Test bank for Chapter 03: Overview of
Health Concepts for Medical-Surgical
Nursing questions and verified answers
1. A client had a recent thromboembolism and must resume work which requires frequent
car and plane travel. What self-care measure does the nurse teach to reduce the risk of
impaired clotting in this client?
2. a. Get up and walk around at least every 2 hours while traveling.
3. b. Use a soft toothbrush and an electric razor for safety.
4. c. Be sure to sit with the legs elevated as much as possible.
5. d. Increase fiber in the diet so as not to strain to move the bowels. - ANS-ANS: A
6. Clients who are at risk of increased clotting (as evidenced by prior thromboembolic
event) can take several measures to reduce their risk of further problems. One measure
is to get up and walk frequently when sitting for a long period of time. Using a soft
toothbrush and an electric razor and needing to prevent constipation would be important
for a client at risk of bleeding. Elevating the legs is not as beneficial as ambulating.
7. A client has impaired tissue integrity and a nonhealing wound. The nurse has taught the
client about diet changes to improve wound healing. What diet selections does the nurse
evaluate as good understanding by the client? (Select all that apply.)
8. a. Chicken breast
9. b. Orange juice
10. c. Boost supplement
11. d. Spinach salad
12. e. Cantaloupe
13. f. Whole wheat bread - ANS-ANS: A, B, C, D
14. Protein and vitamin C are important for wound healing. Foods high in protein include
meat sources such as chicken and nutritional supplements. Foods high in vitamin C
include orange juice and spinach. Cantaloupe is a good source of vitamin A. Whole
wheat bread, while healthy, does not contribute directly to wound healing.
15. A client has urinary incontinence. Which assessment finding indicates that outcomes for
a priority nursing diagnosis have been met?
16. a. Client reports satisfaction with undergarments for incontinence.
17. b. Client reports drinking 8 to 9 glasses of water each day.
18. c. Skin in perineal area is intact without redness on inspection.
19. d. Family states that client is more active and socializes more. - ANS-ANS: C
20. Urinary incontinence can lead to skin breakdown and possibility of infection. Skin that is
intact without redness shows that a major goal for this client has been met. Becoming
more social is a positive finding as many adults with incontinence limit their social
, activities, but this psychosocial outcome is not the priority over a physical outcome.
Being satisfied with undergarments is also not the priority. Drinking adequate water can
sometimes help with incontinence and is important for general health, but is not directly
related to an important goal for this client.
21. A nurse is caring for a client who is acidotic. The nurse asks the charge nurse why the
client is breathing rapidly. What response by the charge nurse is best?
22. a. Anxiety is causing the client to breathe rapidly.
23. b. The client is trying to get rid of excess body acids.
24. c. The rapid respirations cause buildup of bicarbonate.
25. d. An increased respiratory rate is due to increased metabolism. - ANS-ANS: B
26. The client is acidotic, and the respiratory system is attempting to compensate by
"blowing off" excess acid in the form of carbon dioxide. The increased respiratory rate is
not due to anxiety or increased metabolism. An increased respiratory rate does not
cause a buildup of bicarbonate.
27. A nurse is caring for clients on an inclient surgical unit. Which clients does the nurse
identify as having a risk for impaired immunity? (Select all that apply.)
28. a. 86 years old
29. b. Has type 2 diabetes
30. c. Taking prednisone
31. d. Has many allergies
32. e. Drinks a beer a day
33. f. Low socioeconomic status - ANS-ANS: A, B, C, F
34. Risk factors for impaired immunity include but are not limited to: older adults (diminished
immunity due to normal aging changes), low socioeconomic groups (inability to obtain
proper immunizations), nonimmunized adults, adults with chronic illnesses that weaken
the immune system, adults taking chronic drug therapy such as corticosteroids and
chemotherapeutic agents, adults experiencing substance use disorder, adults who do
not practice a healthy lifestyle, and adults who have a genetic risk for decreased or
excessive immunity. Allergies and one beer a day are not risk factors.
35. A nurse is caring for four clients. Which client does the nurse assess first for impaired
cognition?
36. a. A 28-year-old client 2 days post-open cholecystectomy
37. b. An 88-year-old client 3 days post-hemorrhagic stroke
38. c. A 32-year-old client with a 20-pack-year history of smoking
39. d. A 42-year-old client with a serum sodium of 134 mEq/L (134 mmol/L) - ANS-ANS: B
40. There are many risk factors for impaired cognition including advanced age and diseases
and disorders that affect the brain. The 88-year-old client who is recovering from a stroke
has two such risk factors and is at highest risk for impaired cognition. The nurse
assesses this client first. The other clients have a much lower risk of developing impaired
cognition.
41. A nurse is planning a community education event-related to impaired cellular regulation.
What teaching topics would the nurse include in this event? (Select all that apply.)
42. a. Ways to minimize exposure to sunlight
43. b. Resources available for smoking cessation
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