Title: Quiz: PrePost Op, BioPsychoSocial
Course: PRN 0096 Practical Nursing III > Section: Nursing Care of Clients with Mental Health Disorders

Q: To assist the postoperative patient to cough, the nurse:
- supports the patient’s back.
- offers an antitussive.
- splints the abdomen with a pillow.
- leans patient against the bedside table.
A: splints the abdomen with a pillow.
If right: To assist a postoperative patient to cough, splinting the abdomen with pillow, hands, or a towel roll is helpful to relieve stress on the suture line.
If wrong: To assist a postoperative patient to cough, splinting the abdomen with pillow, hands, or a towel roll is helpful to relieve stress on the suture line.

Q: The day following surgery, the nurse notes bloody drainage on the dressing. The nurse will record this drainage as:
- serosanguineous.
- sanguineous.
- serous.
- purulent.
A: sanguineous.
If right: The term sanguineous means bloody. It is indicative of active bleeding.
If wrong: The term sanguineous means bloody. It is indicative of active bleeding.

Q: When the nurse discovers that the gauze dressing has adhered to the wound, the nurse should:
- call the RN.
- gently remove the gauze with sterile forceps.
- cover with occlusive dressing.
- moisten the dressing with sterile water.
A: moisten the dressing with sterile water.
If right: When a dressing has adhered to the wound, the nurse may moisten the dressing with sterile water or sterile normal saline to loosen it.
If wrong: When a dressing has adhered to the wound, the nurse may moisten the dressing with sterile water or sterile normal saline to loosen it.

Q: The nurse follows the basic concept of wound irrigation when directing the flow of the irrigant:
- from the area of least contamination to the area of most contamination.
- forcefully into the wound.
- gently over the skin into the wound.
- from a distance of about 12 inches.
A: from the area of least contamination to the area of most contamination.
If right: The irrigant should flow from the least contaminated area to the most contaminated area to prevent microorganisms from entering the wound.
If wrong: The irrigant should flow from the least contaminated area to the most contaminated area to prevent microorganisms from entering the wound.

Q: The nurse observes a loop of bowel protruding from the surgical incision. The nurse’s initial intervention should be to:
- call the RN.
- cover the bowel with a sterile saline dressing.
- turn the patient to the side of the evisceration.
- raise the patient up to a high Fowler’s position.
A: cover the bowel with a sterile saline dressing.
If right: Although the RN must be notified, covering the loop of bowel takes priority. The patient may be raised to a semi-Fowler’s position to relieve strain on the suture line.
If wrong: Although the RN must be notified, covering the loop of bowel takes priority. The patient may be raised to a semi-Fowler’s position to relieve strain on the suture line.

Q: Because the physician has not ordered a dressing change for a draining wound, the nurse should assess the amount of drainage by:
- weighing the patient to estimate the weight of the saturated dressing.
- reinforcing the dressing.
- circling and dating the outline of the exudate on the dressing.
- counting each dressing as 1 mL of drainage.
A: circling and dating the outline of the exudate on the dressing.
If right: Without an order to change the dressing, the drainage should be circled and dated. Should the dressing become saturated, the dressing can be reinforced but the exudate should still be circled.
If wrong: Without an order to change the dressing, the drainage should be circled and dated. Should the dressing become saturated, the dressing can be reinforced but the exudate should still be circled.

Q: During assessment of a postoperative patient, the nurse discovers that the pulse is rapid, blood pressure has decreased, urinary output has decreased, and the dressing is dry. The nurse recognizes these findings as indicative of:
- pain shock.
- dehydration.
- internal hemorrhage.
- acute infection.
A: internal hemorrhage.
If right: If a patient has a rapid pulse, decreased blood pressure, decreased urinary output, and the dressing is dry, then the diagnosis is most likely an internal hemorrhage.
If wrong: If a patient has a rapid pulse, decreased blood pressure, decreased urinary output, and the dressing is dry, then the diagnosis is most likely an internal hemorrhage.

Q: The nurse assessing a patient’s wound notes bright red drainage. The nurse documents this finding as:
- serous drainage.
- purulent drainage.
- sanguineous drainage.
- serosanguineous drainage.
A: sanguineous drainage.
If right: Serous drainage has the appearance of clear, watery plasma. Purulent drainage has the appearance of thick, yellow, green, tan, or brown drainage. Sanguineous drainage is bright red and indicates active bleeding. Serosanguineous drainage is pale, red, and watery and is a mixture of serous and sanguineous drainage.
If wrong: Serous drainage has the appearance of clear, watery plasma. Purulent drainage has the appearance of thick, yellow, green, tan, or brown drainage. Sanguineous drainage is bright red and indicates active bleeding. Serosanguineous drainage is pale, red, and watery and is a mixture of serous and sanguineous drainage.

Q: The nurse is assisting a patient to a sitting position when the patient suddenly complains of feeling that his surgical incision has separated. The nurse recognizes this as an indication of:
- cellulitis.
- dehiscence.
- evisceration.
- extravasation.
A: dehiscence.
If right: Dehiscence is separation of a surgical incision or rupture of a wound closure.
If wrong: Dehiscence is separation of a surgical incision or rupture of a wound closure.

Q: Which of the following is most commonly taught to help prevent post-surgical respiratory complications?
- Turning, coughing, and deep breathing
- Splinting incisions
- The use of post-surgical compression stockings
- How to measure intake and output
A: Turning, coughing, and deep breathing

Q: Which of the following members of the surgical team is responsible for monitoring the patient’s vital signs during surgery?
- The surgeon
- The circulating nurse
- The first surgical assistant
- The anesthesiologist
A: The anesthesiologist

Q: The nurse who is working in the post-anesthesia care unit (PACU) recognizes that a patient is most likely to experience which of the following complications while in the unit?
- Hypoventilation
- Deep vein thrombosis
- Atelectasis
- Pneumonia
A: Hypoventilation

Q: After assisting with the transfer of a patient from the post-anesthesia care unit into the bed on the unit, the nurse should first
- Review the physician’s orders.
- Determine the type and amount of intravenous fluid hanging.
- Perform a physical assessment.
- Reassure the patient that he will receive excellent care on the unit.
A: Perform a physical assessment.

Q: The nurse is providing care to a 32-year-old who returned from a thyroidectomy 6 hours previously. The nurse notes that the patient’s temperature is 99.5°F, and that the patient has been taking sips of clear liquids, reports mild nausea, and is using a patient-controlled anesthesia to control her pain, which is 3/10. The nurse should
- Order a low-salt diet.
- Document the findings.
- Contact the physician.
- Assess the back of the patient’s throat.
A: Document the findings.

Q: The nurse is caring for a 28-year-old man who returned from the repair of a broken jaw 3 hours earlier. The patient reports an urge to urinate and tried to use the urinal in the bed without success. The best action by the nurse is to
- Call to obtain an order to catheterize the patient.
- Perform a digital rectal exam.
- Assist the patient to stand and use the urinal.
- Use the bladder scanner to determine the degree of distention.
A: Assist the patient to stand and use the urinal.

Q: The nurse is providing care for a patient with a nasogastric (NG) tube in place 10 hours after a vagotomy and an antrectomy. The patient’s plan of care would include
- Providing mouth care every 4 hours.
- Keeping NG to continuous suction.
- Draping NG tubing over the patient’s shoulder.
- Providing tube feeding every 3 hours.
A: Providing mouth care every 4 hours.

Q: When using the term behavior, the mental health nurse is referring to:
- an isolated incident.
- the manner in which a person performs.
- a product of a coping strategy.
- failure to adapt.
A: the manner in which a person performs.
If right: Behavior may be defined as the manner in which a person performs any or all of the activities of daily living.
If wrong: Behavior may be defined as the manner in which a person performs any or all of the activities of daily living.

Q: The nurse clarifies the concept of “mental health” by defining it as:
- a wellness of attitude.
- a person’s response to disease and dysfunction.
- the ability to cope and adjust to everyday stresses.
- how the person performs activities of daily living.
A: the ability to cope and adjust to everyday stresses.
If right: Mental health can be defined as a person’s ability to cope and adjust to everyday stresses.
If wrong: Mental health can be defined as a person’s ability to cope and adjust to everyday stresses.

Q: During the 17th and 18th centuries, care of patients with mental illness often was cruel. Dr. Phillippe Pinel brought about change by advocating:
- personal care.
- individual care.
- behavior care.
- humane care.
A: humane care.
If right: Dr. Phillippe Pinel advocated humane care.
If wrong: Dr. Phillippe Pinel advocated humane care.

Q: The majority of people function in a relatively healthy manner, but their functioning capacity can be diminished by:
- lack of a support system.
- periods of crisis.
- nutritional deficits.
- a physical disease process.
A: periods of crisis.
If right: Periods of crisis can decrease functional capacity, moving a person toward the illness end of the continuum.
If wrong: Periods of crisis can decrease functional capacity, moving a person toward the illness end of the continuum.

Q: The nurse is assessing a 26-year-old man who is unmarried, dates many different women, and spends his income on himself. Using Erikson’s developmental theory, the classifies this behavior as:
- unconscious.
- self-absorbed.
- mentally ill.
- acting out.
A: self-absorbed.
If right: The inability to find intimacy results in self-absorption.
If wrong: The inability to find intimacy results in self-absorption.

Q: The nurse assesses a patient as having a poor self-concept because the patient consistently:
- wears bright-colored clothing.
- demands the attention of staff.
- apologizes to others repeatedly.
- becomes angry when frustrated.
A: apologizes to others repeatedly.
If right: Apologizing repeatedly is indicative of self-effacement. Anger, demanding attention, and wearing attention-getting clothing are not characteristics of a poor self-concept.
If wrong: Apologizing repeatedly is indicative of self-effacement. Anger, demanding attention, and wearing attention-getting clothing are not characteristics of a poor self-concept.

Q: The nurse documents a flat affect when the patient:
- stomps on and flattens the envelope from the IRS announcing his audit.
- goes to bed after his dog was run over.
- laughs vigorously when his physician trips and falls.
- receives the news of his mother’s death without response.
A: receives the news of his mother’s death without response.
If right: Affect refers to external manifestations of inner feelings. If there is no manifestation by facial expression or verbal response, the affect is flat.
If wrong: Affect refers to external manifestations of inner feelings. If there is no manifestation by facial expression or verbal response, the affect is flat.

Q: A nursing intervention that helps build trust, encourages the patient to have faith in the care being received, and meets psychosocial needs is
- developing a care plan.
- implementing nurse orders.
- patient education.
- meeting patient goals.
A: patient education.
If right: One of the steps to meet the psychosocial needs of the patient is patient education.
If wrong: One of the steps to meet the psychosocial needs of the patient is patient education.

Q: When developing a care plan for a mentally ill patient, the nurse’s first priority would be to assess:
- coping strategies.
- emotional status.
- medications taken.
- nutritional status.
A: emotional status.
If right: The nurse’s first priority would be to assess the emotional status of the mentally ill patient.
If wrong: The nurse’s first priority would be to assess the emotional status of the mentally ill patient.