Chronic Health Challenges ANSWER Key

Answer Key
Chapter 1
I. Interpretation, Completion, and Comparison
Multiple-Choice
1. d 4. b 7. d
2. a 5. c 8. d
3. d 6. c 9. d
Fill-In
1. Refer to textbook page 6.

2. Legislative and sociologic changes that are impinging on nursing care are chronic illnesses, the increase in
the population older than 65 years of age, the shift from disease cure to health promotion, and cost control
and resource management.
3. In Maslows hierarchy of needs, needs are ranked as follows (Figure 11):
Need Example
Physiologic Food
Safety and security Financial security
Belongingness and affection Companionship
Esteem and self-respect Recognition by society
Self-actualization Achieved potential in an area
Self-fulfillment Creativity (painting)
Knowledge and understanding Information and explanation
Aesthetics Attractive environment
4. Income and social status, social support networks, employment and working conditions, education,
physical environment, social environment, biology and genetic endowment, personal health practices and
coping skills, healthy child development, health services, gender, and culture.
Copyright 2008 by Lippincott Williams & Wilkins, a Wolters Kluwer Business. Student Access to thePoint Solution for the Study Guide
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5. Clinical pathways serve as an interdisciplinary care plan and a tool for tracking a patients progress toward
achieving positive outcomes within specified time frames.
8. clinical expert, facilitator, coordinator, liaison, supporter, educator, researcher, negotiator, monitor,
advocate, and manager.
II. Critical Thinking Questions and Exercises
Supporting Arguments
1. Share your data and discuss your response with your instructor and classmates. There are no specific right
or wrong answers. The validity of your response is determined by your ability to consciously support your
argument. Refer to textbook pages 79.
Recognizing Contradictions
1. The majority of health problems today are chronic in nature.

2. A person with chronic illness can attain a high level of wellness if he or she is successful in meeting his or
her health potential within the limits of the chronic illness.
3. The World Health Organizations definition of health is accurate, current, and comprehensive.
4. The elderly in Canada will constitute 20% of the total population by the year 2026.
5. The British North American Act made health care a matter of provincial jurisdiction.
6. The main focus of continuous quality improvement (CQI) is on the processes that affect quality.
7. It has been projected that by 2016, visible minorities will constitute close to 20% of the Canadian
population.
Examining Associations
1. Your discussion should include a focus on physiologic needs and safety and security. It would be difficult
for this patient to consider the three higher levels. Refer to pages 5 and 6.
2. Refer to textbook pages 6 and 7.
Chapter 2
Multiple Choice
1. d 3. c 5. d
2. d 4. d 6. c
Fill-In
1. Nurses will need to be expert, independent decision makers who are self-directed, flexible, adaptable, and
competent in critical thinking, physical assessment, health education, and basic nursing care.
352 for Brunner & Suddarths Textbook of MedicalSurgical Nursing, First Canadian Edition, by Pauline Paul, Rene A. Day, and Bev Williams
2. Community-based nursing is an umbrella philosophy guiding nursing care given to individuals and families
in the community in which they live, work, play, and go to school. It involves various service providers
outside of hospitals. It includes home health nursing and school health nursing. Community health nursing
is a specific type of nursing service equated to public health nursing, a speciality area focused on total
populations.
3. Skilled nursing services may include intravenous therapy, injections, parenteral nutrition, venipuncture,
catheter insertion, pressure ulcer and wound care, and ostomy care.
4. Call the patient to obtain permission for a visit, schedule the visit, and verify the address.
5. During the initial home visit, the patient is evaluated and a plan of care is established.
6. Ambulatory health care can be provided in medical clinics, ambulatory care units, urgent care centres, cardiac
rehabilitation programs, mental health and student health facilities, and nurse-managed centres.
7. Nurse practitioners can specialize in gerontology, midwifery, pediatrics, family planning, family, adult,
and/or womens health.
8. Common problems include diabetes, hypertension, heart disease, AIDS, and mental illness.
Discussion and Analysis
1. Refer to textbook pages 1520. 3. Refer to textbook page 19.

2. Refer to textbook pages 1520. 4. Refer to textbook page 15.
1. Community health nursing, generally equated to public health nursing, is a speciality area focused on
total populations.
2. Tertiary prevention is a level of community nursing care that focuses on minimizing deterioration and
improving the quality of life. Secondary prevention focuses on early disease detection.
3. The primary purpose of the initial home care visit is for the nurse to establish a trusting relationship with the
patient and his/her family.
Chapter 3
Multiple Choice
1. b 7. d 13. a
2. c 8. c 14. a
3. b 9. b 15. d
4. d 10. d 16. b
5. a 11. d
6. d 12. c
Fill-In
1. Critical thinking is a multidimensional skill, a cognitive or mental process or set of procedures that involves
conscious, systematic, reflective, rational, and goal-oriented examination and analysis of all available
information and ideas. The formulation of logical conclusions and creative decisions is reflective of the
process.
2. Critical thinking is influenced by the culture, attitude, and experiences of the individual, who sees the
situation through the lens of his or her experiences.
3. Two types of legal documents are an advance directive and a durable power of attorney.
4. An advance directive provides health care practitioners with information about the patients wishes for
health care before his or her illness and is used if the person is unable to speak for himself or herself.
5. Suggested statements include: Please tell me what brought you to the hospital, Please tell me what you
think your needs are, and Please tell me about your past history.
6. A nursing diagnosis identifies actual or potential health problems that are amenable to resolution by
nursing actions. Collaborative problems are physiologic complications that nurses monitor, in collaboration
with a physician, to detect onset or changes in a patients status. The nursing diagnosis and collaborative
problems are the patients nursing problems. A medical diagnosis identifies diseases, conditions, or
pathology that can be medically managed. (Fig. 32)
7. Expected outcomes of nursing intervention should be stated in behavioural terms and should be realistic as
well as measurable. Expected behavioural outcomes serve as the basis for evaluating the effectiveness of
nursing intervention.
Nursing Diagnoses and Collaborative Problems (Fig. 32 and Chart 37).
1. ND 6. ND
2. ND 7. CP
3. CP 8. CP
4. CP 9. ND
5. ND 10. CP
Matching (Critical Thinking) (Chart 31)
1. e 5. a
2. g 6. c
3. f 7. b
4. d
Matching (Ethical Principles) (Chart 32).
1. d 4. f
2. e 5. a
3. b 6. c
Reference pages for questions 13 are pages 3340.
1. Nursing ethics is a distinct form of applied ethics because nursing is its own separate profession.
2. A moral dilemma occurs when a clear conflict between one or more principles exist.
3. Ethical distress exists when a nurse is prevented from doing what he or she believes is correct.
4. A request for withdrawal of food and hydration necessitates an evaluation of harm and may not be
routinely supported even for competent patients.
5. An advance directive is always honoured. There are fines or other penalties in place if an advance
directive is not followed.
13. Answers are individualized; there are no right or wrong responses.
Clinical Situations
Outcomes per Nursing Diagnosis
1. Patient will be able to walk from his room to the nursing station every morning with respiratory rate within
normal limits.
2. Patient will move from bed to chair on second postoperative day with legs abducted.
3. Patient will achieve a balance between fluid intake and output with a weight gain no greater than
0.5 kg/week.
4. Patient will eat 1800 cal/day to maintain a desired weight of 61.2 kg.
5. Patient will sleep 6 to 8 hours, without interruption, every evening.
CASE STUDY: Ethical Analysis

Assessment:
Your answer should include the conflict between the nurses professional obligation to provide treatment to all
and the unpleasant outcome of choosing the lesser of two evils.
Planning:
You should be able to analyze the medical and political data that influence the treatment options. Because of
the vast numbers of infected citizens relative to available treatment, not everyone can be cared for.
Implementation:
You need to carefully analyze the outcomes of both theories for your decision making. There is no right or
wrong answer. You just need to support your decision with an ethical theory.
Evaluation:
Your evaluation needs to show logical sequencing of problem solving based on an ethical theory. There is no
right or wrong response. (Chart 32).
Chapter 4
Multiple Choice
1. d 5. a 9. b
2. d 6. a 10. a
3. d 7. a
4. b 8. a
Fill-In
1. Significant factors are the availability of health care outside the conventional hospital setting, the
employment of diverse health care providers to accomplish care management goals, and the increased
use of alternative strategies.
2. People with chronic illness need as much health care information as possible to actively participate in and
assume responsibility for the management of their own care. Health education can help the patient adapt
to illness and cooperate with a treatment regimen. The goal of health education is to teach people to
maximize their health potential.
3. Patient education can: reduce health care costs by preventing illness, help patients avoid expensive
medical treatment, facilitate earlier discharge, and decrease lengthy hospital stays.
4. Adherence implies that a patient makes one or more lifestyle changes to carry out specific activities to
promote and maintain health.
5. Factors influencing adherence include demographic variables such as age, sex, and education; illness
variables such as the severity of illness and the effects of therapy; psychosocial variables such as
intelligence and attitudes toward illness; financial variables; and therapeutic regimen variables.
6. The teachinglearning process requires the active involvement of teacher and learner, in an effort to reach
the desired outcome, a change in behaviour. The teacher serves as a facilitator of learning.
7. The elderly have difficulty adhering to a therapeutic regimen because of: increased sensitivity to
medications, difficulty in adjusting to change and stress, financial constraints, forgetfulness, inadequate
support systems, lifetime habits of self-medication, visual impairments, hearing deficits, and mobility
limitations.
8. Increased age decreases: (a) mental functioning, (b) short-term memory, (c) abstract thinking, (d)
concentration, and (e) reaction time.
9. The effects of a learning situation are influenced by a persons physical, emotional, and experiential
readiness to learn. Physical readiness implies the physical ability of a person to attend to a learning
situation. Basic physiologic needs are met so that higher-level needs can be addressed. Emotional readiness
involves the patients motivation to learn and can be encouraged by providing realistic goals that can be
easily achieved so that self-esteem needs can be met. A person needs to be ready to accept the emotional
changes (anxiety, stress) that accompany behaviour modification resulting from the learning process.
Experiential readiness refers to a persons past experiences that influence his or her approach to the
learning process. Previous positive feedback and improved self-image reinforce experiential readiness.
10. Both processes are cyclic and recurrent with each step related to the others. Continuous evaluation
supports the processes and helps maintain accountability.
11. Lalondes (1974) health determinants model includes human biology, environment, lifestyle, and the
health care system
12. The principles are: self-responsibility, nutritional awareness, stress-reduction and management, and
physical fitness.
1. Health education is an independent function of nursing practice that is a primary responsibility of the
nursing profession.
2. Although diseases in children and those of an infectious nature are of utmost concern, the largest group of
people today who need health education are those with chronic illness.
3. Patients are encouraged to adhere to their therapeutic regimen. Adherence connotes active, voluntary,
collaborative patient efforts whereas compliance is a more passive role.
4. Evaluation should be continuous throughout the teaching process so that the information gathered can be
used to improve teaching activities.
5. The elderly usually experience significant gains from health promotion activities.
6. About 80% of those older than 65 years of age have one or more chronic illnesses.
Refer to Chart 42 to complete the chart.
Chapter 5
Multiple Choice
1. d 6. c 11. d
2. d 7. b 12. a
3. d 8. d 13. a
4. b 9. b 14. a
5. b 10. a 15. a
Fill-In
1. The responsibilities are obtaining a patient health history and performing a physical examination.
2. The nursing database is a combination of the traditional medical history and the nursing assessment. The
systems review and patient profile are expanded to include individual and family relations, lifestyle
patterns, health practices, and coping strategies.
3. When an atmosphere of mutual trust and confidence exists between an interviewer and a patient, the
patient becomes more open and honest and is more likely to share personal concerns and problems.
4. Through the use of open-ended questions, ask the patient to provide details of the present health concern
or illness (history, analysis of any symptom mentioned, and review of relevant systems). Refer to textbook
pages 5964.
5. Answer may include any of the following: cancer, hypertension, heart disease, diabetes, epilepsy, mental
illness, tuberculosis, kidney disease, arthritis, allergies, asthma, alcoholism, and obesity.
6. The leading causes are: cancer, heart disease, and stroke.
7. The values are 2529.9; 3039.9; greater than 40.
8. Negative nitrogen balance occurs when nitrogen output (urine, feces, perspiration) exceeds nitrogen intake
(food). When this happens, tissue is breaking down faster than it is being replaced.
9. The minerals often in deficit are: iron, folate, and calcium.
Correlation
1. inspection
2. inspection
3. palpation
4. palpation
5. percussion
6. auscultation
7. auscultation
8. palpation
Matching
1. h 4. e
2. c 5. g
3. d 6. b
Chapter 6
Multiple Choice
1. d 11. c 21. c
2. d 12. a 22. d
3. b 13. b 23. d
4. a 14. b 24. d
5. d 15. d 25. b
6. d 16. d 26. b
7. d 17. a 27. a
8. b 18. d 28. c
9. a 19. d 29. a
10. b 20. d 30. d
Matching
1. b 4. a 7. b
2. a 5. b 8. a
3. a 6. a
Fill-In
1. When the body suffers an injury, the response is maladaptive if the defense mechanisms have a negative
effect on health.
2. Hyperpnea is the bodys development of rapid breathing after intense exercise in response to an
accumulation of lactic acid in muscle tissue and a deficit of oxygen.
3. Examples of acute, time-limited stressors would be: taking an examination, giving a speech, or driving in a
snowstorm. Examples of chronic, enduring stressors would be: poverty, a handicap or disability, or living
with an alcoholic.
4. Answer may include any of the following: traffic jam, sick child, missed appointment, car wont start, train is
late (day-to-day stressors), earthquakes, wars, terrorism, events of history (major events that affect large
groups of people); marriage, birth, death, retirement (infrequently occurring major stressors).
5. Adolph Meyer, in the 1930s, first showed a correlation between illness and critical life events. A Recent Life
Changes Questionnaire (RLCQ) was developed by Holmes and Rahe that assigned numerical values to life
events that require a change in an individuals life pattern. A correlation was seen between illness and the
number of stressful events; the higher the numerical value, the greater the chance for becoming ill.
6. Cognitive appraisal refers to the evaluation of an event relative to what is at stake and what coping
resources are available. External resources consist of money to purchase services and materials and social
support systems that provide emotional and esteem support.
7. Hans Selye stated that stress is essentially the rate of wear and tear on the body. He also defined stress as
being a nonspecific response of the body regardless of the stimulus producing the response.
Clinical Situations
Flow Chart (Table 61)
General body arousal Physiologic Reaction Rationale

)Norepinephrine )blood coagulability cardiac output
)heart rate )myocardial contractility
)blood pressure peripheral vasoconstriction
)blood glucose levels )glycogen breakdown
(Effects on:
Skeletal muscles increased tension )increased excitation of muscles
Pupils dilated )contraction of radial muscle of iris
Ventilation rapid and shallow oxygen preservation; bronchodilation
CASE STUDY: Hypertensive Heart Disease
Selected Compensatory
Mechanisms Nursing Implications Rationale
Renal blood flow is Assessment
decreased as a result
of hypertensive heart A. Blood pressure A. Changes in the cardiovascular
disease system are reflected in the
blood pressure
B. Urinary output
1. Amount 1. Output decreased with
decreased blood flow
2. Characteristics 2. Colour changes occur with
increased blood flow
3. Urine chemistry values
a. Osmolality a. Osmolality increases with
heart failure
b. Electrolytes b. Potassium increases with
renal failure
C. Ability to cope with stress C. Stress results in increased
resistance to cardiac output
Nursing Diagnoses/
Collaborative Problem
A. Fluid volume excess A. Renin-angiotensin has a direct
related to renin-angiotensin vasoconstriction effect on
stimulation arterioles which leads to water
retention
Planning
A. Plan time for assessment A. Rest lowers metabolic rate and
around patients need facilitates the healing process
for rest.
B. Plan an individual program B. Compliance with a stress-
of stress reduction management program will be
higher if the program is
individualized
Implementation
A. Teach various relaxation A. Stress tends to increase
techniques epinephrine secretion, which
causes vasoconstriction; this,
in turn, increases the heart rate
and resistance to cardiac output
B. Develop specific ways to B. Stress reduction tends to reduce
help the patient cope with epinephrine secretion
and reduce stress
C. Modify diet to reduce C. Lowered sodium levels tend to
sodium intake decrease fluid retention, which
decreases the work load of the
heart
Evaluation
A. Stress-reduction measures A. Blood pressure reduction may
be indicative of successful
stress-reduction measures
B. Dietary compliance relative B. Weight estimates, serum sodium
to lowered sodium intake levels, and the presence of
edema are indicators of fluid
retention and possible excess
intake of sodium.
Flow Chart
Sympathetic-Adrenal-Medullary Response
release of epinephrine and produce ACTH

norepinephrine
increases increases
stimulate adrenal cortex inhibits glucose uptake
blood pressure blood glucose
heart rate
decreases
perfusion of
release of glucocorticoids
abdominal organs
increases
available
energy promotes protein stimulates uptake of
peripheral calabolism amino acids
vasoconstriction
releases
amino acids gluconeogenesis
Chapter 7
Multiple Choice
1. d 5. c 9. a
2. d 6. b 10. b
3. d 7. d 11. c
4. b 8. b
Fill-In
1. The most common definition of a mental disorder is from the American Psychiatric Association: a group of
behavioural or psychological symptoms or a pattern which manifests itself in a significant distress, impaired
functioning, or accentuated risk of enduring severe suffering or possible death.
2. Five significant family functions are: (a) the use of power, decision making about resources, the
establishment of rules, and provision of finances and future planning; (b) boundary setting; (c)
communication; (d) education, family support, and appropriate modeling skills for living; and (e)
socialization of acceptable behaviours for life.
3. Seven coping skills for families under stress are: (a) communication; (b) spirituality; (c) cognitive abilities;
(d) emotional strength; (e) relationship capabilities; (f) use of community resources; and (g) personal
talents and strengths.
4. Five characteristics of emotional responses to PTSD are: (a) anxiety; (b) anger; (c) aggression; (d)
depression; and (e) fear of being threatened.
5. Physiologic responses are increased: activity of the sympathetic nervous system; plasma catecholamine
levels, and urinary epinephrine and norepinepnrine levels.
6. Seven examples of life events that trigger PTSD are: (a) rape; (b) family violence; (c) torture; (d)
earthquake; (e) terrorism; (f) fire; and (g) military combat.
7. Intoxication and withdrawal are two common substance abuse problems.
Matching
1. e 4. d 7. c 10. c
2. c 5. b 8. a
3. a 6. a 9. e
1. Since the 1980s there has been an increase in the use of holistic health care.
2. The holistic approach to health care reconnects the mind and body traditionally separated by medicine.
3. Depression and its accompanying symptoms of sadness, anxiety, and fatigue is a common response to
health problems. Clinical depression is distinguished from everyday feelings of sadness by duration and
severity.
4. A diagnosis of clinical depression requires the presence of five out of nine diagnostic criteria.
Clinical Situations
CASE STUDY: Hodgkins Disease

1. a 2. b 3. d
CASE STUDY: Radical Mastectomy
1. a 2. b 3. b
4. d
Chapter 8
Multiple Choice
1. d 5. a 9. c
2. d 6. b 10. b
3. d 7. a
4. d 8. a
Fill-In
1. The founder is: Madeleine Leininger.

2 The four basic characteristics of culture are that it is learned from birth through langauge and socialization,
it is shared by all members of the same cultural group, it is influenced by specific environmental and
technical factors, and it is dynamic and ever-changing.
3. The elements are: colour, religion, and geographic area.
4. Subcultures can be grouped accordingly by religion, occupation, age, sexual orientation, geographic
location, and race.
5. Four strategies include changing the subject, nonquestioning, inappropriate laughter, and nonverbal cues.
6. The Catholics, Mormons, Buddhists, Jews, and Muslims routinely abstain from eating as part of their
religious practice.
7. The yin and yang theory of illness proposes that the seat of energy in the body is within the autonomic
nervous system where balance is maintained between the key opposing forces. Yin represents the female
negative forces, whereas yang represents the male positive energy.
1. The goal of Leiningers theory is to provide culturally congruent nursing care to improve care to people of
different or similar cultures. Her theory provides care through culture care accommodation and culture
care restructuring.
2. Culture care accommodation refers to professional nursing actions and decisions to help patients of a
designated culture achieve a beneficial outcome. Culture care restructuring refers to the professional
actions that help patients reorder, change, or modify their lifestyles toward more beneficial health care.
3. Acculturation is the process by which members of a cultural group adapt to or learn how to take on the
behaviours of another group. Cultural imposition is the tendency to impose ones cultural beliefs, values,
and patterns of behaviour on others from a different culture.
Chapter 9
Multiple Choice
1. b 5. a 8. b
2. b 6. c 9. d
3. a 7. a 10. a
4. c
Fill-In
1. Genomic medicine encompasses the recognition that mulitple genes work in concert with environmental
influences resulting in the appearance and expression of disease.
2. To integrate genetics into nursing practice, the nurse (a) uses family history and the results of genetic tests,
(b) informs patients about genetic concepts, (c) is aware of the personal and societal impact of genetic
information, and (d) values privacy and confidentiality.
3. Penetrance refers to the percentage of persons known to have a particular gene mutation who actually
evidence the trait.
4. Down syndrome
5. 1 in every 500
6. Pharmacogenetics involves the use of genetic testing to identify genetic variations that relate to the safety
and efficacy of medications and gene-based treatments.
7. Hemochromatosis (iron overload)
8. The nursing activities are: (a) collect and help interpret relevant family and medical histories, (b) identify
patients and families who need genetic evaluation and counseling, (c) offer genetics information and
resources, (d) collaborate with the genetic specialist, and (e) participate in management of patient care.
Matching
1. b 3. e 5. a 7. d
2. c 4. d 6. a 8. f
Chapter 10
Multiple Choice
1. b 5. b 8. a
2. c 6. a 9. b
3. d 7. b 10. b
4. c
Fill-In
1. Answer should include four of the following six causes:

a. decreased mortality from infectious disease
b. longer life spans due to advances in technology and pharmacology
c. improved screening, diagnosis, early detection, and treatment of diseases
d. aggressive management of acute conditions
e. level of poverty and unavailability of health care coverage
f. modern habits of living such as smoking
2. pain, fatigue, and some degree of disability
3. Inability to shower or bathe because of a fear of falling and the inability to get to the bathroom are the two
most frequent interferences with daily activities that occur in chronic illnesses.
4. unhealthy lifestyles, smoking, and overeating
5. Answers may include preventing the occurrence of other chronic conditions; alleviating and managing
symptoms; preventing, adapting, and managing disabilities; preventing and managing crises and
complications; adapting to repeated threats and progressive functional loss; living with isolation and
loneliness.
6. The Trajectory Model refers to the path or course of action taken by the ill person, his or her family, health
professionals, and others to manage the course of the illness.
1. Medical conditions are associated with psychological and social problems which can affect body image
and alter lifestyles.
2. Chronic conditions have acute, stable, and unstable periods, flare-ups, and remissions. Each phase requires
different types of management.
3. Complying with a treatment plan helps prevent the incidence of complications. Time, knowledge, and
planning are necessary.
4. The whole family experiences stress and caretaker fatigue. Social changes that can occur include loss of
income, role reversals, and altered socialization activities.
5. Management requires many different health care professionals working with the family.
6. Chronic illness frequently goes through periods of remission which can last years, shadowing the reality of
the presence and severity of the illness.
Clinical Situations
Use of the Trajectory Model

1. Step 1. The nurse uses assessment to determine the specific Trajectory phase of the chronic illness. For
example, the nurse determines whether any musculoskeletal deficiencies are evident, whether fatigue is
interfering with activities of daily living, and whether the patient is emotionaly capable of coping with the
diagnosis.
2. Step 2. The nurse interacts with the family and the medical team to establish some collaborative goals of
management and support. For example, the nurse, working with the physician and physical therapist,
designs an exercise program that will maximize current musculoskeletal strength while preventing
excessive stress on major joints.
3. Step 3. The nurse can help the patient draft a list of activities, exercises and rest periods that can support
established goals. The nurse could also identify specific criteria to be used to measure progress toward goal
attainment. For example, the patient can keep a daily record of pain and joint stiffness, participation in
work activities, and time allocated for recreation. The nurse can review the plan periodically with the
patient.
4. Step 4. The nurse identifies environmental, social, and psychological factors that may facilitate or hinder
goal achievement. For example, the nurse could explore the time commitment and types of activities
required for child care and how they affect the patient. Does the patient have support from extended family
members? Can the patient adjust his or her work schedule if necessary? Are there any associated systemic
conditions that may compromise a plan of care, such as renal problems or swollen joints?
5. Step 5. The nurse uses interventions to provide care. The nurse can help with direct care (eg, range-of-
motion exercises, applications of warm compresses, adjustments to the environment). The nurse can
recommend referrals to counselling or agencies that can help provide services. The nurse can help the
family work together to determine a life-long approach to treatment and support.
Chapter 11
Multiple Choice
1. d 6. b 11. a 16. a
2. c 7. c 12. a 17. d
3. b 8. d 13. b 18. d
4. b 9. d 14. d 19. d
5. c 10. c 15. d
Fill-In
1. disability supports, skill development and learning, employment, income, health and well-being, capacity
of the disability community
2. A contracture is a shortening of the muscle and tendon that leads to deformity. Contractures limit joint
mobility.
3. Weakened muscles, joint contractures, and deformity are common complications associated with
prolonged immobility.
4. external rotation of the hip and plantar flexion of the foot (footdrop)
5. prolonged bed rest, lack of exercise, incorrect positioning in bed, and the weight of the bedding
6. three
7. right; right
8. braces, splints, collars, corsets, supports, and calipers
9. sepsis, osteomyelitis, pyarthrosis, and septic shock
10. Eschar does not permit free drainage of the tissue.
Matching
1. e 3. b 5. f
2. a 4. d 6. c
1. For example, define the goal of the activity. The goal would be to demonstrate independent self-care in
bathing/hygiene with assistance. The nurse would assess the home environment and family support and
then design a realistic plan of care for 1 to 2 weeks.
2. Answer may include: impaired physical mobility, activity intolerance, risk for injury, risk for disuse
syndrome, impaired walking, and impaired mobility.
Clinical Situations
Clinical Situation: Impaired Skin Integrity

1. Pressure ulcers are localized areas of infarcted soft tissue that occur when pressure applied to the skin over
time is greater than normal capillary closure pressure, approximately 32 mm Hg.
2. erythema; reactive hyperemia
3. sacrum and heels
4. c
5. b
6. As the body sinks into the fluid, more surface area becomes available for weight-bearing, thus decreasing
body weight per unit area (Pascals law).
7. Increased elevation increases the downward-pulling force of body weight, which increases pressure on the
skin, which results in localized blood flow reduction.
CASE STUDY: Traumatic Amputation-Psychosocial Perspective
1. c 3. b
2. c 4. d
CASE STUDY: Bucks Extension Traction
1. b 3. a
2. a
CASE STUDY: Assisted Ambulation: Crutches
1. b 3. c
2. b 4. b
Chapter 12
Multiple Choice
1. b 8. a 15. d
2. b 9. b 16. c
3. d 10. a 17. c
4. b 11. c 18. d
5. b 12. c 19. b
6. d 13. a 20. a
7. a 14. b
Fill-In
1. 25%
2. 82.1 years
3. Alzheimers disease, stroke, epilepsy, bowel problems, and urinary incontinence
4. cardiovascular diseases, cancer, and respiratory diseases
5. aged 85 and over
6. 70 years
7. memory, abstract reasoning, judgment, and language
8. Pneumonia, urinary tract infections, tuberculosis, gastrointestinal infections, and skin infections
1. The muscles, composed of postmitotic cells, diminish in size and lose strength, flexibility, and endurance
with decreased activity and advanced age.
2. Osteoporosis can be arrested or prevented, but not reversed.
3. If the symptoms of delirium go untreated and the underlying cause is not treated, permanent, irreversible
brain damage or death can occur.
4. It is a myth that older people should avoid vigorous activity. Activity is a desired state in older adults.
5. In the older person, the baseline body temperature is usually lower than in a younger person. Therefore, a
temperature elevation should be considered serious.
Clinical Situations
CASE STUDY: Loneliness

1. d 4. d
2. d 5. d
3. a
CASE STUDY: Alzheimers Disease (Chart 123)
1. a 3. d
2. c 4. d
CASE STUDY: Dehydration
1. d 3. d
2. c 4. d
Chapter 13
Multiple Choice
1. d 8. a 15. c
2. b 9. a 16. b
3. d 10. a 17. d
4. b 11. d 18. d
5. c 12. d 19. c
6. c 13. d 20. d
7. b 14. c
Fill-In
1. duration, location, and etiology
2. nociceptors and chemical mediators
3. histamine, bradykinin, acetylcholine, serotonin, and substance P
4. tachycardia, hypertension, tachypnea, pallor, diaphosesis, mydriasis, hypervigilance, and increased muscle
tone
5. opioids, NSAIDs, and local anesthetics
6. transcutaneous electrical nerve stimulation (TENS) and dorsal spinal cord stimulation.
Crossword Puzzle
4 5
P F
1 1 6
E N D O R P H I N S E A
7
O N W A N I N G
C T X
2 2
H I S T A M I N E A I
C S N E
3
P L A C E B O A Y T
4
C P E P I D U R A L Y
A T D
5
O M A S S A G E
R
6
T E N S
1. Chronic pain is constant or intermittent pain that persists beyond the expected healing time. It is seldom
specific to an injury or cause. It has a poorly defined onset, is difficult to treat, and usually lasts longer than
6 months.
2. The classic Gate Control Theory proposes that stimulation of the skin evokes nervous impulses which are
then transmitted by three systems located in the spinal cord. The noxious impulses are influenced by a
gating mechanism. The concept proposed is that stimulation of the large-diameter fibres inhibits the
transmission of pain, thus closing the gate. Conversely, when smaller fibres are stimulated, the gate is
opened. This mechanism is influenced by nerve impulses that descend from the brain. This theory also
proposes a specialized system of large-diameter fibres that activate selective cognitive processes via the
modulating properties of the spinal gate.
3. Distraction, which involves focusing the patients attention on something other than the pain, reduces the
perception of pain by stimulating the descending control system. This results in fewer painful stimuli being
transmitted to the brain.
Clinical Situations
CASE STUDY: Pain Experience

1. a 3. d
2. c 4. d
Chapter 14
Multiple Choice
1. c 11. b 21. b
2. b 12. b 22. b
3. b 13. c 23. c
4. c 14. c 24. d
5. b 15. c 25. c
6. a 16. c 26. a
7. a 17. a 27. c
8. b 18. b 28. b
9. b 19. d 29. a
10. a 20. c 30. d
Fill-In
1. potassium; sodium
2. Colloidal osmotic pressure refers to the pressure exerted by plasma proteins to hold fluid within vessels. The
osmotic pressure is a pulling force.
3. kidney
4. Calcium levels are primarily regulated by the combined actions of parathyroid hormone and vitamin D.
5. 7.35 to 7.45
6. Blood pH levels incompatible with life are about 6.8 on the lower range and 7.8 on the upper range.
7.
a. Low
b. Low
c. High
d. High
e. High
f. Low
g. High
h. Low
i. Low
j. High
k. High
l. Low
8.
a. Low
b. High
c. Low
d. Low
e. High
f. Low
g. Low
h. Low
i. Low
j. High
k. Low
l. High
9.
a. High
b. Low
c. High
d. High
e. Low
f. High
g. Low
h. Low
10.
a. Low
b. High
c. Low
d. Low
e. Low
11.
a. Low
b. High
c. Low
d. Low
e. High
12.
a. R-acid
b. M-acid
c. M-acid
d. R-acid
e. R-alka
f. R-acid
g. M-acid
h. M-alka
i. M-alka
j. R-alka
13. Intense supervision is required, because only small volumes are needed to elevate the serum sodium from
dangerously low levels.
14. dyspnea, cyanosis, a weak pulse, hypotension, and unresponsiveness
15. infection
1. An early indicator of a third space fluid shift is a decrease in urinary output despite adequate fluid intake.
This occurs because fluid shifts out of the intravascular space. The kidneys, receiving less blood, attempt to
compensate by decreasing urine output.
2. Hydrostatic pressure (pressure exerted by fluid on the walls of the blood vessels) affects the movement of
fluids through the capillary walls of the blood vessels. Osmotic pressure is pressure exerted by proteins in
the plasma. Both pressures help maintain a high extracellular concentration of sodium and a high
intracellular concentration of potassium.
3. The usual daily urine output is 1.0 L/kg of body weight, per hour. The per-hour output would be: 50 kg (50
mL), 60 kg (60 mL), and 80 kg (80 mL).
1. Osmosis is the movement of fluid, through a semipermeable membrane, from an area of low solute
concentration to an area of high solute concentration until the solutions are of equal concentration.
Example: the oncotic pressure of plasma proteins (albumin).
Diffusion is the movement of a substance from an area of higher concentration to one of lower
concentration. Example: the exchange of oxygen and carbon dioxide between the pulmonary capillaries
and the alveoli.
Filtration is the movement of water and solutes from an area of high hydrostatic pressure to an area of low
hydrostatic pressure. Example: the filtration of water and electrolytes by the kidneys.
2. Refer to Figure 142 for an illustration of the interdependence of multiple factors.
3. Three Column Matching
1. d a. V
2. e b. IV
3. f c. III
4. a d. II
5. b e. VI
6. c f. I
Clinical Situations
CASE STUDY: Extracellular Fluid Volume Deficit

1. b 3. a
2. b 4. b
CASE STUDY: Congestive Heart Failure
1. b 3. d
2. d 4. b
CASE STUDY: Diabetes Mellitus
1. a 3. a
2. a 4. c
Chapter 15

Multiple Choice
1. c 8. d 15. a
2. d 9. b 16. d
3. b 10. c 17. d
4. d 11. a 18. a
5. d 12. b 19. a
6. b 13. d 20. d
7. d 14. d 21. d
Scramblegram
1. shock 9. dopamine
2. ATP 10. septic
3. renin 11. CVP
4. ADH 12. pulmonary edema
5. hypoxemia 13. colloids
6. preload 14. lungs
7. oliguria 15. Nipride
8. albumin
8 12 6 3
D A O L E R P B D F H R
B L C F I L U M P R E T
15
C B A J A R L D G N H G
Y U D K S E M J I L F K
7
L M G W F B O N E D N O
14
M I S P T G N S G N U L
A N D T C R A R M I H I
4 2 9
I V I A D H R I R P D G
M L O R O C Y P J R K U
E A L T P X E L S I O R
X C L B A I D M N D M I
1
O S O K M W E S O E P A
13 11
P V C O I L M A H K I F
Y R A Q N F A N T O C P
5 10
H T R C E S E P T I C J
C K G P N W T U C M B K
F H J M E S B M E D I A
H A D G K O R H L O B F
Matching
1. c 6. d
2. a 7. c
3. a 8. b
4. e 9. b
5. f 10. e
Flow Chart: Hypovolemic Shock
intravascular volume from hemorrhage or severe dehydration results in

(venous blood return and (ventricular filling which causes
(stroke volume and (cardiac output which leads to
(blood pressure and
inadequate tissue perfusion
Clinical Situations
CASE STUDY: Hypovolemic Shock

1. c 6.
2. 20 a. colloids, Ringers lactate, and normal saline
3. rise, decline b. elevating the lower extremities at a 20-degree angle
4. 90 c. keeping the patient warm
5. 30 d. providing supplemental oxygen therapy as ordered
e. maintaining strict intake and output measurements
CASE STUDY: Septic Shock
1. Escherichia coli 4. aggressive fluid replacement, antibiotic
2. 40% and 90% pharmacotherapy, crystalloids, and colloids
3. urine, blood, sputum, and wound 5. cardiovascular overload and pulmonary edema
drainage 6. 38 cm H2O
Chapter 16

Multiple Choice
1. b 9. b 16. a
2. d 10. c 17. d
3. d 11. b 18. d
4. d 12. a 19. a
5. c 13. d 20. a
6. a 14. b 21. d
7. d 15. a 22. d
8. c
Fill-In
1. Anaplasia. Cells that lack normal cellular 5. Metastasis. The spread of cancer cells from the
characteristics and differ from other cells in shape primary tumour to distant sites.
and organization. Anaplastic cells are usually 6. Nadir. The lowest point of white blood cell
malignant. depression.
2. Alopecia. Hair loss. 7. Vesicant. A substance that can cause tissue
3. Carcinogenisis. The process of transforming necrosis.
normal cells into malignant cells. 8. Xerostomia. A dry oral cavity caused by
4. Cytokines. Substances produced by immune dysfunction of the salivary glands.
system cells to enhance the immune system.
Fill-In
1. Men: lung, prostate, and colorectal area. Women: 5. Answer may include cabbage, broccoli,
lung, breast, and colorectal area. cauliflower, brussels sprouts, and kohlrabi.
2. Invasion: The growth of the primary tumour into 6. Primary prevention is concerned with reducing
surrounding host tissues in a variety of ways. the risk or preventing the development of cancer
Metastasis: Direct spread of tumour cells to body in healthy people. Example: Teaching people the
cavities or through lymphatic and blood importance of stopping smoking to decrease the
circulation. incidence of lung cancer.
3. carcinoembryonic antigen (CEA) and prostate- Secondary prevention involves detection and
specific antigen (PSA) screening efforts to achieve early diagnosis and
4. 85 prompt intervention to halt the cancerous
process. Example: Teaching principles of breast cell cycle phases, which lead to cell damage
self-examination to facilitate the early detection of or death.
breast cancer. 10. An extravasation of an infusion of a cancer
7. Cure implies complete eradication of malignant chemotherapeutic agent is believed to have
disease. Control strives for prolonged survival with occurred if there is redness, pain, swelling, a
the presence of malignancy. Palliation implies mottled appearance, phlebitis, loss of blood return,
relief of symptoms associated with the cancerous resistance to flow, tissue necrosis, or damage to
disease. underlying tendons, nerves, and blood vessels.
8. a. Skin: alopecia, erythema, desquamation 11. Hyperthermia, the generation of temperatures
b. Oral mucosal membrane: xerostomia, greater than physiologic fever range, elicits
stomatitis, decreased salivation, loss of taste tumouricidal effects by irreparably damaging the
c. Stomach or colon: anorexia, nausea, vomiting, DNA and cell membranes, by increasing cellular
diarrhea metabolic demands to which the cancer cells are
d. Bone marrow producing sites: anemia, not able to respond, and by stimulating the bodys
leukopenia, and thrombocytopenia immune system.
9. Cell cyclespecific agents destroy cells in 12. Interferons are biologic response modifiers
specific phases of the cell cycle by interfering (BRMs), with antiviral and antitumour properties
with DNA and RNA synthesis or by halting that stimulate an immune response. It is believed
mitosis. Cell cyclenonspecific agents exert that the stimulated immune system will eradicate
prolonged effects on cells, independent of the malignant growth.
Matching
1. b 4. b
2. a 5. b
3. a
Matching
1. e 6. b
2. c 7. d
3. a 8. a
4. f 9. c
5. a 10. e
1. detection and screening for an early diagnosis and treatment

2. tumour cell classification
3. a donor from an identical twin
4. the thinning or complete loss of hair
5. appetite failure resulting in a wasting syndrome
Clinical Situations
CASE STUDY: Cancer of the Breast

1. b 6. c
2. d 7. a
3. a 8. d
4. d 9. b
5. d
CASE STUDY: Cancer of the Lung
1. d 5. a. answer questions and concerns
2. disease progression, immune competence, b. identify resources and support persons
increased incidence of infection, delayed tissue c. communicate and share concerns
repair, and diminished functional ability d. help frame questions for the physician
3. fear, apprehension, fatigue, anger, and social 6. infection
isolation 7. Pseudomonas aeruginosa and Escherichia coli
4. c 8. b
Chapter 17
Multiple Choice
1. b 4. b 7. d
2. c 5. d 8. d
3. b 6. d
Fill-In
1. Kbler-Ross 5. Hospice care is a coordinated program of

2. Assisted suicide refers to providing another person interdisciplinary services provided by professional
the means to end his or her own life. Physician- caregivers and trained volunteers to patients with
assisted suicide involves a prescription by a serious, progressive illnesses that are not
physician of a lethal dose of medication to end life. responsive to curative treatments.
3. Expressively prohibited. 6. Decadron (dexamethasone), Periactin
4. Palliative care does not focus primarily on prep- (cyproheptadine), Megace (megestrol), and
aration for death as does hospice care. Marinol (dronabinal).

1. Refer to Chart 172 as an outline for discussion and analysis.
2. Response is individualized.
3. Refer to Table 174 as resource to personalize your responses.
Chapter 18

Multiple Choice
1. a 10. a 19. a
2. d 11. d 20. a
3. a 12. b 21. d
4. d 13. a 22. d
5. c 14. d 23. a
6. a 15. d 24. c
7. a 16. d 25. c
8. a 17. c
9. c 18. a
Fill-In
1. perioperative period
2. begins when the patient is transferred to the operating room table and ends when the patient is admitted to
the PACU
3. when it is invasive, requires anesthesia, involves radiation, and/or has more than a slight risk of potential harm
4. dehydration, hypovolemia, and electrolyte imbalances
5. improve circulation, prevent venous stasis, and promote optimal respiratory function
6. Food is withheld before surgery to prevent aspiration, which has a 60% to 70% mortality rate.

For assistance in completing this exercise about the effects of prior drug therapy, see textbook pages 409410.
For assistance in completing this matching exercise about preoperative nursing interventions, see pages
413418.
Sample
Column I: Nursing Activity Column II: Nursing Goal

Restriction of nutrition and fluids Prevent aspiration
1. About 60% of surgeries are performed on an outpatient basis despite the use of advanced technology.
2. The intraoperative phase of perioperative nursing ends when the patient is admitted to the recovery area or
PACU.
3. Cosmetic surgery is based on personal choice and is, therefore, classified as optional.
4. Vitamin C is needed for collagen synthesis; vitamin K is used for clotting and prothrombin production.
5. Corticosteroids should never be abruptly discontinued before surgery because cardiovascular collapse may
occur.
Clinical Applications
1. Lean forward slightly from a sitting position. Interlace fingers together. Place hands across the incisional site
to supply a splint-like support.
2. Breathe with the diaphragm.
3. Open mouth slightly and breathe in fully.
4. Hack out sharply using three short breaths.
5. Keep the mouth open, take in a quick deep breath, and immediately cough strongly once or twice.
Chapter 19

Multiple Choice
1. b 4. d 7. c
2. d 5. d 8. a
3. a 6. b 9. d
10. d 12. c 14. b
11. b 13. d
Fill-In
1. Anesthesia is reduced with age because the percentage of fatty tissue increases. Fatty tissue has an affinity
for anesthetic agents.
2. Answer should include four of these five: handling tissue, providing exposure at the operative field, using
instruments, suturing, and providing hemostasis.
3. moderate sedation; Versed and Valium
4. thiopental sodium (Pentothal), respiratory depression
5. the subarachnoid space at the lumbar level (usually at L2)
6. epidural
7. Complete return of sensation in the patients toes, in response to a pinprick, indicates recovery.
8. nausea and vomiting, anaphylaxis, hypoxia, hypothermia, malignant hypothermia, and disseminated
intravascular coagulation (DIC)
9. 50%
II. Critical Analysis Questions

1. Older patients require less anesthesia and take longer to eliminate anesthetic drugs.
2. The circulating nurse controls the environment, coordinates the activities of other personnel, and monitors
aseptic techniques.
3. Whenever sterility is in question, an item is considered unsterile.
4. Only the top of a table that is draped is considered sterile. Drapes hanging over the edge are clean but not
sterile.
5. The unsterile arm of the circulating nurse should never extend over a sterile area.
Clinical Situations
CASE STUDY: General Anesthesia
1. b 3. b
2. b
CASE STUDY: Intravenous Anesthesia
1. d 3. b
2. a
Chapter 20

Multiple Choice
1. c 6. c 11. b
2. d 7. a 12. c
3. d 8. d 13. c
4. a 9. a 14. d
5. d 10. c 15. d
16. a 19. d 22. d
17. d 20. a 23. c
18. c 21. d
Fill-In
1. The answer may include any of the following:

Medical diagnosis
Type of surgery performed
Patients general condition: age, airway patency, vital signs
Anesthetic and other medications used
Any intraoperative problems that might influence postoperative care (shock, hemorrhage, cardiac arrest)
Any pathology encountered
Fluid administered, blood loss and replacement
Tubing, drains, catheters, or other supportive aids
Specific information about which surgeon or anesthesiologist wishes to be notified
2. Respiratory function and patency of the airway
3. Primary hemorrhage occurs at the time of the operation. Intermediary hemorrhage occurs within the first
few hours after an operation and is caused by the return of blood pressure to its normal level. Secondary
hemorrhage occurs some time after the operation as a result of the slipping of a ligature, which may happen
because of infection, insecure tying, or erosion of a vessel by a drainage tube.
4. respiratory
5. self-perception, personality, learning, ethnic and cultural factors, and environment
6. Patient-controlled analgesia refers to self-administration of pain medication by way of intravenous or

epidural routes within prescribed time/dosage limits.
7. Atelectasis and hypostatic pneumonia are reduced with early ambulation because ventilation is increased
and the stasis of bronchial secretions in the lungs is reduced.
8. absence of nausea, absence of vomiting, and presence of bowel sounds
9. bowel sounds and the passage of flatus
1. The nurse should tilt the postoperative patients head back and push forward on the angle of the lower jaw.
This manoeuvre pulls the tongue forward and closes the air passages.
2. Refer to pages 448449 for a list of 12 possible nursing diagnoses.
3. The respiratory depressive effects of opioids, decreased lung expansion secondary to pain, and decreased
mobility are three conditions that put patients at risk for atelectasis, pneumonia, and hypoxemia.
Applying Concepts
CASE STUDY: Postoperative Pain

Pain stimulates the stress response, which increases muscle tension and local vasoconstriction.
Noxious impulses stimulate sympathetic activity, which increases myocardial demand and oxygen consumption.
Hypothalmic stress responses increase blood viscosity and platelet aggregation, which can lead to
phlebothrombosis and pulmonary embolism.
Benedetti (1992) found that cardiovascular insufficiency can be three times more frequent and infection
five times greater with inadequate postoperative control.
Clinical Situations
CASE STUDY: Hypovolemic Shock

1. b 3. a 5. b
2. b 4. a
CASE STUDY: Hypopharyngeal Obstruction

1. d 3. d
2. b 4. c
CASE STUDY: Wound Healing

1. b 3. d
2. a 4. b
Illustration Interpretation: Phlebothrombosis

1. The nurse is gently palpating the calf muscle for tenderness.
2. To assess for the presence of Homans sign, the nurse would ask the patient to flex his knee and dorsiflex
his foot. Calf pain is an early sign of phlebothrombosis.
3. Phlebothrombosis is blood clotting in a vein without marked inflammation.
4. The nurse assesses for calf swelling in the affected leg by measuring calf circumference in both legs and
comparing the results.
Chapter 21
I. Interpretation, Completion and Comparison
Multiple Choice
1. d 3. c 5. c
2. b 4. a 6. a
7. b 15. c 23. a
8. b 16. a 24. a
9. b 17. d 25. b
10. d 18. c 26. b
11. b 19. d 27. c
12. a 20. d 28. d
13. b 21. a 29. d
14. d 22. d
Fill-In
1. Ventilation refers to the movement of air in and out of the airways, whereas respiration refers to gas
exchange between atmospheric air and blood and between the blood and the cells of the body.
2. The epiglottis is a flap of cartilage that covers the opening of the larynx during swallowing.
3. Compliance refers to the ability of the lungs and thorax to stretch and distend with ventilation. Low or
decreased compliance exists with certain pathology, such as atelectasis, pneumothorax, hemothorax, and
pulmonary fibrosis.
4. The apneustic centre in the lower pons and the pneumotaxic centre in the upper pons
5. age 50 years
6. Cheyne-Stokes respirations are characterized by alternating episodes of apnea (cessation of breathing) and
periods of deep breathing. It is usually associated with heart failure and damage to the respiratory center.
Clinical Situations
CASE STUDY: Bronchoscopy
1. c 4. d
2. d 5. a
3. b
CASE STUDY: Thoracentesis
1. d 4. d
2. b 5. c
3. b
Interpreting Data
Reference pages for an explanation of the oxyhemoglobin dissociation curve are pages 474475, Chart 214.
Chapter 22
Multiple Choice
1. a 4. a 7. a
2. d 5. a 8. d
3. c 6. d 9. d
10. a 15. d 19. a
11. c 16. b 20. b
12. d 17. d 21. d
13. a 18. b 22. d
14. a
Fill-In
1. Rhinitis causes the nasal passages to become inflamed, congested, and edematous. The swollen conchae
block the sinus openings and cause sinusitis.
2. Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.
3. viral; symptoms include hoarseness, aphonia, and severe cough.
4. Complications may include sepsis, a peritonsillar abscess, otitis media, sinusitis, and meningitis.
5. Obstructive sleep apnea is defined as frequent loud snoring and breathing cessation for 10 seconds or
longer with five or more episodes per hour. This is followed by awakening abruptly with a loud snort when
the blood oxygen level drops.

Clinical Situations
CASE STUDY: Tonsillectomy and Adenoidectomy

1. d 3. a
2. c 4. c
CASE STUDY: Epistaxis
1. Gilberta should sit upright with her head tilted 2. d
forward to prevent swallowing and aspiration of 3. b
blood. She should also pinch the soft outer 4. d
portion of the nose against the midline spectrum
for 5 to 10 continuous minutes.
CASE STUDY: Laryngectomy
1. b 4. d
2. d 5. d
3. d
Chapter 23

Multiple Choice
1. d 12. d 23. c
2. a 13. a 24. a
3. c 14. a 25. a
4. d 15. d 26. a
5. d 16. c 27. a
6. c 17. a 28. b
7. a 18. d 29. a
8. a 19. b 30. b
9. c 20. b 31. c
10. d 21. d
11. d 22. b
Fill-In
1. Answer should include at least 10 possible causes found on pp. 521522.

2. Answer should include at least 10 pathogenic mechanisms found on p. 522, Fig. 231.
3. Reduced alveolar ventilation impedes the passage of air into and from the alveoli. Trapped air is absorbed
into the bloodstream and additional or replacement air cannot be absorbed. Therefore, an isolated portion
of the lung shrinks.
4. cough, sputum production, low-grade fever, dyspnea, tachycardia, tachypnea, pleural pain, and central
cyanosis
5. frequent turning, early mobilization, deep breathing manoeuvres, assistance with the use of spirometry,
suctioning, postural drainage, aerosol nebulizer treatments, and chest percussion.
6. impaired host defenses, an inoculum of organisms that reach the lower respiratory tract, and the presence
of a highly virulent organism.
7. hypotension, shock, and respiratory failure
8. Superinfection is suspected when a subsequent infection occurs with another bacteria during antibiotic
therapy.
9. M. tuberculosis
10. alveolar hypoventilation, diffusion abnormalities, ventilation-perfusion mismatching, and shunting.

1. The pathophysiology of pneumonia
Inflammation in alveoli Neutrophils fill alveoli
Exudate formation r Partial occlusion of alveoli and
u
w bronchi decrease
u
q alveolar oxygen tension
Interference with diffusion of r Bronchospasm and hypoventilation
u
oxygen and carbon dioxide w ventilation-perfusion mismatch
u
q arterial hypoxemia
2. The pathophysiology of acute respiratory distress syndrome (ARDS)
Inflammatory event
Alveolar collapse
Release of cellular and chemical mediators
Airways narrow with bronchial obstruction
Injury to alveolar capillary membrane
Stiff lungs and hypoxemia
Leaks fluid into alveolar interstitial spaces
Clinical Situations
CASE STUDY: Community-Acquired Pneumonia

1. d 4. d
2. b 5. b
3. d 6. d
CASE STUDY: Tuberculosis
1. b 4. b
2. b 5. c
3. d
CASE STUDY: Acute Respiratory Distress Syndrome (ARDS)
1. d 4. d
2. d 5. d
3. c
CASE STUDY: Pulmonary Embolism
1. c 4. b
2. a 5. c
3. b 6. d
Chapter 24

Multiple Choice
1. d 11. b
2. d 12. d
3. d 13. c
4. d 14. a
5. b 15. c
6. b 16. c
7. d 17. d
8. d 18. c
9. b 19. d
10. d 20. d
Fill-In
1. narrowing of the small peripheral airways.
2. Emphysema is an abnormal distention of the air spaces, beyond the terminal bronchioles, that results in
destruction of the walls of the alveoli.
3. cigarette smoking
4. a deficicency in -antitrypsin
5. cough, sputum production, and dyspnea on exertion
6. cessation of smoking
7. tracheobronchial infection and air pollution
8. hypoxemia stimulates respiration
9. asthma
10. status asthmaticus, respiratory failure, pneumonia, and atelectasis
The pathophysiology of chronic bronchitis

Smoke and environmental pollutants irritate the airways
hypersecretion of mucus
inflammation
Reduced ciliary function
increased goblet cells
increased mucus production
Bronchial wall thickening
bronchial lumen narrowing
airway plugging with mucus
Adjacent alveoli may become damaged and fibrosed
alters function of alveolar macrophages
increased susceptibility
Respiratory infections (viral, bacterial, and mycoplasmal)
The pathophysiology of emphysema

Alveolar walls are destroyed, causing an increase in dead space r impaired oxygen diffusion
u
w
u hypoxemia
q
In later stage emphysema, carbon dioxide elimination is r hypercapnia

impaired u
w
u
q respiratory acidosis
As the alveolar walls break down, the pulmonary capillary bed is reduced, causing increased pulmonary
blood flow
right-sided heart failure r congestion

u
w
u
q dependent edema
Cardiac failure
Panlobular Centrilobular
destruction of respiratory bronchiole, alveolar duct, altered ventilation-perfusion ratios
and alveoli
chronic hypoxemia
minimal inflammatory disease
hypercapnia, polycythemia, and right-sided
hyperinflated chest barrel chest heart failure
dyspnea on exertion central cyanosis, peripheral edema, and
respiratory failure
weight loss
Clinical Situations
CASE STUDY: Emphysema

1. c 4. d
2. b 5. b
3. a 6. d
Chapter 25
Multiple Choice
1. a 11. c 20. d
2. b 12. d 21. c
3. a 13. d 22. a
4. b 14. d 23. c
5. d 15. a 24. d
6. d 16. c 25. c
7. b 17. a 26. b
8. c 18. d 27. d
9. d 19. a 28. d
10. a
Fill-In
1. cardiac output, arterial oxygen content, 7. inflating the lungs by exerting pressure on the
hemoglobin concentration, and metabolic airway, forcing the alveoli to expand during
requirements inspiration
2. 21% 8. A patient bucks the ventilator when his or her
3. 80% to 98% breathing is out of phase with the machine. This
4. decreased blood oxygen rather than elevated occurs when the patient attempts to breathe out
carbon dioxide levels during the ventilators mechanical inspiratory
5. nasal cannula, simple mask, partial-rebreather, phase or when there is jerky and increased
and nonrebreather abdominal muscle effort.
6. 68 L/min
Complete the chart on a disposable chest drainage system.
Vent
To suction Vent to
From patient source or air room air
30
20
SUCTION
LEVEL 10
2500
Drainage
500
collection
5
2400
FILL LINE 0 2300
450
2200
350
2100
2000
chambers
300
1900
1800
1700
20
250
2500ml
1600
1500
1400
cm
200 Collection Unit
1300
1200
150
100
1100
1000
900
250
50
800
700
600
mm
Water seal
Suction control
Clinical Solutions
CASE STUDY: Pneumonectomy: Preoperative Concerns

1. d 3. d 4. a
2. a
CASE STUDY: Pneumonectomy: Postoperative Concerns
1. a 3. d 4. a
2. b
CASE STUDY: Ventilator Patient
1. d 3. d 4. d
2. a
CASE STUDY: Weaning From Ventilator
1. d 2. d 3. d
Chapter 26
Multiple Choice
1. a 6. d 10. a
2. a 7. d 11. b
3. d 8. c 12. d
4. d 9. a 13. d
5. c
Fill-In
1. The atrioventricular (AV) valves separate the atria from the ventricles. The tricuspid separates the right
atrium and ventricle; the bicuspid separates the left atrium and ventricle. The AV valves permit blood to
flow from the atria into the ventricles. The semilunar valves are situated between each ventricle and its
corresponding artery. The pulmonic valve is between the right ventricle and the pulmonary artery; the
aortic valve is between the left ventricle and the aorta. These valves permit blood to flow from the ventricles
into the arteries.
2. Depolarization is said to have occurred when the electrical difference between the inside and the outside
of the cell is reduced. The inside of the cell becomes less negative, membrane permeability to calcium is
increased, and muscle contraction occurs.
3. Cardiac output would equal 5320 mL.
4. Starlings law of the heart refers to the relationship between increased stroke volume and increased
ventricular enddiastolic volume for a given intrinsic contractility.
5. Physiologic effects of the aging process may include reduction in the size of the left ventricle, decreased
elasticity and widening of the aorta, thickening and rigidity of cardiac valves, and increased connective
tissue in the sinoatrial and atrioventricular nodes and bundle branches.
6. Creatine kinase (CK) and isoenzyme CK-MB; troponin I (cTnI)
7. Cardiac catheterization is used most frequently to assess the patency of the patients coronary arteries and
to determine readiness for coronary bypass surgery. It is also used to measure pressures in the various heart
chambers and to determine oxygen saturation of the blood by sampling specimens.
8. Selective angiography refers to the technique of injecting a contrast medium into the vascular system to
outline a particular heart chamber of blood vessel.
9. A lowered central venous pressure reading indicates that the patient is hypovolemic. Serial measurements
are more reflective of a patients condition and should be correlated with the patients clinical status.
10. Complications of pulmonary artery monitoring may include infection, pulmonary artery rupture, pulmonary
thromboembolism, pulmonary infarction, catheter kinking, dysrhythmias, and air embolism.
Matching
1. c 2. e 3. a
4. d 5. b 6. f
Crossword Puzzle
References: use pages throughout the chapter
1 2
C S
H M
3 4
O M A L E O
5
L T L K
6
E H I D I E T
7
S C H E S T P A I N
8
T R I A G E
9 10
E S O D B O
11
D Y S R H Y T H M I A S E B
12
O R A S T Y L E
13
L U M E N S E S
14
S F S I
S A T
15
I N A C T I V I T Y
Analyzing Comparisons
1. the remainder of the body 4. the aortic and pulmonic valves

2. myocardium 5. abrasion of the pericardial surfaces
3. third intercostal space
Reference pages 661662 and Table 262.
Interpreting Data
Myocardial Infarction Angina Pectoris

Assessment Substernal pain or pain over Substernal or
precordium. May spread widely retrosternal pain
throughout chest. Painful spreading across
disability of shoulders and chest. May
hands may be present. radiate to inside of
arm, neck, or jaws.
Pain lasting longer than Pain lasting 5 to 10
15 minutes minutes
Precipitating events Occurs spontaneously but may be Usually related to
sequelae of unstable angina exertion, emotion,
eating, or cold
Nursing interventions Morphone sulfate, successful Rest, nitroglycerin,
reperfusion of blocked coronary oxygen
artery
CASE STUDY: Cardiac Assessment for Chest Pain

1. c 3. c 5. b
2. d 4. d
Chapter 27
Multiple Choice
1. d 8. d 15. d
2. b 9. c 16. c
3. c 10. b 17. a
4. b 11. a 18. d
5. d 12. d 19. d
6. a 13. c
7. b 14. d
Fill-In
1. atria, atrioventricular node or junction, sinus node, and ventricles

2. Electrical conduction through the heart begins in the sinoatrial node (SA), travels across the atria to the
atrioventricular node (AV), and then travels down the right and left bundle branches and Purkinje fibres
to the ventricular muscle.
3. Sinus tachycardia can be caused by any of the following: fever, hypovolemia, anemia, exercise, pain,
congestive heart failure, anxiety, and sympathomimetic or parasympatholytic drugs.
4. 100 beats per minute
5. more than three PVCs in a row and a rate exceeding 100 beats per minute
6. a thromboembolic event, heart failure, and cardiac arrest
7. A demand pacemaker is set for a specific rate and stimulates the heart when normal ventricular
depolarization does not occur; the fixed-rate pacemaker stimulates the ventricle at a preset constant rate,
independently of the patients rhythm.
8. The standard procedure is to place one paddle to the right of the upper sternum below the right clavicle
and the other paddle just to the left of the cardiac apex.
Unscrambled Words
1. dysrhythmic 4. depolarization
2. automaticity 5. diastole
3. conductivity
Graph Analysis
1. a. T wave d. QRS complex
b. P-R interval e. ST segment
c. P wave
2. a. Q wave is larger. c. T wave is inverted.
b. ST segment is elevated.
Graphic Recordings
1. Premature atrial complexes (PACs): P waves 3. Ventricular tachycardia: Three or more PVCs in
come early in cycle and close to T wave of previous a row, occurring at a rate 100 beats/minute
heartbeat.
2. Premature ventricular complexes (PVCs): QRS
complex is bizarre. P waves are hidden in QRS
complexes.
Clinical Situations
CASE STUDY: Permanent Pacemaker

1. Yes. Heart rate can vary as much as five beats 4. dislodgment of the pacing electrode
above or below the preset rate. 5. (a) pacemaker model, (b) date and time of
2. bleeding, hematoma formation, and infection insertion, (c) stimulation threshold, (d) pacer
3. hemothorax, ventricular ectopy and tachycardia, rate, (e) incision appearance, (f) patient
dislocation of the lead and phrenic nerve, tolerance
diaphragmatic or skeletal muscle stimulation
6.
Goals Nursing Activities Expected Outcomes
a. absence of infection a. sterile wound care a. free from infection
b. adherence to a self-care program b. patient teaching b. adheres to a self-care program
c. maintenance of pacemaker function c. patient teaching c. maintains pacemaker function
7. a. has a normal temperature, white blood cells c. assesses pulse rate at regular intervals and
within normal range, and no evidence of experiences no abrupt changes in pulse rate
redness or swelling at insertion site or rhythm
b. understands sign and symptoms of infection
and knows when to seek medical attention
Chapter 28
Multiple Choice
1. b 11. a 21. d
2. d 12. b 22. b
3. a 13. b 23. d
4. c 14. a 24. a
5. d 15. b 25. d
6. c 16. c 26. b
7. a 17. d 27. b
8. d 18. c 28. c
9. a 19. d 29. a
10. c 20. c 30. d
Fill-In
1. coronary artery disease 6. 30%

2. chest pain 7. severe and incapacitating
3. Age, more than 50% are older than 65 years of age 8. Transmyocardial laser revascularization (TLM)
4. Four modifiable risk factors are: abnormal diverts blood flow into temporary channels, thus
cholesterol levels, cigarette smoking, decreasing ischemia and creating new blood
hypertension, and diabetes mellitus. vessels.
5. Blood cholesterol should be less than 200 mg/dL, 9. Answer should include five of the following: fever,
and the LDL-to-HDL ratio should be 3.5:1.0. The pericardial pain, pleural pain, dyspnea,
LDL level should be less than 160 mg/dL and the pericardial effusion, pericardial friction rub, and
HDL level greater than 35 mg/dL. arthralgia.

1. Cigarette smoking contributes to coronary heart disease in three ways. Smoke inhalation increases the level
of blood carbon monoxide by causing hemoglobin to combine more readily with carbon monoxide than
with oxygen. Nicotinic acid triggers the release of catecholamines, which raise heart rate and blood
pressure and cause the coronary arteries to constrict. Smoking causes a detrimental vascular response and
increases platelet adhesion, increasing the probability of thrombus formation.
2. Recent research studies do not support the use of hormone replacement therapy as an effective means of
preventing coronary artery disease. Its use has been associated with an increased risk of breast cancer,
deep vein thrombosis, and pulmonary embolism.
1. the profile of those at highest risk for a cardiac event in 10 years

2. metabolic syndrome, a significant risk factor for coronary artery disease
3. factors, weighted by points, that indicate increased risk of having a cardiac event
4. modified risk factors for coronary artery disease
5. four primary factors of fat metabolism that affect the development of heart disease
Identifying Patterns
1. Arterial lumen narrowing begins with the deposit of fatty streaks (lipids) on the intima (inner vessel wall).
Some develop into advanced lesions as atherosclerosis advances. An inflammatory response occurs, and
T lymphocytes and monocytes infiltrate the area and ingest lipids and die. Smooth muscle cells then
proliferate, and form a fibrous cap around a dead fatty core. These deposits narrow and obstruct blood
flow.
2. a fatty thickening or degeneration of the walls of the arteries that results from an atherosclerotic response to
lipid deposits.
3. the formation of a thrombus
4. obstructed blood flow; cause an acute myocardial infarction or result in sudden death.
1. (a) Hemoglobin combines more readily with CO than with O2, thereby limiting the oxygen being supplied to
the heart. (b) Nicotine triggers the release of catecholamines, which cause arterial constriction and decreased
oxygenation. (c) Smoking increases platelet adhesion, which increases thrombus formation.
2. Calcium ion blockers increase myocardial oxygen supply (a) by dilating the smooth muscle wall of the
coronary arterioles, (b) by decreasing myocardial oxygen demands, and (c) by decreasing systemic arterial
pressure.
Clinical Situations
CASE STUDY: Angina Pectoris

1. b 3. b
2. c 4. c
CASE STUDY: Decreased Myocardial Tissue Perfusion
1. c 4. b
2. a 5. a
3. a 6. d
Chapter 29
Multiple Choice
1. d 6. d 11. a
2. b 7. c 12. d
3. c 8. a 13. a
4. a 9. c 14. a
5. a 10. a
Fill-In
1. Mitral valve prolapse syndrome is a dysfunction 2. caffeine, alcohol, and smoking

of the mitral valve leaflets, that results in valve 3. at the third and fourth intercostal spaces at
incompetency and regurgitation. Valve dysfunction the left sternal border; a blowing diastolic
progresses, and symptoms of heart failure ensue. murmur
4. prophylactic antibiotics
5. Answer should include four of the following: 9. Myocarditis is an inflammatory process that
congestive heart failure, ventricular dysrhythmias, usually results from an infection. The infectious
atrial dysrhythmias, cardiac conduction defects, process can cause heart dilation, thrombi
pulmonary or cerebral embolism, and valvular formation, infiltration of blood cells around the
dysfunction. coronary vessels and between the muscle fibres,
6. penicillin therapy; rheumatic fever and eventual degeneration of the muscle fibres
7. An inflamed endothelium causes a fibrin clot to themselves.
form (vegetation), which converts to scar tissue 10. Listen at the left sternal edge of the thorax in the
that thickens, contracts, and causes deformities. fourth intercostal space where the pericardium
The result is leakage or valvular regurgitation and comes in contact with the left chest wall.
stenosis.
8. streptococci, enterococci, pneumococci, and
staphylococci
Matching
1. a 4. b
2. e 5. c
3. d
1. On auscultation, an extra heart sound will be heard. This mitral click is an early sign that the valve leaflet is
ballooning into the left atrium. Sometimes a murmur can be heard if the valve leaflet has stretched and
regurgitation has occurred.
2. Left ventricular hypertrophy develops with mitral valve insufficiency because incomplete valve closure
allows a regurgitation of blood from the left ventricle to the atrium during ventricular systole. This
regurgitated blood is returned to the left ventricle, increasing the volume of blood that the left ventricle
must handle. Hypertrophy of the left atrium and the left ventricle develops.
3. In aortic regurgitation, blood from the aorta returns to the left ventricle during diastole. Left ventricular
dilation occurs. Left ventricular hypertrophy occurs, raising systolic blood pressure. Reflex vasodilation
results as a compensatory measure. Peripheral arterioles relax reducing peripheral resistance and diastolic
blood pressure.
4. The characteristic sound is a systolic crescendo-decrescendo murmur which is low-pitched, rough, rasping,
and vibrating.
5. All cardiomyopathies result in impaired cardiac output. The decrease in stroke volume stimulates the
sympathetic nervous system and the renin-angiotensin-aldosterone response, resulting in increased systemic
vascular resistance and increased sodium and fluid retention.
Mitral valve stenosis
resistance to aortic blood flow through narrowed orifice
dilation and hypertrophy of the left atrium
congested pulmonary circulation
excessive strain on the right ventricle
Right ventricular failure
Clinical Situations
CASE STUDY: Infective Endocarditis

1. toxicity of the infection, heart valve destruction, 4. total eradication of the invading organism
or embolization of fragments of vegetative growth 5. c
on the heart 6. congestive heart failure, strokes, valvular
2. a stenosis, and myocardial erosion
3. headache, transient cerebral ischemia, focal 7. d
neurologic lesions, and strokes
CASE STUDY: Acute Pericarditis
1. a 5. left sternal edge in the fourth intercostal space
2. Pain related to inflammation of the pericardium 6. freedom from pain and absence of
3. d complications
4. analgesics, antibiotics, and corticosteroids
Chapter 30
Multiple Choice
1. a 9. a 17. d
2. a 10. d 18. b
3. d 11. a 19. a
4. b 12. d 20. c
5. b 13. d 21. a
6. c 14. b 22. b
7. d 15. b 23. c
8. a 16. d
Matching
1. a 6. a
2. b 7. a
3. a 8. b
4. b 9. a
5. b 10. b
Fill-In
1. Preload is the amount of myocardial stretch 5. coronary artery disease, cardiomyopathy,

created by the volume of blood within the hypertension, and valvular disorders
ventricle before systole. Afterload refers to the 6. symptomatic hypotension, hyperuricemia,
amount of resistance to the ejection of the blood ototoxicity, and electrolyte imbalances
from the ventricle. 7. (a) weak pulse, (b) faint heart sounds,
2. Cardiac output equals the heart rate times the (c) hypotension, (d) muscle flabbiness,
stroke volume (the amount of blood pumped out (e) diminished deep tendon reflexes, and
with each contraction). (f) generalized weakness
3. venous return and ventricular compliance
4. jugular venous distention and mean arterial
blood pressure
Pathophysiology of Pulmonary Edema
Decreased left ventricular pumping
Elevated left ventricular Decreased blood flow

from left atrium to left
End-diastolic pressure ventricle
Increased pressure in the left atrium
Increased pulmonary venous pressure
Increased hydrostatic pressure
Forces fluid from the pulmonary capillaries into interstitial spaces and the alveoli
Impaired gas exchange Severe hypoxemia
Death if not treated
Clinical Situations
CASE STUDY: Pulmonary Edema

1. cardiac disease 4. b
2. a 5. d
3. d 6 d
Chapter 31
Multiple Choice
1. d 9. b 17. d
2. b 10. d 18. d
3. b 11. d 19. c
4. a 12. b 20. d
5. a 13. b 21. d
6. b 14. d 22. b
7. b 15. d 23. a
8. c 16. a
Matching
1. a 5. b
2. b 6. b
3. a 7. a
4. a 8. a
1. intermittent claudication 5. approximately 4 mm Hg

2. ratio of ankle to arm systolic pressure 6. force generated by plasma proteins
3. adventitia
4. lympatic delivery to the remainder of the body
Clinical Situations
CASE STUDY: Peripheral Arterial Occlusive Disease

1. a 6. d
2. a 7. b
3. d 8. 0.50 ABI
4. one joint level below the stenosis or occlusion 9. d
5. muscle metabolites and lactic acid
Pathophysiology of Atherosclerosis
See Figures 316 and 317 for assistance in this assignment.
Atherosclerosis leads to
Aneurysm
Lumen Thrombosis Vessel
development
stenosis obstruction rupture
and ulcerations
Ischemic
necrosis
Fibrous tissue
formation
Chapter 32
Multiple Choice
1. d 4. c 7. c
2. c 5. d 8. c
3. b 6. b 9. b
Fill-In
1. cardiac output; peripheral resistance 6. accumulation of atherosclerotic plaques,

2. heart rate; stroke volume fragmentation of arterial elastins, increased
3. 90% to 95% collagen deposits, and impaired
4. heart, kidneys, brain, and eyes vasodilation
5. myocardial infarction, cardiac failure, renal 7. acute myocardial infarction, a dissecting
failure, stroke, impaired vision, and left ventricular aortic aneurysm, and an intracranial
hypertrophy hemorrhage
1. Answer should include the five hypotheses listed on page 860.
2. The control of hypertension is multifaceted. Discuss the role of diet, exercise, smoking cessation,
medication regime compliance, and stress reduction in this process.
(Refer to a pathophysiology textbook.)
sodium and
water retention
cortisole
epinephrine
acetycholine
vasoconstriction
vasoconstriction
renin
angiotensin
norepinephrine
vessel
constriction
CASE STUDY: Secondary Hypertension

1. b 3. c
2. d 4. d
Chapter 33

Multiple Choice
1. b 4. a 7. c
2. a 5. d 8. c
3. d 6. c 9. a
10. d 17. d 24. c
11. b 18. d 25. d
12. b 19. b 26. d
13. a 20. d 27. b
14. d 21. d 28. c
15. d 22. b
16. d 23. c
Fill-In
1. 5 to 6
2. bone marrow
3. ribs, vertebrae, pelvis, and sternum
4. transport oxygen between the lungs and the tissues
5. 15
6. 120
7. protect the body from invasion by bacteria and other foreign entities
8. albumin and globulins
9. the sternum and the iliac crest
10. Primary polycythemia or polycythemia vera is a proliferative disorder in which all cells are nonresponsive
to normal control mechanisms; secondary polycythemia is caused by excessive production of
erythropoietin.
Scramblegram
F I B R I N O G E N A N O E L
B D H E M O S T A S I S P R M
F R S S C M P R H S G T H Y I
I E W C V R T C E L L S A T P
B E A B B T L D E F I J G H R
R S W A O H O A S V T S O R K
I F T P N R K L B J N M C O L
N E U T R O P H I L S K Y C B
F W O D C M F N K G H A T Y O
A H B E R B S J C T C B O T N
H E M A T O P O I E S I S E E
E M N E E C F M F G P S I S M
M O N O C Y T E S P L A S M A
O S C G D T K L A I E L K A R
G T O A H E E I J B E B A J R
L A G P E S F R M C N U L B O
O S G T I J D S A N M M S L W
B I H E O A G H H D O I I T L
I S D A U O U L M E S N P U M
N A S E L Y M P H O C Y T E S
Definition of Terms
1. plasma 8. monocytes 14. lymphocytes
2. thrombocytes 9. fibrinogen 15. erythrocyte
3. neutrophils 10. albumin 16. RES
4. hematopoiesis 11. spleen 17. Hemostasis
5. bone marrow 12. hemostasis 18. T cells
6. hemoglobin 13. fibrin
7. phagocytosis
Clinical Situations
CASE STUDY: Sickle Cell Crises

1. a 5. d
2. deformed, rigid, and sickle-shaped 6. managing pain, preventing and managing
3. bone marrow expansion to offset anemia infection, promoting coping skills, minimizing
4. tissue hypoxia and necrosis due to inadequate deficient knowledge, and monitoring/managing
blood flow to a specific organ or tissue potential complications
CASE STUDY: Leukemia
1. hematopoietic stem cells 4. b
2. immature blast cells 5. b
3. d
CASE STUDY: Hodgkins Disease
1. a 3. c
2. b 4. d
CASE STUDY: Transfusion
1. d 3. b
2. b 4. b
Chapter 34

Multiple Choice
1. b 9. c 17. c
2. c 10. b 18. b
3. a 11. c 19. d
4. b 12. d 20. c
5. c 13. a 21. b
6. d 14. a 22. c
7. b 15. d 23. d
8. d 16. c 24. d
Matching
1. f 4. c
2. a 5. b
3. e 6. d
Fill-In
1. a. low-residue diet 12 days before test 3. a. NPO 612 hours before the procedure
b. clear liquids the day before b. spraying or gargling with a local anesthetic
c. a laxative the evening before c. administering IV Versed before the scope is
d. NPO after midnight introduced
e. cleansing enema until returns are clear in 4. a. liquids 2472 hours before the examination
the AM b. laxative 48 hours before procedure
2. a. NPO 812 hours before the procedure c. laxatives until clear the AM of test, usually a
b. no medications affecting gastric secretions polyethylene glycol electrolyte lavage solution
2448 hours before test (Golytely)
c. no smoking in AM before test d. clear liquids starting at noon on the day before
test
Chapter 35
Multiple Choice
1. c 7. b 13. a
2. d 8. b 14. a
3. b 9. d 15. a
4. a 10. b 16. a
5. d 11. a 17. a
6. b 12. a 18. a
Matching
1. f 5. d
2. g 6. b
3. e 7. c
4. a 8. h
Applying Concepts: Radical Neck Dissection
1. local-regional metastasis 5. hemorrhage and nerve injury

2. shoulder drop and poor cosmesis (visible neck 6. d
depression) 7. c
3. pectoralis major 8. b
4. altered respiratory status, wound infection, and 9. b
hemorrhage 10. b
Clinical Situations
CASE STUDY: Mandibular Fracture

1. The latest treatment for mandibular fractures metal plates and screws into the bone to
involves rigid plate fixation or the placement of approximate and stabilize the bone.
2. b 5. c
3. b 6. b
4. Nasogastric suctioning is needed to remove 7. c
stomach contents, thereby reducing the danger 8. a wire cutter
of aspiration.
CASE STUDY: Cancer of the Mouth
1. The typical lesion is a painless, indurated 5. a. resectional therapy
(hardened) ulcer with raised edges. b. radiation therapy
2. d c. chemotherapy
3. d
4. a
Chapter 36
Multiple Choice
1. c 8. a 14. b
2. a 9. b 15. b
3. b 10. c 16. b
4. a 11. d 17. c
5. d 12. d 18. a
6. d 13. a 19. d
7. a
Matching
1. g 5. d
2. h 6. f
3. a 7. b
4. c 8. c
Clinical Situations
CASE STUDY: Cantor Tube

1. d 4. d
2. d 5. a
3. c
CASE STUDY: Dumping Syndrome
1. zinc deficiency, contaminated formula, 3. a
malnutrition, and medication therapy 4. d
2. Cleocin, digitalis, Inderal, Lincocin,
theophylline, and quinidine
CASE STUDY: Total Parenteral Nutrition
1. b 4. d
2. c 5. d
3. c
Applying Concepts
1. a. Risk for impaired skin integrity at tube site 5. 3060 seconds

b. Risk for infection related to the presence of 6. gently apply pressure with the bulb top of the
the wound and tube syringe or elevate the syringe so the tubing is
c. Body image disturbance related to the less curved
presence of a tube 7. Increasing the height increases the pressure
2. a. wound infection of gravity, which could result in too much force
b. gastrointestinal bleeding on the incisional area and the outlet.
c. premature removal of tube 8. An upright position facilitates digestion and
3. leakage of fluid decreases the risk for aspiration.
4. seepage of gastric acid and spillage of feeding
Chapter 37
Multiple Choice
1. d 9. d 17. d
2. b 10. c 18. c
3. a 11. a 19. b
4. b 12. a
5. d 13. d
6. d 14. d
7. c 15. d
8. d 16. b
Fill-In
1. Dilute and neutralize the corrosive acid by using common antacids such as milk and aluminum hydroxide.
2. Patients with gastritis due to a vitamin deficiency exhibit antibodies against intrinsic factor, which interferes
with vitamin B12 absorption.
3. Hypersecretion of acid pepsin and a weakened gastric mucosal barrier predispose to peptic ulcer
development.
4. Helicobacter pylori is the bacillus commonly associated with ulcer formation.
5. Answer may include hypersecretion of gastric juice, multiple duodenal ulcers, an increase in parietal cell
mass, hypertrophied duodenal glands, and gastrinomas.
6. Stress ulcer refers to acute mucosal ulceration of the duodenal or gastric area that occurs after a stressful
event.
7. Cushings ulcers, which are common in patients with brain trauma, usually occur in the esophagus,
stomach, or duodenum. Curlings ulcers occur most frequently after extensive burns and usually involve the
antrum of the stomach and duodenum.
8. The objective of the ulcer diet is to avoid oversecretion and hypermotility in the gastrointestinal tract.
Extremes of temperature should be avoided, as well as overstimulation by meat extractives, coffee, alcohol,
and diets rich in milk and cream. Current therapy recommends three regular meals per day.
9. Hemorrhage, perforation, and pyloric obstruction.
10. When peptic ulcer perforation occurs, the patient experiences severe upper abdominal pain, vomiting,
collapse, and an extremely tender abdomen that can be boardlike in rigidity; signs of shock will be present.
1. Gastritis occurs because the gastric mucous 2. H. pylori can be diagnosed by biopsy, serologic
membrane becomes edematous and hyperemic. testing for antibodies, a 1-minute ultrarapid
Superficial erosion occurs. Excess mucus is urease test, and a breath test.
produced along with a scanty amount of gastric
juice. Superficial ulceration can lead to hemorrhage.
Extracting Inferences
Outline needs to include content found on pages 10191020.
Chapter 38
Multiple Choice
1. d 9. b 17. c
2. b 10. d 18. c
3. c 11. a 19. b
4. c 12. d 20. b
5. a 13. d 21. c
6. b 14. d 22. b
7. b 15. a
8. d 16. c
Crossword Puzzle
Answers are found throughout chapter.
1 2 3 4
F M 5 C
5
I E F F L U E N T
6
S G U L V
7 8
S T O M A E A C
U C R L R
9
L B O R B O R Y M U S O
A L A H
O L N
10/12 11 13
C O R N L A X A T I V E S
E E A
14 15
A E T P N
C E
16
P E R I T O N I T I S
L M
I U
S
Matching
1. b5 4. a1
2. d3 5. c2
3. e6 6. f4
1. A series of neuromuscular actions are necessary for defecation. Rectal distention stimulates the inhibitory
rectoanal reflex. This causes the internal and external sphincter, as well as the muscles in the pelvic region,
to relax. Intra-abdominal pressure increases to propel the colon contents.
2. Straining at stool can cause the Valsalva manoeuvre (forcibly exhaling with the nose, mouth, and glottis
closed), which results in increased intrathoracic pressure. This pressure tends to collapse the large veins in
the chest. Cardiac output is decreased and arterial pressure decreases. Almost immediately, a rebound rise
in arterial and venous pressure occurs. This can be dangerous for those with hypertension.
3. Pancreatic insufficiency causes reduced intraluminal pancreatic enzyme activity with maldigestion of lipids
and proteins. Zollinger-Ellison syndrome causes hyperacidity in the duodenum that inactivates pancreatic
enzymes. Celiac disease results in the destruction of the absorbing surface of epithelium as a toxic response
to gluten fraction.
Recognizing Contradiction
1. Diarrhea refers to more than three bowel movements per day, increased amount of stool, and looseness.
2. Appendicitis, the most common cause of emergency abdominal surgery, occurs in about 7% of the
population.
3. Perforation, the major complication of appendicitis, occurs in 10% to 32% of cases.
4. Sepsis is the major cause of death from peritonitis.
5. The distal ileum and colon are the most common areas affected by Crohns disease.
6. More than 50% of patients with regional enteritis require surgery at some point.
Clinical Situations
CASE STUDY: Appendicitis

1. c 3. d
2. c 4. d
CASE STUDY: Peritonitis
1. d 3. a
2. a 4. a
Chapter 39
Multiple Choice
1. d 10. a 19. d
2. c 11. b 20. c
3. d 12. a 21. d
4. c 13. d 22. b
5. b 14. d 23. d
6. d 15. d
7. d 16. d
8. b 17. d
9. a 18. d
Matching
1. c 4. a 6. g
2. e 5. d 7. f
3. b

1. Conjugation refers to a process of medication metabolism whereby the drug binds with a variety of
compounds to form more soluble substances to reach the systemic circulation (bioavailability).
2. Hemolytic jaundice is the result of an increased destruction of red blood cells which overload the plasma
with bilirubin so quickly that the liver cannot excrete the bilirubin as fast as it is formed. Hepatocellular
jaundice is caused by the inability of damaged liver cells to clear normal amounts of bilirubin from the
blood. Obstructive jaundice is usually caused by occlusion of the bile duct by a gallstone, an inflammatory
process, a tumour, or pressure from an enlarged organ.
3. Hepatic encephalopathy occurs when ammonia accumulates because damaged liver cells fail to detoxify
and convert ammonia to urea. Elevated ammonia levels cause brain damage.
4. Alcoholic cirrhosis. Necrotic liver cells are replaced by scar tissue, which gradually exceeds functioning
liver tissue. Liver enlargement leads to obstruction of the portal circulation, which causes the shunting of
blood into vessels with lower pressures. Edema results from the concentration of plasma albumin. An
overproduction of aldosterone causes sodium and water retention and potassium excretion. Anemia,
gastritis, and vitamin deficiency lead to overall physical and mental deterioration.
Clinical Situations
CASE STUDY: Liver Biopsy

1. d 4. b
2. b 5. d
3. c
CASE STUDY: Paracentesis
1. c 3. a
2. d
CASE STUDY: Alcoholic or Nutritional Cirrhosis
1. c 5. c (normal sodium intake is 3 to 6 g/24 hours
2. d without ascites; sodium restriction is minimal
3. c rather than severe)
4. c (normal protein intake is 0.8 to 1 g/kg)
CASE STUDY: Liver Transplantation
1. d 3. c
2. d 4. a
Chapter 40
Multiple Choice
1. c 9. a 16. d
2. c 10. d 17. b
3. c 11. d 18. c
4. a 12. d 19. d
5. a 13. a 20. d
6. b 14. a 21. a
7. a 15. b 22. b
8. d
Clinical Situations
CASE STUDY: Cholecystectomy

Brendas Preoperative Situation
1. d 3. d
2. b
Brendas Postoperative Situation
1. a 3. c
2. d
CASE STUDY: Chronic Pancreatitis
1. long-term alcohol consumption
2. The inflammatory process causes the replacement of cells by fibrous tissues. This results in mechanical
obstruction of the pancreatic and common bile ducts and the duodenum. Atrophy of the epithelium of the
ducts causes destruction of the secreting cells of the pancreas.
3. diabetes mellitus
4. pancreaticojejunostomy
5. avoidance of alcohol and avoidance of foods found to cause abdominal pain and discomfort
Chapter 41

Multiple Choice
1. b 13. d 25. c
2. c 14. d 26. d
3. c 15. a 27. d
4. d 16. c 28. d
5. a 17. d 29. d
6. d 18. d 30. c
7. d 19. d 31. a
8. d 20. a 32. d
9. c 21. c 33. c
10. c 22. a 34. d
11. a 23. b 35. c
12. a (use 1520 kcal/kg for IBW) 24. d
Matching
1. c 4. e
2. a 5. d
3. b
Fill-In
1. nontraumatic amputations, blindness among working- 4. nutrition management, exercise, monitoring,
age adults, and end-stage renal disease pharmacologic therapy, and education
2. 9.911 mmol/L
3. 3.5% to 3.8%
5. 50% to 55% carbohydrate, 30% fat, and 15% to 20% hyperglycemic hyperosmolar nonketotic
protein syndrome
6. directly stimulating the pancreas to secrete 9. hypotension, profound dehydration, tachycardia,
insulin (cannot be used in patients with type and altered neurologic status (seizures, hemi-
1 diabetes) paresis)
7. abdomen, posterior surface of the arms, anterior 10. cerebral edema, hyperglycemia and ketoacidosis,
surface of the thighs, and the hips hypokalemia, hypoglycemia, and fluid overload
8. hypoglycemia, diabetic ketoacidosis (DKA), and (pulmonary edema, congestive heart failure)

Discussions and Analysis
1. Insulin regulates the production and storage of glucose. In diabetes, either the pancreas stops producing
insulin or the cells stop responding to insulin. Hyperglycemia results and can lead to acute metabolic
complications such as diabetic ketoacidosis and hyperglycemic hyperosmolar nonketotic syndrome. Long-
term complications can contribute to macrovascular or microvascular complications.
2. Type 1 diabetes is characterized by an absence of insulin production and secretion due to the autoimmune
destruction of the beta cells of the islets of Langerhans. Type 2 diabetes is characterized by deficiency of
insulin production and a decreased insulin action as well as increased insulin resistance.
3. The Dawn Phenomenon refers to hyperglycemia that occurs around 3:00 AM, possibly related to nocturnal
surges in the growth hormone in patients with type 1 diabetes. The Somogyi Effect refers to nocturnal
hypoglycemia around 3:00 AM followed by rebound hyperglycemia.
1. 2 5. 1 9. 2
2. 2 6. 2 10. 1
3. 1 7. 1
4. 1 8. 2
The pathophysiologic sequence of changes that occur with type 1 diabetes
Decreased insulin Unchecked glucose Eaten glucose
production by beta cells production by liver cannot be stored
Postprandial Impaired protein Glucosuria

hyperglycemia and fat metabolism
Polyphagia Weight loss Osmotic diuresis
Polyuria Polydipsia
Glycogenolysis Gluconeogenesis Ketone bodies
KETOACIDOSIS
Applying Concepts
1. Sensory neuropathy causes loss of sensation to pain and pressure; autonomic neuropathy causes an
increase in skin dryness and the formation of skin fissues; motor neuropathy results in muscular atrophy.
2. 50%
3. Inadequate and compromised lower-extremity circulation interferes with the ability to get nutrients to the
wound to promote healing and prevent the development of gangrene.
4. Hyperglycemia impairs the ability of specialized leukocytes to destroy bacteria, thus lowering the resistance
to infection.
5. soft-tissue injury, formation of a fissure, and formation of a callus
6. bathe, dry, and lubricate the feet; inspect both feet; look for fissures on dry skin or between the toes; report
any redness, swelling, or drainage; wear well-fitting, closed-toe shoes.
7. Peripheral vascular disease may prevent oxygen, nutrients, and antibiotics from reaching the injured tissue.
Clinical Situations
CASE STUDY: Type 1 Diabetes

1. b 3. b
2. c
CASE STUDY: Hypoglycemia
1. a 3. d
2. d 4. d
CASE STUDY: Diabetic Ketoacidosis
1. d 4. a
2. a 5. b
3. d 6. d
Chapter 42
Multiple Choice
1. d 9. a 17. d
2. a 10. d 18. a
3. d 11. d 19. d
4. a 12. b 20. c
5. a 13. a 21. d
6. d 14. d 22. d
7. b 15. c 23. a
8. b 16. d 24. a
Matching
1. h 6. c
2. g 7. f
3. i 8. e
4. d 9. j
5. a 10. b
Fill-In
1. negative feedback 7. autoimmune thyroiditis

2. steroid, protein, and amine 8. diabetes mellitus
3. vasopressin and oxytocin 9. Graves disease
4. Cushings disease 10. Propacil and Tapazole
5. diabetes insipidus 11. Trousseau or Chvostek
6. thyroxine, triiodothyronine, and calcitonin 12. glucocorticoids, mineralocorticoids, and
androgens
Unscrambled Words
1. pituitary 5. iodine
2. hypothalamus 6. exophthalmos
3. somatotropin 7. tetany
4. SIADH (syndrome of inappropriate antidiuretic
hormone)
Clinical Situations
CASE STUDY: Primary Hypothyroidism

1. d 4. d
2. d 5. b
3. b
CASE STUDY: Hyperparathyroidism
1. a 4. kidney stones
2. a 5. d
3. apathy, fatigue, muscular weakness, nausea, 6. b
vomiting, constipation, hypertension, and 7. c
cardiac dysrhythmias
CASE STUDY: Subtotal Thyroidectomy
1. d 4. a
2. d 5. b
3. d 6. a
Chapter 43
Multiple Choice
1. b 6. c 11. d
2. b 7. d 12. d
3. c 8. a 13. d
4. a 9. a
5. b 10. b
Fill-In
1. 12th thoracic, 3rd lumbar 5. 300 and 1,100 mmol/kg

2. nephron 6. increased
3. 300 to 600 mL 7. antidiuretic hormone (ADH)
4. aldosterone 8. creatine clearance
Renal perfusion decreases

and
blood pressure decreases
Kidneys release renin
Liver manufactures angiotensin I

which converts to
angiotensin II (a powerful vasoconstrictor)
Adrenals release aldosterone

which increases sodium retention
Pituitary releases ACTH
Blood pressure increases
Renal autoregulation occurs Circulating blood volume increases
Chapter 44
Multiple Choice
1. d 7. d 13. d
2. d 8. d 14. b
3. b 9. d 15. d
4. c 10. c 16. b (1 litre 1 kg 2.2 lbs)
5. b 11. c 17. b
6. b 12. d 18. d
Matching
1. a 6. j
2. b 7. h
3. c 8. f
4. e 9. g
5. d 10. i
Fill-In
1. anticholinergics, antispasmodics, and tricyclic urinary tract infections may include cloudy urine,
antidepressants hematuria, fever, chills, anorexia, and malaise
2. a. to allow drainage in patients with neurogenic 5. Arteriosclerotic cardiovascular disease is one
bladder dysfunction leading cause of death.
b. to bypass an obstruction that blocks urine flow 6. Answer may include: hypotension, air embolism,
c. to provide postoperative drainage following chest pain, dysrhythmias, pruritus, dialysis
urologic and other surgeries disequilibrium, painful muscle cramping, nausea,
d. to monitor hourly urinary output in critically ill vomiting, and exsanguination.
patients 7. Peritonitis is the most common and most serious
3. Escherichia coli, Klebsiella, Proteus, Pseudomonas, complication of CAPD.
Enterobacteriaceae, Serratia, and Candida 8. Abdominal distention and paralytic ileus are
4. Signs and symptoms seen in catheter-induced common complications of renal surgery.

1. About 750,000 adults in Canada suffer from urinary incontinence.
2. More than 50% of nursing home residents suffer from urinary incontinence.
3. Almost 50% of patients with a closed drainage system will experience bacteriuria within a 2-week period.
4. Hemodialysis does not cure or reverse renal disease; it prevents death.
5. CAPD is done on an ongoing, 24hour schedule, usually in the patients home.
Clinical Situations
CASE STUDY: Continuous Ambulatory Peritoneal Dialysis (CAPD)

1. d 3. d
2. a 4. c
Chapter 45

Multiple Choice
1. a 4. b 7. d
2. d 5. b 8. d
3. b 6. d 9. b
10. b 19. d 27. d
11. a 20. a 28. b
12. c 21. a 29. c
13. c 22. d 30. b
14. a 23. d 31. a
15. d 24. d 32. d
16. b 25. d 33. c
17. a 26. a 34. d
18. a
Fill-In
1. Escherichia coli 7. Clinical manifestations seen in chronic renal

2. Cystitis, from an uncomplicated lower UTI, is failure include lethargy, headache, muscle
usually associated with feelings of urgency, twitching, seizures, nausea, vomiting, and
burning, and pain on urination; nocturia; diarrhea. There is also dehydration and the odour
incontinence; pelvic pain; and sometimes of urine on the breath.
hematuria and back pain. 8 Threatened graft rejection is suspected in a
3. chills, fever, lower back or flank pain, patient who evidences oliguria, edema, fever,
costrovertebral angle (CVA) tenderness, apprehension, increased blood pressure, weight
bacteriuria, pyuria, and leukocytosis gain, and swelling or tenderness over the graft or
4. The urine in the early stages of acute glomerulo- kidney.
nephritis is characteristically cola-coloured. 9. Urinary tract stones are formed by calcium
5. Proteinuria, hypoalbuminemia, edema, and oxalate, calcium phosphate, and uric acid.
hypercholesterolemia 10. wound infection, wound dehiscence, urinary
6. Prerenal conditions are hemorrhage and sepsis; leakage, ureteral obstruction, hyperchloremic
intrarenal conditions are crush injuries and acidosis, small-bowel obstruction, and ileus and
infections; postrenal conditions are obstruction stomal gangrene
distal to kidney or kidneys
1. The majority of nosocomial infections in the 4. Glomerulonephritis is primarily a disease of

hospital are caused by instrumentation of the children usually older than 2 years of age.
AU: Computed elsewhere?
urinary tract or catheterization. 5. Hyperkalemia, secondary to decreased

2. Urethrovesical reflux refers to the backward flow glomerular filtration and oliguria, is the most
of urine from the urethra into the bladder. immediate life-threatening imbalance in acute
3. Today, two diagnostic studies, computerized renal failure.
tomography (CT) and ultrasonography, are the 6. Painless hematuria is the earliest clinical
preferred methods for diagnosing UTIs. manifestation of renal trauma.
Clinical Situations
CASE STUDY: Acute Renal Failure

1. c 4. b
2. d 5. b
3. b 6. d
Chapter 46

Multiple Choice
1. d 8. b 15. b
2. a 9. b 16. c
3. b 10. c 17. c
4. c 11. a 18. c
5. a 12. b 19. b
6. c 13. a
7. d 14. a
Fill-In
1. 45 to 52, with a median age of 51 years 8. Risk factors would include a history of
2. irregular or excessive vaginal bleeding, abnormal thromboembolic disorders, cerebrovascular
discharge, bleeding after menopause, painful disease, breast cancer, pregnancy, liver tumours,
intercourse (dyspareunia), bleeding after congenital hyperlipidemia, and abnormal vaginal
intercourse, urinary disturbances, and painful bleeding.
menstruation 9. Depo-Provera, a long-acting progestin that is
3. endometrial biopsy injected intramuscularly, effectively inhibits
4. atherosclerosis, angina, coronary artery disease, ovulation for 3 months.
and osteoporosis 10. An emergency dose of estrogen or estrogen and
5. Answer may include headache, fatigue, low back progesterone, properly timed, can prevent
pain, engorged or painful breasts, abdominal pregnancy by inhibiting or delaying ovulation.
fullness, mood swings, general irritability, fear 11. For in vitro fertilization, at an appropriate time,
of loss of control, binge eating, crying spells. the egg is recovered by transvaginal ultrasound
6. Lack of body fat and low caloric intake decrease retrieval. Sperm and egg are coincubated for up
hormonal function, to 36 hours so that fertilization can occur. Forty-
7. The pill blocks the stimulation of the ovary by eight hours after retrieval, the embryo is
preventing the release of follicle-stimulating transferred to the uterine cavity by means of a
hormone (FSH) from the anterior pituitary. trancervical catheter. Implantation should occur
in 3 to 4 days.
Matching
1. f 5. e
2. d 6. g
3. h 7. c
4. a 8. b

1. Nurses conducting a health assessment need to know that more than 50% of women have been sexually
abused as children.
2. Women born to mothers who took diethylstilbestrol (DES) during their pregnancy have a higher than
average chance of developing cancer of the cervix.
3. A biopsy excision of an inverted cone of tissue is done when a Pap smear is suspicious. The patient must
be anesthetized for this procedure.
4. Magnetic resonance imaging uses a magnetized field to produce an image. Radiation is not necessary.
5. Progesterone is the most important hormone for preparing the endometrium for the fertilized ovum.
6. Painful cramps result from an excessive production of prostaglandins.
7. Methotrexate and misoprostol combined are the approved drug combination used for elective abortions
up to 49 days from the last menstrual period
Extracting Inferences
1. A fertilized ovum implants in tissue other than the uterine area.

2. Possible causes are: salpingitis, peritubal adhesions, structural abnormalities of the fallopian tube, previous
ectopic pregnancy or tubal surgery, the presence of an IUD, and multiple previous abortions.
3. abdominal tenderness; sharp, colicky pain; some bleeding; gastrointestinal symptoms; and abnormal
bleeding
4. The tube can be resected (salpingostomy) or removed (salpingectomy) along with an ovary (salpingo-
oophorectomy).
5. determine whether any tissue remained
6. hemorrhage and shock
Chapter 47
Multiple Choice
1. d 10. b 19. b
2. d 11. c 20. d
3. c 12. a 21. d
4. b 13. d 22. d
5. c 14. c 23. a
6. a 15. d 24. c
7. c 16. b 25. b
8. b 17. b
9. a 18. d
Scramblegram
A E E T D A C Y C L O V I R
H L B K E M O M C M U R S C
C E D H R A L I T L K L P H
V C P A M D E C V Y L M R A
P O A L O N G O S G B E O D
B T P U I M D S C A R N L S
Y S S T D Y L T N L I O A M
M Y M S N M F A B F L R P Y
O C E I R A C T G O T R S T
T R A F O S F I Y E B H E I
C E R T S C I N O J K A L R
E W D R B D B E P I S G C A
R B G B F C R A R M D I B P
E R C L M D O I O E S A N I
T D S E P T I C S H O C K L
S H E R M H D R J R A T H L
Y B A G A C S Y A T B O L U
H B H M D M T P C K T I D N
1. vulvodynia 7. Pap smear 12. HRT

2. Mycostatin 8. hysterectomy 13. Kegal
3. Flagyl 9. menorrhagia 14. fistula
4. acyclovir 10. fibroids 15. prolapse
5. septic shock 11. DES 16. dermoid
6. cystocele

1. Estrogen breaks down gylcogen into lactic acid, which is responsible for producing a low vaginal pH. A pH
of 3.5 to 4.5 suppresses bacterial growth.
2. Pelvic inflammatory disease (PID) is a condition of the pelvic cavity that may involve the uterus, fallopian
tubes, ovaries, pelvic peritoneum, or pelvic vascular system.
3. The majority of females with AIDS are in their reproductive years, are intravenous drug users or have been
exposed through sexual contact with HIV-infected partners.
Clinical Situations
CASE STUDY: Bacterial Vaginosis

1. a 4. a
2. b 5. a
3. c
CASE STUDY: Herpes Genitalis
1. d 6. pain related to the presence of genital lesions,
2. a risk for recurrence of infections or spread of
3. c infection, anxiety and distress related to
4. mouth, oropharynx, mucosal surface, vagina, embarrassment, and insufficient knowledge
and cervix about the disease and methods of avoiding
5. Acyclovir, valcyclovir, and famciclovir spread and recurrences
CASE STUDY: Toxic Shock Syndrome (TSS)
1. c 4. d
2. a 5. c
3. b
CASE STUDY: Pelvic Inflammatory Disease (PID)
1. uterus, fallopian tubes, ovaries, pelvic peritoneum, 5. ectopic pregnancy, infertility, recurrent pelvic
and pelvic vascular system pain, ovarian abscess, and recurrent disease
2. acute, subacute, recurrent, chronic, localized, 6. Localized: vaginal discharge, lower abdominal
and widespread pain, dyspareunia, and tenderness after menses.
3. a Generalized: fever, general malaise, anorexia,
4. gonorrhea and chlamydia nausea, headache, and vomiting.
Chapter 48
Multiple Choice
1. c 10. d 18. b
2. b 11. c 19. c
3. a 12. d 20. b
4. a 13. c 21. d
5. d 14. d 22. c
6. d 15. b 23. a
7. a 16. a 24. d
8. d 17. b 25. c
9. b
Clinical Situations
CASE STUDY: Simple Mastectomy

1. c 4. c
2. d 5. b
3. b 6. c
F I G U R E 1 / S t e p 1 : Stand before a mirror. F I G U R E 2 / S t e p 2 : Watch closely in the

Check both breasts for anything unusual. Look for a mirror as you clasp your hands behind your head and
discharge from the nipples, puckering, dimpling, press your hands forward. Note any change in the
scaling of the skin, or change in contour of your contour of your breasts
breast.
F I G U R E 3 / S t e p 3 : Next, press your hands FIGURE 4/Step 4: Raise your left arm. Use three or
firmly on your hips and bow slightly toward the mirror four fingers of your right hand to feel your left breast
as you pull your shoulders and elbows forward. Note firmly, carefully, and thoroughly. Beginning below
any change in the contour of your breasts. your collarbone at the middle of your chest, press the
fat part of your fingers in small circles, moving back
and forth across the chest or up and down the chest
on imaginary lines. Be sure to cover from below the
collarbone to 3 cm below the breast, from the centre
of your chest to the opposite side. This includes all the
breast tissue and nipple. Pay special attention to the
area between the breast and the underarm, including
the underarm area itself. Feel for any unusual lump or
mass under the skin. If you have any spontaneous
discharge during the monthwhether or not it is
during your breast self-examination (BSE) see your
doctor. Repeat the examination on your right breast.
F I G U R E 5 / S t e p 5 : Step 4 should be repeated
lying down. Lie flat on your back, with your left arm
over your head and a pillow or folded towel under
your left shoulder. This position flatterns the breast
and makes it easier to check. Use the same circular
motion described above. Repeat on your right breast.
Chapter 49
Multiple Choice
1. b 8. d 14. b
2. d 9. a 15. c
3. b 10. c 16. b
4. a 11. b 17. a
5. a 12. a 18. c
6. a 13. d
7. d
Fill-In
1. Prostate-specific antigen (PSA) and digital rectal tract infections, interruption of the urinary stream,
examination (DRE) and dribbling
2. Answer should include four of these five 6. diethylstilbestrol
medications: antipsychotics, anticholinergics, 7. Heparin is given prophylactically because there is
antiadrenergics, thiazide diuretics, and tricyclic a high incidence of deep vein thrombosis and
antidepressants. pulmonary embolism after prostatectomy.
3. E. coli 8. Epididymitis is an infection of the epididymis that
4. burning, urgency, perineal discomfort, frequency, usually descends from an infected prostate or
and pain with or after ejaculation urinary tract. It passes upward through the urethra
5. frequency of urination, nocturia, urgency and a and ejaculatory duct and along the vas deferens
sensation that the bladder has not emptied to the epididymis.
completely, hesitancy in starting urination, 9. Priapism is an uncontrolled, persistent erection of
abdominal straining, a decrease in the volume the penis that causes the penis to become large,
and force of the urinary stream, recurring urinary hard, and often painful.
Matching
1. c 5. d
2. f 6. h
3. e 7. g
4. a 8. b
Clinical Situations
CASE STUDY: Prostatectomy

1. assessment of general health status and 7. anxiety related to the surgical procedure and its
establishment of optimum renal function outcome, pain related to bladder distention, and
2. before acute urinary retention develops and knowledge deficit about factors related to the
damages the urinary tract and collecting system, problem and the treatment protocol
or before cancer develops 8. Warm compresses to the pubis and sitz baths can
3. d help relieve spasm.
4. stricture formation and retrograde ejaculation 9. Prolonged sitting increases intra-abdominal
5. hemorrhage, clot formation, catheter obstruction, pressure and increases the possibility of bleeding
and sexual dysfunction 10. Teach the patient to tense the perineal muscles by
6. damage to the pudendal nerves may cause pressing the buttocks together, holding the
impotence position for 1520 seconds, and then relaxing.
Chapter 50
Multiple Choice
1. d 6. c 11. a
2. a 7. b 12. b
3. d 8. b 13. d
4. c 9. d 14. d
5. d 10. c 15. c
Fill-In
1. Disorders arise from excesses or deficiencies of 3. Complement is a term used to describe

immunocompetent cells, alterations in cellular circulating plasma proteins that are made in the
functioning, immunologic attack on self-antigens, liver and activated when an antibody couples
and inappropriate or exaggerated responses to with an antigen.
specific antigens. 4. Biologic response modifiers (BRMs) suppress
2. Natural immunity, which is nonspecific, is present antibody production and cellular immunity.
at birth. Acquired immunity is more specific and 5. Stem cells continually replenish the bodys
develops throughout life. Passive acquired supply of red and white cells. Once the immune
immunity is a temporary immunity transmitted system has been destroyed, stem cells can
from another source that has developed immunity completely restore it with just a few cells.
through previous disease
or immunization.
Matching
Immunoglobulins
1. c 5. a
2. e 6. b
3. c 7. a
4. d
Medications
1. d 5. b
2. b 6. a
3. a 7. e
4. c
Unscrambled Words
1. antibody 4. helper T cells

2. complement 5. phagocytes
3. antigen 6. interferons
Chapter 51
Multiple Choice
1. d 5. b 8. b
2. d 6. d 9. b
3. d 7. a 10. d
4. b
1. phagocytic dysfunction 4. ataxia-telangiectasia

2. B-cell deficiency, probably CVID 5. a secondary immunodeficiency
3. T-cell deficiency
1. B-lymphocyte 3. progressive neurological deterioration

2. CVID 4. excess occurrences of lysis of erythrocytes
Chapter 52
Multiple Choice
1. b 5. c 9. b
2. a 6. c 10. c
3. b 7. c 11. b
4. a 8. d 12. b
Fill-In
1. Ontario, Qubec, and British Columbia 7. maximum suppression of viral load,

2. unprotected sex and the sharing of injection drug restoration/preservation of immunologic
use equipment function, improved quality of life, and reduced
3. blood, seminal fluid, vaginal secretions, amniotic HIV-related mortality and morbidity
fluid, and breast milk 8. Anti-HIV drugs attempt to block viral replication
4. retroviruses that carry their genetic material in within cells by inhibiting either reverse
the form of RNA transcriptase of HIV protease
5. enzyme immunoassay (EIA), Western blot 9. Pneumocystis carinii pneumonia
assay, viral load, and CD4/CD8 ratio 10. Alpha-interferon
6. HIV-RNA viral load, CD4 T-cell count levels, and
the clinical condition of the patient
Matching
1. c 5. c
2. b 6. b
3. c 7. a
4. a 8. c
1. Refer to Chart 523

2. Primary infection is that period from infection with HIV to the development of antibodies to HIV. It is the
time during which the viral burden set point is achieved and includes the acute symptoms and early
infection phases.
3. The lesions are usually brownish pink to deep purple. They may be flat or raised and surrounded by
hemorrhagic patches and edema
Clinical Situations
CASE STUDY: Acquired immunodeficiency syndrome (AIDS)

1. risky sexual practices and intravenous drug use syndrome, fluid and electrolyte imbalance,
2. c and adverse reaction to medications.
3. c 5. d
4. Answer may include opportunistic infections, 6. d
impaired breathing or respiratory failure, wasting
Chapter 53
Multiple Choice
1. d 4. d 7. b
2. c 5. a 8. d
3. c 6. a 9. d
10. a 14. d 17. c (a minimum of
11. a 15. d 0.1 mg/kg)
12. a 16. b 18. c
13. b 19. c
Fill-In
1. neutralizing toxic antigens, precipitating the 4. systemic lupus erythematosus, rheumatoid

antigens out of solution, and coating the surface arthritis, serum sickness, certain types of
of the antigens nephritis, and some types of bacterial
2. an inappropriate or exaggerated antigen and endocarditis
antibody interaction or response causes tissue 5. contact dermatitis and latex allergy
injury 6. avoidance of latex products
3. the pain and fever seen with inflammatory
responses
1. An allergic reaction occurs when the body is invaded by an antigen, usually a protein that the body
recognizes as foreign. The body responds in an effort to destroy the invading antigen. Antibodies (protein
substances) are produced. When an interaction between the antigen and antibody results in tissue injury,
an allergic reaction occurs and chemical mediators are released into the body.
2. Immunoglobulins are a group of serum proteins (antibodies formed by lymphocytes and plasma cells) that
bind specifically with certain antigens to neutralize, agglutinate, and destroy various bacteria and foreign
cellular material.
3. The systemic reactions of flushing, warmth, and itching rapidly progress to bronchospasm, laryngeal
edema, severe dyspnea, cyanosis, and hypotension. Cardiac arrest and coma can occur.
Clinical Situations
CASE STUDY: Allergic Rhinitis

1. Potential ineffective breathing patterns, related 2. restoration of a normal breathing pattern,
to an allergic reaction: Knowledge deficit about knowledge about the causes and control of
allergy and recommended modifications in allergic symptoms, adjustment to alternations
lifestyle; and Impaired adjustment, related to and modifications, and absence of complications
chronicity of condition and need for environ- 3. d
mental modifications 4. d
5. d
6. c
Chapter 54
Multiple Choice
1. d 4. d 7. a
2. d 5. c 8. a
3. b 6. b 9. d
10. a 14. b 18. b
11. c 15. d 19. b
12. d 16. b 20. a
13. d 17. d
Matching
1. a 4. a
2. d 5. f
3. e 6. b
1. Exacerbation is a period of time when the symptoms of a disorder occur or increase in intensity and
frequency. Remission is a period of time when symptoms are reduced or absent.
2. In inflammatory rheumatic disease, the inflammation occurs as the result of an immune response. Newly
formed synovial tissue is infiltrated with inflammatory cells (pannus formation), and joint degeneration
occurs as a secondary process. In degenerative rheumatic disease, synovitis results from mechanical
irritation. A secondary inflammation occurs.
3. Refer to Table 542 and pages throughout the chapter for your answers.
Clinical Situations
CASE STUDY: Diffuse Connective Tissue Disease

1. b 4. d
2. b 5. c
3. Answer may include: weight loss, fever, anemia, 6. COX-2 inhibitors
fatigue, lymph node enlargement, and Raynauds 7. d
phenomenon.
CASE STUDY: Systemic Lupus Erythematosus (SLE)
1. chemical, hormonal,environmental, and genetic 4. severe anemia, thrombocytopenia, leukocytosis,
2. an increase in autoantibody production results leukopenia, and positive antinuclear antibodies
from abnormal suppressor T-cell function, leading 5. antimalarial
to immune complex deposition and tissue damage 6. hypertension and atherosclerotic heart disease
3. pericardial friction rub, myocarditis, and
pericarditis
Interpreting Patterns
Refer to Figures 541 and 543 as a framework for your outline.
Chapter 55
Multiple Choice
1. b 4. a
2. a 5. b
3. b 6. c
Analyzing Comparisons
1. skin colouring 5. scurvy

2. jaundice 6. inspection
3. immune system 7. scales
4. alopecia
1. telangiectasis 4. urticaria
2. syphilis 5. Kaposis sarcoma
3. ecchymosis or petechia
Primary and secondary lesions: Answers to 18 should include any characteristics listed for each lesion in Chart
553.
Applying Concepts
1. Thinning of dermis and epidermis at their junction 3. Decreased cellular replacement

a. appearance of wrinkles a. delayed wound healing
b. overlapping skin folds b. smaller vessels decrease in number and
c. appearance of sags size
d. increased vulnerability to injury 4. Decrease in number and function of sweat
2. Loss of subcutaneous tissue of elastin, fat, and sebaceous glands
and collagen a. dry and scaly skin
a. diminished protection and cushioning of 5. Reduced hormonal levels of androgens
underlying organs and tissues a. decreased sebaceous gland functioning
b. decreased muscle tone
c. decreased insulating properties
Chapter 56
Multiple Choice
1. d 11. b 21. d
2. c 12. a 22. d
3. c 13. b 23. a
4. d 14. d 24. c
5. d 15. a 25. d
6. b 16. d 26. d
7. d 17. d 27. c
8. c 18. c 28. d
9. b 19. c
10. b 20. a
Fill-In
1. Moisture-retentive dressings have a high moisture 3. Risk for impaired skin integrity related to changes in
vapor transmission rate. Some dressings even the barrier function of the skin.
have reservoirs to hold excessive exudate. 4. acne vulgaris
2. Cytokines are proteins with mitogenic activity that 5. impetigo and folliculitis
release increased amounts of growth factors into a 6. Staphylococcus aureus
wound. This process stimulates cell growth and 7. sepsis and keratoconjunctivites
granulation of skin. 8. skin; basal cell and squamous cell carcinoma
Discussions and Analysis
1. The purpose of wet-to-dry dressings is to remove crusts, scales, and exudate from erosions or ulcers; to
reduce inflammation; to maintain drainage of infected areas; and to promote healing so new granulation
tissue can form. The process involves leaving the dressings in place until they dry and then removing them
without soaking so that pus and exudate will adhere to the dressings when they are removed.
2. Moisture-retentive dressings result in reduced pain, fewer infections, less scar tissue, gentle autolytic
dbridement, and decreased frequency of dressing changes.
3. Enzymatic dbridement is a process whereby the bodys own digestive enzymes are used to break down
necrotic tissue. A foul odour occurs when cellular debris is broken down. It is normal and expected.
Clinical Situations
CASE STUDY: Acne Vulgaris

1. open comedones, closed comedones, 5. Vitamin A clears up the kertatin plugs from the
erythematous papules, inflammatory pustules, pilosebaceous ducts by speeding up cellular
and inflammatory cysts turnover and forcing the comedone out of the
2. d skin.
3. c 6. c
4. Benzoyl peroxide has an antibacterial effect 7. a
because it suppresses Propionibacterium acnes, 8. scarring and infection
depresses sebum production, and helps
breakdown comedone plugs.
CASE STUDY: Malignant Melanoma

1. b 4. c
2. d 5. a
3. c
Chapter 57
Multiple Choice
1. b 5. c 9. c
2. b 6. d 10. c
3. d 7. b 11. a
4. c 8. b 12. a
13. a 18. b 23. c
14. a 19. b 24. b
15. a 20. c 25. d (protein requirement
16. d 21. c should be 3 g/kg)
17. b 22. b 26. b
Fill-in
1. young children and the elderly 4. acute respiratory failure and acute respiratory
2. in the home and usually in the kitchen distress syndrome (ARDS)
3. the depth of the injury and the extent of injured 5. sepsis
body surface area 6. morphine sulfate
1. Survival after large burn injury has significantly improved because of the following: research in fluid
resuscitation, emergent burn treatment, inhalation injury treatment, and earlier dbridement of wounds.
2. Carbon monoxide, a byproduct of the combustion of organic materials, combines with hemoglobin to form
carboxyhemoglobin. Carboxyhemoglobin competes with oxygen for available hemoglobin-binding sites.
3. Fluid overload may occur when fluid is mobilized from the interstitial compartment back into the
intravascular compartment. If the cardiac system cannot compensate for the excess volume, congestive
heart failure may result.
Identifying Patterns (Fig. 573)
Loss of capillary integrity
Fluid shift from intravascular space to interstitial space
Clinical Situations
See Plan of Nursing Care pages 1724-1727 for assistance with the completion of the assignment. Sample:
Aimees Situation
Nursing diagnosis: Altered comfort, related to pain resulting from a burn injury
Goals: Pain relief
Nursing actions: Continue developmental growth patterns while providing for skin healing and
grafting
Maintain socialization patterns consistent with Aimees peer group
Assess Aimees respiratory status
Rationale: Airway compromise can occur rapidly in a significant burn injury as fluid shifts occur
Expected outcome: Aimee has a patent airway and does not exhibit any respiratory distress
Chapter 58

Multiple Choice
1. d 7. d 12. c
2. c 8. c 13. c
3. d 9. d 14. a
4. d 10. b 15. c
5. d 11. a 16. b
6. c
Fill-In
1. cataracts, glaucoma, and macular degeneration 6. irrigation with normal saline
2. glaucoma 7. Streptococcus pneumoniae, Hemophilus
3. pallor and cupping of the optic nerve disc influenzae, and Staphylococcus aureus
4. laser trabeculoplasty and laser iridotomy 8. diabetic retinopathy
5. cataracts
Matching
1. b 6. e
2. c 7. g
3. f 8. d
4. j 9. h
5. a 10. i
Crossword Puzzle
(Reference pages throughout chapter.)
1 2 3
E S R
4 5
U P H O T O P H O B I A
V I Y G
6 7
L E F T P M H
I H Y T
8
T I O O
9 10
I R R P A P H A K I A
11
A S T I G M A T I S M E
T A R
I A
12 13
P T O S I S U T
14
L A C E R A T I O N
C T
E I
15
S T R A B I S M U S
1. blepharitis 4. keratitis
2. sty (external hordeolum) 5. cataract
3. conjunctivitis
Clinical Situations
Nursing Care Plan: Cataract Surgery

Elise would have several immediate, intermediate, and long-term goals. Following is an example of one with a
nursing diagnosis. Page references for assistance with the completion of this care plan are in Chapter 58.
Sample:
Nursing diagnosis: Altered visual sensory perception related to cataract formation
Goals: Make Elise familiar with her new environment.
Prepare the affected eye for surgery.
Encourage Elise to walk with her cane as independently as possible.
Nursing action: Assess Elises level of knowledge about her surgery
Rationale: Baseline information is necessary to determine teaching plan.
Expected outcome: Elise understands the purpose, process, and expected outcomes of her surgery.
CASE STUDY: Cataract Surgery
1. smoking, diabetes mellitus, alcohol abuse, and 4. d
inadequate intake of antioxidant vitamins over time 5. extracapsular extraction
2. painless blurring of vision, sensitivity to glare, and 6. c
functional impairment due to reduced visual acuity 7. c
3. a greyish pearly haze in the pupil
Chapter 59
Multiple Choice
1. a 8. d 15. d
2. b 9. b 16. d
3. d 10. d 17. c
4. a 11. c 18. c
5. b 12. d 19. a
6. c 13. a 20. d
7. b 14. c
Answers for questions 111 related to Figure 591 can be found under Function of the Ears (p.1802).
Clinical Situations
CASE STUDY: Mastoid Surgery

1. Answer may include: infection, otalgia, otorrhea, 3. a sense of aural fullness or pressure (intermittent
hearing loss, vertigo, erythema, edema, and odour pain may last for 23 weeks after surgery)
of discharge. 4. d
2. Answer may include: reduction of anxiety, 5. an elevated temperature and purulent drainage
freedom from pain and discomfort, prevention 6. d
of infection, stabilization/improvement of learning, 7. c
absence of injury from vertigo, absence of or 8. straining, exertion, and moving or lifting heavy
adjustment to altered sensory perception, return objects
of skin integrity, and knowledge about the disease
process and surgical intervention.
CASE STUDY: Mnieres Disease
1. vertigo, tinnitus, fluctuating and sensorineural 3. vertigo
hearing loss, and a feeling of pressure or fullness 4. b
in the ear 5. a
2. an overabundance of circulating fluid 6. a
Chapter 60

Multiple Choice
1. a 7. d 13. a
2. c 8. a 14. a
3. a 9. b 15. c
4. a 10. c 16. b
5. b 11. a 17. b
6. d 12. c 18. c
Matching
1. e 4. c
2. f 5. a
3. d 6. b

Autonomic Nervous System
Organ or Tissue Parasympathetic Effect Sympathetic Effect

a. bronchi constriction dilation
b. cerebral vessels dilation constriction
c. coronary vessels constriction dilation
d. heart inhibition acceleration
e. iris constriction dilation
f. salivary glands secretion secretion
g. smooth muscle of
(1) bladder wall constriction inhibition
(2) large intestine increased motility inhibition
(3) small intestine increased motility inhibition
Cranial Nerves
Nerve No. Column I Column II
I olfactory smell
II optic vision
III oculomotor eye movement
IV trochlear eye movement
V trigeminal facial sensation
VI abducens eye movement
VII facial taste and expression
VIII vestibuolcochlear hearing and equilibrium
IX glossopharyngeal taste
X vagus swallowing, gastric motility,
and secretion
XI spinal accessory trapezius and sternomastoid
muscles
XII hypoglossal tongue movement
Diagram of the Brain

Thalamus
1. Receives, synthesizes, and relays all sensory 2. Relays impulses to visceral and somatic effectors
stimuli except for olfactory stimuli
Hypothalamus
1. Maintains sugar and fat metabolism 5. Influences the bodys response to stress
2. Regulates water balance and metabolism 6. Maintains the sleep-wake cycle
3. Regulates body temperature 7. Controls the autonomic nervous system
4. Regulates blood pressure 8. Regulates aggressive and sexual behaviour
Pituitary
1. Regulates growth and reproduction 2. Controls various metabolic activities
Chapter 61

Multiple Choice
1. d 9. d 16. c
2. d 10. d 17. a
3. a 11. c 18. c
4. c 12. d 19. b
5. b 13. a 20. b
6. d 14. d 21. a
7. c 15. d 22. b
8. a
Fill-In
1. respiratory distress, pneumonia, aspiration, 6. intraventricular catheter, subarchnoid bolt,

pressure ulcer, and deep vein thrombosis epidural or subdural catheter, and fibreoptic
2. pneumonia, aspiration, and respiratory failure transducer-tipped catheter
3. a change in the level of consciousness (LOC) 7. increased ICP, infection, and neurologic deficits
4. brain stem herniation, diabetes insipidus, and 8. cerebrovascular disease
syndrome of inappropriate anti-diuretic hormone 9. status epilepticus
(SIADH) 10. Answer may include: bright lights, stress,
5. administer osmotic diuretics and corticosteroids, depression, sleep deprivation, fatigue, foods
restrict fluids, drain cerebrospinal fluid, hyper- containing tyramine, monosodium glutamate or
ventilate the patient, control fever, and reduce nitrates, aged cheese, and oral contraceptives.
cellular metabolic demands
Matching
1. a and f 4. a
2. c and e 5. c
3. b
II. Critical Thinking Questions
1. Airway management is a vital nursing function for a patient with altered level of consciousness. The nurse
should: put the patient in the lateral or semiprone position with the head elevated about 30 degrees,
remove secretions from the posterior pharynx and upper trachea by suctioning, perform frequent oral
hygiene, auscultate the lungs every 8 hours, and initiate postural drainage and chest physiotherapy.
2. It is believed that reducing body temperature helps decrease cerebral edema, reduce the oxygen and
metabolic requirements of the brain, and protect the brain from continued ischemia.
3. Refer to Chart 614 for a complete list of activities.
1. surgery involving removal of a portion of the skull 4. unrelenting pain accompanied by nausea,
2. increased blood pressure and decreased heart rate vomiting, and visual disturbances
and respirations in response to increased pressure 5. rhythmic waxing and waning of the rate and
on the medulla oblongata depth of respirations alternating with brief
3. decortication periods of apnea
Clinical Situations
Plan of Nursing Care: Unconscious Patient

Use Table 611 as a guide for a plan of care for Miss Potter.
Chapter 62
Multiple Choice
1. b 6. c 10. a
2. a 7. d 11. b
3. b 8. c 12. d
4. b 9. a 13. d
5. d
Fill-In
1. stroke; brain attack

2. age, sex, race, and ethnicity
3. transient ischemic attack, reversible ischemic neurologic deficit, stroke in evolution, and completed stroke
4. A bruit is an abnormal sound heard on auscultation resulting from interference with normal blood flow. A
patient with a TIA may have a bruit over the carotid artery.
5. carotid endarectomy
6. decreased cerebral blood flow and inadequate oxygen delivery to the brain
7. brain tissue, the ventricles or the subarachnoid space
8. the development of cerebral vasospasm
9. cerebral hypoxia, decreased cerebral blood flow, and extension of the area of injury.
Matching
1. d 5. b
2. h 6. g
3. e 7. c
4. a 8. f
1. A brain attack is a disruption of cerebral blood flow caused by either an obstruction or the rupture of a
blood vessel. Blood alteration initiates a series of cellular metabolic events called an ischemic cascade.
Initially, low cerebral blood flow (a penumbra region) exists. Intervention needs to occur at this time,
before calcium influx and increased glutamate activate a number of damaging pathways.
2. Based on the major nursing diagnoses, the nurse would focus her care on the following interventions,
which are not all-inclusive: improving mobility and preventing joint deformities, preventing shoulder pain,
enhancing self-care, managing sensory-perceptual difficulties, managing dysphagia, attaining bladder and
bowel control, improving communication, maintaining skin integrity, and helping with family coping.
Clinical Situations
See Charts 622 and 623 for development of Mrs. Coes nursing care plan.
Chapter 63
Multiple Choice
1. d 8. c 14. b
2. c 9. d 15. b
3. c 10. a 16. d
4. d 11. b 17. a
5. d 12. d 18. b
6. d 13. c 19. b
7. d
Fill-In
1. leakage of cerebrospinal fluid from the ears and and herniation; impaired oxygenation and
the nose ventilation; impaired fluid, electrolyte, and
2. Obstructed blood flow can decrease tissue nutritional balance; and risk of post-traumatic
perfusion, thus causing cellular death and brain seizures
damage. 8. eye opening, verbal responses, and motor
3. headache, dizziness, lethargy, irritability, and responses to verbal commands or painful stimuli
anxiety 9. systemic infections, neurosurgical infections, and
4. difficulty in awakening, difficulty in speaking, heterotrophic ossification
confusion, severe headache, vomiting, and 10. 5th cervical, 6th cervical, 7th cervical, 12th
weakness on one side of the body thoracic, and 1st lumbar
5. hematoma, either epidural, subdural, or 11. pleuritic chest pain, anxiety, and shortness of
intracerebral breath, and abnormal blood gas values
6. coma, hypertension, bradycardia, and bradypnea 12. deep vein thrombosis, orthostatic hypotension,
7. decreased cerebral perfusion; cerebral edema and autonomic dysreflexia
1. Head injuries, the most common cause of tissue perfusion. The brain cannot store oxygen
death from trauma in Canada, affect about 50,000 and glucose to any significant degree. Irreversible
people. Males between the ages of 15 and 19 years brain damage and cell death occurs when the
are at highest risk. blood supply is interrupted for even a few
2. Brain injury can cause significant brain damage minutes.
because of obstructed blood flow and decreased 3. Refer to Chart 635 for a list of activities.
Clinical Situations
Plan of Nursing Care: Cervical Spine Injury

See pages 19411945 for assistance with the development of a nursing care plan for Katie.
Plan of Nursing Care: Paraplegia
See pages 19451949 for assistance with the development of a nursing care plan for Matthew.
Chapter 64
Multiple Choice
1. a 5. a 8. b
2. a 6. c 9. c
3. d 7. c 10. c
4. d
Fill-in
1. severe headache, high fever, a stiff neck (nuchal 4. myelin material that surrounds the nerve fibres in
rigidity), photophobia, a positive Kernig sign, and the brain and the spinal cord
positive Brudzinski sign 5. relapsing-remitting, secondary progressive, and
2. herpes simplex virus (HSV); acyclovir (Zovirax) primary progressive
3. the presence of a polyclonal antibody (protein 6. acetylcholine receptors
14-3-3) in cerebrospinal fluid 7. diabetes, alcoholism, and occlusive vascular
disease
1. To assess for Kernigs sign, the nurse would ask the patient to extend one leg while the opposite thigh is
flexed on the abdomen. Inability to do this is considered positive for bacterial meningitis. To assess for
Brudzinskis sign, the nurse would ask the patient to flex his neck. If flexion of the knees and hips occurs at
the same time, the test is considered positive for bacterial meningitis.
2. Demyelination refers to the destruction of myelin, the fatty and protein material that surrounds nerve fibres
in the brain and spinal cord. This destruction results in impaired transmission of nerve impulses.
Clinical Situations
CASE STUDY: Multiple Sclerosis

1. d 3. a
2. d 4. d
Chapter 65
Multiple Choice
1. d 6. d 11. b
2. c 7. a 12. b
3. d 8. b 13. d
4. c 9. a 14. a
5. c 10. b 15. c
Fill-In
1. lung, breast, lower gastrointestinal tract, flushing, orthostatic hypotension, gastric and
pancreas, kidney, and skin urinary retention, constipation, and sexual
2. headache, nausea and vomiting, and a sixth- disturbances.
nerve palsy 7. fatigue, progressive muscle weakness, cramps,
3. hemiparesis, seizures, and mental status changes fasciculations (twitching) and incoordination
4. intramedullary 8. muscle wasting and weakness, abnormal
5. Answer should include five of the following elevation in blood muscle enzymes, and
seven: Parkinsons disease, Huntingtons disease, myopathic findings on EMG and muscle biopsy
Alzheimers disease, amyotrophic lateral 9. C5C6 or C6C7
sclerosis, muscular dystrophies, degenerative 10. hematoma at the surgical site, causing cord
disc disease, and (new) post-polio syndrome. compression and neurologic deficit and
6. Answer should include four of the following: recurrent or persistent pain after surgery
excessive and uncontrolled sweating, paroxysmal
1. A variety of physiologic changes can occur, such as increased ICP and cerebral edema, seizure activity and
focal neurologic signs, hydrocephalus, and altered pituitary function
2. Brain tumours are classified according to origin: those arising from the covering of the brain, those
developing in or on the cranial nerves, those originating within brain tissue, and metastatic lesions
originating elsewhere in the body
CASE STUDY: Parkinsons Disease
1. d 3. d
2. c 4. b
Plan of Nursing Care: Huntingtons Disease
See Chart 655 (p. 1998) for assistance with the development of a nursing care plan for Mike.
Chapter 66
Multiple Choice
1. b 5. a 8. b
2. a 6. a 9. b
3. a 7. d 10. b
4. c
Matching
1. h 6. e
2. i 7. d
3. b 8. c
4. j 9. a
5. g 10. f
Fill-In
1. General functions of the musculoskeletal system 6. Vitamin D increases calcium in the blood by
include protection, support, locomotion, mineral promoting calcium absorption from the
storage, hematopoiesis, and heat production. gastrointestinal tract and by accelerating the
2. 98% mobilization of calcium from the bone.
3. 206 7. parathyroid hormone and calcitonin
4. epiphyseal plate 8. 4 months
5. sternum, ileum, vertebrae, ribs 9. crepitus
Unscrambled Words
1. periosteum 5. osteoporosis
2. ligaments 6. scoliosis
3. sarcomere 7. effusion
4. tendons 8. arthrocentesis
Chapter 67
Multiple Choice
1. c 10. c 18. a
2. b 11. b 19. a
3. b 12. b 20. c
4. d 13. d 21. c
5. a 14. b 22. a
6. d 15. c 23. a
7. b 16. a 24. d
8. d 17. d 25. d
9. b
Fill-In
1. reduce a fracture, correct a deformity, apply discolouration, tingling, numbness, inability to

uniform pressure to underlying soft tissue, and move fingers or toes, or any temperature changes.
provide support and stability for weak joints 6. compartment syndrome, pressure ulcers, and
2. A fibreglass cast is light in weight and water disuse syndrome
resistant; it does not soften when wet. 7. to minimize muscle spasms; to reduce, align, and
3. necrosis, impaired tissue perfusion, pressure immobilize fractures; to lessen deformities; and to
ulcer formation, and possible paralysis increase space between opposing surfaces within
4. The toes or fingers should be pink, warm, a joint
and easily moved (wiggled). There should be 8. Bucks extension traction, cervical head halter,
minimal swelling and discomfort. The blanch and a pelvic belt
test should be carried out to determine rapid 9. osteomyelitis
capillary refill. 10. thromboembolism, peroneal nerve palsy,
5. Answer may include: unrelieved pain, swelling, infection, and limited range of motion
1. Three potential complications are: compartment syndrome, pressure ulcer, and disuse syndrome.
2. The major goals for a patient with a cast include knowledge of the treatment regimen, relief of pain,
improved physical mobility, achievement of maximum level of self-care, healing of lacerations and
abrasions, maintenance of adequate neurovascular function, and absence of complications.
3. Compartment syndrome occurs when the circulation and function of tissue within a confined area (casted
area) is compromised. Treatment requires that the cast be bivalved; a fasciotomy may be necessary.
4. Volkmanns contracture is a serious complication of impaired circulation in the arm. Contracture of the
fingers and wrist occurs as the result of obstructed arterial blood flow to the forearm and the hand. The
patient is unable to extend the fingers, describes abnormal sensation, and exhibits signs of diminished
circulation to the hand. Permanent damage develops within a few hours if action is not taken.
5. The major nursing goals for a patient in traction may include understanding of the treatment regimen,
reduced anxiety, maximum comfort, maximum level of self-care, maximum mobility within therapeutic
limits of traction, and absence of complications.
Clinical Situations
CASE STUDY: Bucks Traction

1. a 4. d
2. the patients body weight and the bed position 5. skin colour, skin temperature, capillary refill,
adjustments edema, pulses, sensations, and ability to move
3. Inspect the skin for abrasions and circulatory 6. A positive Homans sign indicates deep vein
disturbances and make certain the skin is clean thrombosis.
and dry before any tape or foam boot is applied.
CASE STUDY: Total Hip Replacement

1. deep vein thrombosis and pulmonary embolism 5. leg shortening, inability to move the leg,
2. dislocation of the hip prosthesis, excessive wound malalignment, abnormal rotation, and increased
drainage, thromboembolism, and infection localized discomfort
3. c 6. b
4. d 7. b
Chapter 68
Multiple Choice
1. d 7. d 13. d
2. b 8. c 14. b
3. b 9. c 15. d
4. c 10. d 16. c
5. a 11. d 17. a
6. c 12. b 18. b
Fill-In
1. Answer should include five of these conditions: 3. reduced bone density and altered bone structure
acute lumbosacral strain, unstable lumbosacral 4. third
ligaments, weak lumbosacral muscles, osteo- 5. Calcitonin, which inhibits bone resorption and
arthritis of the spine, spinal stenosis, intervertebral promotes bone formation, is decreased;
disk problems, and unequal leg length. estrogen, which inhibits bone breakdown, is
2. a. risk for ineffective tissue perfusion; peripheral decreased. Parathyroid hormone, which
related to swelling increases with age, enhances bone turnover
b. acute pain related to surgery, inflammation, and resorption.
and swelling 6. 2.5 SD below; 1.02.5 SD below
c. impaired physical mobility related to foot- 7. a deficiency in activated vitamin D (calcitriol),
immobilizing device which promotes calcium absorption from the
d. risk for infection related to the surgical gastrointestinal tract
procedure/surgical incision
Applying Concepts
Refer to Figure 686 as a reference.
Clinical Situations
CASE STUDY: Osteoporosis

1. The rate of bone resorption is greater than the 3. c
rate of bone formation. 4. a
2. Women have a lower peak bone mass than men, and 5. d
estrogen loss affects the development of the disorder. 6. d
Chapter 69
Multiple Choice
1. d 9. d 17. a
2. b 10. a 18. c
3. d 11. b 19. a
4. b 12. b 20. d
5. c 13. a 21. c
6. d 14. d 22. d
7. a 15. b
8. b 16. d
Matching
Part I
1. c 3. b
2. a 4. e
Part II
1. c 3. a
2. b 4. d
Fill-In
1. osteomyelitis, tetanus, and gas gangrene 3. restoring blood volume and circulation, relieving
2. Early: Answer should include three of the the patients pain, providing adequate splinting,
following: shock, fat embolism, compartment protecting against further injury
syndrome, deep vein thrombosis, thrombo- 4. Compartment syndrome occurs when tissue
embolism, DIC, and infection. Delayed: Answer perfusion in the muscles is less than that required
may include three of the following: delayed for tissue viability. Permanent function can be
union and nonunion, avascular necrosis of bone, lost if the anoxic situation occurs for longer than
reaction to internal fixation devices, complex 6 hours.
regional pain syndrome (CRPS), and 5. deep vein thrombosis, thromboembolism, and
heterotrophic ossification. pulmonary embolus
6. Colles fracture
1. an injury to the ligaments around a joint 4. failure of the fractured bone ends to unite
2. subluxation 5. allograft
3. surgical repair 6. trochanteric region
Clinical Situations
CASE STUDY: Above-the-Knee Amputation

1. d 5. a
2. d 6. d
3. d 7. b
4. d 8. d
Chapter 70
Multiple Choice
1. c 8. c 15. d
2. d 9. d 16. d
3. b 10. c 17. d
4. c 11. d 18. c
5. a 12. a 19. d
6. d 13. c 20. a
7. d 14. d
Fill-In
1. Answer may include: smallpox, measles, mumps, 5. West Nile virus, Legionnaires disease, Lyme
rubella, chicken pox, polio, diphtheria, pertussis, Disease, Hantavirus, and Ebola virus
and tetanus. 6. Northeast and Mid-Atlantic
2. pneumococcus, meningococcus, and 7. 56,000 (in 2002)
Haemophilus influenzae 8. sexually transmitted
3. Linezolid and Vancomycin 9. gonorrhea, hepatitis B, hepatitis C, HIV infection,
4. coagulase-negative staphylococci and diphtheroids and syphilis
Matching
1. a 5. f
2. d 6. c
3. b 7. g
4. e 8. h
Examining Associations and Applying Concepts
Use Figure 701 to fill in each blank. Use terms on the perimeter of each link as a guide for choosing a nursing
intervention.
Chapter 71
Multiple Choice
1. b 7. c 13. d
2. b 8. d 14. d
3. b 9. d 15. c
4. a 10. c 16. d
5. b 11. d 17. a
6. a 12. c
Fill-In
1. hepatitis B and human immunodeficiency virus 4. education, legislation, and automatic protection
(HIV) 5. syrup of ipecac
2. speak, breathe, or cough
3. a hematoma refers to a tumour-like mass of blood
trapped under the skin
1. Activities are based on the following objectives:

establish a patent airway and provide adequate ventilation
evaluate and restore cardiac output by controlling hemorrhage and its consequences
determine the patients ability to follow commands; evaluate motor skills and pupillary size and reactivity
perform a physical examination
start cardiac monitoring, if appropriate
splint suspected fractures
protect and clean wounds; apply sterile dressings
identify allergies and significant medical history
document vital signs, neurologic status, and intake/output
2. Families usually experience emotions based on the stages of crises: anxiety and denial, remorse and guilt,
anger and grief.
3. Lactated Ringers solution is initially useful because it approximates plasma electrolyte composition and
osmolality, allows time for blood typing and screening, restores circulation, and serves as an adjunct to
blood component therapy.
4. Refer to textbook pages 21602161 and Chart 711.
Applying Concepts
1. Refer to textbook pages 21632164 and Chart 713 for assistance with nursing actions to clear an obstructed
airway.
Clinical Situations
1. See textbook pages 21702171 for assistance with nursing care for a patient who has experienced blunt,
abdominal trauma.
2. See textbook pages 21762177, Chart 719 for assistance with emergency measures to manage an
anaphylactic reaction.
3. See textbook pages 21792180, and Chart 7111 to develop nursing measures to assist with gastric lavage.
4. See textbook page 2182 and Table 711 for assistance with nursing actions necessary for drug abuse
reaction.
5. See textbook pages 21902191 for assistance with nursing actions necessary for the management of
psychiatric patients.
Chapter 72
I. Interpretation, Completion and Comparison
Multiple Choice
1. c 5. b 9. a
2. b 6. d 10. b
3. c 7. b 11. d
4. b 8. b 12. b
Fill-In
1. Refer to textbook pages 21962197 and Chart 722 tion; it involves 2- to 3-hour processes during
for possible answers. which participants are asked about their emo-
2. The Incident Command System is a management tions, symptoms and any other psychological
tool for organizing personnel, facilities, ramifications.
equipment and communication for any 5. Refer to textbook page 2203 and Chart 725 for
emergency. Its activation during emergencies is answers.
mandated by the federal government. 6. anthrax; chlorine
3. The degree and nature of the exposure to disaster, 7. anthrax and smallpox
loss of loved ones, existing coping strategies, 8. ciprofloxacin or doxycycline
available resources and support, and personal 9. 30%
meaning attached to the event 10. Pulmonary chemical agents act by destroying the
4. Defusing is a process by which an individual pulmonary membrane that separates the alveolus
receives education about recognition of stress from the capillary bed. When this happens, the
reactions and management strategies for handling individual cannot release carbon dioxide or
stress. Debriefing is a more complicated interven- acquire oxygen.
1. A critically ill individual with a high mortality rate would be assigned a low triage priority because it would
be unethical to use limited resources on those with a low chance of survival. Others who are seriously ill
and have a greater chance of survival should be treated.
2. Some cultural considerations include: language differences, a variety of religious preferences (hygiene,
diet, medical treatment), rituals of prayer, traditions for burying the dead, and the timing of funeral services.
3. Some common behavioral responses are: depression, anxiety, somatization (fatigue, malaise), post-
traumatic stress disorder, substance abuse, interpersonal conflicts, and impaired performance.
4. Refer to textbook pages 21992202 and Chapter 3.
5. Refer to textbook pages 22032205.
6. Refer to textbook pages 22042205.

Chronic Health Challenges ANSWER Key

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Answer Key

I. Interpretation, Completion, and Comparison

1. Refer to textbook page 6.

II. Critical Thinking Questions and Exercises

1. The majority of health problems today are chronic in nature.

I. Interpretation, Completion, and Comparison

II. Critical Thinking Questions and Exercises

Discussion and Analysis

1. Refer to textbook pages 1520. 3. Refer to textbook page 19.

I. Interpretation, Completion, and Comparison

Nursing Diagnoses and Collaborative Problems (Fig. 32 and Chart 37).

Matching (Critical Thinking) (Chart 31)

Matching (Ethical Principles) (Chart 32).

II. Critical Thinking Questions and Exercises

Discussion and Analysis

Reference pages for questions 13 are pages 3340.

13. Answers are individualized; there are no right or wrong responses.

Outcomes per Nursing Diagnosis

CASE STUDY: Ethical Analysis

I. Interpretation, Completion, and Comparison

Refer to Chart 42 to complete the chart.

I. Interpretation, Completion, and Comparison

I. Interpretation, Completion, and Comparison

II. Critical Thinking Questions and Exercises

General body arousal Physiologic Reaction Rationale

release of epinephrine and produce ACTH

I. Interpretation, Completion, and Comparison

II. Critical Thinking Questions and Exercises

CASE STUDY: Hodgkins Disease

I. Interpretation, Completion, and Comparison

1. The founder is: Madeleine Leininger.

II. Critical Thinking Questions and Exercises

Discussion and Analysis

I. Interpretation, Completion, and Comparison

I. Interpretation, Completion, and Comparison

1. Answer should include four of the following six causes:

II. Critical Thinking Questions and Exercises

Use of the Trajectory Model

I. Interpretation, Completion, and Comparison

Discussion and Analysis

Clinical Situation: Impaired Skin Integrity

I. Interpretation, Completion, and Comparison

II. Critical Thinking Questions and Exercises

CASE STUDY: Loneliness

I. Interpretation, Completion, and Comparison

1. duration, location, and etiology

2. nociceptors and chemical mediators

3. histamine, bradykinin, acetylcholine, serotonin, and substance P

5. opioids, NSAIDs, and local anesthetics

Discussion and Analysis

CASE STUDY: Pain Experience

I. Interpretation, Completion, and Comparison

II. Critical Thinking Questions and Exercises

Discussion and Analysis

CASE STUDY: Extracellular Fluid Volume Deficit

I. Interpretation, Completion, and Comparison

II. Critical Thinking Questions and Exercises

Flow Chart: Hypovolemic Shock

intravascular volume from hemorrhage or severe dehydration results in

CASE STUDY: Hypovolemic Shock