Grandma Lois Is Dehydrated 1. Grandma Lois was lethargic and had altered mental status; low-grade temperature; concentrated urine; dry, sticky mucous membranes; tachycardia; and poor skin turgor. 2. Shortness of breath with elevated respiratory rate, crackles in lungs, and edema. 3. Older adults have a lower percentage of body water to begin with and so are more easily dehydrated than younger people. Their kidneys also do not work as efficiently as younger people’s. VOCABULARY 1. diffusion 2. isotonic 3. hypertonic 4. hypovolemia 5. cations 6. hypernatremia 7. hypokalemia 8. hypocalcemia 9. Acidosis 10. alkalosis DEHYDRATION Corrections are in boldface. Mrs. White is a 78-year-old woman admitted to the hospital with a diagnosis of severe dehydration. The licensed practical nurse/licensed vocational nurse (LPN/LVN) assigned to Mrs. White is asked to collect data related to fluid status. The LPN/LVN expects Mrs. White’s blood pressure to be low because of fluid loss. The nurse also finds Mrs. White’s skin turgor to be poor, and the nurse notes that the urine output is scant and dark amber. The nurse asks Mrs. White if she knows where she is and what day it is, because severe dehydration may cause confusion. In addition, the nurse initiates taking daily weights because this is the most accurate way to monitor fluid balance. ELECTROLYTE IMBALANCES 1. (4) 2. (5) 3. (2) 4. (3) 5. (1) CRITICAL THINKING 1. Check Mr. James’s vital signs. Elevated blood pressure, bounding pulse, and shallow, rapid respirations are common signs of fluid overload. If he is able to stand, weigh him to see if his weight has increased since yesterday. Auscultation of his lungs may reveal new-onset or worsening crackles. (He may have had crackles on admission related to his bronchitis.) 2. Kidney function declines in the older adult, and the intravenous (IV) fluids may have been too much for him. Regular assessment and caution with IV therapy can prevent overload from occurring. 3. The registered nurse may decide to reduce the IV infusion rate until orders are obtained. The LPN/LVN can do the following: Elevate the patient’s head to ease breathing. Make sure oxygen therapy is being administered as ordered. Stay with him to help him feel less anxious. Anticipate a possible diuretic order. Continue to monitor fluid balance. 4. If a diuretic is administered, urine output should increase, but this does not signal resolution of the problem. It is probably unrealistic to expect Mr. James’s lungs to clear completely because he was admitted with bronchitis. However, return of lung sounds to admission baseline would signal resolution of the acute overload. Other signs would include return to admission vital signs and weight and the ability to walk to the bathroom again without excessive shortness of breath. REVIEW QUESTIONS—CONTENT REVIEW The correct answers are in boldface. 1. (2) is correct. 0.9% is isotonic, making 0.45% hypotonic. (1) is isotonic; (3, 4) are hypertonic. 2. (1) is correct. Antidiuretic hormones retain water. (2, 3, 4) do not affect water balance. 2 Chapter 6 Answers 3. (2) is correct. Deli meats are high in sodium. (1, 3, 4) are not high in sodium. 4. (3) is correct. Potatoes are high in potassium. (1, 2, 4) are not high in potassium. 5. (2) is correct. Fluid gains and losses are evidenced in weight gains and losses. (1, 3, 4) are all ways to monitor fluid balance, but they are not as reliable. Intake and output may be inaccurate, vitalsigns may be affected by other factors, and measurement of skin turgor issubjective. 6. (2) is correct. Vomiting, diarrhea, and profuse sweating can cause dehydration that may manifest itself by thirst, a rapid heartbeat but weak pulse, low blood pressure, dark urine, dry skin and mucous membranes, and elevated blood urea nitrogen and hematocrit levels. Temperature often increases in cases of dehydration but may not be apparent in older people who often have a lower normal body temperature than younger people. (1) is incorrect. Hypervolemia, or overhydration, is the opposite of dehydration. Excess fluid may result in (3) edema in the lower extremities and elevated blood pressure; increased rate of respiration; pale, cool skin; and diluted urine. (4) is incorrect. Hyponatremia, or low sodium level, may occur with dehydration but can be confirmed only by laboratory tests. In any case, the fluid imbalance must be assessed and treated first. REVIEW QUESTIONS—TEST PREPARATION The correct answers are in boldface. 7. (2) is correct. Failing kidneys cannot effectively excrete water, making the patient at risk for overload. (1, 3, 4) do not cause fluid retention. Influenza can cause fluid loss if vomiting or diarrhea is present. 8. (1, 4, 6) are correct. The patient with an ileostomy loses large amounts of water with continuous liquid stools. Fever is associated with an increased risk of dehydration. Diuretic therapy increases the risk for dehydration. (2) Asthma, (3) diabetes (as long as it is stable), and (5) fractures do not cause fluid loss. 9. (1) is correct. Hyponatremia accompanied by fluid loss resultsin dehydration and mentalstatus changes. (2, 3, 4) are not aslikely to affect fluid balance and mental status. 10. (3) is correct. Ambulation can help prevent bone loss. Because the patient is weak and is at risk for falls and fractures, assistance should be provided. (1) is incorrect. Bedrest promotes bone loss. (2) is incorrect. Fluids will not help bone or calcium levels. (4) is incorrect. The patient needs calcium, not protein. 11. (2) is correct. The patient is probably hyperventilating because of the anxiety. Rebreathing carbon dioxide exhaled into a paper bag can temporarily relieve symptoms of alkalosis until the underlying cause is corrected. (1, 3, 4) all help increase oxygenation, which is not needed at this time. 12. (2) is correct. Hypoventilation related to lung disease leads to retention of carbon dioxide, which causes acidosis. (1) is incorrect. Hyperventilation causes alkalosis. (3) is incorrect. Loss of acid causes alkalosis. (4) is incorrect. Loss of base causes acidosis, but it is not the cause in this case. 13. (3, 4, 6) are correct. Potassium supplements should be taken with food. Slow-K should not be crushed. Diarrhea is not expected and should be reported to the physician. If the patient makes these statements, more teaching is needed. (1, 2, 5) are incorrect. Answers 1 CHAPTER 7 NURSING CARE OF PATIENTS RECEIVING INTRAVENOUS THERAPY AUDIO CASE STUDY Mrs. Andrews’s Complications of IV Therapy 1. Gloves, chlorhexidine pads, a tourniquet, various sizes of cannulas, tape, a transparent dressing, intravenous (IV) tubing, a pole, and IV solution bag. 2. The indirect method is useful for small, rolling veins. 3. Mrs. Andrews has heart failure and cannot tolerate rapid ―positional.‖ Check the tubing for kinks and the clamp to be sure it is open. If the infusion is still not running, the catheter may be occluded with a fibrin or blood clot. The catheter may need to be discontinued. Never attempt to flush the catheter, because this could dislodge a clot into the circulation. 2) The role of the licensed practical nurse/licensed vocational nurse varies by state. 3) In many states, the registered nurse (RN) would need to be consulted before discontinuing and restarting a new IV site. The RN may attempt to withdraw a clot by aspiration. CALCULATION PRACTICE fluid infusions. 4. Mrs. Andrews gained 6 pounds, is edematous, is short of breath, and has basilar crackles. VOCABULARY 1. (1) 2. (6) 1. 2. 3. 1 L 1,000 mL = 25 gtt minute = 83 mL = 21 gtt minute 3. (7) 4. (2) 5. (5) 6. (8) 7. (4) 8. (3) COMPLICATIONS OF IV THERAPY 12 hours 4. 5. 1 L hour = 8 mL hour = 42 gtt minute 1. phlebitis 2. a local infection 3. extravasation 4. circulatory overload 5. infiltration 6. septicemia 7. venous spasm 8. venous air embolism CRITICAL THINKING 1) Begin by observing the infusion site. Look for redness and signs of infiltration (such as coolness and swelling), compare extremities, and check catheter/administration hub connection to make sure it is secure. Next assess for mechanical problems such as position of the catheter by moving the extremity around to see if the IV is simply REVIEW QUESTIONS—CONTENT REVIEW The correct answers are in boldface. 1. (1) is correct. A clot could be flushed from the cannula into the circulation and lodge in a pulmonary artery, causing a pulmonary embolism. (2) is incorrect. Air, not a clot, causes an air embolism. (3) is incorrect. Arterial spasm is caused by injecting medication. (4) is incorrect. Extravasation is caused by infiltration of vesicant drugs. 2. (3) is correct. Leakage of intravenous fluid into tissues causes puffiness. (1, 2, 4) indicate infection or inflammation. 3. (1) is correct. Phlebitis, an inflammation of a vein, has signs and symptoms of redness, warmth, swelling, and pain at the infusion site. (2) is incorrect. Thrombosis is manifested by a slowed-to-stopped infusion, fever, and malaise. (3) is incorrect. Hematoma evidenced by 83 mL 1 hour 15 gtt 1 hour 60 minutes mL 50 mL 10 gtt 20 minutes mL 800 units 500 mL 1 hour 50,000 units 1,000 mL 1 hour 24 hours 60 minutes 60 gtts mL 2 Chapter 7 Answers swelling and bruising. (4) is incorrect. Signs of infiltration are swelling and a resistance or inability to advance or flush the catheter. accurate. (4) is incorrect. Oral furosemide does not cause more side effects. 7. (3) is correct. (1, 2, 4) are incorrect. 4. (4) is correct. A peripherally inserted central catheter, or 1,000 mL 125 mL PICC, is inserted in the arm and terminates in the central = circulation. (1, 2, 3) are incorrect. REVIEW QUESTIONS—TEST PREPARATION The correct answers are in boldface. 5. (4) is correct. Fluid overload could be worsened with the use of continuous fluids. (1, 2, 3) are incorrect. All would benefit from continuous fluid administration. 6. (2) is correct. Intravenous medications act rapidly because they are instantly in the bloodstream. (1) is incorrect. Furosemide (Lasix) can be given orally. (3) is incorrect. Intravenous dosing is not necessarily more 8 hours hour 8. (3) minute is correct. (1, 2, 4) are incorrect. = 50 gtt minute 9. (2) is correct. An occlusion may be caused by a kink or closed clamp. (1) is incorrect. There is no need to notify the health care provider. (3) is incorrect. Flushing can dislodge a blood or fibrin clot into the patient’s bloodstream. (4) is incorrect. This would require an order from the health care provider. 50 mL 1 hour 60 gtt 1 hour 60 minutes 1 mL Answers 1 CHAPTER 8 NURSING CARE OF PATIENTS WITH INFECTIONS AUDIO CASE STUDY Tisha and Treating Patients With Infections 1. It is hard to treat, has a high mortality rate, and affects mainly the older adult and the chronically ill. 2. The assumption that all patients and their body fluids and substances are infectious regardless of their diagnosis. 3. Direct or indirect contact. 4. Tisha washes her hands; when she gets home, she puts her uniform in the washing machine and steps into the shower. Afterward, she cleans her shoes and stores them in a container. VOCABULARY Antigen Definition: A protein marker on a cell’s surface that identifies the cell as self or nonself. Asepsis Definition: A condition free from germs, infection, and any form of life. Bacteria Definition: One-celled organisms that can reproduce but need a host for food and a supportive environment. Bacteria can be harmless normal flora or disease-producing pathogens. Clostridium difficile (C. diff) Definition: A Gram-positive bacteria normally found in the intestine that can multiply after antibiotic therapy and release toxins that cause diarrhea. Hand Hygiene Definition: Cleansing of the hands with hand washing or the use of alcohol-based hand rubs. Pathogens Definition: Microorganisms or substances capable of producing a disease. Personal Protective Equipment Definition: Items such as gloves, gowns, masks, goggles, and face shields that help prevent the spread of infection to those wearing them. Phagocytosis Definition: Ingestion and digestion of bacteria and particles by phagocytes that destroy particulate substances such as bacteria, protozoa, and cell debris. Sepsis Definition: Immune system response to a serious infection with systemic inflammation. Virulence Definition: The ability of the organisms to produce disease. Viruses Definition: Small intracellular parasites that can live only inside cells and may produce disease when they enter a cell. PATHOGEN TRANSMISSION 1. (4) 2. (4) 3. (3) 4. (4) 5. (2) 6. (2) 7. (3) 8. (2) 9. (2) 10. (1) PATHOGENS AND INFECTIOUS DISEASES 1. staphylococci 2. fungi 2 Chapter 8 Answers 3. Candida albicans 4. Epstein-Barr 5. pneumonia (histoplasmosis) 6. toxoplasmosis 7. protozoa 8. viruses 9. rickettsia 10. Clostridium difficile (C. difficile) CRITICAL THINKING 1. Mask, gown, gloves, a sign reading ―Contact Precautions,‖ soap and paper towels, special bags for linen and trash, wash area in the room. 2. Disposable thermometer, blood pressure cuff, stethoscope, grooming items, bedpan, bathing equipment, and sharps container that all remain in the room. Nondisposable intravenous (IV) equipment and any other equipment needed for the care of the patient must be able to be disinfected. 3. Because visitors are limited, the patient has few social contacts and may lack a support system. Environmental stimuli are limited. Activities are limited. Patient is dependent on others for some needs due to confinement. 4. Allow visitors as appropriate and instruct them on how to implement isolation precautions. Offer visitors masks or respirators as appropriate. Encourage contact via telephone with family and friends who cannot visit. Maintain a cheery environment; open curtains; maintain sensory stimuli by remaining with the patient as long as possible. Encourage diversional activities and things the patient likes to do, such as TV or reading books. Always answer call light promptly. 5. C. difficile REVIEW QUESTIONS—CONTENT REVIEW The correct answers are in boldface. 1. (1) is correct. Warm skin is a sign of local infection. (2, 4) are seen in shock. (3) is typical of a systemic infection. 2. (2) is correct. Use of autoclaves is a method of sterile technique. (1, 3, 4) are all medical asepsis practices. 3. (3) is correct. Health care–associated infections result from hospitalization. (1) is a chronic infection, and (2) is due to a sexually transmitted infection. (4) is incorrect because the infection was present before hospitalization. 4. (4) is correct. Vancomycin is the treatment of choice for methicillin-resistant Staphylococcus aureus (MRSA). (1, 2, 3) are incorrect. 5. (1, 3, 5) are correct. All pathogens require moisture, food, and warmth. (2, 4) are incorrect. All pathogenic organisms need darkness to multiply. Some need oxygen, but others do not. REVIEW QUESTIONS—TEST PREPARATION The correct answers are in boldface. 6. (2, 3, 5 ,6) are correct. Stethoscopes have been found to be contaminated with harmful organisms and should be cleaned before and after each patient use. Washing hands before and after patient contact is considered the most important method of infection prevention. Patient hand hygiene is often overlooked and is a key link in preventing health care–associated infection. It should be done after toileting, before meals, when handling own secretions, upon return to own room, and throughout the day as needed. (1) is incorrect. Hands cannot be sterilized. (4) is incorrect. Gloves are worn only during certain procedures when the caregiver is likely to come in contact with blood or body fluids. Even when gloves are worn, hand washing before and after wearing the gloves is essential for infection control. 7. (1) is correct. Surgical asepsisis aimed at the destruction of microbes before they enter the body. (2, 4) describe medical asepsis. (3) is not related to surgical asepsis. 8. (4) is correct. Tuberculosis is transmitted by airborne transmission, and anyone entering the room of a patient with tuberculosis must wear a fit-tested high-efficiency particulate air (HEPA) mask, which filters the tiniest particles from the air. Other types of masks and personal protective equipment will not provide protection from airborne pathogens. (1, 2, 3) are incorrect because they are not transmitted by air. 9. (3, 6) are correct. The only way to obtain a sterile specimen is to catheterize the patient, and the specimen must be placed into a sterile specimen container. (1, 2, 4, 5) are incorrect because any voided specimen is contaminated. 10. (1) is correct. Urinary catheters are a cause of health care–associated infections and should be avoided if possible. (2, 3, 4) do not prevent infection, and restricting fluids may promote infection and dehydration. 11. (4) is correct. A high fever indicates that the patient has developed a secondary bacterial infection. (1, 2, 3) are incorrect. Viral infections such as the common cold are usually associated with a low-grade fever. Symptoms of the common cold include stuffy nose with watery discharge, scratchy throat, dry cough, sneezing, and watery eyes. 12. (1) is correct. A culture identifies pathogen presence. (2) is incorrect. A drug level or peak and trough would measure antibiotic levels. (3) is incorrect. A sensitivity report would indicate what pathogens are sensitive to certain antibiotics. (4) is incorrect. 13. (2, 4, 5) are correct. Irritability, restlessness, and pacing behavior can be signs of infection in an older adult. (1, 3, 6) are not signs of infection. Chapter 8 Answers 3 14. ( 2 ) is correct. Sterile water should be used instead of tap water for an immunocompromised patient to prevent in - fection. (1, 3, 4) are appropriate actions so they would not require further instruction. 15. The most essential personal protective equipment, a fit - tested disposable respirator, is worn by the nurse prior to entering the room of a patient with tuberculosis. Answers 1 CHAPTER 9 NURSING CARE OF PATIENTS IN SHOCK AUDIO CASE STUDY José and Anaphylactic Shock 1. Use the thumbnail or a credit card to brush the stinger away, being careful not to pinch it and push more venom into the body. Yes, José performed it properly. 2. There may be an allergy to bees now after sensitization from the first sting. VOCABULARY 1. acidosis 2. anaerobic 3. anaphylaxis 4. arrhythmia 5. cardiogenic 6. cyanosis 7. tachypnea 8. oliguria 9. tachycardia 10. hypoperfusion MATCHING Compensated Progressive Irreversible Heart rate Tachycardia Tachycardia Slowing Greater than 150 beats/min Pulses Bounding Weak, thready Absent Systolic blood pressure Normal Below 90 mm Hg Below 60 mm Hg In hypertensive patient, 25% below baseline Diastolic blood pressure Normal Decreased Decreasing to 0 Respirations Increased rate, deep Tachypnea, crackles, shallow Slowing, irregular, shallow Temperature Varies Decreased, can rise in septic shock Decreasing Level of consciousness Anxious, restless, irritable, Confused, lethargic Unconscious, comatose alert, oriented, sense of impending doom Skin and mucous Cool, clammy, pale Moist, cold, clammy, pale Cyanosis, mottled, cold, membranes clammy Urine output Normal Decreasing to less than 20 mL/hr 15 mL/hr decreasing to anuria Bowel sounds Normal Decreasing Absent 3. The next insect sting could cause more severe anaphy- 1. (3) lactic symptoms. If symptoms occur, José can give 2. (1) himself an auto-injection of epinephrine. Since its 3. (2) effects may only work for a short time, emergency 4. (2) care is urgent. SIGNS AND SYMPTOMS OF SHOCKSTAGES 5. (2) Signs/Symptoms Stages 2 Chapter 9 Answers CRITICAL THINKING 1. Stage: Irreversible Category of Shock: Hypovolemic Initial Action: Notify health care provider (HCP), aid volume restoration by monitoring intravenous(IV) infusion 2. Stage: Compensated Category of Shock: Septic Initial Action: Notify HCP, maintain oxygen 3. Stage: Progressive Category of Shock: Cardiogenic Initial Action: Stop IV infusion, notify HCP REVIEW QUESTIONS—CONTENT REVIEW The correct answers are in boldface. 1. (2) is correct. Decreased peripheral tissue perfusion may be seen first as slow capillary refill, except in the older patient. (1, 3, 4) do not convey peripheral tissue perfusion status. 2. (3) is correct. Tachypnea is compensatory to maintain normal oxygen levels when cardiac output decreases. (1) is incorrect. If anxiety occurs, it is not the primary cause of tachypnea. (2) is incorrect. Decreasing retention of carbon dioxide is not the primary reason for tachypnea, although it is a benefit. (4) is incorrect. 3. (2) is correct. Blood pressure is dropping, so peripheral vasoconstriction occurs to compensate, resulting in less blood flow to the extremities; sympathetic nervous system compensation causes sweating to cool the body for ―fight or flight.‖ (1, 3) are incorrect. 4. (3) is a 25% decrease from baseline. (1, 2, 4) are incorrect. 5. (2) is correct. The goal is to increase understanding when knowledge is deficient. (1, 3, 4) are incorrect. REVIEW QUESTIONS—TEST PREPARATION The correct answers are in boldface. 6. (3) is correct. Notify the HCP immediately because the patient is hypovolemic and could need intravenousfluids. (1) is incorrect. This weight loss after dialysis is to be expected. (2) is incorrect. Resting is not the priority at this time. (4) is incorrect. The patient requires intervention now and more frequent monitoring. 7. (2) is correct. Elevated creatinine indicates possible renal damage. (1, 3, 4) are normal or near normal and not indicative of a problem. 8. (2) is correct. The pulse elevates to compensate for decreasing cardiac output in compensated shock and is therefore the earliest indication of shock from these options. (1, 3, 4) are found in progressive shock and would be seen later than tachycardia. 9. (1) is of highest concern because it is a symptom of progressive shock. (2, 3, 4) are found in compensated shock. 10. (2) is correct. Inform the registered nurse so the intravenous rate can be increased while the HCP is being notified because the patient is hypovolemic. (1, 3, 4) are incorrect because the patient needs immediate intervention. (1) provides no intervention, (3, 4) can worsen the condition. 11. (4) increases blood pressure. (1, 2, 3) are incorrect, as they do not increase blood pressure. 12. (4, 2, 5, 6, 1, 3) is correct. Use the Maslow hierarchy of human needs as a guide. Airway is considered first (4) and then oxygen (2); determining vital signs (5) will guide further treatment; intravenous fluids are needed to replace lost fluid in hypovolemic shock, so ordered intravenous fluids need to be monitored and maintained (6); and urine output monitoring will help guide treatment (1). (3) is not a priority at this time. 13. (1, 2, 5, 6) is correct. Symptoms of obstructive shock are similar to those of hypovolemic shock except that jugular veins are usually distended. Blood pressure is low, urine output is less than 20 mL per hour, and changes in level of consciousness, including confusion and lethargy, are seen. (3, 4) are incorrect because tachycardia and tachypnea would occur. 14. (1, 3, 4) are correct. Acute respiratory distress syndrome, disseminated intravascular coagulation, and multiple organ dysfunction syndrome are complications of prolonged shock. (2, 6) are genetic conditions. (5) is a bone marrow problem. Answers 1 CHAPTER 10 NURSING CARE OF PATIENTS IN PAIN AUDIO CASE STUDY Wilma Gets a Lesson in Pain Control 1. Acute pain lasts less than 3 months. Pain lasting more than 3 months would be considered chronic. 2. WHAT’S UP? Where is it? How does it feel? Aggravating and alleviating factors; Timing; Severity; Useful other data; Patient’s perception. 3. With opioids, check vital signs first, especially respiratory rate. If opioids will be given for more than one or two doses, implement measures to prevent constipation. Tell the patient to expect some initial drowsiness and to avoid driving until the effects of the medication are known. Give nonsteroidal anti-inflammatory drugs (NSAIDs) with food or a snack, and report stomach pain or signs of gastrointestinal bleeding. 4. NSAIDs reduce inflammation; acetaminophen and opioids do not. VOCABULARY 1. (4) 2. (3) 3. (6) 4. (1) 5. (9) 6. (8) 7. (10) 8. (5) 9. (2) 10. (7) CULTURALLY RESPONSIVE CARE 1. (1) is correct. Spirituality is a key area to monitor in providing culturally responsive care. Traditional healing methods should be incorporated as much as possible. 2. Teach him how to identify if his mother is having pain and show him how to help make her more comfortable by talking and helping her to relax. 3. (3) is correct. Language is a cultural expression that includes both verbal and nonverbal cues. Some patients may not use the word pain to describe discomfort. CRITICAL THINKING 1. Using the WHAT’S UP? format, you would assess where her pain is, how it feels, what makes it better or worse, when it began, how severe it is on a scale of 0 to 10, related symptoms, and her perception of the pain and what will relieve it. 2. Morphine is an opioid that works by binding to opioid receptors in the central nervous system. Even though the registered nurse gives the medication, you are in a position to observe for therapeutic and side effects. 3. Because you can expect Ms. Murphy to be in pain on her operative day, it is most beneficial to administer her analgesic every 4 hours, before pain begins to recur (as long as her level of sedation and respiratory rate are within safe parameters). This will help her walk and cough and prevent postoperative complications. Often postoperative analgesics are administered via a patient-controlled analgesia pump. 4. Common side effects of opioids include drowsiness, nausea, and constipation. Respiratory depression and constricted pupils are signs of overdose. 5. If the morphine has been effective, Ms. Murphy will be able to ambulate and cough with minimal difficulty and will rate her pain at a level that is acceptable to her. 6. According to the equianalgesic chart, the 30 mg of oral codeine in Tylenol #3 would be equal to about 2.5 mg of intravenous morphine, a much smaller dose than she has been receiving. The health care provider should be contacted for a more appropriate order. 7. Relaxation, distraction, back rubs, music, and imagery might all be effective in addition to the morphine. She has already been using distraction asshe visits with her family. REVIEW QUESTIONS—CONTENT REVIEW The correct answers are in boldface. 1. (4) is correct. Pain is whatever the experiencing person says it is, occurring whenever the experiencing person says it does. (1, 2, 3) may all be true in some situations but are not general definitions of pain and do not guide nursing care. 2. (3) is correct. Suffering is the term used to describe the sense of threat that can accompany pain. (1, 2, 4) may all be present with pain, but they are not the same assuffering. 3. (1) is correct. Constipation is a common side effect. (2) is serious but not common. (3) is not a side effect of opioids. (4) is not common and is different from a side effect. 2 Chapter 10 Answers 4. (3) is correct. The patient’s self-assessment is the best measure of pain available. (1) is incorrect. Some patients may moan or cry, but others may not; this may be a cultural variation. (2) is incorrect. Vital signs are an indirect measure and are most reliable when assessing acute pain. (4) is incorrect. The patient’s request for pain medication may be unrelated to the severity of pain. 5. (2) is correct. Distraction can be effective when used with analgesics. (1) is incorrect. Some patients may deny their pain, but most will not. (3) is incorrect. Laughing and talking do not mean pain is not present. (4) is incorrect. There is no evidence that laughing changes the duration of action of medications. REVIEW QUESTIONS—TEST PREPARATION The correct answers are in boldface. 6. (4) is correct. Meperidine has a toxic metabolite called normeperidine, which can build up and cause cerebral irritation. It is inappropriate for use in most people. (1, 2, 3) may all be appropriate, but the nurse must first consider the patient’s safety before trying other approaches. 7. (3) is correct. Pain level should be assessed before giving any analgesic, and respiratory rate should be assessed before giving any medication that can depress respirations. (1) is incorrect. Liver and kidney function are not routinely assessed with normal doses of medication. (2) is incorrect. Tachycardia may be present with acute pain, but blood glucose and pulse rate are not routinely assessed. (4) is incorrect. The emotional and physical cause of pain may not always be known. 8. (1) is correct. Naloxone is a narcotic antagonist. (2, 3, 4) are not narcotic antagonists. 9. (3) is correct. There is no research to justify the use of placebos to treat pain. (1, 2, 4) all imply that the placebo will be given. Placebos should be given only in research settings with patient consent. 10. (3) is correct. If the patient is drowsy, the nurse should evaluate vital signs to ensure safety and then contact the registered nurse or health care provider if the patient continues to appear painful. (1, 2) are incorrect. If the patient is too drowsy to push the button, it is not safe for someone else to push it. (4) is incorrect. Increasing the dose requires a health care provider’s order. 11. (2) is correct. The patient should always be believed. (1, 3, 4) may all be true, but if the nurse makes a wrong assumption, a patient in pain may go without treatment. Injuries sustained in a motorcycle accident are likely to be very painful. 12. (1) is correct. The maximum safe dose of acetaminophen (Tylenol) is 4 g per day and less in an alcohol user, so the nurse would be concerned by the patient’s report of high alcohol use. (2, 3, 4) are incorrect. Answers 1 CHAPTER 11 NURSING CARE OF PATIENTS WITH CANCER AUDIO CASE STUDY Michael Manages Side Effects of Chemotherapy 1. Symptoms to be vigilant for include: • Thrombocytopenia: Watch for bleeding, bruising, hematuria, hematemesis, blood in stool. • Leukopenia: Watch for signs of infection, including fever, purulent drainage, cough, sore throat, dysuria, redness, swelling. • Anemia: Watch for fatigue, pallor, dyspnea. 2. Because red blood cells carry oxygen and fewer red blood cells are circulating in an anemic patient. 3. Mr. Woo is at risk for infection, and the apple must be washed or peeled first. Bacteria can reside on the skin. VOCABULARY 1. alopecia 2. anorexia 3. Leukopenia or neutropenia 4. xerostomia 5. palliative 6. Chemotherapy 7. cytotoxic 8. Neoplasm 9. metastasizes 10. benign 11. biopsy 12. cytoprotective CELLS 1. True 2. False. For one protein. 3. False. To the ribosomes. 4. True 5. False. On the messenger RNA. 6. True 7. False. Only those needed for its specific functions are active. 8. False. 46. 9. False. Each cell has a full 46 chromosomes. 10. False. It is also necessary for repair of tissues. BENIGN VERSUS MALIGNANT TUMORS Benign tumors typically grow slowly, cause minor tissue damage, remain localized, and seldom recur after treatment. Cells resemble tissue of origin. Malignant tumors often grow quickly, cause damage to surrounding tissue, spread to other parts of the body (metastasize), and recur after treatment. Cells are altered to be less like their tissue of origin. CRITICAL THINKING 1. Leukopenia: Use careful hand washing; teach Delmae and her family the importance of doing the same. Teach her to avoid crowds, people with infections, and bird, cat, or dog excreta. Instruct her to avoid eating fresh fruits or vegetables that cannot be peeled. Teach her signs and symptoms of infection to report. Make sure she talks to her health care provider about the risks of returning to work while on chemotherapy. 2. Thrombocytopenia: Teach Delmae the importance of avoiding injury to prevent bleeding. Avoid intramuscular injections. Teach her to watch for and report symptoms of bleeding, such as bruising, petechiae, or blood in urine, stool, or emesis. 3. Anemia: Provide a balanced diet, with supplements as prescribed. Administer oxygen as ordered for dyspnea. Provide opportunities to rest. Assist with blood transfusions as ordered. 4. Stomatitis: Offer soft, mild foods. Offer frequent sips of water. Provide a mouthwash such as diphenhydramine diluted in water or saline. Teach her to avoid hot, cold, spicy, and acidic foods. 5. Nausea and vomiting: Administer antiemetics as ordered. Use prophylactically, not just when nausea is present. Provide mouth care before meals. Provide small, frequent meals and room-temperature or cool foods. Serve meals in a clean, pleasant environment that is free from odors and unpleasant sights. Offer hard candy. Use music or relaxation as distractions. 2 Chapter 11 Answers 6. Alopecia: Offer an accepting attitude. Help Delmae locate a wig or other head covering if she wishes. Assure her that her hair will grow back. REVIEW QUESTIONS—CONTENT REVIEW The correct answers are in boldface. 1. (2) is correct. (1, 3, 4) are incorrect. 2. (3) is correct. (1, 2, 4) are incorrect. 3. (2) is correct. High-fat foods may increase the risk of some cancers. (1) is incorrect. Broccoli and cauliflower help reduce cancer risk. (3) is incorrect. Chicken and fish are low-fat meats that are healthy choices. (4) is incorrect. Cakes and breads are not problems unless they are high in fat or other high-risk ingredients. 4. (2) is correct. Remember the importance of time, distance, and shielding. (1) is incorrect. Leaving the patient alone for 24 hours is inappropriate. (3) is incorrect. Body fluids should not be touched, but it is not feasible to care for the patient and avoid touching altogether. (4) is incorrect. A ―contaminated‖ sign will make the patient feel even more isolated and afraid. REVIEW QUESTIONS—TEST PREPARATION The correct answers are in boldface. 5. (3) is correct. A biopsy enables the pathologist to examine and positively identify the cancer. (1) is incorrect. Cultures diagnose infection. (2) is incorrect. X-rays can help locate a tumor but cannot determine whether it is benign or malignant. (4) is incorrect. A bronchoscopy may be done, but a biopsy is necessary to positively identify the cancer. 6. (1) is correct. Frequent mouth care will help prevent the discomfort and dryness that accompany mucositis. (2) is incorrect. Cold liquids may worsen mucositis. (3) is incorrect. High-carbohydrate foods will not help. (4) is incorrect. Juices are acidic and can irritate the mucous membranes. 7. (2) is correct. Petechiae are small hemorrhages into the skin. (1) is incorrect. Fever is a sign of infection. (3) is incorrect. Pain is not usually a sign of bleeding. (4) is incorrect. Vomiting is not a sign of bleeding unless it is bloody. 8. (1, 4, 5) are correct. Washing hands frequently is an excellent way to help prevent infection in the patient at risk. Colony-stimulating factors are provided to stimulate increased production of white blood cells and reduce the length or severity of leukopenia. Taking vital signs frequently and monitoring for signs of an infection is an important part of early detection, which helps reduce additional complications related to neutropenia. (2, 3, 6) are incorrect. Avoiding injections will help prevent bleeding but will do little to prevent infection. Visitors with infections should be discouraged, but the patient needs the support of family at this time. Fresh fruits and vegetables can transmit infection. 9. (4) is correct. Alternative methods for pain control can be helpful but should never be expected to substitute for analgesics in the patient with cancer. (1) is incorrect. Distraction should be used with, not instead of, medication. (2) is incorrect. The nurse must believe the patient’s report of pain. (3) is incorrect. Distraction can be effective when used with medication and in no way indicates that the patient’s pain is not real. 10. (3, 5, 6) are correct. The goal of hospice is to help patients achieve a comfortable death and to provide emotional or physical assistance to family members and other caregivers during the patient’s dying process. Respite care for family members may be provided, and follow-up counseling is available for up to a year after the patient’s death. (1, 2, 4) are not correct. They are all aimed at curing the patient’s cancer. If cure is the goal, a referral to hospice is inappropriate. 11. (3) is correct. Accurate identification of a cancer can only be done by biopsy; surgery is not always the treatment of choice. (1, 2, 4) are incorrect. Answers 1 CHAPTER 12 NURSING CARE OF PATIENTS HAVING SURGERY AUDIO CASE STUDY Alan and the Surgical Patient 1. Put name bracelet on, remove underwear as necessary, remove nail polish, remove jewelry (or tape wedding ring in place if surgery is not on extremity), remove dentures, send hearing aid and glasses with patient, record vital signs, and verify that informed consent, diagnostic tests results, and history and physical are completed and in the medical record. 2. Places the bed in its lowest position, locks the wheels, and raises the side rails for safety. 3. Alan does the following: • Informs the patient of the call button location and advises her to call if she needs something. • Informs the patient her call will be answered promptly. • Reminds the patient not to try to get up alone, as she might be dizzy or weak and fall. • Informs the patient that he will be checking on her frequently. • Assists the patient to sit on the side of the bed to dangle her legs prior to standing. • Puts slippers on the patient for nonslip footing. 4. Early ambulation, coughing and deep breathing exercises, and leg exercises. VOCABULARY 1. Surgeons 2. perioperative 3. preoperative 4. intraoperative 5. postoperative 6. Induction 7. adjunct 8. dehiscence 9. Anesthesiologists 10. Anesthesia 11. Atelectasis 12. Debridement 13. Hypothermia 14. Evisceration 15. certified registered nurse anesthetist SURGERY URGENCY LEVELS 1. (4) 2. (3) 3. (3) 4. (4) 5. (2) 6. (1) 7. (2) 8. (1) 9. (3) 10. (1) NOURISHING THE SURGICAL PATIENT Corrections are in boldface. Healing requires increased vitamins A and D for collagen formation, vitamin K for blood clotting, and zinc for tissue growth, skin integrity, and cell-mediated immunity. Proteins are essential for controlling fluid balance and manufacturing antibodies and white blood cells. Hypoalbuminemia, a low serum albumin, impedes the return of interstitial fluid to the venous return system, increasing the risk of shock. A serum albumin level is a useful measure of protein status. MEDICATIONS 1. True 2. False. The surgeon determines if the anticoagulant therapy is to be stopped several days before surgery, which it often is. 3. True 4. False. The surgeon and patient must mark the site before surgery begins. 5. True 6. True 7. True 8. False. Circulatory collapse can develop if steroids are stopped abruptly. 9. False. An indwelling urinary catheter can be a source of infection. Usually, it should be removed by postoperative day 2, as ordered. 10. False. Intermittent pneumatic compression devices are used to prevent blood clots. 2 Chapter 12 Answers PERIOPERATIVE NURSING DIAGNOSES AND OUTCOMES 1. Will state reduced anxiety or fear before surgery. 2. Will demonstrate understanding of surgical information and routines before surgery. 3. Will remain free from injury. 4. Will maintain skin integrity. 5. Will report pain is relieved to satisfactory level within 30 minutes of report of pain. Will describe pain management plan by first postoperative day. 6. Will remain free from infection at all times. WOUND HEALING PHASES Phase Time Frame Wound Healing Patient Effect Phase I Incision to second postoperative day Inflammatory response Fever, malaise Phase II Third to 14th postoperative day Granulation t